University Health System Blog

Dr. Shawn Tsuda answers the question: “I have acid reflux. How do I know if I’m a good candidate for surgery?”

Gastroesophageal reflux disease, also known as GERD, is a common problem and can affect people’s lives from occasional mild discomfort to severe, disruptive pain. The potential complications include erosive esophagitis, increased risk for esophageal cancer, strictures impairing swallowing and the cost of medications used over years.

The majority of patients can control their symptoms with lifestyle changes, such as avoiding foods that cause reflux, not eating too close to going to bed, sleeping with one’s head up, as well as, medications, primarily H2 blockers and proton pump inhibitors.

However, some patients may have already developed complications from GERD or are refractory to even the most aggressive medication regimens. In other cases, a hernia of the stomach through the diaphragm, called a hiatal hernia, may be a contributing factor. For these patients, surgery may be the best option.

After appropriate studies that involve examining the acidic levels of the stomach and the function of the esophagus, a laparoscopic procedure called a Nissen fundoplication can be performed.  This involves wrapping the top of the stomach around the esophagus, preventing acid reflux.

This procedure can be successful up to 90 percent of cases.

Shawn Tsuda, M.D. is vice chief for bariatric surgery at University Health System and the University of Nevada School of Medicine in Las Vegas. Dr. Tsuda completed his fellowship training in minimally invasive and bariatric surgery at Harvard Medical School. He is board certified in general surgery and consults patients at the school’s Patient Care Center in Las Vegas.

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Dr. Jay Coates answers the question: “What can I expect before and after surgery?”

Few events in life create as much anxiety as having to undergo surgery. To help allay some of your anxieties with ‘going under the knife’ I’d like to offer some general guidelines for undergoing surgery with general anesthesia.

Consent

First of all, before surgery, you must have informed consent. Sounds obvious but some patients may feel too intimidated to ask their surgeon basic questions. What procedure is being preformed? Why is it necessary? Who will be doing it? What are the risks and complications associated with this surgical procedure? Surgery should not be taken lightly. Every surgical procedure has potential risks and complications. Among the most common are bleeding, infection and problems with general anesthesia. Your surgeon and you should review these risks and you should fully understand these risks before undergoing the procedure.

Pre-op clearance

The pre-op clearance answers the surgeon’s basic question of whether the patient is healthy enough to tolerate the surgery. If you’re young and in good general health the surgeon may clear you through with a physical exam. If you’re older or have health problems, your surgeon may want medical clearance from your internist or cardiologist. Your doctor will submit a medical report to your surgeon that indicates what risks, if any, you may encounter while undergoing the physical stress of surgery. If the risks are high your surgeon will discuss these with you and decide whether surgery should still be preformed or if an alternative treatment is a better option.

The night before

No food or drink after midnight the night before the day of the surgery. Patients often wonder why they can’t eat anything past midnight. The answer’s simple actually.

If you’re receiving general anesthesia, you’ll be intubated, meaning you’ll have a breathing tube placed during surgery. The medications that you’ll be given and the intubation procedure itself, could cause you to reflux what you ate the night before. If this happens you can experience aspiration while you’re under, meaning food or liquid from your stomach can come up and then go down the wrong pipe (trachea) and into your airways, possibly causing aspiration pneumonia. The risk of getting aspiration pneumonia is greatly reduced by having your stomach empty. You may have to take pre-operative antibiotics the night before or morning of surgery and perhaps even for a day or so after. These help reduce the chance of infection. There may also be some medications that you’re currently on which you must stop taking from the night before to two weeks before surgery. For instance, you shouldn’t take aspirin 10 days before surgery as it interferes with platelet function, as platelets help your blood clot.

