PATIENT INFORMATION ENDOSCOPIC RETROGRADE CHOLANGIO PANCREATOGRAPHY (ERCP)

INTRODUCTION

This is a standard procedure used in the diagnosis and treatment of diseases of the pancreas and biliary tree (Bile ducts and Gallbladder). It is a similar examination to the common Gastroscopy, in that it is an endoscopic procedure done through the mouth, but more complex and requiring more skill to obtain visualisation of the bile duct and pancreatic duct. Furthermore, this procedure is also used to perform possible therapeutic procedures, such as extracting common bile duct stones. X-Rays are taken at the time of the procedure and you should inform us if there is a possibility of pregnancy.

INDICATIONS

Evaluation of the patient with jaundice that could be due to obstruction of the bile ducts.
Evaluation of other diseases of bile ducts.
Evaluation of patient’s with suspected pancreatic cancer, recurrent pancreatitis, or pancreatic cysts.
Evaluation of bile ducts or pancreatic duct after trauma.
To determine the anatomy of the bile ducts and pancreatic ducts before surgery.

PROCEDURE

The doctor and/or nurse will explain the procedure to you prior to the examination. It is performed under conscious sedation or light general anaesthesia, depending on your doctor’s assessment of your condition. You will need to remove dentures, contacts and spectacles, jewellery. The procedure is performed on an X-Ray table. Your throat will be sprayed with a local anaesthetic. A mouth guard will be placed between your teeth. Sedation will be administered by an intra venous catheter and the instrument will be passed through your mouth into the oesophagus. The endoscope will not interfere with your breathing and will not cause pain. The procedure may take 30 – 60 minutes.
After the procedure you may experience numbness in your throat. You should not eat or drink anything for 1 hour afterwards, and you will not be able to drive a vehicle, as the sedation impairs your reflexes and judgements.

RISK AND POSSIBLE COMPLICATIONS

This procedure is generally safe, but can result in complications such as

• Pancreatitis (inflammation in the pancreas) – (in 0,7 – 9 % of procedures).
• Infections in bile ducts (0,65 – 0,8 %).
• Perforations and bleeding (rare).

These complications might be serious enough to require urgent treatment, hospitalisation or even an operation.

ERCP TREATMENTS (THERAPY)

If the X-Rays reveal that stones or other obstruction are present in the bile ducts, the opening of the bile duct can be enlarged, by cutting with an electrical wire, and stones removed or the obstruction relieved by inserting a plastic tube (stent) through the narrowed area to allow bile to flow freely into the intestine.

QUESTIONS AND PROBLEMS AFTER THE PROCEDURE

Contact the doctor who performed the procedure, or your referring doctor, or in case of emergency, go to your nearest 24-H casualty for assistance.

GENERAL INFORMATION

A cholecystectomy is the removal of the gallbladder which is located under your liver on the right side of your upper abdomen. The reason for removing the gallbladder is usually that it contains stones that cause inflammation and symptoms.

COMMON SIGNS AND SYMPTOMS

• There is pain over the gallbladder on the right side of the upper abdomen.
• Often the pain comes on after a heavy meal. It may come and go or be there all the time.
• The pain may shoot to the back and to the tip of the right shoulder blade.
• There is loss of appetite or nausea. Sometimes there is vomiting which may have a bitter taste.
• There may be fever and chills.
• There is tenderness over the gallbladder. This may be mild or it may be very severe.
• A fullness may be felt over the gallbladder area.

DIAGNOSIS

• Can sometimes be made clinically.
• An X-ray of the abdomen may show gallstones.
• An ultrasound may show the disease of the gallbladder.

TREATMENT

The best treatment is to remove the gallbladder. Until a few years ago most gallbladders were removed through an abdominal incision.
These days most gallbladders can be removed laparoscopically through 3 or more small incisions. The patient has less pain and a faster recovery. It is important to remember that at times it may not be safe to do the operation with a laparoscope and an open cholecystectomy may need to be done. When your doctor converts a laparoscopic cholecystectomy to an open cholecystectomy, this is not considered a complication, this is considered to be good surgical practice.
It is important to remember that a cholecystectomy remains a major operation, even when doing it with the laparoscope. This however makes it easier for you. Do not think it is a minor operation.

PRE-OPERATIVE PREPARATION

• Make sure your doctor knows what medicines you take, especially medicines which may affect blood clotting.
• Do not eat or drink anything for 6 hours before the operation.

OPERATION

• The operation will be done under general anaesthetic. Three or more small incisions will be used through each of which cannulae are inserted.
• The operation usually takes one hour or longer.
• Usually the whole gallbladder with all the stones it contains is removed.

POST OPERATIVE CARE

• After the operation you will be taken to a recovery room. When you are stable you will be taken to your regular hospital bed.
• Any pain, discomfort, or nausea will be controlled with medication.
• If the operation has been completed with a laparoscope you can expect to be discharged a day or two after the operation.

