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Oesophagogastric Surgery E-Book

Oesophagogastric Surgery E-Book

S. Michael Griffin | Simon A. Raimes | Jonathan Shenfine

(2013)

Additional Information

Abstract

Oesophagogastric Surgery meets the needs of surgeons in higher training and practising consultants for a contemporary and evidence-based account of this sub-specialty that is relevant to their general surgical practice. It is a practical reference source incorporating the most current information on recent developments, management issues and operative procedures. The text is thoroughly referenced and supported by evidence-based recommendations wherever possible, distinguishing between strong evidence to support a conclusion, and evidence suggesting that a recommendation can be reached on the balance of probabilities.

This is a title in the Companion to Specialist Surgical Practice series whose eight volumes are an established and highly regarded source of information for the specialist general surgeon.

  • The Companion to Specialist Surgical Practice series provides a current and concise summary of the key topics within each major surgical sub-specialty.
  • Each volume highlights evidence-based practice both in the text and within the extensive list of references at the end of every chapter.
  • An expanded authorship team across the series includes additional European and World experts with an increased emphasis on global practice.
  • The contents of the series have been extensively revised in line with recently published evidence.
  • This revised edition takes full account of the advances in the roles of endoscopic and laparoscopic investigation, management and the treatment of benign and malignant oesophagogastric disease.
  • Key areas of evolving oesophagogastric practice are reflected in state of the art chapters from authors in the United States, Japan and Australia.
  • Over half of the chapters have been updated to reflect the latest opinions on complicated and rapidly changing disciplines in endoscopic and open surgery

Table of Contents

Section Title Page Action Price
Front Cover Cover
Oesophagogastric Surgery: A Companion to Specialist Surgical Practice iii
Copyright iv
Contents v
Contributors vii
Series Editors' preface ix
Editor's preface xi
Acknowledgements xi
Evidence-based practice in surgery xiii
Chapter 1: Pathology of oesophageal and gastric tumours 1
Oesophagus 1
Introduction 1
Epithelial tumours of the oesophagus and the gastro-oesophageal junction 1
Benign tumours and tumour-like lesions 1
Malignant tumours 1
Squamous cell carcinoma 1
Precursor lesions of squamous cell carcinoma 3
Molecular pathology of squamous cell carcinoma 4
Adenocarcinoma 4
Adenocarcinoma associated with Barrett's oesophagus 5
Variants of oesophageal adenocarcinoma 5
Neuroendocrine tumours of the oesophagus 6
Mesenchymal tumours of the oesophagus 6
Leiomyoma 6
Granular cell tumour 6
Stomach 6
Gastric polyps 6
Fundic gland polyps 6
Polyposis syndromes 7
Gastric carcinoma 7
Epidemiology of gastric carcinoma 7
Aetiology and risk factors of gastric carcinoma 7
Lesions predisposing to gastric carcinoma 9
Chronic atrophic gastritis and intestinal metaplasia 9
Chronic gastric ulcer 9
Gastric dysplasia 10
Early and advanced gastric carcinoma 10
Morphological subtypes of gastric carcinoma 12
Molecular pathology of gastric carcinoma 13
Neuroendocrine tumours of the stomach 13
Mesenchymal tumours of the stomach 15
Lymphoma of the stomach 16
MALT lymphoma 16
Diffuse large B cell lymphoma 17
References 18
Chapter 2: Epidemiology, genetics and screening for oesophageal and gastric cancer 22
Introduction 22
Definitions 22
Epidemiology 23
Incidence 23
