Upper GI Surgery Nursing Guide — GCC

Indications for Nutritional Support

• BMI <18.5 kg/m²
• Unintentional weight loss >10% in 6 months
• Serum albumin <30 g/L
• Inadequate oral intake >5 days
• NRS-2002 score ≥3

Supplementation Options

• ONS: 2 × high-protein supplements daily for minimum 2 weeks
• Nasojejunal (NJ) feeding: bypasses gastric obstruction; post-pyloric placement confirmed by X-ray
• Nasogastric (NG) feeding: if tolerated; risk of aspiration in oesophageal disease
• TPN: only if GI tract non-functional; associated with higher infection risk

• 400ml carbohydrate drink evening before surgery
• 200–400ml carbohydrate drink 2–3 hours before anaesthesia
• Reduces post-operative insulin resistance
• Decreases pre-operative anxiety and thirst
• Reduces hospital length of stay (evidence: Cochrane review)

Pharmacological

• LMWH (e.g., enoxaparin 40mg SC OD) — commence 12h post-op or pre-op in high-risk
• Continue for minimum 28 days post major cancer surgery
• Dose adjust for weight (>100kg) and renal function (eGFR <30)
• Check platelet count if HIT suspected

Mechanical

• Thromboembolic deterrent (TED) stockings — measure correctly
• Intermittent pneumatic compression (IPC) intra-operatively and post-op
• Early mobilisation — key non-pharmacological intervention
• Adequate hydration

• First choice: Cefuroxime 1.5g IV + Metronidazole 500mg IV
• Administer 30–60 minutes before skin incision
• Single dose sufficient in most cases; repeat if surgery >4h or blood loss >1.5L
• Penicillin allergy: Clindamycin + Gentamicin (local protocol)

Patient Preparation

• Verify patient identity (3 identifiers)
• Confirm consent signed and documented
• Confirm operative site marking
• Remove jewellery, dentures, prostheses
• Skin preparation / antiseptic shower
• Confirm NBM status (solids 6h, clear fluids 2h, carbohydrate drink given)

Clinical Checks

• IV access patent — minimum 2 large-bore cannulae
• Foley catheter inserted (aseptic technique)
• NG tube — usually inserted in theatre by anaesthetic team
• Antibiotic prophylaxis administered
• LMWH administered (if pre-op protocol)
• TED stockings applied
• Baseline observations documented
• Blood results and imaging available

• If surgical jejunostomy placed — commence feeding within 24 hours post-operatively
• Start at 20–30ml/h; increase by 20ml/h every 8h to target rate
• Use isotonic polymeric feed initially
• Check jejunostomy site for leakage/inflammation daily
• Flush with 30ml water before and after medications
• Maintain head of bed at 30° during feeding

Monitoring

• Blood glucose monitoring 4-hourly (target 6–10 mmol/L)
• Daily weight when clinically stable
• Electrolytes: Na, K, Mg, Phos — refeeding syndrome risk
• Signs of tube displacement: abdominal pain, distension
• Aspirate NOT routinely checked (jejunal — no residual volume monitoring)

Early Warning Signs

• Tachycardia (>100 bpm) — often the FIRST sign
• Fever (>38.5°C) or persistent low-grade temperature
• Rising CRP (day 3 CRP >150 mg/L highly predictive)
• Change in drain character (turbid, bilious, faeculent)
• Abdominal pain or tenderness disproportionate to expected
• Failure to progress as expected (ileus, nausea)
• Deteriorating inflammatory markers / rising WBC

Investigation and Management

• CT abdomen with IV contrast — gold standard
• Water-soluble contrast swallow (if tolerated)
• Blood cultures if septic
• NBM, IV fluids, IV antibiotics (broad-spectrum)
• Radiology-guided drain insertion if collection present
• Endoscopic stenting (oesophago-jejunal anastomosis)
• Surgical re-exploration if generalised peritonitis

Early Dumping (15–30 min post-eating)

• Palpitations, flushing, sweating
• Diarrhoea, bloating, cramps
• Dizziness, hypotension
• Caused by rapid hyperosmolar chyme → fluid shift into bowel

Late Dumping (1–3 h post-eating)

