Gastroenterologic surgery includes a variety of surgical procedures performed on the organs and conduits of the digestive system. These procedures include the repair, removal, or resection of the esophagus, liver, stomach, spleen, pancreas, gallbladder, colon, anus, and rectum. Gastroenterologic surgery is performed for diseases ranging from appendicitis, gastroesophageal reflux disease (GERD), and gastric ulcers to the life-threatening cancers of the stomach, colon, liver, and pancreas, and ulcerative conditions like ulcerative colitis and Crohn's disease.
Purpose
Scientific understanding, treatment, and diagnostic advances, combined with an aging population, have made this century the golden age of gastroenterology. Gasteroenterologic surgery's success in treating conditions of the digestive system by removing obstructions, diseased or malignant tissue, or by enlarging and augmenting conduits for digestion is now largely due to the ability to view and work on the various critical organs through video representation and by biopsy. The word abdomen is derived from the Latin abdere, meaning concealed or un-seeable. The use of gastrointestinal endoscopy, laproscopy, computer tomography (CT) scan, and ultrasound has made the inspection of inaccessible organs possible without surgery, and sometimes treatable with only minor surgery. With advances in other diagnostics such as the fecal occult blood test known as the Guaiac test, the need for bowel surgery can be determined quickly without expensive tests. This is especially important for colon cancer, which is the leading cause of cancer mortality in the United State, with about 56,000 Americans dying from it each year.
Some prominent surgical procedures included in gasteroentologic surgery are:
Fundoplication to prevent reflux acids in the stomach from damaging the esophagus.
Appendectomy for removal of an inflamed or infected appendix.
Cholecystectomy for removal of an inflamed gallbladder and the crystallized salts called gallstones.
Vagotomy, antrectomy, pyloroplasty are surgeries for gastric and peptic ulcers, now very rare. In the last 10 years, medical research has confirmed that gastric and peptic ulcers are due primarily to Heliobacter pylori, which causes more than 90% of duodenal ulcers and up to 80% of gastric ulcers. The most frequent surgeries today for ulcers of the stomach and duodenum are for complications of ulcerative conditions, largely perforation.
Colostomy, ileostomy, and ileoanal reservoir surgery are done to remove part of the colon by colostomy; part of the colon as it enters the small intestine by ileostomy; and removal of part of the colon as it enters the rectal reservoir by ileonal reservoir surgery. These surgeries are required to relieve diseased tissue and allow for the continuation of waste to be removed from the body. Inflammatory bowel disease includes two severe conditions: ulcerative colitis and Crohn's disease. In both cases, portions of the bowel must be resected. Crohn's disease affects the small intestine and ulterative colitis affects the lining of the colon. Cancers in the area of the colon and rectum can also necessitate the resection of the colon, intestine, and/or rectum.
Demographics
Gasteroentologic diseases disproportionately affect the elderly, with prominent disorders including diverticulosis and other diseases of the bowel, and fecal and urinary incontinence. Many diseases, like gastrointestinalmalignancies and liver diseases, occur more frequently as people age. Because the number of Americans age 65 and above is expected to rise from 35 million in 2000 to 78 million by 2050, with those over 85 rising from four million in 2000 to almost 18 million by 2050, gastroenterologic surgeries are greatly in need, not only to prolong life but to relieve suffering. It is not surprising that the elderly account for approximately 60% of health care expenditures, 35% of hospital discharges, and 47% of hospital days.
Sixty to 70 million Americans are affected by digestive diseases, according to the National Digestive Diseases Clearinghouse. Digestive diseases accounted for 13% of all hospitalizations in the United States in 1985 and 16% of all diagnostic procedures. The most costly digestive diseases are such gastrointestinal disorders as diarrhea infections ($4.7 billion); gallbladder disease ($4.5 billion); colorectal cancer ($4.5 billion); liver disease ($3.2 billion); and peptic ulcer disease ($2.5 billion). Appendectomy is the fourth most frequent intra-abdominal operation performed in the United States. Appendicitis is one of the most common causes of emergency abdominal surgery in children. Appendectomies are more common in males than females, with incidence peaking in the late teens and early twenties. Each year in the United States four appendectomies are performed per 1,000 children younger than 18 years of age. Gallstones are responsible for about half of the cases of acute pancreatitis in the United States. More than 500,000 Americans have gallbladder surgery annually. The most common procedure is the laparoscopic cholecystectomy. Women 20–60 years of age have twice the rate of gallstones as men, and individuals over 60 develop gallstones at higher rates than those who are younger. Those at highest risk for gallstones are individuals who are obese and those with elevated estrogen levels, such as women who take birth control pills or hormone replacement therapy.