COMPLICATIONS

1. Complications are infrequent after a LAPAROSCOPIC CHOLECYSTECTOMY. It is however important for you to remember that it is a major abdominal operation and complications may occur.
2. A bleed or an infection is always possible at the site of the small incisions.
3. Very occasionally a small incisional hernia can develop at a port site.
4. Occasionally a collection of bile develops in the peritoneal cavity. This can delay your recovery. If you are not recovering fairly promptly after the operation your doctor may decide to do an ultrasound. A collection of bile can mostly be drained by needle or catheter without the need for an operation. Very rarely is a further laparoscopic or open operation necessary.
5. There is a 0.5% incidence of damage to the bile ducts in the vicinity of the gallbladder. When this occurs further surgery will be necessary.
6. Also remember that as this is an intra-abdominal operation it is possible for intraabdominal organs to be injured during the operation.
7. Systemic complications like venous thrombosis and pulmonary embolism are rare, but possible after any operation or anaesthetic

GALLBLADDER – REMOVAL FOR GALLSTONES, USUALLY LAPAROSCOPIC CHOLECYSTECTOMY

Overview

Gallstones are very common in most western countries. About 10% of adults have gallstones. Gallstones do not always cause symptoms but if they do then surgical removal is the best treatment currently available.

What causes gallstones?

Most gallstones are formed from cholesterol in the bile crystallising in the gallbladder. This is more likely to happen in women and in people eating a high-fat, high-calorie diet.

Some people develop “pigment” gallstones, which are the result of the breakdown of the red cells in the blood.

What are the symptoms of gallstones?

Gallstones may cause no symptoms at all. The most common complication is cramping pain usually felt in the upper right abdomen or in the back on that side. Vomiting often occurs and fatty foods may trigger an attack. If the gallstone passes out of the gallbladder into the duct draining the liver, obstruction can occur resulting in jaundice (yellow discolouration).

How do I know if I have gallstones?

If the symptoms suggest gallstones then an ultrasound scan will usually confirm the diagnosis. Blood tests to check on the function of the liver are usually needed and sometimes a special test called an ERCP or a MRCP is used to ensure no stones are present in the bile ducts. Stones that have escaped from the gallbladder into the bile ducts can usually be removed before surgery.

What are the treatment options for gallstones?

If gallstones are not causing any problems then they can be left alone. If they are causing pain then surgical removal is the safest way to ensure cure of the symptoms and prevent complications. Traditionally gallstones were removed through a large incision (wound) which was painful for some weeks. Modern technology has made it possible to remove the gallbladder through much smaller incisions using a special video camera called a laparoscope. This operation is called a laparoscopic cholecystectomy (“key-hole surgery”) and patients are now able to return home after only one night in hospital. Occasionally for safety reasons a surgeon will decide to use the traditional (“open”) method to remove the gallbladder. This is not a complication of surgery but is an accepted method still widely used if needed.

What about shock-wave treatment?

This method using ultrasound waves (lithotripsy) has been very successful for treating kidney stones, which are calcified (contain calcium) and very hard. The technique allows the stones to be removed while preserving the kidney, which is very important. Gallstones are not often calcified and as a result do not shatter as easily with ultrasound waves. There is also a danger that if the stones are shattered the small pieces will block the duct draining the liver resulting in jaundice or inflammation of the pancreas gland. If the gallbladder is not removed then further stones are likely to form so shock wave treatment is not considered a permanent cure for gallstones. For all of these reasons shock-wave treatment is usually only used for people unfit for surgery.

Can gallstones be dissolved?

Gallstones can be dissolved but the chemicals used are toxic and gallstones usually recur when treatment stops.

Pre-Operative Investigations:

Liver function tests (LFTs),  Full blood count (FBC),  Urea/Creatinine/Electrolytes (If hypertensive/diabetic/renal impairment).

Abdominal ultrasound is the diagnostic modality of choice to confirm cholecystolithiasis, determine stone size and bile duct dilitation.

The associated presence of choledocholithiasis may influence the operative strategy. Risk factor indentification aids in the prediction of the likelyhood of choledocholithiaisis being present. A variety of different diagnostic and therapeutic options are avaliable to achieve this. They will vary depending on resource availabilty and local expertise. For those identified at low risk of choledocholithaisis ERCP should be performed after a less invasive modality eg (EUS, MRC) has confirmed the presence of stones in the duct. In patients with cholangitis, percutaneous or ERCP drainage are the preferred methods of bile duct decompression.

Indications For Procedure: Symptomatic gallstones

Acute cholecystitis (calculus/acalculus)

Chronic cholecystitis ( HIDA Scan)

Mucocoele of the gallbladder

Gangrene of the gallbladder

Calcified/porcelain gallbladder

Gallstone pancreatitis

Asymptomatic gallstones in diabetic patients

Asymptomatic gallstones – the indications for cholecystectomy in patients with asymptomatic gallstones remains controversial

Gallbladder polyps > 5 mm

Contraindications: No absolute contraindications

How is the operation performed?

In most cases general anaesthesia is used with the patient asleep. Two cuts of 1 cm and two of 5 mm in length are made. Carbon dioxide gas is used to distend the abdomen to allow room for operating. The gallbladder is separated from the liver and the blood vessels supplying it are divided. The duct draining the gallbladder is clipped and the cut. The gallbladder is normally removed through the cut at the belly button (umbilicus). If there is a suspicion that there are gallstones in the bile duct draining the liver then an x-ray called a cholangiogram can be taken during the operation. Following surgery most patients can eat a light .

