Upper Gastrointestinal Surgery
Upper Gastrointestinal Surgery is a subspecialty discipline within General Surgery, focussed on treatment of the upper gastrointestinal tract including diseases of the oesophagus, stomach, duodenum, gallbladder, pancreas, liver and spleen.
Gastro-oesophageal reflux disease (GORD)
GORD is the regurgitation of acidic stomach contents into the gullet a.k.a. oesophagus. This is a normal phenomenon when we overindulge and eat too much in one occasion, but becomes a disease when it is symptomatic and affecting quality of life when not overindulging.
GORD is caused by a number of factors that result in the loss of the natural antireflux mechanisms that exist in your body. Some of these factors are influenced by diet and lifestyle, such as certain foods (e.g. chocolate, coffee, chili, alcohol) and obesity. Other factors are unrelated to diet and lifestyle, such as anatomical changes as a result of a hiatus hernia.
Common symptoms include heartburn, regurgitation, waterbrash, nocturnal coughing, recurrent lung infections and poor sleep.
Left untreated, it can cause damage to the oesophagus and changes to it’s lining, which can eventually predispose you to developing Barrett’s oesophagus or oesophageal cancer.
How is GORD treated?
GORD is treated with multiple methods depending on the exact cause. In simple cases of lifestyle induced reflux, often adjusting your diet by reducing certain triggers like chocolate and coffee can significantly improve your symptoms.
In cases that do not respond to lifestyle measures, your general practitioner may prescribe you a tablet which reduces the acid production in your stomach. This does not reduce the volume of the reflux itself, but it does decrease it’s acidity. In the setting of a hiatus hernia, medical therapy may not be very effective given that medication does not influence the volume of regurgitation but rather just the acidity.
In cases that do not respond to medical therapy or in cases of a hiatus hernia, the recommended treatment is surgery.
Hiatus Hernias
A hiatus hernia is an anatomical abnormality whereby a part, or all of your stomach, herniates through the oesophageal hiatus in the diaphragm. This results in a near complete loss of the normal anatomical antireflux mechanisms, which therefore contributes to reflux.
Hiatus hernias may also cause a number of other non-reflux related issues, such as impaired heart and lung function, along with another major concern with hernias which is strangling of the herniated contents, which can be life-threatening.
Antireflux Surgery
Antireflux surgery aims to restore and augment the anatomical mechanisms that stop reflux. This surgery is performed laparoscopically or minimally invasively, whereby a camera is inserted into your abdomen along with instrument ports.
In the presence of a hiatus hernia, the first step is to reduce the stomach from the chest protecting the key surrounding structures, and then repair the defect in the hiatus. This is called a laparoscopic hiatus hernia repair.
Following this, a laparoscopic fundoplication is performed, whereby the normal antireflux mechanisms are restored and augmented. Following this, the top part of the stomach, a.k.a. the fundus, is wrapped around the oesophagus, further augmenting the antireflux mechanisms.
This surgery is often suitable for a simple overnight stay and discharge the following day. It is very well tolerated and most patients report very minimal discomfort if at all.
Recovery after a laparoscopic hiatus hernia repair and fundoplication is usually very simple, and one can return to normal activities within a few days of surgery including work and driving.
You will be on a modified diet for a few weeks following surgery, which is restricted to fluids and puree/slippery foods (such as scrambled eggs, porridge, soups). After this time, you will be able to eat without restrictions.
Diaphragmatic Hernia
What is a diaphragmatic hernia?
Diaphragmatic hernias are rare,
These are often found incidentally, during scans for other issues. When explored further, most patients have upper abdominal symptoms or impaired heart and lung function, and this has often been a long-standing issue.
They are often present since birth, or after a sudden high-mechanism physical trauma such as a car accident.
What is diaphragmatic hernia surgery?
Diaphragmatic hernia surgery is performed laparoscopically, whereby a camera is inserted into your abdomen along with instrument ports, and sometimes thoracoscopically, where a camera is also inserted into your chest between your ribs. The herniated contents are reduced back into the abdomen and the defect in the diaphragm is defined. The defect is then repaired using a combination of sutures and mesh.
Recovery following a laparoscopic diaphragmatic hernia repair requires you to stay in hospital for a few days to ensure that you have completely recovered prior to discharge home. You will be on a normal diet following surgery. Following discharge home, you will be able to return to work and driving, but will be on restricted activities to minimise any heavy lifting for 6 weeks from surgery.
Achalasia
Achalasia is a unique motility disorder of the oesophagus, where there is failure of the lower-oesophageal sphincter to relax. This results in difficulty swallowing, and patients have often struggled for a long time prior to seeking medical attention. Patients have often restricted their own diet to soft, puree foods or even liquids and suffer nutritional failure.
How is achalasia treated?
- There are several treatment options available depending on your other medical issues and nutritional status. The goal is to restore nutrition and improve the swallowing mechanism.
- Endoscopic options include balloon dilatation and per-oral endoscopic myotomy (POEM). Balloon dilatation is a highly effective treatment option, but with some specific pros and cons, which will be discussed with you at time of consultation. POEM is a procedure that is not offered by our group, but we liaise closely with the specialists in Brisbane who do perform this procedure and if we feel that this is the best option for you, we will refer you onwards accordingly.
- Surgical options include a laparoscopic Heller’s myotomy, which is the most effective and durable treatment option. The procedure is minimally invasive, where a camera is inserted into the abdomen along with instrument ports. The oesophagus and stomach are carefully dissected, and the muscles are carefully divided to release their extrinsic compression of the oesophagus.
- Recovery is excellent following a laparoscopic Heller’s myotomy, and patient’s often feel dramatically improved immediately following surgery.
Cancers of the Foregut
Thankfully, cancers of the foregut (oesophagus, stomach, pancreas, liver) are rare in the population. However, when they occur they can present silently or with symptoms that can be quite distressing.
- If found early, these cancers may present with weight loss, loss of appetite, difficulty swallowing, abdominal discomfort and jaundice.
- Patients will undergo a clinical assessment involving a detailed history and physical examination, and then undergo a series of tests including blood and imaging. A CT scan will usually yield some clues as to where the problem may be.
- Patients will often then undergo an endoscopic evaluation for direct visualisation and biopsy.
- Your surgeon will then arrange ‘staging’ investigations to be completed, which may include a PET scan.
- Your surgeon will then review your case in a multidisciplinary team meeting, where the appropriate treatment plan can be formulated and presented to you.