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The stomach andduodenum 235
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given either prior to surgery, to shrink a large
tumour in order to make it operable, or postoperatively to treat metastases or when complete resection was not possible.
Gastric lymphoma
Primary gastric lymphoma is rare, accounting for
about 5% of gastric tumours, but one of the commonest sites for ‘extracommon in men as in women and median age at
diagnosis is 60–65 years, except in patients with
human immunodeficiency virus (HIV), who develop
the disease earlier. It often presents with the same
non- specific signs of dyspepsia and vague epigastric
discomfort. Surgery, therefore, has a limited role in
the modern management of gastric lymphoma; it is
used for resection of locoregional disease if medical
treatment fails or in the emergency setting for bleeding or perforation.
nodal’ lymphoma. It is twice as
Gastroenteropancreatic
neuroendocrine tumours
(GEP-
Gastroenteropancreatic neuroendocrine tumours
(GEP- NETs) are classified into intestinal neuroendocrine tumours (previously termed ‘carcinoids’),
accounting for about two- thirds, and pancreatic
endocrine tumours, accounting for the remaining
oneallgastric neoplasms and are often discovered incidentally during upper GI endoscopy. Alternatively,
they may present with bleeding (iron deficiency anaemia or frank GI blood loss), abdominal pain or dyspepsia. Rarely, they present late with metastatic
disease and symptoms from the release of bioactive
substances.
NETs)
third. Gastric NETs make up just under 2% of
Eastern Asia (42 per 100 000, compared to 10 per 100
000in the UK). Approximately, 75% of all gastric carcinoma is diagnosed in Asia. Gastric carcinoma is the
third leading cause of cancer death in both sexes
worldwide, responsible for 10% of all cancer deaths.
Gastric cancer develops through a wellprecancerous cascade: from atrophic gastritis (AG)
to gastrointestinal metaplasia, low-
grade dysplasia and eventually carcinoma, with
highthe likelihood of progression increasing as this cascade advances.
established
grade dysplasia,
Aetiology andrisk factors
The risk factors for gastric cancer can be classified
into three groups:
Predisposing conditions
1
• Pernicious anaemia and AG, conditions where
achlorhydria is present.
Previous gastric resection (two- to threefold
•
increased incidence).
•
Chronic peptic ulcer (believed to give rise to
1% of gastric cancer cases).
Environmental factors
2
•
H. pylori infection. Seropositive patients (indi-
cating past or present infection) have a six- to
fold increased risk of gastric cancer.
nineHowever, fewer than 1% of those infected with
H. pylori will go on to develop gastric cancer.
•
Epstein- Barr virus (EBV) infection: it has been
estimated that 10% of gastric carcinomas are
associated with EBV.
Low socioeconomic status.
•
•
Smoking.
• Nationality: gastric cancer is much more common in Japan, although recent work suggests
that much of this excess is related to H. pylori.
The incidence declines in Japanese immigrants to America.
Genetic factors
3
•
Blood group A.
•
Hereditary non- polyposis colon cancer syn-
drome, associated with an increased incidence
of gastric as well as colon and other cancers.
Gastric carcinoma
It is the fifth most common carcinoma in the world,
although not as common in the UK where the incidence is falling. It is twice as common in men as in
women, with the highest geographical incidence in
Pathology
Macroscopic pathology
One- third diffusely involve the stomach; one- quarter
arise in the pyloric region; and the remainder are
236 The stomach andduodenum
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distributed fairly evenly throughout the rest of the
stomach.
There are three macroscopic appearances:
A malignant ulcer with raised, everted edges.
•
A polypoid tumour proliferating into the stomach
•
lumen.
•
Linitis plastica (the ‘leather- bottle stomach’)
caused by submucosal infiltration of tumour with
marked fibrous reaction. This produces a small,
thickened, contracted stomach without, or with
only superficial, ulceration; hence, occult bleeding is rare in this group.
