Gastrointestinal (Gastroscopy) Surgery Singapore

Gastrointestinal Surgery

Gastrointestinal surgery is a treatment for diseases of the parts of the body involved in indigestion. This includes the esophagus, stomach, small intestine, large intestine, and rectum. It also includes the liver, gallbladder, and pancreas.

Below are gastrointestinal conditions that may be treated with surgery:

Gastroesophageal reflux disease (GERD) and Hiatus Hernia

What Is Gastroesophageal Reflux?

Gastroesophageal refers to the stomach and esophagus. Reflux means to flow back or return. Therefore, gastroesophageal reflux is the return of the stomach’s contents back up into the esophagus.

In normal digestion, the lower esophageal sphincter (LES) opens to allow food to pass into the stomach and closes to prevent food and acidic stomach juices from flowing back into the esophagus. Gastroesophageal reflux occurs when the LES is weak or relaxes inappropriately, allowing the stomach’s contents to flow up into the esophagus.

The severity of GERD depends on LES dysfunction as well as the type and amount of fluid brought up from the stomach and the neutralising effect of saliva.

What Is the Role of Hiatal Hernia in GERD?

Hiatal hernia may weaken the LES and increase the risk for gastroesophageal reflux. Hiatal hernia occurs when the upper part of the stomach moves up into the chest through a small opening in the diaphragm (diaphragmatic hiatus). The diaphragm is the muscle separating the abdomen from the chest. Recent studies show that the opening in the diaphragm helps support the lower end of the esophagus. Many people with a hiatal hernia will not have problems with heartburn or reflux. But having a hiatal hernia may allow stomach contents to reflux more easily into the esophagus.

Coughing, vomiting, straining, or sudden physical exertion can cause increased pressure in the abdomen resulting in hiatal hernia. Obesity and pregnancy also contribute to this condition. Many otherwise healthy people age 50 and over have a small hiatal hernia. Although considered a condition of middle age, hiatal hernias affect people of all ages.

Hiatal hernias usually do not require treatment. However, treatment may be necessary if the hernia is in danger of becoming strangulated (twisted in a way that cuts off blood supply) or is complicated by severe GERD or esophagitis (inflammation of the esophagus). The doctor may perform surgery to reduce the size of the hernia or to prevent strangulation.

What Other Factors Contribute to GERD?

Dietary and lifestyle choices may contribute to GERD. Certain foods and beverages, including chocolate, peppermint, fried or fatty foods, coffee or alcoholic beverages, may trigger reflux and heartburn. Studies show that cigarette smoking relaxes the LES. Obesity and pregnancy can also play a role in GERD symptoms.

What Are the Symptoms of Heartburn?

Heartburn, also called acid indigestion, is the most common symptom of GERD and usually feels like a burning chest pain beginning behind the breastbone and moving upward to the neck and throat. Many people say it feels like food is coming back into the mouth leaving an acid or bitter taste.

The burning, pressure, or pain of heartburn can last as long as 2 hours and is often worse after eating. Lying down or bending over can also result in heartburn. Many people obtain relief by standing upright or by taking an antacid that clears acid out of the esophagus.

Heartburn pain is sometimes mistaken for the pain associated with heart disease or a heart attack, but there are differences. Exercise may aggravate pain resulting from heart disease, and rest may relieve the pain. Heartburn pain is less likely to be associated with physical activity. But you can’t tell the difference, so seek immediate medical help if you have any chest pain.

How Common Is Heartburn and GERD?

More than 60 million American adults experience heartburn at least once a month, and more than 15 million adults suffer daily from heartburn. Many pregnant women experience daily heartburn. Recent studies show that GERD in infants and children is more common than previously recognised and may produce recurrent vomiting, coughing and other respiratory problems.

What Is the Treatment for GERD?

We recommend lifestyle and dietary changes for most people needing treatment for GERD. Treatment aims at decreasing the amount of reflux or reducing damage to the lining of the esophagus from refluxed materials.

