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An Internist’s Illustrated Guide to
An Internist’s Illustrated Guide to
Gastrointestinal
Gastrointestinal
Surgery
Surgery
Edited by
Edited by
George Y. Wu,
George Y. Wu,
Khalid Aziz,
Khalid Aziz,
Giles F. Whalen,
Giles F. Whalen,
Illustrations by
Illustrations by
Lily H. Fiduccia
Lily H. Fiduccia
MD, PhD
MD, PhD
MBBS, MRCP
MBBS, MRCP
MD, FACS
MD, FACS
AN INTERNIST’S ILLUSTRATED GUIDE TO GASTROINTESTINAL SURGERY
CLINICAL GASTROENTEROLOGY
George Y. Wu, MD, PhD, SERIES EDITOR
An Internist's Illustrated Guide to Gastrointestinal Surgery, edited by
George Y. Wu,
Inflammatory Bowel Disease: Diagnosis and Therapeutics, edited by
Russell D. Cohen,
Acute Gastrointestinal Bleeding: Diagnosis and Treatment, edited by Karen
E. Kim, MD, 2003
Diseases of the Gastroesophageal Mucosa: The Acid-Related Disorders,
edited by James W. Freston, MD, PhD, 2001
Chronic Viral Hepatitis: Diagnosis and Therapeutics, edited by Raymond
S. Koff, MD, and George Y. Wu, MD, PhD, 2001
MD, PhD, Khalid Aziz, MBBS, and Giles F. Whalen, MD, 2003
MD, 2003
AN INTERNIST’S
ILLUSTRATED GUIDE
TO GASTROINTESTINAL
SURGERY
Edited by
GEORGE Y. WU, MD, PhD
KHALID AZIZ, MBBS, MRCP (UK), MRCP (IRE), FACG
GILES F. W HALEN, MD, FACS
University of Connecticut Health Center, Farmington, CT
Foreword by
TADATAKA YAMADA, MD
GlaxoSmithKline, King of Prussia, PA
With illustrations by
LILY H. FIDUCCIA
HUMANA PRESS
TOTOWA, NEW JERSEY
© 2003 Humana Press Inc.
999 Riverview Drive, Suite 208
Totowa, New Jersey 07512
www.humanapress.com
All rights reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any
means, electronic, mechanical, photocopying, microfilming, recording, or otherwise without written permission from the
Publisher.
Production Editor: Tracy Catanese.
Cover Illustration: From Figs. 1 and 2 in Chapter 1, “Esophagectomy and Reconstruction” by Michael Kent, Jeffrey Port, and
Nasser Altorki; Fig. 3 in Chapter 11, “Surgery for Obesity” by Carlos Barba and Manuel Lorenzo; and Fig. 4 in Chapter 25,
“Transjuglar Intrahepatic Portosystemic Shunt” by Grant J. Price.
Cover design by Patricia F. Cleary.
For additional copies, pricing for bulk purchases, and/or information about other Humana titles, contact Humana at the above
address or at any of the following numbers: Tel: 973-256-1699; Fax: 973-256-8341; E-mail: humana@humanapr.com or visit
our website at www.humanapress.com
Due diligence has been taken by the publishers, editors, and authors of this book to assure the accuracy of the information published
and to describe generally accepted practices. The contributors herein have carefully checked to ensure that the drug selections and
dosages set forth in this text are accurate and in accord with the standards accepted at the time of publication. Notwithstanding, as new
research, changes in government regulations, and knowledge from clinical experience relating to drug therapy and drug reactions
constantly occurs, the reader is advised to check the product information provided by the manufacturer of each drug for any change
in dosages or for additional warnings and contraindications. This is of utmost importance when the recommended drug herein is a
new or infrequently used drug. It is the responsibility of the treating physician to determine dosages and treatment strategies for
individual patients. Further it is the responsibility of the health care provider to ascertain the Food and Drug Administration status of
each drug or device used in their clinical practice. The publisher, editors, and authors are not responsible for errors or omissions or
for any consequences from the application of the information presented in this book and make no warranty, express or implied, with
respect to the contents in this publication.