According to the Centers for Disease Control and Prevention, 25 million Americans suffer from peptic ulcer disease some time in their life. Between 500,000 and 850,000 new cases of peptic ulcer disease and more than one million ulcer-related hospitalizations occur each year. Ulcers cause an estimated one million hospitalizations and 6,500 deaths per year. According to the American College of Gastroenterology Bleeding Registry, patients tend to be elderly; male; and users of alcohol, tobacco, aspirin, non-steroidal anti-inflammatory drugs (NSAIDs), and anticoagulants. According to the National Diabetic and Digestive Diseases (NDDK), about 25–40% of ulcerative colitis patients must eventually have their colons removed because of massive bleeding, disease, rupture, or the risk of cancer. The use of corticosteroids to control inflammation can destroy tissue and require removal of the colon. According to the Society of American Gastrointestinal EndoscopicSurgeons, 600,000 surgical procedures alone are performed in the United States to treat a colon disease.
The incidence of gasteroenterologic diseases differs among ethnic groups. For instance, while gastroesophageal reflux disease (GERD) is common in Caucasians, its incidence is lower among African Americans. This is true for the incidence of esophageal and gastric-cardio adenocarcinoma. On the other hand, African Americans, Hispanics, and Asians have a different form of cancer of the esophagus called squamous cell carcinoma, seen also in new immigrants from northern China, India, and northern Iran. While gastric and peptic ulcerative incidence due to Heliobacter pylori ranges in rates from 70–80% for African Americans and Hispanics, the rate for Caucasians is only 34%. Caucasians, on the other hand, have higher rates of intestinal gastric cancer. Finally, there are differences in colon cancer mortality between African Americans and Caucasians. African Americans with colon cancer have a 50% higher mortality risk than Caucasians. Advanced cancer stage at presentation accounts for half of this increased risk. Restricted access to health care, especially screening innovations, may account for much of this disparity.
Description
Advances in laparoscopy allow the direct study of large portions of the liver, gallbladder, spleen, lining of the stomach, and pelvic organs. Many biopsies of these organs can be performed by laparoscopy. Increasingly, laparoscopic surgery is replacing open abdomen surgery for many diseases, with some procedures performed on an outpatient basis. Gastrointestinal applications have resulted in startling changes in surgeries for appendectomy, gallbladder, and adenocarcinoma of the esophagus, the fastest increasing cancer in North America. Significant other diseases include liver, colon, stomach, and pancreatic cancers; ulcerative conditions in the stomach and colon; and inflammations and/or irritations of the stomach, liver, bowel, and pancreas that cannot be treated with medications or other therapies. Recent research has shown that laparoscopy is useful in detecting small (< 0.8 in [< 2 cm]) cancers not seen by imaging techniques and can be used to stage pancreatic or esophageal cancers, averting surgical removal of the organ wall in a high percentage of cases. There are also recent indications, however, that some laparoscopic procedures may not have the long-lasting efficacy of open surgeries and may involve more complications. This drawback has proven true for laparoscopic fundoplication for GERD disease.
Advances in gastrointestinal fiber-optic endoscopic technology have made endoscopy mandatory for gastrointestinal diagnosis, therapy, and surgery. Especially promising is the use of endoscopic techniques in the diagnosis and treatment of bowel diseases, colonoscopy, and sigmoidoscopy, particularly with acute and chronic bleeding. Combined with laparoscopic techniques, endoscopy has substantially reduced the need for open surgical techniques for the management of bleeding.
For most gasteroenterologic surgeries, whether laparoscopic or open, preoperative medications are given as well as general anesthesia. Food and drink are not allowed after midnight before the surgery the next morning. Surgery proceeds with the patient under general anesthetics for open surgery and local or regional anesthetics for laparoscopic surgery. Specific diseases require specific procedures, with resection and repair of abdomen, colon and intestines, liver, and pancreas considered more serious than other organs. The level of complication of the procedure dictates whether laparoscopic procedures may be used.
Diagnosis/Preparation
The need for surgery of the esophagus, duodenum, stomach, colon, and intestines is assessed by medical history, general physical, and x ray after the patient swallows barium for maximum visibility. Diagnosis and preparation for gasteroentological surgery involve some very advanced techniques. Upper and lower gastrointestinal endoscopies are more accurate in spotting abnormalities than x ray and can be used in treatment. Endoscopy utilizes a long, flexible plastic tube with a camera to look at the stomach and bowel. Quite often, physicians will also use a CT scan for procedures like appendectomy. Upper esophagogastroduodenal endoscopy is considered the reference method of diagnosis for ulcers of the stomach and duodenum. Colonoscopy and sigmoidoscopy are mandatory for diseases and cancers of the colon and large intestine.