• Sweating, tremor, confusion
• Reactive hypoglycaemia (blood glucose <3.5 mmol/L)
• Caused by excessive insulin release → GLP-1 effect
• Can be severe — risk of loss of consciousness

Monitoring

• Record drain output hourly for first 6h, then 4-hourly
• Note character: serosanguinous, haemorrhagic, milky, clear
• Observe for air leak: bubbling in water seal chamber
• Document oscillation (swinging with respiration)
• Chest X-ray on return from theatre and day 1

Actions

• >200ml/h blood: urgent surgical review — haemothorax
• Cessation of oscillation: drain blocked — reposition/flush (per protocol)
• Large air leak persisting >72h: bronchoscopy/surgical review
• Milky white fluid: suspect chyle leak (see below)
• Removal: <200ml/day, no air leak, lung expanded on CXR

Diagnosis

• Milky white/opalescent pleural fluid
• Drain fluid triglycerides >1.1 mmol/L (confirms diagnosis)
• Lymphocyte-predominant fluid on cytology
• Volume typically >500ml/day

Management (Stepwise)

• Step 1: Low-fat diet / medium-chain triglyceride (MCT) formula
• Step 2: Nil by mouth + TPN if high output (>1L/day)
• Step 3: Octreotide 100–200mcg SC TDS (reduces lymphatic flow)
• Step 4: Thoracic duct ligation if persistent >7–14 days

Cervical Anastomotic Leak

• Incidence: 5–15% (higher leak rate but lower mortality)
• Signs: neck wound discharge, saliva from drain/wound, erythema
• Management: open cervical wound, irrigate and pack
• Nasogastric/jejunostomy feeding maintained
• Usually heals conservatively with wound care
• Monitor for RLN injury simultaneously

Intrathoracic Anastomotic Leak

• Incidence: 2–5%; mortality up to 50% if septic
• Signs: sepsis, chest pain, pleural effusion, surgical emphysema
• CT with water-soluble contrast swallow — URGENT
• Small contained leak: endoscopic stent + drain + antibiotics
• Generalised contamination: emergency re-thoracotomy
• ICU admission; broad-spectrum antibiotics; antifungals if indicated

Interventions

• Aggressive chest physiotherapy — minimum twice daily
• Incentive spirometry: target 10 breaths per session, hourly
• Early mobilisation: sit out day 0–1, ambulate day 1–2
• Upright positioning ≥30° at all times
• Adequate analgesia (epidural preferred) to enable deep breathing
• Consider NIV (CPAP/BiPAP) if SpO₂ <92% on 4L/min O₂

Monitoring

• Continuous SpO₂; target ≥94%
• ABG on return from theatre and if deterioration
• CXR daily for first 3 days
• Observe for: atelectasis, consolidation, pleural effusion, pneumothorax
• Physiotherapy escalation if sputum retention
• Sputum cultures if temperature >38°C

• Pyloroplasty: surgical widening of pylorus to prevent DGE
• Pyloromyotomy: incision of pyloric muscle
• Intra-operative Botox: pyloric injection to prevent spasm
• Not universally performed — surgeon preference

• Change in drain character (turbid, bilious, faeculent)
• Sudden increase in drain volume
• Drain amylase >3× serum

• Tachycardia >100 bpm (often the first sign)
• Temperature >38.5°C or hypothermia <36°C (sepsis)
• Hypotension, rising lactate

• Increasing abdominal tenderness
• Peritonism or rigidity
• Distension

• Pain disproportionate to expected post-op course
• Back or shoulder tip pain
• Pain worsening after initial improvement (day 4–7 "dip")

Risk Factors in Upper GI Surgery

• Malignancy (Trousseau's syndrome)
• Prolonged surgery (>90 min)
• Immobility post-operatively
• Dehydration / poor oral intake
• Previous VTE history
• Obesity (especially bariatric patients)

Prevention and Treatment

• LMWH commenced 12h post-operatively (if haemostasis adequate)
• IPC devices — start intra-operatively
• Extended prophylaxis: 28 days for cancer surgery
• Suspected PE: CTPA — do not delay anticoagulation
• Massive PE: consider thrombolysis (haemodynamically unstable)
• Sub-massive: therapeutic LMWH or DOAC

