Gastrointestinal Intubation: Salem Sump Tube

• A tube with a single lumen is used to take air and fluid from the stomach or to take gastric fluid samples.
• It is connected to suction.

Salem Sump Tube

• A Salem Sump Tube is a two-lumen tube.
• It removes fluids and air from the stomach.
• Long tubes can extend into the small intestine.
• Salem Sump Tubes range between 180 cm and 300 cmm.
• Miller-Abbott and Cantor tubes are the most commonly used.

Application and Maintenance of Tubes

• Tubes are administered to the gastrointestinal system, stomach, or small intestines.
• Administration usually occurs nasally, but can occur orally.
• The reasons for nasogastric tube (NGT) application and its advantages/disadvantages should be clearly explained so that the patient can understand.
• The risks associated with nasogastric intubation should be evaluated.
• Informed consent should be obtained from the patient before nasogastric tube application.
• If the patient is unconscious, informed consent should be obtained from relatives.
• In urgent cases where relatives cannot be reached, the healthcare team should discuss the necessity of nasogastric intubation and make a decision.
• The patient should be placed in an upright sitting position.
• Nasogastric intubation should be attempted three times maximum.
• If the application is unsuccessful, assistance should be sought from another healthcare professional.
• Use water-soluble lubricating gel or saline.
• A water-insoluble lubricant may cause the patient to develop aspiration pneumonia if the tube enters the trachea.
• Patients should tilt their head back slightly during the procedure.
• If a patient coughs, has difficulty breathing, or develops cyanosis, the advancement should be stopped immediately.
• Remove the tube and try the other nostril.
• As the tube moves down from the pharynx, the patient should tilt their head forward.
• Closing the trachea will make way for the esophagus transit.
• If there is no respiratory distress and the patient is conscious, the patient should be asked to swallow.
• Advance the tube until it reaches the measured location in the stomach.
• Tape the tube to the patient's nose to keep it in place.
• Proper tube placement should be confirmed.
• Nostrils should be cleaned and cream should be applied.
• Provide oral care to the patient at frequent intervals.
• Chewing gum can be given to the patient to increase saliva release.
• Monitor the color, odor, and amount of the liquid coming from the tube.
• Suction function and tube attachment should be checked.
• If irrigating the tube, use saline to prevent electrolyte loss.
• The fluid used for irrigation should be accounted for when calculating the patient's intake-extraction.
• When feeding or medicating via nasogastric tube, elevate the patient's head 30°-45° to prevent aspiration and reflux.
• Prevent obstruction by washing the inside of the tube with 20-30 ml of warm drinking water every 4 hours before and after drug administration.
• Rotate the tube once a day to prevent it from sticking to the gastrointestinal tract.
• Change the patient's nose bands daily, ensuring the tube's location doesn't change.

Tube Removal

• Intestinal tubes should be pulled slowly for 10-15 cm at a time.
• If encountering resistance, wait an hour before pulling again 10-15 cm until the tube reaches the stomach.
• Once in the stomach, it is removed like a nasogastric tube.
• Clamp tubes before pulling to reduce the risk of stomach contents passing into the esophagus and pharynx.
• Before removing a Miller-Abbott tube, draw the mercury from the balloon into the injector.

Total Parenteral Nutrition

• Total Parenteral Nutrition (TPN) IV provides nutrients to deactivate the gastrointestinal system (GIS).
• Hypertonic glucose, amino acids, and fats are administered via IV.
• Sodium, potassium, chlorine, calcium, magnesium, and phosphate electrolytes are administered.
• Zinc, copper, and manganese are administered.
• TPN rests the GIS after fistula, intestinal inflammation, intestinal obstruction, and surgical interventions.
• TPN is administered through a central vein because hypertonic solutions can damage small veins.

TPN Complications

• During the procedure: pleural perforation, artery perforation, air embolism, subclavian vein thrombosis.
• Due to hyperalimentation: infection, hyperglycemia, fluid-electrolyte imbalance, hypoglycemia, nausea, headache, infiltration.

Esophagus Diseases

• Esophagus diseases may require surgical interventions like motility disorders, divetics, hiatal hernias, tumors, and traumas.