This publication is printed on acid-free paper. ∞
ANSI Z39.48-1984 (American National Standards Institute)
Permanence of Paper for Printed Library Materials.
Photocopy Authorization Policy:
Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by
Humana Press, provided that the base fee of US $20.00 per copy is paid directly to the Copyright Clearance Center at 222
Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license from the CCC, a
separate system of payment has been arranged and is acceptable to Humana Press Inc. The fee code for users of the Transactional
Reporting Service is: [1-58829-023-9/03 $20.00].
Printed in the United States of America. 10 9 8 7 6 5 4 3 2 1
Library of Congress Cataloging-in-Publication Data
An internist's illustrated guide to gastrointestinal surgery / edited by George Y. Wu ... [et al.].
p. ; cm. -- (Clinical gastroenterology)
Includes bibliographical references and index.
ISBN 1-58829-023-9 (alk. paper); 1-59259-389-5 (e-book)
1. Gastrointestinal system--Surgery. I. Wu, George Y., 1948- II. Series.
[DNLM: 1. Digestive System Surgical Procedures--methods. WI 900 I598 2003]
RD540 .I586 2003
617'.43--dc21
2002038763
DEDICATION
This book is dedicated to my students, whose questions prompted the writing, my
family, whose patience permitted its creation, to Sigmund and Jenny Walder, who
have supported and encouraged us in all of our academic endeavors, and to Herman
and Frances Lopata and their family, whose generosity toward our research has made
available the time to devote to this book.
G. Y. W.
To the memory of my parents, whose guidance has provided me with inspiration
for all of my accomplishments in life.
K. A.
To my teachers who have inspired me by their example, to my students who teach
me still by their questions and curiosity, to my patients whose lessons I have tried to
absorb, and to my family whose patience and tolerance of these endeavors make it
all worthwhile.
G. F. W.
v
FOREWORD
Few clinical disciplines have been transformed so dramatically by advancements
in science and technology as gastrointestinal surgery. To begin with, modern pharmacology has virtually eliminated some kinds of surgery altogether. If one were to
take a peek at a typical operating room schedule in a busy hospital of the 1960s,
gastrectomies of one kind or another would have constituted a large block of the
major surgeries. The advent of effective H2-histamine receptor antagonists and, more
recently, the H
those procedures such that they are rarely performed today. Exciting new approaches
to treating inflammatory bowel diseases and their complications—such as fistulas—
with anticytokine therapy may one day have a similarly profound effect on surgery
for this condition as well.
Beyond pharmaceutics, advances in imaging techniques have greatly facilitated
the identification and characterization of pathology in the gastrointestinal tract in a
way that would have been unimaginable only a few years ago. Just to visualize the
pancreas in some way was a horrendous task until abdominal ultrasound, magnetic
resonance imaging, or computer tomography made it simple. The fact that the gut is
a hollow organ that can be accessed through the mouth, anus, or even through the
wall of the abdomen has been fully exploited with fiberoptic endoscopes that can
bend around corners with ease and permit surgery to be conducted through them.
Many physicians have earned their spurs in the operating room by laboriously hanging on to a Deaver retractor while a surgeon deftly removes a patient’s gallbladder.
Today, of course, laparoscopic surgery has virtually eliminated open cholecystectomy and threatens to make other complex surgeries, such as fundoplication or colectomy, obsolete. Other advanced technologies, such as transhepatic intravenous
porta-systemic shunts, have practically converted dangerous and difficult operations
to relieve portal pressure in liver disease to an outpatient procedure.
Despite these amazing advances, today’s surgeon may still be called on to per-
form virtually all of the operations that have been performed for years, some even
for centuries. Gastrectomies, cholecystectomies, fundoplications, colectomies, and
porta-caval shunts all have to be performed on patients. The surgeon of today must
be equally adept at performing traditional abdominal surgery as well as surgery
through scopes, percutaneous wires, and the like.