Aftercare
For simple procedures like appendectomy and gallbladder surgery, patients stay in the hospital the night of surgery and may require extra days in the hospital; but they usually go home the next day. Postoperative pain is mild, with liquids strongly recommended in the diet, followed gradually with solid foods. Return to normal activities usually occurs in a short period. For more involved procedures on organs like stomach, bowel, pancreas, and liver, open surgery usually dictates a few days of hospitalization with a slow recovery period.
Risks
The risks in gastroenterologic surgery are largely confined to wounds or injuries to adjacent organs; infection; and the general risks of open surgery that involve thrombosis and heart difficulties. With some laparoscopic procedures such as fundoplication with injury or laceration of other organs, the return of symptoms within two to three years may occur. With appendectomy, the rates of infection and wound complications range between 10–18% in patients. The institution of new clinical practice guidelines that include wound guidelines and directed management of postoperative infectious complications are substantially reducing patient mortality. Gallbladder surgery, especially laparoscopic cholecystectomy, is one of the most common surgical procedures in the United States. However, injuries to adjacent organs or structures may occur, requiring a second surgery to repair it. Stomach surgical procedures carry risks, generally in proportion to their benefits. Today, surgery for peptic ulcer disease is largely restricted to the treatment of such complications as bleeding for ulcer perforation. Recent research indicates that surgery for bleeding is 90% effective using endoscopic techniques. Laparoscopic surgery for ulcer complications has not been found to be better than regular surgery. Stomach and intestinal surgery risks include diarrhea, reflux gastritis, malabsorption of nutrients, especially iron, as well as the general surgical risks associated with abdominal surgery. The risks of colon surgery are tied to both the general risks of surgical procedures—thrombosis and heart problems—and to the specific disease being treated. For instance, in Crohn's disease, resection of the colon may not be effective in the long run and may require repeated surgeries. Colon surgery in general has risks for bowel obstruction and bleeding.
Morbidity and mortality rates
According to a recent study published by the British Journal of Surgery, a small minority of patients undergoing gastroenterologic surgery are at high risk for postoperative complications that may lead to prolonged hospital stays. In a study of 235 patients, 47% had at least one postoperative complication, with the length of hospital stay at 11 days compared to those without complications with length of stay at six days.
PERIODICALS
Cappell, M. S. "Recent Advances in Gastroenterology." Medical Clinics of North America 86, no.6 (November 2002).
Cappell, M. S., J. D. Waye, J. T. Farrar, and M. H. Sleisenger. "Fifty Landmark Discoveries in Gastroenterology during the Past 50 Years" Gastroenterology Clinics 29, no. 2 (June 2000).
Eisen, G. M., et al. "Ethnic Issues in Endoscopy." Gastrointestinalt Endoscopy 53, no. 7, (June 1, 2001): 874–5.
Farrell, J. J., and L. S. Friedman. "Gastrointestinal Disorders in the Elderly." Gastroenterology Clinics 30, no. 2, (June, 2001).
Lang, M. "Outcome and Resource Utilization in Gastroenterological Surgery." British Journal of Surgery 88, no. 7 (July 1, 2001): 1006–14.
ORGANIZATIONS
Crohn's & Colitis Foundation of America, Inc. 386 Park Avenue South, 17th Floor, New York, NY 10016-8804. (800) 932-2423 or (212) 685-3440; Fax: (212) 779-4098. Email: <info@ccfa.org>. <www.ccfa.org.>.
International Foundation for Functional Gastrointestinal Disorders. P.O. Box 17864, Milwaukee, WI 53217. (414) 964-1799 or (888) 964-2001. <www.iffgd.org.>.
National Digestive Diseases Information Clearinghouse. 2 Information Way, Bethesda, MD 20892-3570. <www.niddk.nih.gov>.
OTHER
The Role of Laparoscopy in the Diagnosis and Management ofGastrointestinal Disease. Society of American Gastrointestinal Endoscopic Surgeons. <www.colonoscopy.info/>.
Nancy McKenzie, PhD
WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?
Gastroenterologic surgery is performed by urologists, internists, and other specialists in digestive diseases and disorders. Surgery is performed in a general hospital. Some less complicated surgeries done by laparoscopy may be used in an outpatient setting.
QUESTIONS TO ASK THE DOCTOR
How often do you perform this surgery?
Is this surgery one that can be done laparoscopically?
How long have you been performing this surgery laparoscopically?