Avoiding foods and beverages that can relax the LES is often recommended. These foods include chocolate, peppermint, fatty foods, caffeine and alcoholic beverages. Foods and beverages that can irritate a damaged esophageal lining such as citrus fruits and juices, tomato products and pepper should also be avoided if they cause symptoms.

Decreasing the size of portions at mealtime may also help control symptoms. Eating meals at least 2 to 3 hours before bedtime may lessen reflux by allowing the acid in the stomach to decrease and the stomach to empty partially. In addition, being overweight often worsens symptoms. Many overweight people find relief when they lose weight.

Cigarette smoking weakens the LES. Stopping smoking is important to reduce GERD symptoms.

Elevating the head of the bed on 6-inch blocks or sleeping on a specially designed wedge reduces heartburn by allowing gravity to minimise reflux of stomach contents into the esophagus. Do not use pillows to prop yourself up; that only increases pressure on the stomach.

Along with lifestyle and diet changes, we may recommend certain medications.

Antacids can help neutralise acid in the esophagus and stomach and stop heartburn. Many people find that antacids provide temporary or partial relief. An antacid combined with a foaming agent helps some people. These compounds are believed to form a foam barrier on top of the stomach that prevents acid reflux from occurring.

Long-term use of antacids, however, can result in side effects, including diarrhea, altered calcium metabolism (a change in the way the body breaks down and uses calcium) and buildup of magnesium in the body. Too much magnesium can be serious for patients with kidney disease.

For chronic reflux and heartburn, the doctor may recommend medications to reduce acid in the stomach. These medicines include H2 blockers, which inhibit acid secretion in the stomach. H2 blockers include: famotidine, nizatidine and ranitidine.

Another type of drug, the proton pump inhibitor (or acid pump), inhibits an enzyme (a protein in the acid-producing cells of the stomach) necessary for acid secretion. Some proton pump inhibitors include dexlansoprazoleesomeprazole, lansoprazole, omeprazole, pantoprazole and rabeprazole.

What If Heartburn or GERD Symptoms Persist?

People with severe, chronic esophageal reflux or with symptoms not relieved by the treatments described above may need more complete diagnostic evaluation. Doctors use a variety of tests and procedures to examine a patient with chronic heartburn.

Endoscopy is an important procedure for individuals with chronic GERD. By placing a small lighted tube with a tiny video camera on the end (endoscope) into the esophagus, the doctor may see inflammation or irritation of the tissue lining the esophagus (esophagitis). If the findings of the endoscopy are abnormal or questionable, biopsy (removing a small sample of tissue) from the lining of the esophagus may be helpful.

An upper GI series may be performed during the early phase of testing. This test is a special X-ray that shows the esophagus, stomach, and duodenum (the upper part of the small intestine). While an upper GI series provides limited information about possible reflux, it is used to help rule out other diagnoses, such as peptic ulcers.

Esophageal manometric and impedance studies  or pressure measurements of the esophagus may occasionally help identify low pressure in the LES or abnormalities in esophageal muscle contraction.

For patients in whom diagnosis is difficult, doctors may measure the acid levels inside the esophagus through pH testing. Testing pH monitors the acidity level of the esophagus and symptoms during meals, activity and sleep. Newer techniques of long-term pH monitoring such as Bravo Capsule are improving diagnostic capability in this area.

Does GERD Require Surgery?

A small number of people with GERD may need surgery because of severe reflux and poor response to medical treatment. However, surgery should not be considered until all other measures have been tried.

The standard surgical treatment of GERD is a laparoscopic repair of the Hiatus Hernia and fundoplication. This means that the loose Hiatal muscle is approximated with sutures and the stomach is fixed within the abdominal cavity to prevent it from migrating into the chest. Occasionally, if the Hiatus hernia is large, a mesh may be placed to reinforce the defect. The doctor can perform it through a laparoscope (small holes through the belly).

