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Endoscopic Surgery What the GP Needs to Know

Back to Medical School, November 2, 2006. Endoscopic Surgery What the GP Needs to Know. Abeezar I. Sarela MSc MS FRCS Consultant Surgeon The General Infirmary at Leeds Wharfedale General Hospital Nuffield Hospital Leeds BUPA Hospital Leeds.

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Endoscopic Surgery What the GP Needs to Know

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  1. Back to Medical School, November 2, 2006 Endoscopic SurgeryWhat the GP Needs to Know Abeezar I. Sarela MSc MS FRCS Consultant Surgeon The General Infirmary at Leeds Wharfedale General Hospital Nuffield Hospital Leeds BUPA Hospital Leeds

  2. Laparoscopic SurgeryMinimally Invasive Surgery/Minimal Access Surgery • Indications and patient-selection • Advantages & disadvantages • Common complications • Frequent questions asked by patients

  3. 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

  4. 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

  5. Gastroesophageal Reflux Disease • Afflicts 40% of adult population p.a. • 2% consult GP • Prescribed drugs & endoscopies: £ 600m • Over the counter drugs: £ 100m NICE, 2005

  6. Poor Quality of Life with GORD 80 70 60 64% 50 % of patients 48% 40 30 29% 20 25% 22% 14% 10 0 Symptoms Interests Sleep Sex life Sport + Concentrating unbearable exercise on job Figures quoted from UK respondents (n=201). N=230 confirmed GORD patients AstraZeneca UK Data on File NEX/084/FEB2003.

  7. Heartburn (>5 years duration) Odds ratios Once-a-week x 8 Nocturnal x 11 >20 yrs, and score >4.5* x 43.5 GORD Predicts Oesophageal Cancer Lagergren J et al. N Engl J Med 1999; 340 (11): 825-831.

  8. 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

  9. 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

  10. 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)

  11. 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.

  12. Severe Oesophagitis Mild Oesophagitis

  13. Stricture Necrotising Oesophagitis

  14. Carcinoma Barrett’s Oesophagus

  15. 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

  16. 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

  17. Anti-Reflux Surgery Sliding Hiatus Hernia Fundoplication Crural Repair

  18. 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

  19. 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

  20. Intra-operative Recognition Should primary repair be attempted?

  21. 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

  22. 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

  23. 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

  24. Laparoscopic Groin Hernia RepairSurgical Anatomy Groin Anatomy Pre-peritoneal Mesh

  25. Laparoscopic Groin Hernia RepairPost-operative Issues • Common features: Bruising, Seroma • Worrying features: Haematoma, Infection • Recurrence: ? superior to open repair

  26. 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

  27. Laparoscopic Ventral Hernia RepairPost-operative Issues • Prolonged-pain • Seroma • Haematoma • Infection • Uncomfortable subcutaneous suture-knots • Missed enterotomy – rare but serious

  28. Laparoscopic Obesity SurgeryNICE Guidance (Reviewed 2005) Recommend for morbidly obese patients • BMI>40kg/m2 • BMI>35kg/m2 with co-morbidity If 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

  29. Laparoscopic Obesity Surgery Purely restrictive operation: Laparoscopic adjustable gastric banding

  30. Laparoscopic Obesity Surgery Restrictive and Malabsorptive Operation: Laparoscopic Roux-en-Y gastric bypass

  31. CHOICE • 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

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