Can I live without a gallbladder?

The gallbladders main function is to store bile until it is needed to help digest fat in the diet. After the gallbladder is removed the bile ducts usually increase slightly in size and store some of the bile. A gallbladder that has stones in it does not usually function normally anyway and so it not missed.

What are the risks of surgery?

• The following risks are common to all operations:
• Heart and lung problems
• Blood clots (thrombosis) in the legs veins
• Wound infections
• Bleeding
• Excessive scar formation

Specific risks of laparoscopic cholecystectomy:

The biggest danger is injury to the main bile duct, which drains the liver into the bowel. For this reason surgeons will often convert to the “open” method (see above) if the gallbladder is too inflamed to allow safe identification of the bile duct. Other rare complications include injury to the digestive tract, injury of a major blood vessel, leakage of bile from a bile duct and injury of other organs near the gallbladder.

Following surgery:

If you develop a fever, chills, drainage from a wound for more than one day or abdominal pain it is important that your surgeon is contacted.

What can I eat after my gallbladder has been removed?

After a few days it is usually possible to eat a normal diet again. For general health reasons though, it is still advisable to avoid fatty foods.

What is a Gastrectomy?

A gastrectomy is the removal of all or part of the stomach. This procedure can be performed for chronic non-healing ulcers, gastric outlet obstruction or cancer of the stomach.

Cancers can develop anywhere in the stomach, but the most common sites are either at the entrance (proximal) or the outlet (distal) of the stomach. Cancers close to the outlet can be removed so that part of the stomach is left (partial gastrectomy). Cancers close to the entrance require the whole stomach to be removed (total gastrectomy).

Why is it necessary?

Gastrectomy is presently the best treatment for potentially curable stomach cancer. It gives good symptom relief and offers the best chance of a long-term cure. It is also the best option for patients with chronic non-healing ulcers and gastric outlet obstruction.

How do you know this operation is the right for me?

The number of tests/investigations you have had will help us find out the size and position of your cancer. These tests will build up an image of your cancer and help us decide if an operation is the right treatment option for you.

What if my cancer has spread beyond my stomach?

If this has happened surgery may not be an option for you. You will be referred to an oncologist to discuss other treatment options such as chemotherapy or radiotherapy.

During the operation

The operation can be performed with an open cut or by laparoscopic (keyhole) surgery. Your surgeon will decide on the most appropriate approach to remove your particular cancer. The operation may involve removing part or all your stomach, depending on the location, size and extent of your tumour.

Occasionally other organs near the tumour may also need to be removed such as the spleen (an organ that filters blood and removes old blood cells) or bowel. The oesophagus or remaining stomach is then connected to the small intestine so you can continue to eat and drink.

What risks and problems are there with this operation?

The risks of this operation are different for each individual and yours will be discussed with you (and your family) in detail. All operations carry the risk of having a heart attack, bleeding or a clot developing. There are also certain problems that are more likely to occur after this type of surgery, the main one being chest related: chest infections and fluid collections on the chest can develop. Infections can also develop in the wounds. The most serious problem is an ‘anastomotic leak’, where the new ‘joins’ inside do not heal as quickly as we would like, or form a small leak. If this occurs you would continue to be fed through your feeding tube while we wait for it to heal. You may also require further surgery.

What will I be like immediately after the operation?

For the first few days after your operation you will usually be nursed on the high care unit. This enables the team to monitor you closely. You will have several tubes attached to you (which are described below) and will be transferred back to the ward as soon as your surgeon is happy with your progress.

Surgical drains – you may have some drains (tubes) in your tummy/neck/chest after the operation. These drains take away fluid from around the operation site.

Naso-gastric tube – this tube goes up your nose and down into your stomach area. It helps us to remove fluid to prevent pressure on the new ‘join’ inside, and also helps to prevent nausea and vomiting. This allows the ‘join’ to heal.

Jejunostomy tube – this is a feeding tube that is placed in your abdomen. This is to ensure you receive a good level of nutrition, as you will not be able to eat or drink for several days (3-5 days). You will be started on the feeds through this tube when your surgeon is happy with your progress. These will be stopped once you are able to take enough food and drink by mouth. The feeding tube may be removed before you are discharged home, this will depend on how you are progressing.

Central line – this is a drip, which goes into your neck vein. It helps us to monitor your fluid needs.

Urinary catheter – you will have a catheter tube going into your bladder to drain urine. This allows us to measure your urine output following surgery. The catheter will be removed once you are up and about.

You will also have an oxygen mask in place.

(All of these drains and tubes will be removed slowly over the next week.

Will I have any pain after my operation?

Yes, but it is very important that your pain is controlled so that you can breath properly, cough and move around. You will be given pain relief.

Will I be able to move around after my operation?

Yes, and it is important that you move around as much as possible in the bed, and in your chair when you are able to sit out. Some of the drains and tubes may restrict you but you will have a physiotherapist working closely with you. S/he will show you some breathing exercises and how to cough effectively, which are very important to prevent you from getting a chest infection or pneumonia.