The Stretta procedure is minimally invasive. The doctors goes down the esophagus with a small tube and uses radiofrequency to tighten the barrier between the esophagus and stomach.

LINX surgery is a newer procedure where the doctor wraps a band of titanium beads around the lower part of the esophagus to prevent stomach acids from splashing back up into the esophagus. This procedure is done using a laparoscope.

What Are the Complications of Long-Term GERD?

Sometimes GERD results in serious complications. Esophagitis can occur as a result of too much stomach acid in the esophagus. Esophagitis may cause esophageal bleeding or ulcers. In addition, a narrowing or stricture of the esophagus may occur from chronic scarring. Some people develop a condition known as Barrett’s esophagus. This condition can increase the risk of esophageal cancer.

Barrett’s esophagus is a potentially serious complication of GERD, which stands for gastroesophageal reflux disease. In Barrett’s esophagus, normal tissue lining the esophagus — the tube that carries food from the mouth to the stomach — changes to tissue that resembles the lining of the intestine. About 10% of people with chronic symptoms of GERD develop Barrett’s esophagus.

Barrett’s esophagus does not have any specific symptoms, although patients with Barrett’s esophagus may have symptoms related to GERD. It does, though, increase the risk of developing esophageal adenocarcinoma, which is a serious, potentially fatal cancer of the esophagus.

Although the risk of this cancer is higher in people with Barrett’s esophagus, the disease is still rare. Less than 1% of people with Barrett’s esophagus develop this particular cancer. Nevertheless, if you’ve been diagnosed with Barrett’s esophagus, it’s important to have routine examinations of your esophagus. With routine examination, your doctor can discover precancerous and cancer cells early, before they spread and when the disease is easier to treat.

What Is GERD and How Does It Relate to Barrett's Esophagus?

People with GERD may experience symptoms such as heartburn, a sour, burning sensation in the back of the throat, chronic coughlaryngitis and nausea.

When you swallow food or liquid, it automatically passes through the esophagus, which is a hollow, muscular tube that runs from your throat to your stomach. The lower esophageal sphincter, a ring of muscle at the end of the esophagus where it joins the stomach, keeps stomach contents from rising up into the esophagus.

The stomach produces acid in order to digest food, but it is also protected from the acid it produces. With GERD, stomach contents flow backward into the esophagus. This is known as reflux.

Most people with acid reflux don’t develop Barrett’s esophagus. But in patients with frequent acid reflux, the normal cells in the esophagus may eventually be replaced by cells that are similar to cells in the intestine to become Barrett’s esophagus.

Does GERD Always Cause Barrett's Esophagus?

No. Not everyone with GERD develops Barrett’s esophagus and not everyone with Barrett’s esophagus has GERD. But long-term GERD is the primary risk factor.

Anyone can develop Barrett’s esophagus, but white males who have had long-term GERD are more likely than others to develop it. Other risk factors include the onset of GERD at a younger age and a history of current or past smoking.

How Is Barrett's Esophagus Diagnosed?

Because there are often no specific symptoms associated with Barrett’s esophagus, it can only be diagnosed with an upper endoscopy and biopsy. Guidelines from the American Gastroenterological Association recommend screening in people who have multiple risk factors for Barrett’s esophagus. Risk factors include age over 50, male sex, white race, hiatal hernia, long standing GERD and overweight, especially if weight is carried around the middle.

To perform an endoscopy, a doctor called a gastroenterologist inserts a long flexible tube with a camera attached down the throat into the esophagus after giving the patient a sedative. The process may feel a little uncomfortable, but it isn’t painful. Most people have little or no problem with it.

Once the tube is inserted, the doctor can visually inspect the lining of the esophagus. Barrett’s esophagus, if it’s there, is visible on camera, but the diagnosis requires a biopsy. The doctor will remove a small sample of tissue to be examined under a microscope in the laboratory to confirm a diagnosis.

