Peptic Ulcer Disease (PUD)
Excess acid in the stomach can cause stomach ulcers. Other risk factors for peptic ulcer disease include Helicobacter infection, smoking, NSAID’s use and Zolliger-Ellison syndrome (gastrin producing tumours). PUD causes burning post-prandial epigastric pain. Complications of PUD include bleeding (vomiting blood called haemetemesis; passing altered bowel motions called melaena), vomiting after eating (secondary to peptic ulcer stricture of pylorus), perforation of gastric/ duodenal ulcer and weight loss.
When suspected of PUD, a trial of medical therapy including a protein pump inhibitors can be helpful. If there is no clinical improvement or complications occur, gastroscopy should be performed to confirm the diagnosis, which may also treat a complication such as peptic ulcer bleeding. A new symptom of epigastic pain in patients > 40 years old should also be investigated with gastroscopy.
An eradication of helicobacter pylori and avoiding any risk factors are important in preventing recurrence of PUD. Medical therapy for PUD is very effective and surgery is rarely needed for uncomplicated PUD.
Surgery is mandatory for a perforated PUD, which can be performed by either laparoscopic or omental omental patch repair. A laparotomy, involving duodenotomy and oversewing of bleeding duodenal ulcer, is occasionally necessary for a bleeding duodenal ulcer, when it cannot be managed endoscopically.
Gastro-oesophageal Reflux Disease (GORD)
Gastro-oesophageal reflux disease (GORD) is a common medical problem, where patients experience intermittent retro-sternal, burning pain associated with water brash (a sore taste due to reflux of acid). GORD may cause other symptoms such as recurrent sore throat, respiratory tract infections or asthma due to aspiration of gastric contents into the respiratory tract. Most of patients with GORD improve on life-style changes and medical treatments. Conservative/ life-style measures for GORD include;
- Avoid (or use only in moderation) foods and substances that increase reflux of acid into the oesophagus, such as: nicotine (cigarettes), caffeine, chocolate, fatty foods, peppermint, alcohol, spearmint.
- Eat smaller, more frequent meals and do not eat within 2-3 hours of bedtime.
- Avoid bending, stooping, abdominal exercises, tight belts, and girdles all of which increase abdominal pressure and cause reflux.
- If overweight, lose weight. Obesity also increases abdominal pressure.
- Elevate the head of the bed 8 to 10 inches by putting pillows or a wedge under the upper part of the mattress. Gravity then helps keep stomach acid out of the esophagus while sleeping.
Medical treatment of GORD is very effective, which include use of protein pump inhibitors, Nexium and H2 antagonist, Zantac. However, a small number of patients may require surgery if these approaches fail.
Indications for laparoscopic fundoplication include –
- Volume regurgitation of food
- Severe GORD despite maximum medical treatments
- Complications of GORDs (oesophageal stricture)
- Recurrent respiratory complications of GORD
Prior to laparoscopic fundoplication, further studies are usually required. These include gastroscopy to document the presence of oesophagitis and/ or hiatus hernia; pH monitoring to document the severity of reflux disease; and oesophageal manometry to exclude oesophageal motility disorder such as Achalasia.
Laparoscopic fundoplication (+/- Open) is a surgical procedure to improve GORD, which involves a laparoscopic mobilisation of fundus of stomach and use it to wrap the gastro-oesophageal junction to increase the low oesophageal sphincter pressure. Laparoscopic fundoplication is a safe and effective method to control reflux symptoms and has > 90% long-term success rate of improving GORD.
Hiatus Hernia
Hiatus is an opening in the diaphragm, through which oesophagus enters the abdominal cavity from the chest. When this opening is enlarged, stomach can herniate into the chest (hiatus hernia). There are four types of hiatus hernia –
- Type I - Sliding hiatus hernia
- Type II - Rolling hiatus hernia (Para-oesophageal hiatus hernia)
- Type III - Mixed sliding and rolling hiatus hernia
- Type IV – Large intra-thoracic hiatus hernia with other abdominal organs inside the chest such as duodenum, spleen, small or large bowel or pancreas
Type I hiatus hernia is common and usually does not require surgery unless a patient has severe GORD. Type II/III/IV hiatus hernia may cause a number of symptoms depending on the size of hernia. Patients may experience chest pain, back pain (high thoracic, inter-scapular), shortness of breath, nausea and vomiting and difficulty swallowing. A symptomatic hiatus hernia in otherwise fit patients may require a laparoscopic hiatus hernia repair usually with fundoplication.
