Surgery for Peptic Ulcer Disease (PUD)
Surgery is mandatory for a perforated PUD, which can be performed by either laparoscopic or 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.
Laparoscopic fundoplication and hiatus hernia repair
Laparoscopic fundoplication (+/- Open) is a surgical procedure to improve GORD, which involves 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.
A symptomatic hiatus hernia in otherwise fit patients may require a laparoscopic hiatus hernia repair usually with fundoplication. The hiatal repair can be performed with suture only, suture with pledgets or suture with mesh (Bio A) depending on the size of hiatal defect.
Specific surgical complications of laparoscopic fundoplication include bleeding, infection, injury to adjacent organs such as oesophagus, stomach and spleen. Patients after fundoplication may have difficulty vomiting and have increased flatulence. They often require a soft diet for 4-6 weeks after surgery until swallowing improves. A small percentage of patients may experience difficulty swallowing especially if full 360-degree fundoplication wrap is performed (Nissen fundoplication). Usually partial (posterior 270 degrees) fundoplication is performed to avoid this problem.
Gastrectomy for gastric cancer or GIST
Gastrectomy (removal of stomach) can be either partial (removing distal 1/3 – 2/3 of stomach) or total gastrectomy. The continuity of stomach can be re-established using a loop of small bowel, as a Roux en Y reconstruction.
Gastric cancer surgery requires special attention to removal of draining lymph nodes. Complete removal of adjacent gastric lymph nodes (D1) and regional lymph nodes along the major gastric vessels (D2) are essential for good long-term outcomes. Concurrent splenectomy or pancreatectomy for gastric cancer is not recommended.
Gastrectomy may be performed laparoscopically or open depending on the type of tumour, stage of disease and patients’ comorbidities.
Complications of gastrectomy include bleeding, infection, anastomotic leak / duodenal stump leak, delayed gastric emptying (nausea and vomiting), and organ dysfunctions. Patients generally require modified diet after surgery for 6 to 12 weeks, including eating small portions of soft food and chewing them well. Long-term nutritional support and follow up is mandatory for these patients.
Weight loss surgery (Sleeve Gastrectomy)
Weight loss surgery is an important tool in the 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