Microscopic appearances
These tumours are all adenocarcinomas with varying
degrees of differentiation. Linitis plastica consists of
anaplastic cells arranged in clumps with surrounding
fibrosis.
Malignant change in a benign ulcer is suggested
when a chronic ulcer, with characteristic complete
destruction of the whole muscle coat and its
replacement by fibrous tissue and chronic inflammatory cells, has a carcinoma developing in its
edge.
supraclavicular nodes of Virchow
(Troisier’s sign
of the subpyloric and hepatic nodes may occur.
Bloodstream. Dissemination occurs via the portal
•
vein to the liver and thence occasionally to the
lungs and the skeletal system.
•
Transcoelomic spread. May produce peritoneal
seedlings, ascites and bilateral Krukenberg
tumours owing to implantation in both ovaries.
15
). At the pyloric end, involvement
14
on the left side
Clinical features
Symptoms may be produced by the local effects of the
tumour, by secondary deposits or by the general features of malignant disease.
Local symptoms
These are epigastric pain and discomfort, pain radiating into the back (suggesting pancreatic involvement), vomiting, especially with a pyloric or antral
tumour producing pyloric obstruction (see earlier in
this chapter) and dysphagia in tumours of the cardia.
The patient may also report a feeling of fullness after
eating little (early satiety). Occasionally, carcinoma of
the stomach may present with perforation or haemorrhage (melaena and/or haematemesis).
16
Early andadvanced gastric
carcinoma
Early gastric carcinoma is defined as adenocarcinoma limited to the mucosa or submucosa with or
without regional lymph node metastases. The term
‘early’ does not refer to the size or age of the lesion.
Gastric carcinoma infiltrating into the muscularis
propria and beyond is defined as ‘advanced’.
Spread
• Local. Spread is often well beyond the naked- eye
limits of the tumour, and the oesophagus or the
first part of the duodenum may be infiltrated.
Adjacent organs (pancreas, abdominal wall, liver,
transverse mesocolon and transverse colon) may
be directly invaded. A gastrocolic fistula may
develop.
• Lymphatic. Lymph nodes along the lesser and
greater curves are commonly involved. Lymph
drainage from the cardiac end of the stomach may
invade the mediastinal nodes and thence the
Symptoms fromsecondaries
(metastases)
The patient may first report with jaundice owing to
liver involvement or abdominal distension with
ascites.
General features
Anorexia (an extremely common presenting symptom), loss of weight and anaemia.
Examination may reveal features corresponding to
these three headings. Local examination may reveal a
mass in the upper abdomen. A search for secondaries
may show enlargement of the liver with or without
jaundice, ascites, enlarged, hard left supraclavicular
14
Rudolf Ludwig Karl Virchow (1821–1902), Professor of
Pathology in Würzburg and later Berlin, Germany.
15
Charles Émile Troisier (1844–1919), Professor of
Pathology, Paris, France.
16
Friedrich Krukenberg (1871–1946), Pathologist, Halle,
Germany. Described transcoelomic cancer spread, such as
gastric cancer metastasizing to the ovaries.
The stomach andduodenum 237
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nodes, or a palpable mass on pelvic examination due
to secondary deposits in the pouch of Douglas or
vesical pouch. There may be obvious signs of
rectoloss of weight or anaemia.
Paraneoplastic syndromes
Haemolytic anaemia, membranous glomerulonephritis and chronic disseminated intravascular coagulation leading to vascular thrombosis (Trousseau’s
17
sign
) are occasionally seen.
Special investigations
• Gastroscopy enables direct inspection and multiple biopsies of any lesion.
CT scan may show nodal and metastatic spread.
•
• EUS enables assessment of lymph node spread
and local tumour infiltration into pancreas, diaphragmatic crura and liver.
•
Staging laparoscopy allows assessment of the pri-
mary tumour, including its mobility and invasion
into adjacent organs, and examination of the peritoneal cavity to exclude small metastases (peritoneal or liver) that are not detectable by CT
scanning. If ascites is found, this can be sampled
for cytology. The presence of even small metastases means the patient has incurable disease.