How will I be able to eat after this operation?

After part or all of the stomach is removed, the intestines are ‘rejoined’ together. If you have part of the stomach remaining (partial gastrectomy) then the small intestine is joined to your new smaller stomach. This means that your eating is likely to be similar to having a normal stomach. As a result some people find they are able to eat normally following their surgery. If the whole stomach is removed (total gastrectomy) the small intestine is joined directly to the oesophagus (gullet). You therefore only have a small reservoir for food and everything you eat goes straight into the small intestine. This means that you will feel full quickly and will need to eat small meals regularly – maybe up to five or six times a day. The dietitian will see you while you are in hospital and is available for advice. You will not harm yourself by drinking alcohol in moderation.

Are there any long-term effects from the operation?

Yes, the first is the wound in your abdomen. It is a big cut but generally heals very well. It will, however, take several months for it to heal completely inside. During the operation on your stomach some of the main nerves (vagus nerves) to the intestines are cut. This has some effects on the bowel and one of the commonest effects is that you may have attacks of unexpected diarrhoea. You can be given some tablets to help with this and with time, if you suffer from this problem, it will improve.

If all of your stomach is removed you will need to have regular Vitamin B12 injections every three months, this is to avoid your blood count becoming too low (becoming anaemic).

What are my chances of cure? (in the case of cancer)

This depends on how early we have detected and treated the cancer. This is called the stage of the tumour. Your consultant will discuss the results with you, either before you leave hospital or at your first follow-up appointment. Some patients may need to have additional treatment (in the form of chemotherapy with or without radiotherapy) after their surgery. If this is necessary it will be discussed with you in detail.

How long will I be in hospital?

You will probably be in hospital for about 10days depending on how you are feeling. If you have any complications this can keep you in hospital longer. You will be discharged home when your surgeon is happy with your recovery and progress.

How long will it take me to fully recover?

It can take up to several months for you to regain your full strength. You will find that you feel very tired when you get home and you will need to rest a lot. This is normal so try not to worry. As your strength improves and the discomfort in your wound settles, you will find that you can do more and more. You will not do yourself any harm by gradually building up your activities and you will not harm yourself by drinking alcohol in moderation. You should not drive for several weeks after your surgery; the exact time varies between patients. Before driving you will need to be confident that you are able to control the car without experiencing any pain or discomfort. This is important for your own safety and others around you.

GENERAL INFORMATION

The gullet passes through a hole (the hiatus) in the diaphragm on its way to the stomach. Sometimes, tissue around the hiatus weakens, so the hiatus stretches, and the weakened tissue bulges into the chest. This is known as a hiatus hernia.

COMMON SIGNS AND SYMPTOMS

Often, there is heartburn. This is the acid from the stomach backing up into the oesophagus. Sometimes there is a feeling of regurgitation of food. This is made worse when stooping or lying flat; it gets better when standing.

DIAGNOSIS

• Usually the diagnosis can be made by taking a detailed history and doing a thorough physical examination.
• A barium swallow may be helpful.
• A gastroscopy is necessary to visualise the inside of the oesophagus and stomach.
• Your doctor may decide to do pH and manometry studies too.

TREATMENT

If the hernia does not produce any symptoms, then no treatment is necessary. If there are symptoms, medical therapy is sometimes tried first. An operation is usually considered if medical therapy fails. The operation can be done with a laparoscope or by open surgery.

PRE-OPERATIVE PREPARATION

Make sure your doctor knows what medicines you take, especially medicines which may affect blood clotting. Do not eat or drink anything for 8 hours before the operation.

OPERATION

You will be asleep for the operation. The technique would have been discussed with you by your doctor. The operation usually takes about 1-1.5 hours.

POST-OPERATIVE CARE

• You will be taken to a recovery room and observed. When you are stable, you will be taken to a regular hospital room.
• The pain will be controlled with medicine.
• Your doctor will decide when you can start taking liquids or solid foods by mouth.
• You should be able to go home in 1-2 days.

HOME CARE

• Chew your food well before swallowing it.
• For the first few weeks you may feel a discomfort in your throat or a sense of the food sticking. With time this feeling should improve.
• Your doctor will discuss with you when you may drive and return to work.

COMPLICATIONS

1. The most common problem is difficulty with swallowing food. This usually settles spontaneously but on rare occasions something active may need to be done. Likewise there is sometimes an inability to burp which may be uncomfortable. This frequently settles spontaneously but occasionally something active may need to be done.
2. It is important for you to know that when the operation is attempted laparoscopically, it may not always be possible to finish it laparoscopically. It may need to be converted to an open operation. This is not considered a complication but usually reflects good surgical practice. However this will entail more discomfort for you, a longer hospital stay and longer time off work.
3. This is a major intra-abdominal procedure and various problems and complications relating to the stomach and gullet are possible. These include perforation of these organs, it includes problems with the blood supply to these organs and it includes problems with the stomach moving up into the chest. It is possible for other intra-abdominal organs to be injured during the operation.
4. Intra-abdominal bleeding or bleeding in a wound may occur. Your doctor will decide how to manage this.
5. Infections in the abdominal wounds are infrequent but do sometimes occur. How this is managed will depend on your doctor.
6. Very occasionally an incisional hernia can develop in the wound or at a port site.
7. Systemic complications like venous thrombosis and pulmonary embolism are rare, but possible after any operation or anaesthetic.