The transformation that surgeons have had to make in the recent past has also
necessitated change in the internist’s practice. To begin with, the internist now has
many options to choose from in treating patients with abdominal illnesses. It is
important for the internist to understand the advantages and limitations of the different therapeutic approaches that might be taken. Thorough discussion and collaboration of an internist with the surgeon, both being well-informed on the approaches to
therapy, will inevitably provide the best outcome for the patient. Beyond initial
+,K+
-ATPase (proton pump) inhibitors led to a precipitous decline in
vii
viii Foreword
therapy, the internist almost certainly sees patients who have undergone various
surgical procedures. It goes without saying that internists must be adept at handling
the sequelae of surgery, some of which may have profound effects on normal physiological function.
An Internist’s Illustrated Guide to Gastrointestinal Surgery by Wu, Aziz, and Whalen
is directed at educating the internist on the common surgical approaches to gastrointestinal disorders. It is carefully written in language that would have meaning to an internist. In a logical way, each topic is approached from the standpoints of pathophysiology,
diagnostic evaluation, treatment, and sequelae. Each chapter is accompanied by clear
and simple diagrams that depict the essentials of the operation performed. The book
covers both the “old surgery” of gastrectomies, colectomies, and cholecystectomies,
as well as the “new surgery” of shunts, laparoscopic procedures, and TIPS. It is meant
not only for the practicing internist but is equally appropriate for all students or other
trainees in medicine who are bound to see patients who undergo surgery for gastrointestinal illness. An Internist’s Illustrated Guide to Gastrointestinal Surgery should not
only provide the reader with an understanding of the science and practice of gastrointestinal surgery, but also equip the reader with the tools to be a better physician.
Tadataka Yamada,
MD
Adjunct Professor
Department of Internal Medicine
University of Michigan Medical School
Chairman, Research and Development
GlaxoSmithKline
PREFACE
In general, primary care providers, family practitioners, and gastroenterologists
have a limited knowledge of abdominal surgical operations, the medical aspects of
these surgical procedures, and their immediate and late complications. In addition,
these patients traditionally are not followed up by the surgeons, and thus the internist
must become familiar with postsurgical problems in order to provide appropriate
long-term care. A clear understanding of the concepts that underlie the surgery is
crucial for proper management of these patients.
In addition, within the last 10 years, laparoscopic surgery has become increasingly
commonplace, with new laparoscopic procedures being developed at a rapid pace.
There are vast differences between traditional and laparoscopic surgery, not only in
the way these procedures are performed, but also in their outcomes and complications.
Many internists, as well as surgeons, have very limited understanding of these procedures. Therefore, the need exists for a book that can provide useful clinical information in an easy to access format, covering a variety of abdominal surgical procedures.
Almost all surgical books provide great detail about the technical aspects of surgi-
cal procedures and their surgical complications. However, the physician who needs
to manage the patient who has undergone gastrointestinal (GI) surgery, currently
must go through surgical texts to find the disease, and then the type of surgery the
patient has undergone, wading through pages of details about the surgical procedure,
without dealing with the issues relevant to the medical management of the patient.
Thus, it is currently difficult for the nonsurgically trained physician to extract the
relevant medical information. An Internist’s Illustrated Guide to Gastrointestinal
Surgery is a comprehensive textbook describing all of the surgical and laparoscopic
procedures for the GI tract in a simple way, with artistic illustrations to educate the
physician about surgery of the GI tract, and to provide not only clear descriptions of
the changes in the anatomy and physiology, but also advice on medical management
of the postsurgical patient.
An Internist’s Illustrated Guide to Gastrointestinal Surgery describes in detail
the indications, contraindications, anatomical alterations, and physiological alterations that result from various GI operations and procedures. Comparison between
alternative operations, complications, medical management issues, and costs of these
surgical procedures and operations are discussed. Clear, detailed, artist-rendered
illustrations of the anatomy before and after surgery are included and, where appropriate, radiological images before and after surgery.
This is a unique textbook, written primarily for primary care physicians, general
internists, and gastroenterologists to educate them about those aspects of GI surgery—including laparoscopic surgery—that are pertinent to an internist. It should
also be a suitable textbook for medical students, residents, nurses and nurse practitioners, nutritionists, dietitians, and various subspecialists, who often take care of
postsurgical patients.
ix
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