Aspiration pneumonia surgery
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:
Overview
Surgery
Management of gastroesophageal reflux
- Patients with swallowing dysfunction, especially those with neurologic impairment, may have increased frequency and volume of gastroesophageal reflux.
- Most patients with mild GER can be effectively managed without fundoplication, using dietary modification and positioning to reduce the frequency of GER, pharmacotherapy for acid suppression, and occasionally prokinetic agents.
- Fundoplication is a surgical procedure to reduce the risk of GER. It should be considered only in patients with GER that is strongly suspected to be contributing to pulmonary disease.
- When evaluating the severity of GER, a gastroenterologist classically focuses on the percent of time that gastric contents spend in the esophagus, which correlate with the risk for peptic esophagitis. From a pulmonary point of view, the number and duration of episodes may be less important than whether the reflux occurs during sleep, when the patient is horizontal and less likely to protect the larynx.
Complications
- Gas bloat syndrome: patients report being unable to belch, leading to an accumulation of gas in the stomach or small intestine. This is said to occur in 2-5% of patients, depending on surgical technique, and is commonly believed to be related to the tightness of the "wrap". Most often, gas bloat syndrome is self-limiting within 2 to 4 weeks, but in some it may persist. The offending gas may come from dietary sources (especially carbonated beverages). Another suspected cause is subconscious swallowing of air (aerophagia). If gas bloat syndrome occurs post operatively and does not resolve with time, dietary restrictions, or counselling regarding aerophagia, it may be beneficial to consider treating the condition with an endoscopic balloon dilitation.
- dysphagia
- dumping syndrome
- achalasia
- Retching
- Esophageal obstruction
- Intrathoracic herniation
- Rrecurrence of GER due to breakdown of the wrap.
- Complications of fundoplication are most common in patients with neurologic impairment. Failure rates of fundoplication range from 2 to 50 percent.
Jejunal feeds
- For patients with GER who are dependent on enteral feeds, an alternate strategy to reduce GER and the associated risks of aspiration is to place the feeding tube in the jejunum rather than in the stomach; this tends to reduce but not eliminate GER. Disadvantages of jejunal feeds include intolerance of rapid feeding infusions (such that continuous rather than bolus feeds must be used), and a tendency for accidental displacement (except with permanent, surgically placed jejunal tubes). A retrospective study in a group of children with neurological impairment found that the rates of aspiration pneumonia and mortality were similar among those treated with jejunal feeding as compared with those treated with fundoplication. [45]