Checking-in

The day of surgery you’ll need to check into the pre-op area of your hospital or surgical center. The nurses will have you change into a gown, place an ID bracelet on you, review any general questions you may have and check your informed consent document and medical clearance. You should be interviewed by your anesthesiologist, who will place you under general anesthesia and intubating you. You’ll repeat a lot of the same information to many different people but this repetition helps to eliminate mistakes. Your surgeon will usually see you before you go to the operating room. If you’re having a procedure like a breast biopsy or hernia repair, you may be asked several times by different people what side of your body the surgery is being done. Again this repetition helps cut down on medical error.

Regardless of the surgical procedure, you should feel confidence in your surgeon and have all your questions answered before surgery. The most common source of conflict between a patient and a doctor is lack of communication. If you don’t feel confident in your surgeon or your questions aren’t being answered, you should look for a second medical opinion and find a surgeon who will take the time to help you understand.

Jay Coates, D.O. is an assistant professor of surgery at the University of Nevada School of Medicine and vice chair of trauma surgery at University Medical Center in Las Vegas.

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Dr. Shawn Tsuda answers the question: “Laparoscopic gastric bypass versus the laparoscopic adjustable gastric band: Is one or the other better for long term weight loss results?”

The number of weight loss procedures performed over the past ten years has increased by more than a ten-fold in the U.S., exceeding 200,000 operations in 2006. The laparoscopic Roux-en-Y gastric bypass, which provides both restriction and malabsorption of food intake, is still considered the gold standard operation for long-term weight loss.

However, the laparoscopic adjustable gastric band, which uses one of two FDA approved devices for primary restriction of food into the gastrointestinal tract, is the second most commonly performed procedure and is quickly gaining in popularity. There is an abundance of data that supports both the gastric bypass and laparoscopic adjustable gastric band as safe (but not risk-free) procedures with sustainable weight loss and a positive impact on obesity-related diseases such as diabetes mellitus, hypertension and obstructive sleep apnea. (Learn more about weight loss surgery procedures from the U.S. National Library of Medicine).

The amount of weight loss that can be expected on average for the gastric bypass ranges between 60 and 80 percent of excess weight loss, or loss of weight beyond a calculated ideal body weight. The laparoscopic adjustable gastric band has a wider spectrum of success, ranging between 30 and 70 percent of excess weight loss.

Both operations are endorsed by most professional medical societies as acceptable treatments for the severely obese. The choice of operation depends on the patient’s preference, along with his or her surgeon’s counseling on any specific contraindications to either of the operations. An informed decision is essential to undergoing any weight loss procedure.

Shawn Tsuda, M.D. is vice chief for bariatric surgery at the University of Nevada School of Medicine, in Las Vegas, Nevada. Dr. Tsuda completed his fellowship training in minimally invasive and bariatric surgery at Harvard Medical School. He is board certified in general surgery.

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Dr. Shawn Tsuda answers the question: “I’ve heard a lot about minimally invasive surgery. What exactly is it?”

Minimally invasive surgery refers to operations performed with small scars. Typically this can be accomplished laparoscopically, or with the use of a tiny camera and long, narrow instruments. The advantages of minimally invasive surgery include less post-operative pain and quicker recovery. The cosmetic result is also more favorable.

The vast majority of weight loss procedures such as the Roux-en-Y gastric bypass and the adjustable gastric band are performed laparoscopically, along with common procedures like gallbladder removal and hernia repairs.

Recently researchers have been looking into performing “scarless” surgery, also known as natural orifice and transluminal endoscopic surgery (NOTES) or single-incision laparoscopic surgery, through a tiny hole in the belly button. Although these advanced techniques are still in development and not widely performed, it is likely we will continue to see more surgery performed with either reduced scars, one single scar in the belly button, or no scars at all.

Shawn Tsuda, M.D. is vice chief for bariatric surgery at the University of Nevada School of Medicine, in Las Vegas, Nevada. Dr. Tsuda completed his fellowship training in minimally invasive and bariatric surgery at Harvard Medical School. He is board certified in general surgery.

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Dr. John Gosche answers the question: “My child has continuous abdominal pain. How do I know if she needs surgery?”

