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Clients profile
Name: Monica Atilano
Age: 49 y/o
Civil Status: Married
Occupation: Housewife
Past history: (-) DM (-) BA (-)HPN
Chief complaint: Dysphagia
Final Diagnosis: Primary Achalasia
Procedure performed: Laparatomy, Hellers myotomy with dor fundoplication
Illness condition: Achalasia
Achalasia ("no relaxation") is a failure of
smooth muscle fibers to relax, which can cause a
sphincter to remain closed and fail to open when
needed. Without a modifier, "achalasia" usually
refers to achalasia of the esophagus, which is also
called esophageal achalasia, achalasia cardiae,
cardiospasm, and esophageal aperistalsis. Achalasia
can
happen
at
various
points
along
the
gastrointestinal tract; achalasia of the rectum, for
instance, in Hirschsprung's disease.
Esophageal achalasia is an esophageal motility disorder involving the smooth
muscle layer of the esophagus and the
An axial CT image showing marked
lower esophageal sphincter. It is characterized by
dilatation of the esophagus in a
incomplete LES relaxation, increased LES tone, and
person with achalasia.
lack of peristalsis of the esophagus (inability of
smooth muscle to move food down the esophagus) in
the absence of other explanations like cancer or fibrosis.
Achalasia is characterized by difficulty in swallowing, regurgitation, and
sometimes chest pain. Diagnosis is reached with esophageal manometry and
barium swallow radiographic studies. Various treatments are available, although
none cures the condition. Certain medications or Botox may be used in some cases,
but more permanent relief is brought by esophageal dilatation and surgical cleaving
of the muscle (Heller myotomy).
The most common form is primary achalasia, which has no known underlying
cause. It is due to the failure of distal esophageal inhibitory neurons. However, a
small proportion occurs secondary to other conditions, such as esophageal cancer
or Chagas disease (an infectious disease common in South America). Achalasia
affects about one person in 100,000 per year. There is no gender predominance for
the occurrence of disease.
Signs and symptoms
sphincter which may increase the difficulty of later Heller myotomy. This therapy is
recommended only for patients who cannot risk surgery, such as elderly people in
poor health. Pneumatic dilation has a better long term effectiveness than botox.
Pneumatic dilatation
In balloon (pneumatic) dilation or dilatation, the muscle fibers are stretched
and slightly torn by forceful inflation of a balloon placed inside the lower esophageal
sphincter. Gastroenterologists who specialize in achalasia have performed many of
these forceful balloon dilatations and achieve better results and fewer perforations.
There is always a small risk of a perforation which requires immediate surgical
repair. Pneumatic dilatation causes some scarring which may increase the difficulty
of Heller myotomy if the surgery is needed later. Gastroesophageal reflux (GERD)
occurs after pneumatic dilatation in some patients. Pneumatic dilatation is most
effective in the long term on patients over the age of 40; the benefits tend to be
shorter-lived in younger patients. It may need to be repeated with larger balloons
for maximum effectiveness.
Surgery
Heller myotomy helps 90% of achalasia patients. It can usually be performed
by a keyhole approach or laparoscopically. The myotomy is a lengthwise cut along
the esophagus, starting above the LES and extending down onto the stomach a
little way. The esophagus is made of several layers, and the myotomy cuts only
through the outside muscle layers which are squeezing it shut, leaving the inner
muscosal layer intact. A partial fundoplication or "wrap" is generally added in order
to prevent excessive reflux, which can cause serious damage to the esophagus over
time. After surgery, patients should keep to a soft diet for several weeks to a month,
avoiding foods that can aggravate reflux.
Most recommended fundoplication along with Heller's myotomy is Dor's
fundoplication. It consists of 180 to 200 degree anterior wrap around the
esophagus. It provides excellent result as compared to Nissen's fundoplication
which is associated with higher incidence of the post surgery dysphagia.
The shortcoming of laparoscopic esophageal myotomy is the need for a
fundoplication. On one hand the myotomy opens the esophagus and on the other
hand the fundoplication causes an obstruction. Recent understanding of the
Gastroesophageal Antireflux Barrier/Valve has shed light on the reason for the
occurrence of reflux following myotomy. The Gastroesophageal Valve is the result of
infolding of the esophagus into the stomach at the esophageal hiatus. This infolding
creates a valve which extends from 7 o'clock to 4 o'clock (270 degrees) around the
circumference of the esophagus. Laparoscopic myotomy cuts the muscle at the 12
o'clock position resulting in incomptence of the valve and reflux. Recent Robotic
Laparoscopic series have attempted a myotomy at the 5 o'clock position on the
esophagus away from the valve.The Robotic Lateral Esophageal Myotomy preserves
the esophgeal valve and does not result in reflux and obviates the need for a
fundoplication. The Robotic Lateral Esophageal Myotomy has had the best results to
date in terms of ability to eat without reflux.
Since 2010, a new endoscopic treatment modality has been introduced.
Called POEM (peroral endoscopic myotomy), this therapy modality has been
performed on about 2500 patients since 2010.
Follow-up
Follow-up monitoring: Even after successful treatment of achalasia,
swallowing may still deteriorate over time. The esophagus should be checked every
year or two with a timed barium swallow because some may need pneumatic
dilatations, a repeat myotomy, or even esophagectomy after many years. In
addition, some physicians recommend pH testing and endoscopy to check for reflux
damage, which may lead to a premalignant condition known as Barrett's esophagus
or a stricture if untreated.
Nursing interventions
For achalasia patients with NGT
1. Assess for and report signs and symptoms of aspiration of secretions or
foods/fluids (e.g. rhonchi, dull percussion note over affected lung area, cough,
tachypnea, tachycardia, dyspnea, presence of tube feeding in tracheal
aspirate, chest x-ray results showing pulmonary infiltrate).
2. Implement measures to reduce the risk for aspiration:
A. withhold oral foods/fluids and place client in side-lying position if
he/she has a depressed or absent gag reflex, severe dysphagia, and/or
is not alert
B. perform oropharyngeal suctioning, encourage client to use tonsil-tip
suction, and provide oral hygiene as often as needed to remove excess
secretions
C. if client is receiving tube feedings:
I.
check tube placement before each feeding or on a routine basis
if feeding is continuous
II.
do not increase rate of continuous tube feeding infusion unless
ordered; administer intermittent tube feedings slowly
III.
maintain client in a high Fowler's position during and for at least
30 minutes after feeding unless contraindicated
IV.
stop tube feeding and notify physician if residuals exceed
established parameters (usually 75-150 ml)
D. if oral intake is allowed:
I.
perform actions to improve ability to swallow (see Diagnosis 2,
action b)
II.
allow ample time for meals
III.
instruct client to avoid laughing and talking while eating and
drinking
IV.
maintain client in high Fowler's position during and for at least
30 minutes after meals and snacks unless contraindicated
V.
assist client with oral hygiene after eating to ensure that food
particles do not remain in mouth.
3. If signs and symptoms of aspiration occur:
A. perform tracheal suctioning
B. withhold oral intake
C. prepare client for chest x-ray.
Nursing management: Post Op incision
1. Reducing complications from surgery.
2.
3.
4.
5.
Accelerate healing.
Restoring the function of patients as much as possible before surgery.
Maintaining the patient's self concept.
Preparing the patient goes home.