Download Controversies in Tracheostomy

Hernias, Heartburn, and
Balloons
Ahmed R Ahmed
Consultant in Laparoscopic, Upper GI and Bariatric Surgery
Clinical Lead – Bariatric Services
Imperial College London
Director of Surgery
Bupa Cromwell Hospital Weight Management Centre
“You can judge the worth of a surgeon by
the way he does a hernia”
Sir Thomas Fairbank
Inguinal hernia surgery–
laparoscopic or open?
“There is no doubt that the first appearance
of the mammal, with his unexplained need
to push his testicles out of their proper
home into the air, made a mess of the
three layered abdominal wall that had
done the reptiles well for 200 million years”
William Ogilvie
The case for open repair
A common, established procedure
• Open repair is the preferred operation for primary
inguinal herniorrhaphy by 86% of surgeons in the
US.
Rutkow IM. Demographic and socioeconomic aspects of hernia repair in the United States in 2003. Surg Clin N Am 2003; 83:1045–51.
Open herniorraphy
•
•
•
•
Short learning curve
Cheap
Less chance of recurrence
Can be done under local anaesthetic
Laparoscopic repair
• is the technique safe?
• is the repair secure?
• are long-term morbidity rates better than in
open repair?
• do patients return to normal activities and
work earlier?
• and are there any additional benefits?
Is the technique safe?
• The EU Hernia Trialists Collaboration
– Meta-analysis of 34 eligible trials (RCTs) with a total of 6804 patients.
– Complications reduce with experience
• Laparoscopic complications show a marked improvement
between the early and late 1990s with an incidence of 5.6% and
0.5%, respectively (P < 0.001).
– Haematoma occurs more frequently after open surgery.
– Testicular injury and wound infection is more common after
open repair
EU Hernia Trialists Collaborative. Br J Surg 2000; 87: 860–7.
Is the repair secure?
34 TRIALS ANALYSED
RECURRENCES
*10 RCTs comparing TAPP with open repair and 4 RCTs comparing TEP with open repair
Prof Grant. EU Hernia Trialists Collaborative. Br J Surg 2000; 87: 860–7.
Are postop morbidity rates better?
• 5-year follow-up of 400 patients treated with either Lichtenstein open
mesh repair or TAPP repair
– the incidence of permanent paraesthesia: 23% vs 3%
– groin pain 10% vs 2%
– all of the patients with pain and paraesthesia significant enough to affect
their daily lives were in the open repair group
Wellwood: Prospective randomized controlled trial of laparoscopic versus
open inguinal hernia mesh repair: five year follow up. BMJ 326:1012, 2003
Do patients return to normal activities
and work earlier?
• 27 RCTs have considered the speed of recovery and return to work.
• 24 of these report an earlier return to both activity and work in the
laparoscopic groups compared
with open repair.
• This is estimated to equate to an absolute difference of about 7
days in terms of time off work.
McCormack K, Scott NW, Go PM, Ross S, Grant AM and EU Hernia
Trialists Collaboration. Laparoscopic techniques versus open
techniques for inguinal hernia repair. Cochrane Databases System
Rev 2003(1); CD 001785.
Are there any additional benefits?
• Laparoscopic surgery allows bilateral hernias to be
repaired through the same three small incisions
– there is no increase in postoperative pain or recovery time
• The same advantages are apparent in the repair of recurrent hernias
particularly when the recurrence has occurred more than once
Is laparoscopic repair cost
effective?
• Both laparoscopic and open techniques can be routinely performed
as day cases in fit patients
• Societal costs due to quicker recovery and return to
employment show clear advantages for the laparoscopic repair.