Laparoscopic Fundoplication for Reflux

Understanding Reflux

Reflux happens when acid from the stomach washes up into the gullet (oesophagus) from the stomach. Typically this causes heartburn – a burning pain in the upper abdomen that may spread up into the chest. Other symptoms include regurgitation of food or fluid, difficulty in swallowing, hoarseness and breathing problems. As many as 1 in 10 people will suffer from some degree of reflux, though this is often controlled by altering your lifestyle or taking tablets. In the vast majority of patients this causes no long term damage. Over a period of time reflux may cause severe or long lasting complications by damaging the oesophagus (oesophagitis) and may result in strictures (narrowing of the gullet) and Barrett’s Oesophagus (there is a change in the cells lining the oesophagus).

Why does reflux happen?

The stomach uses acid to help digest food. The oesophagus is not meant to be exposed to this acid, and so there is a mechanism or valve at the lower end of the oesophagus to prevent reflux. This mechanism involves the lower oesophageal sphincter muscle and part of the diaphragm. The valve may not function properly if:

• You are under a lot of stress.
• You are overweight or pregnant – this puts extra pressure on the valve.
• You eat fatty foods – acid may stay in the stomach for longer.
• You smoke, drink alcohol or take a lot of caffeine – these relax the valve and allow reflux.
• You take medications such as ibuprofen or steroids.
• You have a hiatus hernia (see below).

What is a hiatus hernia?

The stomach normally sits just below the diaphragm, so when part of it gets abnormally pushed up into the lower chest this is known as a hiatus hernia. If this happens, the valve between the oesophagus and stomach may no longer function properly, and can lead to reflux. Hiatus hernias are very common, but it is important to understand that not all patients with reflux have them and conversely you can have a hiatus hernia and not suffer with reflux.

How is Reflux Diagnosed?

Reflux is normally diagnosed on symptoms, gastroscopy, esophageal manometry and PH studies or a Barium swallow. Endoscopy (gastroscopy or OGD) This involves passing an endoscope – a thin tube with a light and camera on the end – down the throat and into the stomach. This allows a good view of the stomach, oesophagus and duodenum. Pictures and tissue samples can be taken if required. It takes around 10-15 minutes with or without sedation. Anyone contemplating antireflux surgery will have to undergo this test. Oesophageal Manometry and pH studies If findings at endoscopy are not conclusive, further tests may be required. The manometry and pH study involves passing a fine tube down a nostril and into the oesophagus where sensors in the tube can monitor pressure and acid levels. This tube will need to be in place for 24 hours to get an accurate recording of how bad your reflux is. It can confirm the diagnosis of reflux disease, or detect some of the rarer causes of reflux-type symptoms.Barium swallow This involves swallowing a liquid that can be seen on x-ray, and is used when there are concerns about swallowing or other abnormalities.

How is reflux treated?

Most patients with acid reflux do not need surgery. The symptoms of reflux may be improved by lifestyle changes such as weight loss, quitting smoking, propping yourself up in bed at night and avoiding the foods that bring on the symptoms. Simple antacids (Rennies or Gaviscon) may also help. The next step after this is to use stronger antacid medications like PPI’s, eg Lansoprazole or Omeprazole. When medical therapy fails or complications develop, anti-reflux surgery may be offered. Surgery relieves heartburn symptoms in the majority of patients (90%) but may not be effective in small number of patients (10%). For those with less typical symptoms, including hoarseness and chronic cough, surgery is effective in relieving symptoms in 7-8 people in 10. Surgery- Laparoscopic Nissen’s fundoplication.

The Nissen’s fundoplication is a surgical technique that strengthens the valve in the lower end of the gullet. This is done by inflating your abdomen (tummy) with gas and using 5-6 small cuts to insert instruments to carry out the operation. The operation takes about 60 to 90 minutes to complete and occasionally (less than 1%) the operation cannot be completed by keyhole method and has to be converted to an open procedure with a larger cut.

What happens during fundoplication?

When performing a fundoplication, the hiatus hernia is repaired by placing your stomach back in the abdomen, the opening in the diaphragm through which the gullet passes from the chest into the abdomen may also be tightened(closing the hernial opening). The part of the stomach that is closest to the entry of the gullet (the fundus) is gathered, and wrapped around the lower end of the gullet where it is then sutured (sewn) into place to create a an improved valve effect.

Risks & Common side effects
Though it is a safe operation there are risks and possible complications

• With this operation there is a risk (less than 1%)that the gullet, stomach or nearby organs may be damaged (perforation, bleeding & infection).
• About 1 in 100 of patients may require further corrective surgery to reduce persistent swallowing difficulty.
• A hernia (less than 1 in 20) may develop at one of the smallcuts that were made.