It is important to note that considerable pain relief
may occur when a gastric carcinoma is treated with
acid suppression (H2inhibitors), owing to diminution in the adjacent
oedema, and may lead to a false diagnosis of benign
ulcer.
antagonists or proton pump
Differential diagnosis
There are five common diseases that give a very
similar clinical picture, of a patient with a slight
lemon- yellow tinge, anaemia and loss of weight:
Carcinoma of the stomach.
1
Carcinoma of the caecum.
2
3
Carcinoma of the pancreas.
Pernicious anaemia.
4
5
Uraemia.
17
Armand Trousseau (1801–1867), Physician, Hôpital
Necker, Hôpital St Antoine and Hôpital Dieu, Paris.
Noted this sign in himself as conrmation of his own
gastric cancer. He also described carpopedal spasm in
hypocalcaemic tetany.
They form an important quintet, and should always
be considered together in terms of appropriate special investigations.
Endoscopic gastric cancer
screening
Countries with a high prevalence of gastric cancer,
such as Japan, have implemented systematic screening programs and demonstrated the benefit of early
detection and endoscopic resection of precancerous
gastric lesions and early gastric cancers, offering
curative treatment with considerably less morbidity.
Japanese guidelines suggest biennial or triennial
endoscopic screening for those over the age of 50.
This approach could prevent up to 63% of gastric
cancer- related mortality.
In the UK, screening is recommended in patients
with multiple risk factors for gastric cancer (male,
smoker, pernicious anaemia, family history in first
degree relative) due to the lower incidence in the
population as a whole.
Treatment ofgastric cancer
Endoscopic treatment
• Endoscopic mucosal resection is the removal of a
mucosal lesion by resecting it from its deeper layers using a snare instrument. This method does
not allow for lesions larger than 2 cm to be
removed en bloc.
• Endoscopic submucosal dissection was devel-
oped for the local treatment of superficial early
gastric cancer limited to the mucosal layer or
with minimal invasion of the submucosal layer.
The main goal of submucosal dissection is to
retrieve the lesion en bloc for histopathological
staging and to minimize the chance for local
recurrence.
Gastrectomy
The three common types of gastrectomy for gastric
cancer are:
Total gastrectomy: this involves removal of the
1
whole stomach including the cardia (oesophagogastric junction) and the pylorus (Figure23.4a). It
is indicated for tumours arising at or invading the
proximal stomach.
238 The stomach andduodenum
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Oesophagus
1
Tumour
our
Stomach
Duodenum
1
3
Roux-en-Y
ou
oesophago-
es
jejunostomy
u
Pancreas
n
r
and ducts
nd ducts
4
(a)
a
Bililary limb
2
3
Jejunum
Common limb
limb
Jejuno-
Jeuno-
jejunostomy
unostomy
2
4
Proximal
stomach
Alimentary
limb
(b)
Figure23.4 The upper panel (a) illustrates a total gastrectomy with a Roux- en- Y reconstruction. The lower panel
(b)illustrates a subtotal gastrectomy with a Roux-
en- Y reconstruction.
2 Distal (subtotal) gastrectomy: this involves
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removal of the stomach including the pylorus but
preserving the cardia (Figure23.4b). Twomore of the stomach is usually removed for gastric
cancer.
3
Proximal gastrectomy: this involves removal of the
stomach including the cardia but preserving the
pylorus. It is indicated for proximal tumours with
or without oesophageal invasion, where more
than half of the distal stomach can be preserved.
thirds or
The stomach andduodenum 239
5-
year survival with resection. Invasion through the
muscle wall but not into adjacent organs, or involvement of more than two perigastric lymph nodes (stage
2) reduces survival to 35%, whereas a more advanced
local cancer with infiltration into surrounding tissues
or more distant nodal involvement (stage 3) has a
poorer survival rate. The presence of metastases
(stage 4) is associated with death before 5 years.
