endoscopic surgery what the gp needs to know abeezar i. sarela msc ms frcs consultant surgeon the...
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Endoscopic SurgeryWhat the GP Needs to Know
Abeezar I. Sarela MSc MS FRCSConsultant Surgeon
The General Infirmary at Leeds Wharfedale General Hospital
Nuffield Hospital LeedsBUPA Hospital Leeds
Back to Medical School, November 2, 2006
Laparoscopic SurgeryMinimally Invasive Surgery/Minimal Access Surgery
• Indications and patient-selection
• Advantages & disadvantages
• Common complications
• Frequent questions asked by patients
AgendaCommon Laparoscopic Operations
• Repair of hiatus hernia & anti-reflux surgery
• Cholecystectomy & bile duct exploration
• Groin hernia repair
• Incisional or para-umbilical hernia repair
• Obesity (bariatric) surgery
• Gastrointestinal cancer surgery
Benefits of Laparoscopic Surgery
• Minimal post-operative pain
• Day-case or only overnight hospital stay
• Quick return to normal activities
• Less impairment of pulmonary function
• Less immune suppression
• Less blood loss
• Minimal risk of wound infection or hernia
Gastroesophageal Reflux Disease
• Afflicts 40% of adult population p.a.
• 2% consult GP
• Prescribed drugs & endoscopies: £ 600m
• Over the counter drugs: £ 100m
NICE, 2005
Figures quoted from UK respondents (n=201).
64%
22%
48%
14%
25%29%
% o
f pati
ents
AstraZeneca UK Data on File NEX/084/FEB2003.
0
10
20
30
40
50
60
70
80
Symptomsunbearable
Interests Sleep Sex life Sport +exercise
Concentratingon job
Poor Quality of Life with GORD
N=230 confirmed GORD patients
GORD Predicts Oesophageal Cancer
Lagergren J et al. N Engl J Med 1999; 340 (11): 825-831.
Heartburn (>5 years duration) Odds ratios
Once-a-week x 8
Nocturnal x 11
>20 yrs, and score >4.5* x 43.5
GORD Treatment
• Full-dose PPI for one or two months
• Recurrent symptoms: PPI at lowest dose
to control symptoms, with minimal repeat
prescriptions
• Treatment “on demand” basis
NICE, 2005
PPI Maintenance Therapy: Limitations
• Nocturnal acid breakthrough
• Twice-daily dose for severe GORD
• Insufficient control of regurgitation
• ? Interaction with H.pylori
• Continuing biliary-pancreatic reflux
• ? Long-term (> 10 years) safety
• Cost
PPI Maintenance Therapy: Limitations
• Recurrent symptoms in 20-30% of patients on regular maintenance, low-dose PPI
• Full dose PPI needs to be maintained for complicated GORD (NICE, 2005)
• PPIs did not eradicate need for caution and restraint (NICE, 2005)
• Most patients want to dispense with need for long-term PPIs (NICE, 2005)
Anti-Reflux SurgeryNICE Guidance, 2005
Surgery is not recommended for the routine
management of uncomplicated GORD, BUT
individual patients whose quality of life
remains significantly impaired may value this
form of treatment.
Mild Oesophagitis
Severe Oesophagitis
Necrotising Oesophagitis
Stricture
Barrett’s Oesophagus
Carcinoma
Laparoscopic Anti-Reflux SurgeryIndications
• Long-standing GORD – PPI dependance
• Poorly controlled GORD
• PPI intolerance
• Respiratory manifestations
• Complications – erosive oesophagitis, stricture, Barrett’s oesophagus
• Regurgitation
• Large hiatus hernia
Laparoscopic Anti-Reflux Surgery
• Keyhole (One 12mm and five 5mm incisions)
• Obesity is not a contra-indication
• Usually overnight stay
• Stop PPI immediately
• Majority have immediate, complete symptom-control
• Global improvement in well-being
Anti-Reflux Surgery
Sliding Hiatus Hernia
Crural Repair Fundoplication
Laparoscopic Anti-Reflux SurgeryPost-operative Issues
• “Sloppy” diet for initial 3-4 weeks
• Problematic dysphagia is rare and indicates a mechanical problem
• Need for supplementary PPI is uncommon
• Is recurrent dyspepsia due to reflux?
• Gaseous bloating: common side-effect
Laparoscopic Cholecystectomy
• Diagnosis: USS versus MRCP
• Increased severity of inflammation in obese individuals
• Value of routine intra-operative cholangiogram: “silent” stones in 5-10% with normal USS and normal LFTs
• Laparoscopic CBD exploration: quick recovery and avoids post-op ERCP
Intra-operative Recognition
Should primary repair be attempted?
Laparoscopic CholecystectomyPost-operative Issues
• Unusually severe abdominal pain: powerful marker of bile leakage
• Prolonged recovery time: often related to inflammation and spillage
• Inflammation around umbilical incision
• Exacerbation of reflux symptoms
• Missed bile duct stones and delayed stricture
Laparoscopic Groin Hernia Repair
• NICE guidance (Sept. 2004)
• Laparoscopic approach is preferred option
for recurrent hernia or bilateral hernias
• Laparoscopic approach should be offered
for primary, unilateral hernia
Laparoscopic Groin Hernia RepairBenefits
• Keyhole (One 1.5cm & two 5mm incisions)
• Minimal pain
• Day-case operation
• Immediate return to normal activities
• Do not drive – 1 week
• Do not go to the gym – 1 month
• Simultaneous repair of “silent” hernias
Laparoscopic Groin Hernia RepairSurgical Anatomy
Groin Anatomy Pre-peritoneal Mesh
Laparoscopic Groin Hernia RepairPost-operative Issues
• Common features: Bruising, Seroma
• Worrying features: Haematoma, Infection
• Recurrence: ? superior to open repair
Laparoscopic Ventral Hernia Repair
• Keyhole (One 12 mm & two-three 5 mm incisions)
• Avoids large incision & wound complications
• Particular valuable for:– Obese patients
– Recurrent hernia
• Usually 2-3 day hospital stay
• Greater security than conventional repair
• Simultaneous repair of silent defects
Laparoscopic Ventral Hernia RepairPost-operative Issues
• Prolonged-pain
• Seroma
• Haematoma
• Infection
• Uncomfortable subcutaneous suture-knots
• Missed enterotomy – rare but serious
Laparoscopic Obesity SurgeryNICE Guidance (Reviewed 2005)
Recommend for morbidly obese patients• BMI>40kg/m2
• BMI>35kg/m2 with co-morbidityIf criteria are satisfied:• Age>18 years• Non-surgical measures have been tried• Understands need for long-term follow-up• No psychological or clinical contra-
indication
Laparoscopic Obesity Surgery
Purely restrictive operation:
Laparoscopic adjustable gastric banding
Laparoscopic Obesity Surgery
Restrictive and Malabsorptive Operation:
Laparoscopic Roux-en-Y gastric bypass
• Results are highly surgeon-dependent
• Best results reported from high-volume,
high-quality centres
• Expertise and technology
• Particularly important to offer prompt, high-
quality service for problems or failures
CHOICE