Common side effects

• Difficulty in swallowing – This is common and usually recovers in about 6 weeks. It may however take about three to six months before the eating normalises (see diet).
• Inability to belch/vomit and bloating- In about 6 out of 10 of patients will not be able to or have difficulty burping or vomiting after the surgery. This may last some months and in some people it may be permanent. If you swallow a lot of air into the stomach, it can cause the stomach to distend and cause discomfort (gas bloat syndrome). This usually is more common in smokers.
• Flatulence – What goes in must come out. Many patients will become more flatulent after the operation.
• Problems with intestinal gas. Over years with reflux you may develop a subconscious habit of swallowing air frequently. After surgery you may have to learn to stop swallowing air and it may take several months to get back to normal. Are there alternatives to a Nissen’s operation? Lifestyle modifications and medications are tried before considering surgery (see above).

What can I expect after the surgery?

Most patients are now able to come in on the morning of their surgery and go home the following day. If you are unwell or the surgery is more complicated than expected, you
may need to stay in for longer. Chest and Shoulder Pains Sometimes patients will experience shoulder pain or deep pain in the chest after surgery. This is due in part to the gas used at laparoscopy and the sutures placed in the diaphragm muscle. This should gradually resolve over a few days.

Medications

You will been given a supply of painkillers. Take the painkillers regularly as per instructions for the first 2 to 3 days. We advise you to take the painkillers before the pain establishes as this will keep you much more comfortable. Drink plenty of liquids (no fizzy drinks), this can help your bowel movements. You may stop taking your antacid medications on the day of surgery. Ask your doctor, nurse or pharmacist if you are not sure what to do with your medications.

Surgical wounds

The stitch material used to close your wounds will dissolve over time. The dressings over your wounds are shower proof, but you should avoid soaking them in water for the first 5 days. After this you may remove the dressings and freely bathe or shower, but do keep the wounds clean and dry.

Rest & Activity

You may feel like resting more after surgery but try to move about as much as possible as this will reduce your chance of developing clots in your legs (deep vein thrombosis).
A bloated sensation is common and loose clothes are needed for a few days or week. Slowly start to do more each day. Rest when you feel it is needed. In general it takes about 5 to 7 days to be back to normal, you may resume sports as soon as you are up to it. You should restrict heavy lifting or high intensity sports for 4 to 6 weeks.

What can I eat after the operation?

Naturally the swallowing will become more difficult for a period of time after the operation. If you follow the dietary advice you may find it easier to cope during the recovery period.

• Follow the diet guidelines that you will receive on discharge
• Do not be too unduly worried if you find it difficult to eat for the first 1-2 weeks. You will be fine as long as you can keep fluids and maintain hydration. It is recommended that you stay on a soft diet – food that will melt in your mouth.
• Drink plenty of liquid (not fizzy drinks).
• After that you may resume solid foods, being sure to take small bites and chew thoroughly before swallowing and eat slowly.
• Do not talk whilst eating to avoid swallowing air. Foods to avoid:
• Chunks of meat such as steak, roast, fried chicken (minced meat is OK).
• White bread (well toasted white bread, brown and wholemeal breads are OK to eat).
• Fizzy drinks and do not drink from a straw as this will encourage swallowing air. Some patients find they have no difficulty swallowing, and other patients may find they take a few weeks, occasionally a few months, before they are able to swallow normally again without pain or without food getting stuck. This is an operation where you will have to adapt your eating habits to the operation. In general it takes between three to six months to relearn new eating habits before getting back to normal. Day 1 to 3 Day 3 to week 2

Food Sticks

It is not uncommon for patients to experience food sticking and pain after eating. When this happens the best things to do are to stand up, walk around slowly and to try sipping some lukewarm water. Generally these pains will pass within 15 minutes. If not you may need to visit your local hospital for an endoscopy to remove the blocked food. Fizzy drinks will cause excess bloating and you should avoid these for the first 3 months before reintroducing them gradually. Dried foods may be difficult to eat, as without a sauce they may not pass through so easily.

Weight loss

It is common to notice that you immediately become full eating less, and have pain if you eat too much. Some patients will lose weight after surgery but most will put the weight back on in time. Reasons for difficulty with swallowing

• Poor eating habits
• Hurried irregular meals
• Gulping air
• Not chewing well enough
• Eating the wrong types of food
• Tension and anxiety.

Signs to look out for
You should call your doctor if you develop any of the following symptoms:

• Fever
• Unusual amount of pain
• Nausea and vomiting.
• Unable to keep liquid down

When can I return to my usual activities/work? You should generally take things easy for 2-3 days after the operation, and then ease back into light household duties. Depending on your work, you may be able to return after 10-14 days. Heavy lifting should be avoided for 4 weeks.

When can I start driving?

When you are pain free and can comfortably perform an emergency stop without any discomfort. You should also check with your insurance company to see if they have any specific requirements regarding driving after surgery to ensure that you are adequately covered.