Thankfully most children won’t need to meet me in my role as a pediatric surgeon. But unfortunately a small number of kids have a medical condition requiring surgical care. In today’s post, I’m going to cover the typical presentation and symptoms related to three abdominal conditions that may need surgery: appendicitis, volvulus and intussusception.

Appendicitis

The appendix is a non-essential structure attached to the part of the colon known as the cecum, usually located in the right lower portion of the abdomen. Inflammation of the appendix, or appendicitis, is the most common reason for emergency surgery in children. The lifetime risk of appendicitis is about nine percent for boys and seven percent for girls.

Appendicitis most commonly develops in children 12 to 18 years old but can develop at any age. Appendicitis happens when the lumen of the appendix becomes blocked, causing a build-up of secretions and pressure inside the appendix, which leads to bacterial growth, tissue swelling, inflammation and ultimately impairment of the blood supply to the appendix’s wall. Appendicitis commonly causes abdominal pain, nausea, vomiting, a loss of appetite and low-grade fever. The abdominal pain associated with appendicitis classically begins as a poorly localized mid-abdominal pain followed minutes or hours later by sharp pain that localizes to the right lower portion of the abdominal wall.

Unfortunately many experience less typical symptoms of appendicitis and as a result, appendicitis can be a difficult diagnosis to confirm. Early diagnosis and treatment is key to decreasing the risk of serious complications. In many cases findings during a physical exam and simple blood tests will help confirm a diagnosis, although some children may require x-rays as well.

Volvulus

Volvulus is twisting of the intestine that frequently impairs blood supply to the affected area of the intestine. Volvulus is commonly associated with malrotation, when the intestine doesn’t position normally in a child’s abdomen during development, causing the base of the intestine to be narrowed and making the intestine prone to twisting. Malrotation may not cause symptoms before twisting. Usually volvulus happens in the first weeks of life. Midgut volvulus however can happen at any age including before birth or later in life. Common symptoms include vomiting yellow or green discharge, abdominal pain in older children or irritability in infants.

Later symptoms include extreme sleepiness and blood in the stool. Early diagnosis and treatment are critical to prevent permanent injury or loss of the intestine. Unfortunately, the symptoms may be nonspecific and may be due to other less life threatening conditions. Prompt medical evaluation however should be sought when a child develops bilious emesis and severe abdominal pain. A special radiographic study called an upper gastrointestinal contrast series can help diagnose malrotation.

Intussusception

An intussusception is movement of one segment of the intestine into an adjacent segment. In intussusception the trapped bowel becomes swollen and its blood supply is compromised. This condition most commonly occurs in five to nine month old infants. Often an intussusception will follow gastroenteritis or an upper respiratory tract infection. The classic symptom of intussusception is episodic, severe abdominal pain. Affected infants frequently scream in pain and draw up their legs during an episode lasting a few minutes then seem normal between episodes.

Other symptoms include vomiting that may become bilious, passage of blood through the rectum and lethargy. The symptoms can be nonspecific but a history of severe, episodic abdominal pain should be a concern. Parents should seek medical advice. A special radiographic test called a contrast enema can confirm the diagnosis and in many cases can be used to push back or reduce the intussuscepted intestine, avoiding the need for surgery. The success rate with contrast enema reduction depends on early recognition and treatment.

Summary

Abdominal conditions requiring emergency surgical care are uncommon in children. Unfortunately many of these conditions may present with symptoms difficult to distinguish from less life-threatening illnesses. Severe or persistent abdominal pain, especially pain that has a unique pattern or associated with bilious vomiting, should raise concern about a potentially serious problem and should prompt immediate medical attention.

John Gosche, M.D., Ph.D. has practiced medicine for more than 20 years. He is professor and chief of the pediatric surgery division at the University of Nevada School of Medicine. Dr. Gosche is board certified in general surgery and pediatric surgery. He practices in Las Vegas.

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