Motility Disorders of the Esophagus: Achalasia

• Achalasia is a rare motility disorder characterized by manometric incomplete relaxation of the lower esophageal sphincter and inhibited peristalsis.
• It is most common between ages 30-50.
• Auerbach nerve plexus degeneration is cited as the cause.
• Extrinsic and intrinsic innervation, interstitial Cajal cells, and smooth muscle cells are factors blamed in the pathogenesis.
• Symptoms include dysphagia, regurgitation, and chest pain.
• Potential complications include esophagitis, pulmonary problems, and esophageal carcinoma.
• Diagnosis: chest radiography, esophagus radiography, endoscopy.
• Treatment: reduce pressure on the sphincter to ease esophageal ejaculation and alleviate symptoms.
• In Achalasia; The loss of function in the esophagus is irreversible.
• Palliative treatments include Pharmacological therapy, botulinum toxin injection, pneumatic and surgical myotomy
• Pharmacological therapy commonly uses calcium channel blockers.
• Placed under the tongue are Nitrates and nifedipine at doses of 10-20 mg, 15-30 minutes before meals.
• Botulinum Toxin Injection uses botulinum neurotoxins, inhibiting neurotransmitter release from cholinergic terminals to block acetylcholine deletion and denervation atrophy.
• Pneumatic Dilatation: pneumatic balloons are passed under endoscopy or fluoroscopy; balloons inflated up to 10-15 ps for 1 minute in the esophagus junction can be repeated with increasing balloon diameters, depending on the clinical picture.
• Surgical treatment: Esophagomyotomy or Heller myotomy involves cutting the lower esophageal sphincters down to the mucosal layer.
• Patients should sleep on a high bed setting, and avoid Phenyl-butazone and Saliclat can occur.
• Anticholinergic drugs, hot/spicy/frozen foods, and alcohol should not be consumed.
• Foods should be thoroughly chewed and mixed with saliva.
• Patients should be fasted for 8-12 hours before dilatation and palced sitting
• Upon the physician's request, sedative or narcotic analgesics can occur.
• Patients post dilatation, should observe for esophageal perforation, tachycardia, substernal/epigastric/abdominal pain, fever and subcutaneous emphysema

Esophageal Diverticula

• Esophageal diverticula are pouches formed when one or more layers of the esophageal wall protrude.
• Just above the upper esophageal sphincter, the diverticula is pharyngo-esophageal.
• Diverticula located in the middle of the esophagus are mid-esophageal or parabronchial.
• Diverticula located just above the lower esophageal sphincter are epiphrenic.

Esophageal Hiatal Hernias

• Hiatal hernias occur when the stomach passes from the esophageal hiatus into the mediastinal space.
• Etiology: congenital or acquired weakness in diaphragmatic muscles, potentially related to trauma.
• Hiatal hernia may develop with diaphragm weakness coupled with increased intra-abdominal pressure from pregnancy, obesity, or excessive exercise.
• Symptoms include wide swings from mild indigestion to severe septic emergencies.
• Reflux, postprandial chest pain, regurgitation, early satiety, epigastric pain, chronic gastrointestinal bleeding, vomiting, difficulty swallowing, palpitations, shortness of breath due to/not due to aspiration may occur.
• The effects of reflux are more prevalent in type 1 hernias.
• Patients experience burning and regurgitation in the chest and dysphagia if the hernia is associated with esophagitis or ulcers.
• Early satiety, chest pain, and regurgitation are possible signs.
• Chest radiography helps for air or air-fluid level diagnosis observation, due to diaphragm obstruction.
• Surgical treatment focuses on relieving complaints and preventing complications.
• Avoid bending over, coughing, heavy lifting, and straining to prevent complications.
• Eat fibrous foods and drink fluids to prevent constipation.
• Do not smoke, and wear loose clothing.
• Soft feed, frequent intervals, is preference.
• Spices, acids and alcohol should be avoided.
• Eat sitting up and not lie down after eating
• Drink after a meal.
• The goal of surgical repair is to relieve symptoms, reduce procedure-related morbidity and mortality, reduce care costs, and decrease the likelihood of recurrence.
• Surgeons choose between thoracic or abdominal approaches based on hernia location/size with standard surgical option like Nissen fundoplication, Belsey (Mark IV) and Hill.
• Pre-operative care is like abdominal and thoracic surgery prep: NG tube implantation during the procedure and deep breathing/coughing exercises are essential.
• Prophylactic antibiotics may also be initiated.
• Post-operative care aims to esophageal suture healing, infection, and fistula prevention.
• Remove fluid and secretions with an NG graft.
• Keep the NG incision secure until completely healed to prevent fistula formation.
• Frequent monitoring of tube placement and function checks happen.
• In a thoracic approach, monitor the chest tube along with the NG tube, with the head of the bed raised at 30 degrees.
• Support the patient, for coughing especially in an incision point, during mobilization.
• After surgery, start with fluids until a normal diet is switched over the 6th week post-operation and monitor for dysphagia.
• To prevent nausea and vomiting lie in the bed should occur eating.
• Stay from carbonated and carbonated foods, eating slow chewing well, with frequent mobilization to help the stomach discharge that should be ensured.