Classification

• Superficial incisional: skin/subcutaneous within 30 days
• Deep incisional: fascia/muscle; up to 90 days
• Organ/space: intra-abdominal collection; up to 90 days (or 1yr if implant)

Management

• Wound swab for culture and sensitivity
• Superficial: open wound + dressings ± antibiotics
• Deep/organ-space: CT-guided drain + IV antibiotics
• Antimicrobials guided by cultures; co-amoxiclav ± gentamicin empirically
• Wound care: moist healing, negative pressure therapy (NPWT) if large

Apfel Score Risk Factors

Multimodal Antiemetic Protocol

• Ondansetron 4–8mg IV (5-HT3 antagonist)
• Dexamethasone 4–8mg IV intra-operative (opioid-sparing + antiemetic)
• Cyclizine 50mg IV/IM (antihistamine)
• Haloperidol 0.5–1mg IV if refractory
• Avoid opioids where possible (multimodal analgesia)
• Adequate hydration

• Loss of LOS and gastric reservoir → severe bile/acid reflux
• Aspiration pneumonitis risk (especially nocturnal)
• Anastomotic stricture risk from chronic reflux

• Head of bed elevation 30° at all times — especially at night
• PPI (omeprazole/lansoprazole) prescribed lifelong
• Small frequent meals — avoid large volumes
• No eating within 3 hours of lying down
• Alginate (Gaviscon) for breakthrough symptoms

Common Procedures

• Sleeve gastrectomy — most common in GCC
• Roux-en-Y gastric bypass — second-line or for T2DM resolution
• One anastomosis gastric bypass (OAGB/MGB) — growing in GCC
• Revisional bariatric surgery — significant proportion (sleeve to bypass)

Nursing Considerations

• Vitamin supplementation adherence critical — B12, iron, D, folate
• Cultural food practices affect post-bariatric dietary compliance
• Long-term follow-up challenges — patient migration between GCC states
• Post-bariatric pregnancy: planning and nutritional monitoring
• Mental health assessment pre- and post-operatively

High Risk — Advise Against Fasting

• Within 3 months of major upper GI surgery
• Active jejunostomy feeding
• Active dumping syndrome
• Significant nutritional deficiency (albumin <30, Hb <90)
• Insulin-dependent diabetes with post-bariatric hypoglycaemia

Guidance for Those Who Choose to Fast

• Consult religious scholar (Sheikh) — medical exemption can be granted
• Iftar: avoid large meal — stick to small portions
• Suhoor: high-protein meal; complex carbohydrates; adequate fluid
• Medications: adjust timing with pharmacist
• Monitor weight, glucose, hydration daily during Ramadan
• Break fast if dizziness, weakness, hypoglycaemia symptoms

Current Challenges

• Limited specialist upper GI oncology nursing training programmes
• Nursing workforce predominantly expatriate — varying baseline training
• High staff turnover disrupts continuity of cancer care
• Language barriers between nurses and Arabic-speaking patients
• Limited clinical nurse specialist (CNS) roles in GCC upper GI units
• Palliative care integration into upper GI oncology pathways in development

Recommendations

• Establish GCC-specific upper GI surgery nursing competency frameworks
• Invest in CNS roles for upper GI cancer navigation
• Arabic-language nurse patient education materials
• Regional nursing education partnerships (e.g., with UK AUGIS, ESSO)
• ERAS nursing champion programmes in each upper GI unit
• Peer support networks for GCC upper GI nursing staff

Progress

• Major tertiary centres (KFSH&RC, Cleveland Clinic Abu Dhabi, HMC Qatar) adopting ERAS for upper GI
• Shorter hospital stays being reported
• Laparoscopic/robotic techniques increasing
• Multidisciplinary nutrition teams established

Barriers

• Cultural expectation of long hospital stay post-surgery
• Nursing ratio constraints limiting early mobilisation support
• Variable anaesthetic practice (opioid-heavy protocols persist)
• Limited outpatient infrastructure for early discharge

Nursing Role in ERAS

• Educate patients on ERAS expectations pre-operatively
• Mobilise patients within 8 hours of ICU admission
• Drain and catheter removal per ERAS protocol
• Accurate audit data collection for ERAS compliance