Oesophageal cancer 23
Oesophageal and oesophagogastric junctional adenocarcinoma 23
Gastric cancer 23
Aetiology 23
Squamous cell carcinoma of the oesophagus 23
Smoking and alcohol 23
Socio-economic and dietary influences 24
Associated conditions 24
Adenocarcinoma of the oesophagus and junctional cancers 24
Gastro-oesophageal reflux disease (GORD) 24
Obesity and dietary factors 25
Helicobacter pylori 25
Socio-economic factors 25
Gastric cancer 26
Socio-economic influences 26
Diet 26
Helicobacter pylori 27
Precancerous conditions 27
Prevention of oesophageal and gastric cancer 27
Genetics of oesophageal and gastric cancer 28
Oesophageal cancer 28
Gastric cancer 28
Hereditary diffuse gastric carcinoma (HDGC) 28
Hereditary cancer syndromes 29
Moderate cancer risk 29
Molecular genetics of oesophageal and gastric cancer 30
Screening for oesophageal and gastric cancer 31
Asymptomatic screening 31
Oesophageal cancer 31
Gastric cancer 32
Symptomatic screening and early detection 32
High-risk groups 33
GORD and Barrett's oesophagus 33
Helicobacter pylori 34
Gastric atrophy and intestinal metaplasia 34
Summary and future 34
References 35
Chapter 3: Staging of oesophageal and gastric cancer 38
Introduction 38
Staging classifications 38
Gastric cancer staging 39
Oesophageal cancer staging 40
Multidisciplinary team 42
Staging investigations 42
Clinical assessment 42
Contrast radiography 42
Endoscopy 42
Computed tomography (CT) 43
Gastric cancer 43
Oesophageal cancer 45
Positron emission tomography (PET) 46
Gastric cancer 46
Oesophageal cancer 46
Endoscopic ultrasonography (EUS) 48
Gastric cancer 48
Oesophageal cancer 49
Ultrasonography (US) 50
Laparoscopy 51
Peritoneal cytology 51
Laparoscopic ultrasonography (lapUS) 52
Magnetic resonance imaging (MRI) 52
Endobronchial ultrasonography (EBUS) 53
Restaging following neoadjuvant or radical therapy 53
Sentinel lymph nodes 54
Future developments 54
Acknowledgements 55
References 55
Chapter 4: Preoperative assessment and perioperative management in oesophageal and gastric surgery 62
Introduction 62
Physiological stress during the treatment of oesophagogastric malignancy 62
Diagnosis 63
Multidisciplinary team evaluation 63
Neoadjuvant therapy 64
Radiotherapy 64
Chemotherapy 64
Nutrition 64
Preoperative assessment 65
Cardiac assessment (Box 4.4) 65
History 66
Functional capacity 66
Investigations (Box 4.4) 66
Electrocardiogram (ECG) 66
Cardiopulmonary exercise testing (CPX) 66
Stress testing 66
Optimisation 67
Preoperative physical cardiopulmonary rehabilitation 67
Beta-blockade 67
Other relevant cardiac medication 68
Statins 68
Anticoagulants 68
Aspirin/clopidogrel 68
Warfarin 68
Pulmonary assessment 68
History 68
Investigations (Box 4.5) 69
Arterial blood gas (ABG) 69
Chest X-ray (CXR) 69
Pulmonary function testing (PFT) 69
Optimisation 69
Neurological assessment 69
History 69
Chapter 5: Surgery for cancer of the oesophagus 81
Introduction 81
Surgical pathology 81
Surgical anatomy 82
Hypopharynx and cervical oesophagus 82
Upper oesophagus 82
Middle oesophagus 82
Lower oesophagus 82
Blood supply and lymphatic drainage 83
Preoperative surgical preparation 83
Nutritional support 83
Preoperative nutritional support 83
Respiratory care 84
Mental preparation/communication 84
Surgical objectives 84
Principles of oesophagectomy 85
Resection of primary tumour 85
Rules on resection margins 85
Resection of lymph nodes 86
Nodal tiers 86
The rationale for lymphadenectomy 86
Optimal staging 86
Locoregional tumour control 86
Improved cure rate 86
Summary 89
Method of reconstruction of the oesophagus 89
Route of reconstruction 89
Presternal route 89
Retrosternal route (anterior mediastinal) 89
Posterior mediastinal route 89
Organ of reconstruction 89
