Hernias, Heartburn, and Balloons

Ahmed R Ahmed Consultant in Laparoscopic, Upper GI and Bariatric Surgery

Clinical Lead – Bariatric ServicesImperial College London

Director of SurgeryBupa 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.

• Short learning curve

• Cheap

• Less chance of recurrence

• Can be done under local anaesthetic

Open herniorraphy

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.

EU Hernia Trialists Collaborative. Br J Surg 2000; 87: 860–7.

– 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

34 TRIALS ANALYSED RECURRENCES

Is the repair secure?

Prof Grant. EU Hernia Trialists Collaborative. Br J Surg 2000; 87: 860–7.

*10 RCTs comparing TAPP with open repair and 4 RCTs comparing TEP with open repair

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 activitiesand 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 comparedwith 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 HerniaTrialists Collaboration. Laparoscopic techniques versus opentechniques for inguinal hernia repair. Cochrane Databases SystemRev 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 2001/2http:/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

– Perforation > Peritonitis and sepsis*

* 50% mortality rate > case for elective repair

strangulation

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)

Healthy Weight (BMI 18.5 to 24.9)

Overweight(BMI 25 to 29.9)

Obese(BMI 30 to 34.9)

Severely Obese(BMI 35 to 39.9 )

Morbidly Obese(BMI 40 or more)

BARIATRIC SURGERY

Weight loss

GASTRIC BALLOON

The Intragastric Balloon

•An option between diets and surgical treatment

Treating obesity with an Intragastric Balloon

The IntragastricBalloon is a

weight-loss system

Education aboutweight-loss

The balloonitself

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

Assessment

Step 2

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 theintragastric 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

Hard to control co-morbidities in lower BMI

>Diabetes / Hypertension

weight = control

Intragastric balloonPossible indications

Weight loss to improve surgical condition

in non bariatric operations

> Orthopaedic surgery

Joints

Spine

Intragastric balloonPossible indications

Infertility

Effective weight loss

> Improves women fertility

Intragastric balloonPossible 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 balloonPossible indications

Aesthetics

>“Preparing for special happenings”

>“Psychological well being”

>“ less risky than liposuction”

Intragastric balloonPossible indications

Lifestyle Lifestyle SurgicalTreatment

BalloonBalloon

Excess Weight

52

QuestionsIf you would like to schedule or refer a patient for consultation:

Contact 108 Harley Street [020 7563 1234]Info@108harleystreet.co.uk

www.ahmedr.com