Hospital Episode Statistics 2001/2
http:/www.doh.gov.uk/hes/freedata/index.html
Heartburn and Hernias
Hiatus (Paraesophageal) hernias
Type 1 paraesophageal hernia
Paraesophageal hernias
Type 2 hernia
Type 3 hernia
Clinical features
•
•
•
•
Asymptomatic
Major
Minor
Emergency
Clinical features
• Asymptomatic
– Stomach freely herniates and reduces
through a open hiatus
Clinical features
• Major symptoms
– Postprandial chest pain (74%)
– Dysphagia (60%)
– Anemia (30%)
• Strangulation > ischaemia > bleeding
• Venous engorgement > chronic oozing
• Cameron’s ulcer
– Pulmonary problems (44%)
• Loss of intrathoracic volume
• aspiration
Clinical features
• Minor symptoms
– Regurgitation (77%)
– Heartburn (60%)
– Nausea and/or vomiting (35%)
Clinical features
• Emergency = volvulus
– Severe pain
– Bleeding
strangulation
– Perforation > Peritonitis and sepsis*
* 50% mortality rate > case for elective repair
Diagnostic Methods
• Upper gastrointestinal contrast study
• CT
• Gastroscopy
Controversies
• Do all paraesophageal hernias require
repair?
Principles of surgical repair
Standard principles of hernia repair apply:
• free the sac
• reduce the hernia
• repair the defect
How to close the crural defect?
Primary suture cruroplasty
How to close the crural defect?
Cruroplasty reinforced by mesh
Balloons and Weight loss
Weight loss - Treatment options
•Lifestyle Modifications e.g. diet and exercise
•Anti-obesity medications - Xenical® (Orlistat/Alli)
•Surgery (in suitable patients – NOCE, NIH criteria)
Weight loss
Healthy Weight
(BMI 18.5 to 24.9)
Overweight
(BMI 25 to 29.9)
Obese
(BMI 30 to 34.9)
GASTRIC BALLOON
Severely Obese
(BMI 35 to 39.9 )
Morbidly Obese
(BMI 40 or more)
BARIATRIC SURGERY
The Intragastric Balloon
•An option between diets and surgical
treatment
Treating obesity with an
Intragastric Balloon
The balloon
itself
The Intragastric
Balloon is a
weight-loss system
Education about
weight-loss
Who is suitable?
Motivated, moderately obese adults.
– BMI of 27 and over
Prepared to make changes in eating habits
and lifestyle
Willing to work with medical team and attend
meetings.
The procedure
Step 1
Step 2
Assessment
Insertion
Step 3
Follow up
Diet and changed
eating habits
Exercise
Step 4
Removal
Maintain
weight-loss
Balloon removal
•Removal of the balloon follows the same simple procedure
as placement
A tube is passed into the stomach and the balloon is
deflated
The deflated balloon is then removed through the mouth
Patients can usually return home within hours
Following the procedure
•Regular scheduled meetings with the team to continue
education and support on new eating and exercise habits
•The balloon helps adjustment to reduced caloric intake by
producing a feeling of satiety
•15-20 Kgs weight loss / 6 months
Life after balloon removal
Balloon removal after six months
Keep practicing the principles
Keep meeting with the team
Nutrition, balance, exercise
Motivation remains the key to success
Benefits of the
intragastric balloon programme
– No surgery is required
– No long-term use of pharmaceuticals
– Feeling of satiety makes success more likely
than other programmes
– 10-20Kgs / 6 months
Intragastric balloon
Possible indications
 Hard to control co-morbidities in lower BMI
>Diabetes / Hypertension
 weight = control
Intragastric balloon
Possible indications
 Weight loss to improve surgical condition
in non bariatric operations
> Orthopaedic surgery
 Joints
 Spine
Intragastric balloon
Possible indications
 Infertility
 Effective weight loss
> Improves women fertility
Intragastric balloon
Possible indications
 Weight loss post “pregnancy obesity”
> Woman should loose all the weight gain
in pregnancy with breast feeding
 But...
 It is not what we see in
consecutive pregnancies
Intragastric balloon
Possible indications
 Aesthetics
>“Preparing for special happenings”
>“Psychological well being”
>“ less risky than liposuction”
Excess Weight
Lifestyle Balloon
Surgical
Treatment
Questions
If you would like to schedule or refer a patient for
consultation:
Contact 108 Harley Street [020 7563 1234]
[email protected]
www.ahmedr.com
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