Reconstruction with stomach 89
Reconstruction with colon 91
Indications for colonic reconstruction (Box 5.3) 91
Surgical technique 91
Reconstruction with jejunum 92
Open surgical approaches to oesophagectomy 92
Pharyngolaryngo-oesophagectomy for carcinoma of the hypopharynx and cervical oesophagus 92
Two-phase subtotal oesophagectomy via a right thoracotomy for carcinomas of the middle and lower thirds of the oesophagus 93
Combined synchronous two-team oesophagectomy 94
Three-phase subtotal oesophagectomy for tumours of the upper middle third of the oesophagus 94
Left-sided subtotal oesophagectomy for lower-third oesophageal cancers 94
Transhiatal oesophagectomy for upper- and lower-third tumours of the oesophagus 94
Minimally invasive surgical approaches to oesophagectomy 95
Minimally invasive three-stage procedures 95
Minimally invasive two-stage procedures 96
Minimally invasive hybrid procedures 96
Overview of minimally invasive approaches 96
Current practice 96
Technique of anastomosis 97
Postoperative management 97
Postoperative complications 98
General complications 98
Specific complications 98
Anastomotic leakage and leakage from the gastric conduit 98
Chylothorax 99
Recurrent laryngeal palsy 99
Gastric outlet obstruction 99
Duodeno-gastro-oesophageal reflux 100
Benign anastomotic stricture 100
Overall results of single-modality resectional therapy 100
Hospital mortality 100
Survival figures 100
Summary and future research 101
References 102
Chapter 6: Treatment of early oesophageal cancer 107
Introduction 107
Definition of early oesophageal cancer and relevant pathology 107
Investigations 108
Endoscopic assessment 108
Barrett's neoplasia 108
Squamous neoplasia 108
Endoscopic mucosal resection (EMR) 108
Endoscopic submucosal dissection (ESD) 109
Imaging 109
Management of early oesophageal cancer 109
Oesophageal resection 110
Endoscopic therapy 111
Endoscopic mucosal resection 111
Endoscopic submucosal dissection (ESD) 111
Mucosal ablation 111
Results from endoscopic therapy for early oesophageal cancer 112
Adenocarcinoma 112
Squamous cell carcinoma 112
Definitive radiotherapy with or without chemotherapy 113
Role of a multidisciplinary team 113
Conclusion 114
References 114
Chapter 7: Surgery for cancer of the stomach 118
Introduction 118
Modes of spread and areas of potential failure after gastric cancer surgery 118
Metastatic pathway 118
Lymphatic spread 118
Peritoneal spread 119
Haematogenous spread 120
Metastasis by uncertain pathway 120
Direct extension 120
Intraoperative spillage 120
Summary 120
The concept of radical gastric cancer surgery 120
Gastric cancer surgery in Japan 121
Development of gastric cancer surgery in the West 121
Different staging systems 121
Different disease hypotheses 121
Proximal location 121
Patient factor 122
Role of radical surgery in Western practice 122
Summary 122
Principles of radical gastric cancer surgery 122
Extent of gastric resection 122
Resection margins 122
Type of gastrectomy 123
Total gastrectomy 123
Distal (subtotal) gastrectomy 123
Proximal gastrectomy 123
Other resections for T1 tumours 123
Total gastrectomy ‘de principe’ for distal cancers 123
Lymphadenectomy 123
Lymph node groups in the former Japanese classifications 124
New definition of lymphadenectomy 126
D2 lymphadenectomy – evidence 127
Number of lymph nodes and extent of lymphadenectomy 127
Bursectomy 127
Splenectomy 128
Distal pancreatectomy 128
Extended resections 128
En bloc resection of involved adjacent organs 129
Extended lymphadenectomy 129
Resection of liver metastases 129
Summary 129
Technique of gastric resection with D2 lymphadenectomy 129
Incision 129
Intraoperative staging 129
Procedure of D2 lymphadenectomy 130
Distal gastrectomy 130