Prognosis
This depends on the extent of spread and degree of
differentiation of the tumour. Microscopic spread is
often much further than apparent at operation, and
lymph node spread has a poor prognosis. Early gastric
carcinomas confined to the stomach wall and no
more than two local lymph nodes (stage 1) have a 65%
Additional resources
Case 52: Vomiting in a baby
Case 53: A gastric ulcer
Case 54: A bloody vomit
Case 55. An acute abdominal emergency
Case 56: A serious gastric lesion
Case 57: A surgical specimen of stomach
2424
weight in kg
height in metres
:
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The surgery ofobesity
Christopher Pring
Learning objectives
✓ To recognize the link between obesity and health.
✓ To understand the evidence base with respect to treatment options for
obesity.
✓ To understand the three main surgical procedures for treating obesity.
Bariatric surgery refers to the surgical treatment for
obesity and its associated comorbidities. Bariatric
derives from the ancient Greek word baros, meaning
weight/pressure.
Given the effectiveness of bariatric surgery in
treating metabolic diseases (type 2 diabetes, hypertension, dyslipidaemia), bariatric surgery is also
referred to as ‘metabolic surgery’.
Obesity
Prevalence
It is widely acknowledged that there is a worldwide
obesity pandemic. Mean worldwide body mass index
(BMI) has been steadily increasing since 1975 and
tion will be classified as having obesity by 2030
(Box24.1). In the UK, 27% of the population is already
classified as having obesity.
The estimated healthcare spend on obesity in
2014/15was £6.1 billion, and this is projected to reach
£9.7 billion by 2050, with an estimated societal cost of
almost £50 billion.
Box 24.1 Classification ofobesity by body
mass index
Body mass index (BMI) is a function of a person’s
weight and height– i.e.
2
2
<18.5kg/m
18.5–25kg/m2 = normal weight
25–30kg/m2 = overweight
30–35kg/m2 = class I obesity
35–40kg/m2 = class II obesity
>40kg/m
= underweight
2
= class III obesity
Aetiology
Like all medical conditions, obesity is the cumulative
outcome of genetic and environmental influences.
There are very few genetically driven syndromes that
cause obesity (e.g. Prader–Willi syndrome
a handful of susceptibility genes have been identified
(e.g. MC4R, FTO). The doubling of the prevalence
1
) and only
Ellis and Calne’s Lecture Notes in General Surgery, Fourteenth Edition.
Edited by Christopher Watson and Justin Davies.
© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
Companion website: www.wiley.com/go/Watson/GeneralSurgery14
1
Andrea Prader (1919–2001) and Heinrich Willi (1900–
1971), Paediatricians, Kinderspital, Zurich. e condition
was rst described by John Langdon Down of Down
Syndrome description in 1887.
The surgery ofobesity 241
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2.5
Digestive and
pulmonary
2.0
1.5
Mortality ratio
1.0
0
Men
Women
Figure24.1 Relative risk of death from all causes according to body mass index.
dieases
Moderate Very
low
20 25 30
Body mass index, kg/m
Cardiovascular
Gallbladder
Diabetes mellitus
Low Moderate High Very
35 40
2
high
of any condition in less than 40 years cannot be
accounted for by a change in our genetic framework;
the only explanation can be environmental factors.
A fundamental shift in the availability/consumption of various foodstuffs (energy dense, micronutrientpoor foods) and changes in our physical environment
have created what is referred to as the ‘obesogenic
environment’.
Consequences ofobesity
Health and body weight are intricately linked. This
was established in a 1999 population study, clearly
demonstrating that mortality risk increases as BMI
increases (Figure 24.1). It is estimated that obesity
reduces life expectancy by 8–10 years.
Obesity is associated with higher risks of type 2 diabetes, cardiovascular disease, osteoarthritis, and
some cancers, among other conditions. Table 24.1
demonstrates this increased risk of disease states
once a person’s BMI > 30kg/m
2
.