The sample will also be examined for the presence of precancerous cells or cancer. If the biopsy confirms the presence of Barrett’s esophagus, your doctor will probably recommend a follow-up endoscopy and biopsy to examine more tissue for early signs of developing cancer.

If you have Barrett’s esophagus but no cancer or precancerous cells are found, the doctor will still most likely recommend that you have periodic endoscopies. This is a precaution, because cancer can develop in Barrett tissue years after diagnosing Barrett’s esophagus. If precancerous cells are present in the biopsy, your doctor will discuss treatment and surveillance options with you.

Can Barrett's Esophagus Be Treated?

One of the primary goals of treatment is to prevent or slow the development of Barrett’s esophagus by treating and controlling acid reflux. This is done with lifestyle changes and medication. Lifestyle changes include taking steps such as:

  • Make changes in your diet. Fatty foods, chocolatecaffeine, spicy foods, and peppermint can aggravate reflux.
  • Avoid alcohol, caffeinated drinks and tobacco.
  • Lose weight. Being overweight increases your risk for reflux.
  • Sleep with the head of the bed elevated. Sleeping with your head raised may help prevent the acid in your stomach from flowing up into the esophagus.
  • Don’t lie down for 3 hours after eating.
  • Take all medicines with plenty of water.

The doctor may also prescribe medications to help. Those medications may include:

  • Proton pump inhibitors that reduce the production of stomach acid
  • Antacids to neutralise stomach acid
  • H2 blockers that lessen the release of stomach acid

Promotility agents — drugs that speed up the movement of food from the stomach to the intestines

Are There Treatments That Specifically Target Barrett's Esophagus?

There are several treatments, including surgery, that are designed specifically to focus on the abnormal tissue. They include:

  • Radiofrequency ablation (RFA) uses radio waves delivered through an endoscope inserted into the esophagus to destroy abnormal cells while protecting the healthy cells underneath.
  • Photodynamic therapy (PDT) uses a laser through an endoscope to kill abnormal cells in the lining without damaging normal tissue. Before the procedure, the patient takes a drug known as Photofrin, which causes cells to become light-sensitive.
  • Endoscopic spray cryotherapy is a newer technique that applies cold nitrogen or carbon dioxide gas, through the endoscope to freeze the abnormal cells.
  • Endoscopic mucosal resection (EMR) lifts the abnormal lining and cuts it off the wall of the esophagus before it’s removed through the endoscope. The goal is to remove any precancerous or cancer cells contained in the lining. If cancer cells are present, an ultrasound is done first to be sure the cancer hasn’t moved deeper into the esophagus walls.
  • Surgery to remove most of the esophagus is an option in cases where severe precancer (dysplasia) or cancer has been diagnosed. The earlier the surgery is done following the diagnosis, the better the chance for the cure.

It’s important to keep several facts in mind:

  • GERD is common among American adults.
  • Only a small percentage of people with GERD (less than one out of every 10) develop Barrett’s esophagus.
  • Less than 1% of those with Barrett’s esophagus each year go on to develop esophageal cancer.

A diagnosis of Barrett’s esophagus is not a cause for major alarm. Barrett’s esophagus, however, can lead to precancerous changes in a small number of people and has an increased risk for cancer. So, a diagnosis is a reason to work with your doctor to be watchful of your health

Gallbladder Disease

What is Laparoscopic Gallbladder Removal Surgery (Laparoscopic Cholecystectomy)?

 

What Is The Gallbladder?

Your gallbladder is a small organ in your upper abdomen. The abdomen is the area in the middle of your body that holds many organs, including the stomach and gallbladder.

What Does The Gallbladder Do?

The gallbladder collects and stores a liquid called bile that helps your body break down food. Small, hard deposits called gallstones can form in the gallbladder. This is a common condition. If your gallstones cause health problems, doctors might do surgery to remove it. For example, you might need surgery if your gallbladder is no longer working correctly and you have pain. Your doctor will talk with you about this.

What Causes Gallbladder Problems?