Kocherisation 130
Omentectomy 130
Division of left gastroepiploic vessels 130
Infrapyloric node dissection (no. 6) 130
Suprapyloric nodes dissection (no. 5) and transection of the duodenum 131
Exposure of the oesophageal hiatus 131
Dissection of the upper border of the pancreas (nos. 8a, 9, 11p and 12a) 131
Dissection of the upper lesser curvature nodes (nos. 1 and 3a) 132
Total gastrectomy 132
Dissection of the upper greater curvature nodes (nos. 2 and 4sa) 132
Dissection along the distal splenic artery (no. 11d) and splenic hilum (no. 10) 133
Splenectomy 133
Summary 133
Modified surgery for early gastric cancer 133
Lymph node metastasis from early gastric cancer 133
Limited lymphadenectomy 134
Pylorus-preserving gastrectomy (PPG) (Fig. 7.8) 134
Local tumour resection based on sentinel lymph node diagnosis 134
Summary 135
Reconstruction after gastric resection 135
Reconstruction after distal gastrectomy (Fig. 7.9) 135
Chapter 8: Endoscopic and surgical treatment of early gastric cancer 146
Introduction 146
Definition of early gastric cancer 146
Risk and development of early gastric cancer 146
Classification of early gastric cancer 146
Endoscopic appearance 147
Lymph node metastasis 148
Endosonography 148
Revised Vienna classification 149
Endoscopic treatment 149
Endoscopic mucosal resection 149
Endoscopic submucosal dissection 150
Complete resections 150
Complications of endoscopic resections 151
Surgical resection 151
Proximal gastrectomy 152
Pylorus-preserving gastrectomy 152
Local (or wedge) segmental resection 153
Minimally invasive surgery 154
Lymphadenectomy 154
Sentinel node biopsy 155
References 157
Chapter 9: Radiotherapy and chemotherapy in treatment of oesophageal and gastric cancer 160
Introduction 160
Oesophageal cancer 161
Potentially curative treatment 161
Preoperative radiotherapy alone 161
Postoperative radiotherapy 161
Preoperative chemotherapy 162
Randomised trials of preoperative chemotherapy 162
Postoperative chemotherapy 163
Preoperative chemoradiotherapy 164
Neoadjuvant chemoradiotherapy or chemotherapy? 167
Definitive radiotherapy and chemoradiotherapy 167
Definitive radiotherapy 168
Definitive chemoradiotherapy 168
Future directions in definitive chemoradiation 169
Definitive CRT versus surgery 170
Small-cell oesophageal cancer 171
Gastric cancer 172
Potentially curative treatment 172
Perioperative adjuvant chemotherapy 172
Intraperitoneal chemotherapy 173
Postoperative chemoradiotherapy 173
Palliative chemotherapy 173
Squamous carcinoma of the oesophagus 173
Adenocarcinoma of the oesophagus and stomach 174
Palliative radiotherapy 175
External beam radiotherapy 175
Brachytherapy 176
Future strategies 176
References 178
Chapter 10: Palliative treatments of carcinoma of the oesophagus and stomach 183
Epidemiology and survival 183
Patient selection and multidisciplinary teams 184
Fitness for treatment 184
Staging investigations 185
Patient preferences and information provision 185
Symptoms and signs of advanced oesophageal and gastric cancer 186
Tumours of the oesophagus and gastric cardia 186
Tumours of the gastric body and antrum 186
Palliative treatments for cancer of the oesophagus and gastric cardia 186
The endoscopic relief of luminal obstruction 187
Intubation 187
Self-expanding metal stents (SEMS) 189
Method of insertion 190
Preparation 190
Endoscopic insertion with fluoroscopy 190
Radiological insertion 190
Postoperative management 190
Complications 190
Early complications 191
Late complications 191
Laser treatment 192
Endoscopic technique 192
Early complications 192
Late complications 193
Combination laser treatment 193
Thermal recanalisation or stenting? 193
Argon-beam plasma coagulation 193
Photodynamic therapy 194
Clinical indications 194
