Robert C. Wright, MD, PS
Informed Consent – Pyloroplasty
You have been diagnosed as having either Gastroparesis. This results in poor emptying of the stomach frequently resulting in bloating, nausea, regurgitation, vomiting and heartburn. For adults urgery is an option if medicine doesn’t help much.
Description of the Procedure
Pyloroplasty: Fully cutting the muscle which controls stomach emptying and permanently rearranging it to promote faster stomach emptying.
Additional Procedures that may be done during Surgery
Hiatal Hernia repair/Anti-reflux procedure: for patients with reflux and heartburn.
Laparoscopy: TV camera directed surgery with smaller incisions.
Alternatives to Treatment
1. Medication – Always tried first, may be required lifelong. Diet must be modified.
2. Resection and Gastrojejunostomy – Removal of part of stomach and creating a second opening.
3. Gastrectomy – Total removal of stomach.
Possible complications following any operation
1. Bleeding – this is a problem that could happen any time the skin is cut. A blood transfusion is possible.
2. Infection – we take special care to prevent an infection, but it is always a possibility. An infection may required prolonged hospitalization and treatment to resolve.
3. Reactions to medications – this could be many things from a minor rash to possible death.
4. Reactions to anesthesia and surgery – this could show up as a heart attack, blood clots, pneumonia, sore throat, or potential death, in rare cases.
- Poor wound healing – breakdown of the incision.
Possible complications of anti-ulcer surgery
1. Persistent pain – Pain may persist after surgery even if the stomach functions normally.
2. Eating problems/early satiety – This could lead to nausea, vomiting and inability to eat following surgery.
This may require medications or another surgery to correct.
3. Gastric dumping – This is a condition that results in cramping and diarrhea soon after you eat. This
usually resolves with time but may require diet modification, medications or surgery to correct.
4. Anastomosis leak – Stomach acid leaks from the site of stomach surgery. Requires surgery to repair.
5. Persistence of gastroparesis – The stomach may not improve enough to resolve symptoms.
(see other side)
Anticipated Recovery/Expected Rehabilitation
Recovery is quite variable, depending on the individual. Hospitalization typically extends from four to seven days. Restrictions on lifting and strenuous physical activity will extend for six weeks. Most people can return to work for “light duty” in two or three weeks. Dietary restrictions will entail small frequent meals for several months. For infants, liquids will be tried within a day of surgery. Upset stomach is common for a few days.
Consent for Treatment
It is my desire for a stomach emptying operation. I have read and understand the above explanation of the procedure being proposed. My surgeon has answered my questions, and I choose to proceed with surgery.
I understand that every operation may yield unexpected finding. I give the surgeon permission to act on his best judgment in deciding to remove or biopsy tissues that appear to be diseased, understanding that complications may arise from that action.
I understand that while most people receiving a stomach operation benefit from the operation, I may not. My condition may not improve, and it may worsen. No absolute guarantee can be made.
HIPAA: Before and after surgery, unless otherwise requested in writing by you, visitors whom you invite to attend the surgery will be informed of the surgical finding, your surgical status, and anticipated recovery issues for effectiveness of communications. Because of the anesthetic, you may or may not remember these important details.
Print Name of Patient ______
Signature ______Date ______
Witness ______Date ______
Surgeon ______Date ______
Relationship to Patient if Signature of Legal Guardian ______
I waive the right to read this form, and do not want to be educated and informed of treatment risks; nonetheless I understand the need for this surgery and grant permission to the surgeon to proceed on my behalf.
Signature ______Date ______
rev 6-30/kab