Because you have been given sedation to make you drowsy for the test, it is important that you:

1. Rest quietly for the remainder of the day, with someone to look after you overnight.
2. It is also very important that for the next 12 hours:

Do not :

• Drive a car
• Drink alcohol or smoke
• Take sleeping tablets
• Operate any machinery or electrical items (including kettles, hot saucepans)
• Sign any legally binding documents
• Work at heights (including climbing ladders or onto a chair)

Sedation can impair your reflexes and judgement. It is advisable to take a light diet for 24 hours after the investigation as the effects of the laxatives
that you took before the test may still cause you to have a loose motion. In order to visualise the bowel properly and make a thorough investigation it is necessary to inflate it with air. This may give you some abdominal discomfort due to flatulence and ‘wind’ type pain. Any discomfort should settle down within a few hours. However, if the pain becomes more severe, changes in character or is accompanied by bleeding please contact your doctor. It is not unusual to pass a small amount of blood following this investigation, especially when you first open your bowels again. However, if this becomes excessive, persistent or is accompanied by pain, please call for advice.

If you have any problems or queries about your test please contact your doctor.
A report will be sent to your GP within the next few days or offered to you to take personally.
Any specimens that were taken will need to be reported on by the laboratory which takes approximately 10 days.

NB: You may have been told that you require further surveillance colonoscopy in the future i.e. to look for further polyps, a family history of bowel cancer or to assess inflammatory bowel disease.

Instructions for patients undergoing colonoscopy

Your physician has asked that the inside of your colon (large intestine) be inspected by using a long flexible tube (colonoscope) so that he can know what disease, if any, is present.

Proper preparation is extremely important for this examination. The large intestine must be clean and empty for the doctor to make an adequate examination. The preparation requires the use of a clear liquid diet for one day before the examination. This is achieved by using a laxative, Moviprep, to clean out the colon before the procedure.

Patients will be sedated by an anaesthetist for the duration of the procedure. The examination is carried out with the patient lying on his left side on the examining table. A lubricant is applied around the anus and the colonoscope is passed into the rectum. It is necessary for the doctor to use some air to aid him in the examination. This may cause you to feel distended and full afterwards. If you have the urge to pass this air by rectum, it is permissible to do so. The large intestine may be twisted and tortuous. As the instrument passes around some of these turns, it may cause a cramping or tugging sensation. This is usually relieved as the instrument is passed around a bend and straightened. The examination may take anything from 15 – 60 minutes. If polyps are to be removed, it may take longer. A nurse is present to help the doctor and to assist in monitoring the patient’s condition. After the examination is completed, you will be asked to rest in an adjoining room until the effects of the medications have subsided and until you have passed much of the air which was introduced during the examination.

Polyps are removed by first locating them with the colonoscope and then placing a wire loop around the base of the polyp. An electric current is used to cut the polyp off at its stalk or base. You will not feel this current. The polyp specimen is usually retrieved by applying suction to the instrument and catching the polyp on the tip of the instrument.

Polyp and instrument are then both withdrawn. If there is more than one polyp it is necessary to re-insert the instrument to remove the additional polyp. There are certain risks to this procedure:

1. There is a very small risk of perforation of the colon. If, however, this should happen, surgery may be required for repair.
2. Following removal of a polyp, there is a small chance/risk of bleeding from the site. This may settle spontaneously, require re-examination or, rarely, surgical intervention.
Blood transfusion may be required.
3. X-ray screening may be used during the procedure so it is important to inform the doctor if you suspect you might be pregnant. It is important to note that, if you are concerned regarding any symptoms which develop following this procedure, you should contact your doctor. He/she will most likely request that you present for assessment without delay.

GENERAL INFORMATION

A colonoscopy is a procedure in which the inside of the entire colon can be looked at with an instrument called a colonoscope. Also, if something abnormal is seen, a small piece of it (a biopsy) can be taken for examination in the pathology laboratory.

THE COLONOSCOPE

The colonoscope is a smooth, flexible, optical instrument about as thick as the tip of your little finger. It has lenses in it as well as a light at its tip that lets the doctor see what is ahead. The colonoscope has several small tunnels in it. One tunnel is used to suck out any mucus that might be in the way. Another tunnel is used to pass a very thin wire with a biting tip at its end that can be used to take a biopsy. The colonoscope is three feet long so that it can be passed up to the very beginning of the large bowel. The end held by the operator has a knob and several buttons that are used to steer the tip of the colonoscope as it is passed up the colon. The buttons are used to control the suction and other functions.

PREPARATION FOR THE COLONOSCOPY

The bowel must be cleansed of all stool so that the lining can be clearly seen. You will be instructed by the doctor how to clean your bowel.

THE COLONOSCOPY PROCEDURE

• A needle will be put into your arm for either an injection or an infusion. This will make you drowsy. The colonoscope will be lubricated thoroughly and inserted gently through
the anus and into the colon. The instrument will be advanced through the entire colon for a thorough examination.
• You will be able to hear and co-operate with the doctor as you are asked to change your position, but you will not be too aware of what is happening.
• When the procedure is completed, the relaxing medicine will be stopped and within a few minutes you will be fully awake.
• The procedure takes approximately 30 minutes. Many patients remember so little of the procedure they think it took just a few minutes, or they may not remember anything at all about it.
• Your blood pressure, pulse and breathing will be watched until they are stable. When you are completely alert, you should be able to go home with a responsible adult. You may not drive yourself or work for the rest of the day.