Complications 194
Bipolar electrocoagulation 194
Chemically induced tumour necrosis 194
Endoscopic technique 194
Outcome 194
External beam and intracavity radiotherapy 195
External beam radiotherapy 195
Complications 195
Brachytherapy (intracavitary irradiation) 195
Relief of dysphagia and patient-reported outcomes 195
Palliative chemotherapy or combination chemoradiotherapy for oesophageal cancer 196
Epidermal growth factor receptor inhibitors in the palliation of oesophageal cancer 196
Aero-digestive fistulas 196
Recurrent laryngeal nerve palsy 197
Bleeding 197
Palliative treatments of tumours of the gastric body and antrum 197
Chemotherapy for advanced gastric and oesophagogastric cancer 197
Gastric outlet obstruction 198
Chronic bleeding 199
Summary 199
References 200
Chapter 11: Other oesophageal and gastric neoplasms 204
Introduction 204
Gastrointestinal stromal tumours (GISTs) 204
Pathophysiology 204
Incidence and malignant potential 205
Patient demographics and anatomical distribution 205
Presentation 206
Investigation 206
Endoscopic ultrasound (EUS) 206
CT scanning 207
Magnetic resonance imaging (MRI) 207
Positron emission tomography (PET) 207
GIST syndromes 207
Treatment and prognosis (Box 11.1) 207
Imatinib 209
Unresectable or metastatic disease 210
Adjuvant therapy post-resection 210
Gastric lymphoma 210
Staging 210
Classification 211
Neuroendocrine gastroenteropancreatic tumours (GEP-NETs) 211
Presentation, classification and treatment 212
Rarities 213
References 213
Chapter 12: Pathophysiology and investigation of gastro-oesophageal reflux disease 218
Introduction 218
Epidemiology 218
Symptoms 219
Normal oesophageal anatomy 219
Normal oesophageal physiology 219
Antireflux mechanisms 220
Lower oesophageal sphincter 221
Diaphragmatic sphincter 222
Distal oesophageal compression 222
Other mechanical barriers 223
Oesophageal mucosal acid defence mechanisms 223
Risk factors for reflux 223
Inherited factors 223
Demographic factors 224
Lifestyle factors 224
Medical factors 224
Hiatus hernia 224
Oesophageal dysmotility and GORD: cause or effect? 225
Role of duodenogastric reflux 226
Investigation and diagnosis 226
Symptomatic diagnosis 226
Endoscopy 227
Contrast radiology 227
pH studies 227
Wireless pH monitoring 229
Oesophageal impedance monitoring 230
Manometry 231
Standard static manometry 231
High-resolution manometry (HRM) 232
References 235
Chapter 13: Treatment of gastro-oesophageal reflux disease 241
Introduction 241
Medical treatment 241
Simple measures 241
H2-receptor antagonists 242
Proton-pump inhibitors 242
Prokinetic agents 242
Surgical treatment 242
Selection criteria for surgery 242
Patients with complicated reflux disease 243
Reflux with stricture formation 243
Reflux with respiratory complications 243
Reflux with throat symptoms 243
Columnar-lined (Barrett's) oesophagus 243
Patients with uncomplicated reflux disease 243
Medical versus surgical therapy 244
Pros and cons of antireflux surgery 245
Advantages 245
Disadvantages 245
Preoperative investigations 245
Endoscopy 245
Manometry 245
Oesophageal pH monitoring 245
Other investigations 245
Antireflux surgery 246
Mechanisms of action of antireflux surgery 246
Techniques of antireflux surgery 246
Nissen fundoplication (Figs 13.1 and 13.2) 246
Posterior partial fundoplication (Fig. 13.3) 247
Anterior partial fundoplication 248
Other antireflux procedures 248
Hill procedure 248
Collis procedure (Fig. 13.7) 249
Augmentation of the lower oesophageal sphincter 249
LINX® 249
EndoStim® 250
Controversies and comparisons 250
Complete or partial fundoplication? 250
Nissen versus posterior fundoplication 250
Nissen versus anterior fundoplication 251
Anterior versus posterior partial fundoplication 251