Gallstones are often the cause. These small, hard deposits form in the gallbladder. They can also get into the bile duct, which connects the gallbladder with your intestines.

You are more likely to get gallstones if you:

  • Are a woman,
  • Have had children,
  • Are overweight, or
  • Are over 40.

You might also get gallstones if other people in your family had them. Doctors do not have a consistent way of preventing gallstones.

What are the symptoms of gallbladder problems?

Symptoms can include:

  • Sharp pain in your abdomen,
  • Nausea and vomiting,
  • Indigestion,
  • Fever, and
  • Yellow skin – Jaundice is the medical term for skin and eyes that look yellow. You might get jaundice if gallstones block your bile duct.

How do doctors find gallbladder problems?

Your doctor will probably order a test called an ultrasound. It shows the inside of the body using sound waves. You are awake during the test, and it does not hurt.

If you need more tests, you might have a CT scan or a test called a HIDA scan. The HIDA scan uses an injection of dye to show how well your gallbladder and bile duct are working.

How do doctors treat gallbladder problems?

Taking the gallbladder out is usually the best way to treat gallbladder problems. You might get some relief from changing your diet. For example, eating less fat can help. But gallstones rarely go away on their own.

You might have heard about treatments to break up gallstones or make them melt away (dissolve). Unfortunately, these do not usually work well.

What are the advantages of laparoscopic gallbladder surgery?

  • Smaller incision – Several small incisions, each less than one (1) inch long, instead of a 5- to 7-inch incision for open surgery.
  • Less pain than after open surgery.
  • Quicker recovery than open surgery – You might go home the same day you have your surgery. You can also go back to regular activities more quickly.

Is Laparoscopic Gallbladder Removal for You?

Laparoscopic gallbladder removal might be the right choice for you because it is the most common type of gallbladder surgery. It might not be an option if:

  • You have severe gallbladder problems, or
  • You had earlier surgery in your upper abdomen.

How is Laparoscopic Gallbladder Removal Done?

You will have general anesthesia for your laparoscopic gallbladder removal. This means you are asleep during surgery. When surgery is finished, the surgeon closes your incisions with tiny stitches, staples, surgical tape or glue. These disappear as you heal, so the doctor does not need to remove them later.

Once you are asleep, the surgeon makes an incision near your belly button and inserts a small device called a port. The port creates an opening that your surgeon can use to fill the abdomen with gas. This creates space to do the operation. Next, they insert a small camera through the port. The camera shows the surgery on a screen in the operating room. Once the surgeon can see clearly, they put in more ports to insert long, narrow instruments. Finally, they gently disconnect your gallbladder and take it out through one of the incisions. Most operations need 3 or 4 incisions, but some have more.

Your surgeon might use a surgical robot to do your operation. It is done the same way as the description above. Your doctor guides the robot instead of guiding the instruments by hand. This is commonly referred to as robotic surgery.

You might have a specialised X-ray of your gallbladder and bile duct during surgery. This X-ray can find gallstones in the common bile duct. If you have them, the surgeon might need to do additional procedures during the surgery or you might need another procedure to remove them later.

What are the Possible Complications of Laparoscopic Gallbladder Removal?

You will probably go back to normal activities within one week. Complications are problems that happen during medical care or after it. Most people who have laparoscopic gallbladder removal have few complications or none at all.

Complications of laparoscopic gallbladder removal (cholecystectomy) do not happen often. They can include bleeding, infection in the surgery area, hernias, blood clots and heart problems. A hernia is when a small amount of your gut (intestine) or other tissue bulges through the muscles that cover it.

You should also know that any surgery has the risk of hurting other body parts. This is not likely, but it is possible. Gallbladder surgery could hurt nearby areas such as the common bile duct, large intestine (colon) or small intestine. You might need another surgery if this happens. It is also possible that bile might leak into the abdomen after gallbladder surgery.

Most complications from gallbladder surgery are rare, which means they almost never happen. If you are concerned about any possible complication, ask your surgeon.