COMPLICATIONS

• It may not be possible to pass the colonoscope all the way through the large bowel. Your doctor may decide to follow this up with a barium enema.
• Very rarely the colonoscope may perforate the large bowel. In the unlikely event that this happens, you will have to have a laparoscopy/laparotomy to have this perforation repaired.
• If a biopsy is done or a polyp is removed, very infrequently there may be a large bleed.

Your doctor will decide how best to manage this.

What are Esophageal Varices?

Oesophageal varices are enlarged or dilated veins that are present in the gullet (oesophagus). These most commonly arise as a result of liver disease but may occur from other causes. In many cases the varices do not cause any problem but they may bleed. Bleeding from oesophageal varices can be a serious event and, therefore, doctors may advise treatment to reduce the risk of bleeding from the varices. There are several different treatments available and your doctor will discuss the best form of treatment with you. Some people do not require any additional treatment, some require treatment with drugs and others require endoscopic intervention. There are two types of endoscopic intervention available:

The method best suited to your needs will depend on a number of factors and is usually decided by the doctor when the varices are assessed during the endoscopy.
1. Band ligation (banding)
In band ligation the endoscopist will, using the endoscope, put a small band around the base of the varix. This will result in the blood inside varix becoming clotted and scarred. Band ligation is the preferred method of treatment of oesophageal varices.
2. Endoscopic sclerotherapy
Endoscopic sclerotherapy is where the varices are injected with a chemical agent which causes the varices to clot and become scarred. A long needle is passed through the endoscope and the doctor injects the varices with the chemical agent. Endoscopic sclerotherapy has largely been replaced by band ligation.

Before the procedure

Treatment of varices may be done either as an inpatient or outpatient procedure. In either case you should have nothing to eat or drink for four hours preceding the investigation.
You need to bring a friend or relative with you to your appointment so they can accompany you home afterwards. If you are taking any medicines or tablets or any form of treatment please ask a doctor or nurse whether you should take the medication or not. If you have diabetes, then please let the doctor or nurse know so that treatment can be arranged appropriately. You should also let the doctor know if you are allergic to anything. Immediately prior to the procedure a small needle (a cannula) will be put in your arm. This cannula will allow the doctor to give you sedation and, if needed, pain relief. Before the procedure starts you will be asked to sign a consent form. It is very important that you ask the doctor or nurse any questions that you may have.

The procedure

The procedure is usually performed in the Endoscopy room. After the doctor has explained the procedure, you will be asked to lie on your left hand side. A small clip will be placed on one of your fingers. This is to measure the amount of oxygen in your blood and your pulse rate. You may be given additional oxygen through a tube placed in your nose. A small plastic mouth piece will be put in between your teeth to protect them during the procedure. Sometimes, you may be given a throat spray to anaesthetise the back of your throat. When you are lying comfortably the doctor will then give you an injection to sedate you. You will be sleepy and relaxed but it is unlikely you will be fully asleep. The doctor will then ask you to swallow so that the endoscope passes into the gullet. The doctor will then assess the varices as well as the rest of the oesophagus, stomach and first part of the small bowel. If treatment is indicated then the doctor will either band or inject the varices.

If the doctor feels that injection of the varices is best, he will inject the varices using a long, flexible needle that is passed through the endoscope. If the doctor has decided that banding ligation is the best treatment, the endoscope will be removed so that an additional attachment can be placed on the end of the endoscope. You will then be asked to swallow the endoscope again and the banding will be done. The procedure usually takes between 15–30 minutes.

What are the risks?

General complications of endoscopy occur rarely; these include perforation of the gullet. This may lead to local complications including an abscess around the gullet.
Additional risks of sclerotherapy and banding :
Bleeding may occur immediately after injection of varices (in about 3–5% of patients) or a few days later. The nurse will carefully monitor your blood pressure and pulse after the procedure. Pain may also occur and this should be treated with painkillers. Paracetamol is usually all that is needed. Sometimes the gullet narrows after sclerotherapy causing difficulty in swallowing. This can usually be treated endoscopically by widening the gullet (dilatation). Sometimes after injection of the varices, ulcers will form. These ulcers themselves may bleed. For this reason you may be asked to take anti–ulcer forming drugs. As with injection sclerotherapy, there are complications with banding. In general, these tend to be similar to those of sclerotherapy mentioned above but occur slightly less commonly.

After the procedure

If you are an inpatient you will be taken back on your bed to the ward. The nurses will monitor your blood pressure and pulse. If you have not had a throat spray you will be able to drink once you are sufficiently awake. If you have had a throat spray you may have to wait for an hour before being able to drink any fluid.
If you have any pain after the procedure please let the nursing team know so they can give you some pain relief.
Please do remember that after sedation you should not drive or operate machinery for at least 24, and preferably, 36 hours. You should have someone with you for the next 12 hours.
Please remember that it often requires several sessions of endoscopic treatment to get rid of the varices. You must be sure that you are aware of the plans for follow–up. This may require a further attendance for endoscopy or outpatient attendance.

General points to remember

• Following the procedure, if you have any problems with persistent abdominal pain or bleeding please contact your docter immediately, informing them that you have had an endoscopy.
• If you are unable to contact or speak to your doctor, you must go immediately to your local Emergency department (A&E).