Division/no division of short gastric vessels 252
Laparoscopic antireflux surgery 253
Laparoscopic versus open antireflux surgery 253
Complications of laparoscopic antireflux surgery 254
Complications that are more common following laparoscopic antireflux surgery 255
Paraoesophageal hiatus hernia 255
Dysphagia 255
Pulmonary embolism 256
Complications unique to laparoscopic antireflux surgery 256
Bilobed stomach 256
Pneumothorax 256
Vascular injury 257
Perforation of the upper gastrointestinal tract 257
Mortality 257
Avoiding complications following laparoscopic antireflux surgery and minimising their impact 257
Synthesis of the results from prospective randomised trials 258
Endoscopic therapies for reflux 258
Radiofrequency 259
Polymer injection 259
Endoscopic suturing 259
EndoCinch 259
NDO Plicator 259
Endoscopic fundoplication 260
Overview of endoscopic antireflux surgery 260
References 262
Chapter 14: Treatment of the complications of gastro-oesophageal reflux disease and failed gastro-oesophageal surgery 269
Introduction 269
Complications of GORD 269
Short oesophagus 270
Gastrointestinal haemorrhage 270
Peptic oesophageal stricture 270
Failed antireflux surgery 271
Investigation of the failed antireflux operation 271
Endoscopy 271
Barium studies 271
Computerised tomography 272
Oesophageal physiology tests 272
Management of failure after antireflux surgery 273
Recurrence of reflux symptoms 273
Persistence of preoperative symptoms 273
Dysphagia 273
Other symptoms 274
Revisional surgery following failed antireflux surgery 274
Complex revisional surgery 276
Summary 277
References 278
Chapter 15: Barrett's oesophagus 280
Definition 280
Epidemiology 280
Endoscopic assessment 281
Pathophysiology of Barrett's oesophagus and progression to adenocarcinoma 281
Risk of cancer and mortality in Barrett's oesophagus 283
Natural history of dysplasia in Barrett's oesophagus 284
Low-grade dysplasia 285
High-grade dysplasia 285
Risk factors for progression to cancer 286
Screening for Barrett's oesophagus and adenocarcinoma using molecular markers 287
Surveillance of non-dysplastic disease 288
Effect of medical therapy and antireflux surgery 288
Endotherapy 289
Endoscopic resection 289
Endoscopic ablation 289
Management of LGD 290
Management of HGD 290
Conclusion 291
References 292
Chapter 16: The management of achalasia and other motility disorders of the oesophagus 298
Introduction 298
Achalasia 298
Background 298
Primary achalasia 298
Clinical features 299
Investigations 299
Treatment 300
Botulinum toxin injection 300
Pneumatic dilatation 300
Cardiomyotomy 301
Revisional procedures and oesophagectomy 301
Secondary achalasia 302
Diffuse oesophageal spasm 302
Oesophagogastric junction outflow obstruction and non-specific oesophageal motor disorders 303
Oesophageal motor disturbances and autoimmune disease 304
Systemic sclerosis 304
Polymyositis and dermatomyositis 304
Systemic lupus erythematosus 304
Polyarteritis nodosa and rheumatoid disease 304
Oesophageal diverticula 304
Clinical features 304
Diagnosis 304
Treatment 305
Acknowledgements 305
References 305
Chapter 17: Paraoesophageal hernia and gastric volvulus 308
Introduction 308
Epidemiology 308
Anatomy and natural history 308
Presentation and diagnosis 309
Operative indications 310
Operative approaches 310
Principles of paraoesophageal hernia repair 310
Transthoracic repair 310
Transabdominal repair 310
Laparoscopic repair 310
Set-up and port placement 311
Reduction of hernia sac and fundic mobilisation 311
Assessment of oesophageal length 311
Crural dissection and repair 312
Fundoplication 312
Current controversies in paraoesophageal hernia management 312
Recurrence rate 312
Oesophageal lengthening procedures 312
