1. 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

2. “You can judge the worth of a surgeon by the way he does a hernia”
Sir Thomas Fairbank

3. Inguinal hernia surgery– laparoscopic or open?

4. “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

6. The case for open repair

7. 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 Surg Clin N Am 2003; 83:1045–51.
GIST represent a subset of sarcomas (tumors of mesenchymal origin) that develops in the gastrointestinal (GI) tract and may spread within the abdomen.
GIST are relatively rare neoplasms, representing less than 1% of all tumors of the GI tract; nonetheless, GIST are the most common mesenchymal malignancy of the GI tract.
The peak incidence seems to occur between 40 and 60 years of age.
Men and women are affected equally, and it is unusual to find GIST in patients younger than 40.
Approximately 4500 to 6000 cases of GIST occur annually in the United States. The prevalence of GIST is higher than its incidence, because the clinical course of the disease can last for 10 to 15 years.
The definition of GIST is evolving and recently has been identified as a distinct clinical and histopathologic entity. In the past, GIST often were underdiagnosed because of confusion over classification and similarities to other tumor types.
Fletcher CD, Berman JJ, Corless C, et al. Diagnosis of gastrointestinal stromal tumors: A consensus approach. Hum Pathol. 2002;33:
Jemal A, Murray T, Ward E, et al. Cancer statistics CA Cancer J Clin. 2005;55:10-30.
Joensuu H, Fletcher C, et al. Management of malignant gastrointestinal stromal tumours. Lancet Oncol. 2002;3:
Miettinen M, Lasota J. Gastrointestinal stromal tumors (GISTs): definition, occurrence, pathology, differential diagnosis and molecular genetics. Pol J Pathol. 2003;54:3-24.
Nilsson B, Bumming P, Meis-Kindblom JM, et al. Gastrointestinal stromal tumors: the incidence, prevalence, clinical course, and prognostication in the preimatinib mesylate era—a population-based study in western Sweden. Cancer. 2005;103:

8. Open herniorraphy Short learning curve Cheap Less chance of recurrence
Can be done under local anaesthetic

9. 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?

10. 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.

11. 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.

12. 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

13. 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

14. 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

15. 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

16. Heartburn and Hernias

17. Hiatus (Paraesophageal) hernias
Type 1 paraesophageal hernia

18. Paraesophageal hernias
Type 2 hernia Type 3 hernia

19. Clinical features
Asymptomatic
Major
Minor
Emergency

20. Clinical features Asymptomatic
Stomach freely herniates and reduces through a open hiatus

21. 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

22. Clinical features Minor symptoms Regurgitation (77%) Heartburn (60%)
Nausea and/or vomiting (35%)

23. Clinical features Emergency = volvulus Severe pain Bleeding
Perforation > Peritonitis and sepsis*
* 50% mortality rate > case for elective repair
strangulation

26. Diagnostic Methods Upper gastrointestinal contrast study CT
Gastroscopy

31. Controversies
Do all paraesophageal hernias require repair?

32. Principles of surgical repair
Standard principles of hernia repair apply:
free the sac
reduce the hernia
repair the defect

33. How to close the crural defect?
Primary suture cruroplasty

34. How to close the crural defect?
Cruroplasty reinforced by mesh

35. Balloons and Weight loss

36. Weight loss - Treatment options
Lifestyle Modifications e.g. diet and exercise
Anti-obesity medications - Xenical® (Orlistat/Alli)
Surgery (in suitable patients – NOCE, NIH criteria)
Clearly, obesity has dramatic consequences for individuals and society.
Fortunately, there are a variety of treatments available. Some have better outcomes than others.
Diet and exercise, the typical recommended approach, are both important but when applied alone, they rarely result in long-term weight loss - just 5%-10% excess weight loss (EWL) on average [1,2,3].
Newer treatments such as medications also lack long-term efficacy - achieving 5%-10% EWL on average [1,2,3,4].
Bariatric surgery, of which there are several different types, is the only treatment option that has been demonstrated to be effective over the long term. More than 50% EWL sustained over 10 years) [2,3].
References:
1. Dixon JB, O'Brien PE. Health outcomes of severely obese type 2 diabetic subjects year after laparoscopic adjustable gastric banding. Diabetes Care. 2002;25(2):
2. O'Brien PE, McPhail T, Chaston TB, et al. Systematic review of medium-term weight loss after bariatric operations. Obes Surg. 2006;16(8):
3. Fisher, BL, Schauer, P. Medical and surgical options in the treatment of severe obesity. American Journal of Surgery. 2002; Volume 184 (6B)
4. Wierzbicki, A. Rimonabant: Endocannabinoid inhibition for the metabolic syndrome Int J Clin Pract. 2006;60(12): 36 36

37. Weight loss BARIATRIC SURGERY GASTRIC BALLOON
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)
The ideal BMI lies in the range between 19 to 25.
If your BMI is between 25 and 29.9, you are considered to be overweight.
If it is between 30 and 39.9, you are obese.
If your BMI is 40 or more, you are said to have morbid obesity.
The term “morbid” obesity is used because this degree of excess weight may considerably reduce life expectancy and is associated with an increased risk of developing conditions or diseases such as diabetes, high blood pressure, joint problems, gallstones, stroke, heart disease, and psychosocial problems.
BARIATRIC SURGERY
GASTRIC BALLOON 37

38. The Intragastric Balloon
An option between diets and surgical treatment 38

39. Treating obesity with an Intragastric Balloon
The Intragastric
Balloon is a
weight-loss system
Education about
weight-loss
The balloon
itself
The intra-gastric balloon is a soft expandable balloon inserted in the stomach. The presence of the balloon in the stomach produces an early and prolonged sense of satiety. The device is designed to remain in the stomach for six months.
Education and support is provided through regular scheduled meetings with the medical team to learn new principles to ensure long term success. The focus is on nutrition, exercise and healthy living.
A multi-disciplinary approach to ensure long term weight loss. The Team of experts includes experienced weight loss professionals who will consult with you and design a program to help you successfully reach and maintain your weight-loss goals. The team can include your surgeon, GP, nutritionist, lifestyle coach, exercise trainer and psychologist. 39

40. 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. 40

41. Step 3 Follow up Diet and changed eating habits Exercise
The procedure
Step 1
Assessment
Step 2
Insertion
Step 3 Follow up Diet and changed
eating habits Exercise
Step 4
Removal
Maintain
weight-loss
Once the balloon is removed, weight-loss can only be maintained if the patients adhere to their new lifestyle regime. 41

42. 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 42

43. 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 43

44. 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
The intragastric balloon will not be successful without commitment from the recipient. Motivation is key to long-term success. 44 44

45. 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
There are a number of advantages associated with treatment with an intragastric balloon. Not only does it avoid surgery but the programme of support that accompanies it support long-term success. 45 45

46. Intragastric balloon Possible indications
Hard to control co-morbidities in lower BMI
>Diabetes / Hypertension
 weight = control 46

47. Intragastric balloon Possible indications
Weight loss to improve surgical condition in non bariatric operations
> Orthopaedic surgery
Joints
Spine 47

48. Intragastric balloon Possible indications Infertility
Effective weight loss
> Improves women fertility 48

49. 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 49

50. Intragastric balloon Possible indications Aesthetics
>“Preparing for special happenings”
>“Psychological well being”
>“ less risky than liposuction” 50

51. Excess Weight
Surgical
Treatment
Lifestyle
Balloon 51

52. Questions www.ahmedr.com
If you would like to schedule or refer a patient for consultation:
Contact 108 Harley Street [ ] 52 52