Treatments forobesity
Conservative treatments
A common ‘throw away comment’ is that people who
suffer with excess weight (and its associated
comorbidities) need to eat less and move more. The
epidemiology of obesity tells us that this paradigm is
not working (worldwide prevalence continues to
increase).
Table24.1 Estimated increased risk forthe
obese ofdeveloping associated diseases
Disease
Type 2 diabetes 12.7 5.2
Hypertension 4.2 2.6
Heart attack 3.2 1.5
Colon cancer 2.7 3
Angina 1.8 1.8
Gall bladder
disease
Ovarian cancer 1.7
Osteoarthritis 1.4 1.9
Stroke 1.3 1.3
Relative risk
(women)
1.8 1.8
Relative
risk (men)
Robust scientific literature also demonstrates the
challenge of successfully implementing conservative treatments. The highly regarded Look AHEAD
study published in 2013 demonstrated that an
intensive programme of eat less, move more, plus
behavioural therapy did not result in sustained
weight loss or improved cardiovascular morbidity
and mortality. In fact after four years, 23% of participants weighed more than they did at the start
and only 20% of participants had lost 10% of their
body weight.
242 The surgery ofobesity
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Medical treatments
For the pharmaceutical industry, developing a tablet
that effectively controls weight is a huge prize. The
research and development funds available for this
quest are enormous. Our evolving understanding of
the link between body weight and gut hormones has
enabled the development of analogues that manipulate these gut hormones in order to support weight
loss. Currently however, the European Medicines
Agency has approved only three drug therapies (orlistat, bupropion/naltrexone and liraglutide).
Nonetheless, recent studies indicate that liraglutide
may offer reasonable efficacy.
Surgical treatment
Bariatric/metabolic surgery has evolved considerably
since its inception in 1954 (the jejunoand subsequently the gastric bypass first performed
by Mason in Iowa in 1966
scopic surgery in the early 1990s, alongside the publication of longprecipitated a paradigm shift in recognizing that surgery offers effective and low risk treatment for obesity
and metabolic disease.
The Swedish Obese Subjects study published in
2007 demonstrated that people with class II obesity
who underwent bariatric surgery had a 24% greater
chance of being alive after 15 years compared to those
who underwent standard non- surgical care. A
2021 meta- analysis has underscored the same finding, documenting that for people with type 2 diabetes
who underwent bariatric surgery, life expectancy
increased by 9.3 years compared to those with type 2
diabetes undergoing standard care. A further systematic review and meta- analysis observed that following
bariatric surgery, the relative risk reductions for the
development of type 2 diabetes, hypertension and
dyslipidaemia were 61%, 64% and 77%, respectively.
The evidence base to support bariatric surgery is
very strong. The National Institute for Health and
Care Excellence (NICE) recognized this by publishing
clinical guidance in 2014 (CG189). This supported
treatment with bariatric surgery for people with class
III obesity and for those with class II obesity who also
have a metabolic disorder. Despite the overwhelming
term surgical outcome data, have
2
. The advent of laparo-
ileal bypass)
evidence that surgery offers effective treatment, as
well as the recommendations of NICE CG189, fewer
than 1% of those who are eligible for bariatric surgery
in the UK actually receive it.
Mechanism ofaction
Essentially, all bariatric surgery works by reducing
absorption of calories from the intestinal tract. Our
understanding of the mechanisms by which this is
achieved is evolving, and includes:
Neuronal pathways.
•
• Hormonal changes.
• Alterations in the gut microbiome.
• Bile salt function.
The relative contributions of these mechanisms
varies between the different procedures. The three
main bariatric operations are gastric band, gastric
bypass and gastric sleeve (Figure 24.2). There are
other recognized bariatric procedures (biliopancreatic diversion; duodenal switch; one anastomosis
gastric bypass) but these are beyond the scope of this
chapter.
Gastric band
An adjustable band is placed around the proximal
aspect of the stomach to create a small pouch above
the band. The surgical complication rate for this procedure is so low that this is commonly performed as a
day case procedure. There is no manipulation of gut
anatomy and the band can be removed at any time
(itis reversible).