Prosthetic crural reinforcement 313
Acute gastric volvulus 313
Frequency and mechanism 313
Presentation and diagnosis 314
Management 314
References 315
Chapter 18: Benign ulceration of the stomach and duodenum and the complications of previous ulcer surgery 317
Introduction 317
Management of refractory peptic ulceration 317
Endoscopic confirmation 317
Confirmation of persistent Helicobacter infection 317
Non-HP-related refractory ulceration 318
Elective surgery for peptic ulceration 318
Operations for refractory duodenal ulcers 318
Operations for refractory gastric ulcers 319
Laparoscopic peptic ulcer surgery 319
Zollinger–Ellison syndrome (ZES) 319
Pathology 319
Diagnosis 320
Tumour localisation 320
Surgery for ZES 320
Emergency management of complicated peptic ulcer disease 321
Perforation 321
Conservative management 321
Surgery 321
Bleeding 322
Medical therapy 322
Endoscopic therapy 322
Surgery 323
Bleeding duodenal ulcer 323
Bleeding gastric ulcer 325
Interventional radiology 325
Pyloric stenosis 326
Resuscitation and medical therapy 326
Endoscopic treatment 326
Surgery 326
Complications of previous ulcer surgery 326
Preoperative evaluation 327
Endoscopy 327
Radiology 327
Gastric-emptying studies 327
Other tests 327
Enterogastric reflux 327
Medical treatment 327
Surgical treatment 327
Chronic afferent loop syndrome 329
Dumping 329
Medical treatment 330
Surgical treatment 330
Diarrhoea 331
Medical treatment 331
Surgical treatment 331
Small stomach syndrome 331
References 332
Chapter 19: Oesophageal emergencies 336
Introduction 336
Perforation of the oesophagus 336
Aetiology and pathophysiology 336
Iatrogenic perforation of the oesophagus 336
Spontaneous perforation of the oesophagus 337
Penetrating injuries 337
Blunt trauma 337
Clinical presentation 338
Investigations 338
Plain radiography 338
Contrast radiography 338
Upper gastrointestinal endoscopy 339
Computed tomography (CT) 339
Other investigations 341
Management 341
Non-operative management 341
Adjuncts to non-operative management 342
Closure: clips and sealants 342
Diversion: stents 342
Drainage: repeated endoscopy 342
Operative management 343
Open surgery 343
Primary repair with or without reinforcement 343
T-tube repair 343
Resection 344
Other approaches 344
Minimally invasive surgery: laparoscopic/thoracoscopic 344
Surgical repair over a stent 344
Management of penetrating injuries 344
Cervical 344
Thoracic 344
Management of underlying pathology 345
Paraoesophageal surgery and procedural injuries 346
Management algorithm 346
Non-perforated spontaneous injuries of the oesophagus 346
Caustic injuries 346
Clinical presentation 348
Investigation and management 348
Long-term complications and outcomes 350
Cancer risk 351
Management algorithm 351
Ingestion of foreign bodies 352
Clinical presentation 352
Diagnosis 352
Management 353
Summary 354
References 355
Chapter 20: Bariatric surgery 358
Introduction 358
Obesity as a public health problem 358
Diabetes risk with obesity 359
Cancer risk with obesity 359
Psychosocial morbidity and prejudice 360
Baseline obesity-related disease 360
Data from the NBSR 360
Multidisciplinary work-up 360
Optimisation of patients 361
Obesity Surgery–Mortality Risk score (OS-MRS) 361
Current bariatric operations and surgical techniques 361
Gastric bypass 361
Gastric banding 362
Sleeve gastrectomy 363
Biliopancreatic diversion/duodenal switch 363
Mechanisms of bypass and banding 364
Weight loss outcomes 364
Band versus bypass RCTs 364
Band versus sleeve gastrectomy RCT 366
Banded versus non-banded gastric bypass RCT 366
Sleeve versus bypass RCTs 366
Bypass versus duodenal switch RCT 366
Complications of surgery 367
Operative mortality 367
Gastric bypass 367
Early 367
Index 381