What Should I Expect After Gallbladder Removal Surgery (Cholecystectomy)?

Going Home

You can probably go home the day you have your surgery, or you might stay in the hospital overnight. You need to be able to drink liquids before you go home.

Will I Be In Pain?

You will feel some pain after surgery. Pain at the incision sites and in your abdomen is common. You might also have pain in your shoulders. This is from the air put into your abdomen during the operation. The shoulder pain should go away in 24 to 48 hours.

Your surgeon might prescribe a small amount of pain medicine to help you with pain. Many people recover from surgery without taking any pain medicine, but some will need it for a few days. If you have questions about the pain after surgery, ask the surgeon or your nurses. They should be able to tell you how long the pain will last and what to expect.

You might feel sick to your stomach (nauseated) or throw up (vomit) after your surgery. Having surgery and anesthesia can make this happen. You should feel better in a day or two. Tell your doctor or nurse if you keep vomiting or feeling nauseated.

Activities

You should be as active as your body allows. Doctors recommend walking. You can go up and down stairs on the day of your surgery. You can expect to feel a little better each day after going home. If not, please call your doctor.

You can probably go back to normal activity about a week after laparoscopic gallbladder removal.

If you do a physical job with heavy lifting, ask your doctor when you can go back to work. You can drive 24 hours after you had anesthesia if you are not taking narcotic pain medicines.

If you had open surgery with a large incision, you need more time to recover. You will probably need to stay in the hospital for a few days after surgery. Expect to go back to full activities in 4 to 6 weeks. You will probably recover more slowly in other ways, too. Your doctor can tell you what to expect.

When To See Your Doctor After Surgery?

You need to see your surgeon 2 to 3 weeks after surgery.

When To Call Your Doctor After Laparoscopic Cholecystectomy?

Be sure to call your surgeon or family doctor if you have any of problems below.

  • Fever over 101 degrees F (38.5 C)
  • Severe pain or swelling in the belly
  • Yellow skin (jaundice)
  • Feeling sick to your stomach or throwing up (nausea or vomiting) – Call your doctor if you cannot eat or drink.
  • Blood or pus coming from any of the small cuts in the surgery area – Or redness that spreads or gets worse.
  • Pain that your medicines do not help
  • Breathing problems or a cough that does not get better.

Glossary

  • Appendicitis. When the appendix becomes infected and inflamed, it may be removed (appendectomy).
  • Colon cancer and other gastrointestinal cancers. Surgery is done to remove cancerous tumors in the digestive system and parts of the digestive system that have cancer. For example, a surgeon may remove a tumor as well as part of the pancreas, liver or intestine with cancer.
  • Diverticular disease. A diverticulum is a small pouch or pocket in the colon (large intestine). Researchers are not sure why these develop. Sometimes they can become inflamed and cause pain (diverticulitis). This is often managed without surgery. If someone has a lot of diverticula that often become inflamed, the doctor may recommend bowel resection surgery to remove that part of the intestine. Sometimes, the diverticuli may cause bleeding
  • Hernia. A hernia is when a part of the body (like the intestine) comes through a hole or weak spot in the wall of muscle or connective tissue that’s supposed to protect it (like the abdomen). It doesn’t come through the skin, but a bulge may be felt under the skin that’s not supposed to be there. It can also be painful. Gastrointestinal surgeons can repair the hole or weak spot.
  • Inflammatory bowel disease (Crohn’s disease and ulcerative colitis). With inflammatory bowel disease, the immune system attacks the intestines and causes pain and inflammation. This can lead to damage in the intestine. Sometimes the damaged parts are removed and the healthy parts are reconnected. This is called bowel resection.
  • Rectal prolapse. Surgery is used to treat rectal prolapse, a condition in which part of the intestine comes through the anus.
  • Weight loss. Different types of bariatric surgery (for example, gastric bypass) may be done to treat obesity. This surgery is usually done by a specialist in bariatric surgery.
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