Weight loss for this procedure is in the order of 16%
total body weight. However, despite its simplicity,
safety and effectiveness, its popularity has recently
waned considerably due to the longband slipping, dysphagia, acid reflux and a high rate
of reoperation.
Gastric bypass
The main body of the stomach and the duodenum/
proximal small bowel are bypassed by stapling across
the proximal stomach in order to create a small
volume (20–30mL) gastric pouch. The gastric pouch
is reconnected to the gastrointestinal tract via a Roux
term risks of the
3
2
Edward Eatoon Mason (1920–2020), Surgeon, University of
Iowa. Considered to be the father of bariatric surgery.
César Roux (1857–1934), Professor of Surgery, Lausanne,
Switzerland. His other claim to fame was for the rst
successful adrenalectomy for a phaeochromocytoma.
The surgery ofobesity 243
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Roux-en-Y
gastric bypass
Figure24.2 The three common bariatric surgical procedures.
limb (sometimes called the alimentary limb) that is
measured to approximately 60–120 cm long. The
Roux limb is then reconnected to the bypassed duodenum/proximal small bowel (the biliopancreatic
limb). Classically, this operation is described as a
Roux- en- Y gastric bypass (the two prongs of the Y
being the Roux limb and biliopancreatic limb; the
stem of the Y being the common channel), similar to
the operation performed for the treatment of peptic
ulcer disease and distal gastric cancer.
Weight loss for this procedure is in the order of 31%
total body weight and there is significant amelioration
of the metabolic conditions (type 2 diabetes, hypertension, dyslipidaemia). Patients must take lifelong
vitamin supplements.
Gastric band
Sleeve gastrectomy
Worldwide, sleeve gastrectomy is now the most popular bariatric procedure. Approximately 85% of the
body of the stomach is resected to create a narrow
stomach sleeve, but the duodenum/small bowel is
left intact. Its simplicity, effectiveness and versatility
(in terms of future operative procedures) are key to its
popularity.
Weight loss for this procedure is in the order of 25%
total body weight and there is significant amelioration
of the metabolic conditions, although probably less
so than for gastric bypass.
Sleeve
gastrectomy
Complications of surgery
(seeBox24.2)
Laparoscopic bariatric surgery is now recognized to
be as safe as laparoscopic cholecystectomy, with
postoperative length of stay around 1–2 days.
Perioperative mortality is fewer than 1:1000 cases and
surgical complications are in the order of 2–3%
(bleeding, infection, staple line/anastomotic leak,
ulceration at the gastric pouch anastomosis, gastrooesophageal reflux).
In the long term, micronutrient deficiencies can
occur, but these are mitigated against by adherence to
daily multivitamin and mineral over-
Box 24.2 Complications ofbariatric surgery
1 Surgical complications.
a Staple line/anastomotic leaks.
b Gastric ulceration.
c Gastro- oesophageal reflux.
d Gallstone formation.
e Bolus intestinal obstruction.
f Failure, with regain of weight.
2 Nutritional deficiencies
a Vitamins: B12, folate, and the fat soluble
vitamins A, D, E and K.
b Chemical elements: calcium, copper, zinc and
iron.
the- counter
244 The surgery ofobesity
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supplements. Weight regain and re- emergence of
metabolic disease are also longthese are mitigated against by specialist input
(particularly from the dietitian). Nonetheless, it is
important to remember the evidence, that despite the
risk of weight regain, people who undergo bariatric
surgery have a survival advantage when compared to
those who follow non-
surgical treatments.
term risks, but again
The decision as to which procedure is best suited to
which patient is based upon multidisciplinary team
assessment. The opinions, experience and support of
bariatric physicians, dietitians, psychologists, anaesthetists and surgeons ensure that the right patients receive
the right treatments. In the face of a continued obesity/
metabolic epidemic, the application of bariatric surgery
is now well-
established and evolving quickly.
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