Esophagus Tumors

• Esophageal tumors rare and mostly malignant.
• Esophageal cancer displays late symptoms and rapid spread with 12-22% 5-year survival post-surgery.
• Esophageal cancer varies geographically, being higher from Northeast China to the Middle East.
• Weight loss, palpable lymph nodes, and fine needle aspiration biopsies physical exams occur.
• Bone pain/neurological symptoms may indicate metastasis via magnetic resonance imaging/bone scintigraphy.
• Posteroanterior and lateral chest radiographs, plus esophageal passage radiographs are used to diagnose pneunomonic infiltrates, metastasis and possible lung pathologies.
• Surgical resection for patients without metastases/contraindications along with Curative resection combined with lymphadenectomy is the most effective for resectability and survival.
• Surgeon's preference; location of the tumor, patient/organs involved and previous surgeries/radiotherapy are the main things to consider.
• Pre-op care varies by patient's eating habits: spans 5 days to 2-3 weeks with focus on weight control, oral care (four times daily), and bowel cleaning for intestinal procedures.
• Patient education on incision, tubes and deep breathing exercise are essential, in terms with importance post system.
• Post-op care involves looking out forabdominal/thoracic surgery complications.
• Patient should lie flat anastomosis and breathalyzing.
• Follow up fever, inflammation, anastomotic leaks.
• Tubes are checked open not moving at good pressure, irrigations.
• If restored, patients should be feed in a siting setting and monitor.

Stomach Diseases

• Stomach diseases that require surgical care: peptic ulcer and stomach tumors.
• Surgical intervention objectives include inhibited ulcers, remove tumors and peptic ulcers with treatment.

Peptic Ulcer

• Peptic ulcer is a universal disease from human population cause by disbalance to the stomach acid and pepsin from balance factors.
• Peptic ulcers consist of gastric and duodenal types (typically in duodenum/stomach).
• It can even more be at the end of esphogaus, and in distal denunum and jejumnam, where acids increased with zolling etc..
• Incidence is 20-60 with ⅔ in men and in recent years decreasing.
• Classically it occurs in the presense of activites that reduce resistance.
• Chronich ulcer (round in oval shape) macroscically versus hypermia edema ulcer (acute).
• Symptoms is intermittent writhting and epigastic pain and can be relieved with meds.
• Night wakening pain occurs ⅔ in patients with duodenal and ⅓ in with gusltric ulcers.
• Diagnosis (symptoms) esaphagogastroductionoscopy; sensitive and specific.
• Sugical intervention for ulcers are complicated by maligancy bleeding, perforamtion and obstructations.
• Subtotqal gastricectomy; 80-95 precent ulcer patients recover vs distal part of stomach (less used because it effects reservorior).
• Vagoyomy Antrectomys physiologically will remove cephalic/gastric. 25-30 or 50 remove for cintinuity.
• When tuncal it prevenets gastric after vagoly and will had piloply.
• Inproxomiy cells, latajet proteects proximal stomach is nervated that and protects from the stomach.
• Bleeding (ulcer harmmorages) perforation and obstruction.
• Bleedings: advance aged or assoicatde, ulcers harmorges may cause from occoult mortality.
• 2-10 perforamtion: It duodnum rarely antrum with epigastrich sudden
• Obsturctions althrough it can deal with NG compression.
• Ulcer that dont heal need around 12 weeks

Post-op Comlications

• Post Bleed and dilotation,
• Pyloric is because inflammation scarring.
• Alkalic: It will reflux biles
• Recurrent tumors
• gastojecolific:
• aferrenct loops
• Dumpin (irrefular entries) fast heart, sweat, etc (eppigastric hour) Presugical or emergency surgery that is is for stmach surgery due to condistilike peforat etc,. For cancerr support. With breathing exercirs, With to much care of drains,, With 30 mili waters with no 5-6 daily meals.