Stomach Cancer
Stomach cancer, also known as gastric cancer, usually begins in the lining in the stomach. Stomach cancer is a relatively common cancer in Australia, however the number of people diagnosed has been falling. It is rare in people under 50 years of age and affects more men than women. In 2012, 2118 new cases of stomach cancer were diagnosed in Australia. The risk of being diagnosed with stomach cancer by age 85 is 1 in 63 for men compared to 1 in 136 for women.
Risk factors of stomach cancer include: smoking; age over 50; being male; Helicobacter pylori infection; a diet high in smoked; pickled and salted foods and low in fresh fruit and vegetables; a family history of stomach cancer; partial gastrectomy for ulcer disease (after about 20 years); inheriting a genetic change that causes the bowel disorders familial adenomatous polyposis or hereditary nonpolyposis colorectal cancer.
Early gastric cancer may not have any specific symptoms apart, apart from minor upper abdominal pain and indigestion. Other symptoms include early satiety, vomiting after eating, difficult swallowing, anaemia, vomiting blood or passing black, offensive bowel motions (melaena), loss of appetite, loss of weight or abdominal distension due to accumulation of fluid (ascites).
A diagnosis of gastric cancer is made on gastroscopy and biopsy of a suspected lesion in the stomach. Adenocarcinoma is the most common histological type. This has two subtypes; intestinal and diffuse type.
Another form of stomach tumour is Gastrointestinal Stromal Tumour (GIST). This arises from the muscular layer of stomach and leads to a mass lesion, which may cause bleeding. This tumour has a better prognosis than the adenocarcinoma of stomach in general. GIST requires a complete surgical excision of tumour with a negative margin, which is commonly performed laparoscopically.
Once a diagnosis of gastric cancer is made, the patient is assessed for the stage of tumour and for fitness for surgery. Staging usually involves CT chest, abdomen and pelvis. If there is no evidence of metastatic disease (spread of tumour outside stomach and adjacent lymph nodes), a diagnostic laparoscopy and washing for cytology is performed. Biopsy result and findings of staging tests are discussed at a multi-disciplinary meeting and treatment plan is formulated. In general, patients with bulky tumour and/ or lymph node involvements are recommended to undergo pre-operative chemotherapy (neoadjuvant therapy), followed by a definitive resection of stomach.
Gastrectomy (removal of stomach) can be either partial (removing distal 1/3 – 2/3 of stomach) or total. The continuity of stomach can be re-established using a loop of small bowel, as Roux en Y reconstruction.
Morbid obesity
Obesity is now one of the most common problems that our population faces with serious long- term consequences. Severity of obesity can be classified into 3 categories using a Body Mass Index (BMI).
BMI = Weight (kg)/ Height (m) 2
- BMI 20- < 25 Normal weight
- BMI < 25- < 30 Over-weight
- BMI < 30 - < 35 Obese
- BMI < 35 Morbidly obese
There are a number of negative health effects of obesity, in particular, morbid obesity including increased risk of –
- Early/ Premature death
- Increased risk of cardiovascular disease
- Hypertension
- Diabetes
- High cholesterols
- Non-alcoholic Fatty Liver disease (NAFLD) / Non-alcoholic Steato-hepatitis (NASH)/ Cirrhosis/ Hepatocellular carcinoma (HCC)
- Cancers – oesophageal cancer, pancreatic cancer, bowel cancer, breast cancer, prostate cancer, HCC
- Arthritis of spine, hip and knees
- Mental health issues
Many of health problems related to obesity can be improved and may be resolved with weight loss.
Weight loss can be initially achieved with life-style changes including caloric restriction diet and exercise. This is a very important step that individuals must be motivated to changes to their life styles. There are a number of medical therapies available for obesity, but have a limited role due to potential side effects and limited efficacy. Unfortunately, life style changes alone are proven to be in effective in achieving a significant long-term weight loss.
Weight loss surgery is an important tool in treatment of obesity, which includes Lap band surgery, Sleeve gastrectomy and Roux-en Y Gastric Bypass. Lap band surgery had been a common procedure, but it has become less common procedure due to its high rate of revisional surgery and long-term failures. Roux- en Y Bypass offers an excellent long-term result, but it has higher initial complication rates and long-term negative effects on metabolic/nutritional status of patients. Sleeve gastrectomy offers a good long-term weight loss (loss of approximately 70% excess weight loss) with low rates complication. It is uncommon to require intense follow up or revisional surgery as required in Lap Band surgery. Bariatric surgery is only one aspect in management of patients with obesity. Medical follow-up and long-term support of patients with obesity are essential to maintain weight loss and improve overall health.
View stomach surgery for more information.
