Current and Future Developments in Surgery

Dyspepsia describes a constellation of symptoms centred in the upper abdomen. In functional dyspepsia, no discernible organic pathology is found. Diagnosis and management of these patients are challenging but centred on individual symptom management. In organic dyspepsia, patients are found to have a number of disorders to account for their symptoms. These include gastritis and peptic ulceration. Gastritis refers to a group of diseases characterized by inflammation of the gastric mucosa. It can be acute or chronic in nature and may involve part or all the stomach. H. pylori infection gives rise to Type B atrophic gastritis where the inflammatory changes are accompanied by atrophy and intestinal metaplasia. There is an increased risk of intestinal type gastric cancer. Other types of gastritis are less common. Peptic ulcer disease and its complications remain a significant cause of morbidity and mortality. It is most commonly caused by H. pylori infection or the use of non-steroidal antiinflammatory drugs. Management involves the use of PPIs together with eradication therapy of H. pylori. The management of perforation and gastric outlet obstruction is mainly surgical. The management of upper gastro-intestinal bleeding consists of resuscitation and haemostasis mainly by endoscopic therapy. In-hospital mortality from bleeding peptic ulcers remains high. Acute gastric dilatation and gastric volvulus are surgical emergencies. The management must commence early by resuscitation followed by prompt surgical management. Mortality remains high in vulnerable and compromised patients.

Oesophageal motility disorders are notoriously difficult to diagnose and manage. They often manifest as dysphagia, regurgitation or chest pain. Oesophageal manometry is the primary investigation. High-resolution manometry refines the discrimination between different disorders and improves the diagnostic yield. Oesophageal motility disorders can be either primary or secondary to a number of systemic diseases such as diabetes. The main primary disorders include achalasia, diffuse spasm, nutcracker oesophagus and sphincter abnormalities. Pharmaceutical treatment is largely unsuccessful. Endoscopic treatments using pneumatic dilatation or botox injections provide short-term relief of dysphagia. Surgery should be considered for young and fit individuals. Gastroparesis is a chronic motility disorder of the stomach, which encompasses delayed gastric emptying in the absence of a fixed mechanical obstruction of the pylorus or duodenum. Symptoms include early satiety, nausea, bloating, vomiting, abdominal pain and weight loss. Diagnostic evaluation requires an initial endoscopy to rule out mechanical causes, followed by a gastric-emptying scintigraphy for diagnosis. Gastroparesis can be primary or secondary. Management includes dietary modification, pharmacological agents, endoscopic botox injections to pylorus, gastroenterostomy and gastric electrical stimulation. Most patients continue to be symptomatic despite all management modalities.

Oesophageal cancer is the eighth most common cancer and the sixth most common cause of death from cancer. Histologically, oesophageal cancers are composed mainly of two variants: squamous cell cancer and adenocarcinoma of the oesophagus. Benign tumours are rare. The aetiology of squamous cell cancer is largely unknown but adenocarcinoma progresses from Barrett’s oesophagus. Diagnosis is by endoscopy and staging is done by a combination of CT, EUS and PET/CT. Many tumour markers have been elucidated and their potential importance in diagnosis and treatment is actively pursued. Endoscopic therapy is appropriate for node negative patients with early cancers limited to the mucosa. Less than 30% of all patients with oesophageal cancer are suitable for curative treatment. Surgical treatment by oesophagectomy is appropriate for medically fit patients with T<4, N<3 and M<1 tumours. Neoadjuvant therapy (chemoradiotherapy or chemotherapy) is advocated for all tumour types. The management of patients with locally advanced or metastatic oesophageal cancer and patients with poor general medical condition must be individualised based on stage, characteristics of the tumour, patient’s medical condition and patient preference. The aim of palliative treatment is to achieve rapid and sustained relief of dysphagia. Chemotherapy alone or in combination with radiotherapy should be considered with other palliative measures. Canalisation of the tumour and restoration of swallowing is best achieved using self-expanding metallic stents. Best supportive care may be appropriate in frail patients with advanced disease at presentation.

Neoplasms of the stomach may be benign or malignant. Gastric cancer is the fourth most commonly diagnosed cancer and the second most common cause of cancer-related death worldwide. Gastric carcinogenesis is probably a multi-step process based on a model referred to as the Correa Cascade. It progresses mainly from H. pylori induced chronic gastritis. Diagnosis is by endoscopy and biopsy. CT and laparoscopy are required for adequate staging. Endoscopic mucosal resection or surgery, are the standard treatment options for Tis, T1 early gastric cancer. No further treatment is necessary if there is no residual or nodal disease. Subtotal or total gastrectomy with regional lymphadenectomy is the standard surgical treatment for early stage gastric cancer with lymph node metastases. In many parts of the world, multi-modality treatment using chemotherapy or chemoradiotherapy (either following surgery or combined pre-operative and post-operative administration) is the preferred treatment strategy. In very advanced cases, a number of clinical trials have produced evidence that chemotherapy improves survival in comparison to best supportive care in selected patients. Gastro-intestinal stromal tumours are responsible for 2.2% of malignant gastric tumours without any gender preference. They have a much better prognosis than adenocarcinoma of the stomach. The incidence of gastric neuroendocrine tumours is constantly rising. The majority of gastric NETs have a benign course and asymptomatic behaviour. Primary gastric lymphoma originates from the gastric wall or from the adjacent lymph nodes. The primary treatment is oncological.

In current clinical practice the majority of patients diagnosed with oesophageal or gastric cancer have metastatic disease at the time of diagnosis. In order to manage these patients successfully, effective systemic treatments are necessary and the impact of these systemic therapies in reducing tumour burden, improving symptoms, quality of life and extending survival in the palliative setting are allimportant. Given the early propensity of these cancers to progress and the potential for dissemination, even in patients with early cancers, local and systemic therapy must be considered along with surgery. The concept of multi-modal treatment is at a welldeveloped stage in oesophago-gastric cancer treatment and best exemplified by neoadjuvant chemo-radio therapy for oesophageal cancer. Adjuvant therapy remains an option in locally advanced cancers. Similar treatments can be used for recurrent disease. Systemic treatments for oesophageal and gastric cancer have evolved from cytotoxic chemotherapies to the more recent emergence of rationally designed targeted therapies which act by inhibiting specific molecular drivers of oncogenesis. They are often used in combination with predictive biomarkers that identify those patients most likely to respond- the precision medicine strategy. Despite their cost, their benefits include reduced toxicity and increased efficacy

The application of endoscopic resection (ER) and endoscopic submucosal dissection (ESD) to gastrointestinal (GI) early neoplasms is limited to lesions with limited depth of invasion with no risk of nodal metastasis. Endoscopic electrosurgical knives are used in combination with high frequency electrosurgical current. Radiofrequency ablation (RFA) is the modality of choice for dysplastic lesions due to its efficacy and low side effect profile. ER and RFA could be used together in combination with encouraging results. Acute upper gastrointestinal bleeding (UGBI) is a common medical emergency and has an average 10% in-hospital mortality rate. A risk stratification score should be calculated and used to guide subsequent management. Endoscopic therapy can be categorized into injection therapy, thermal coagulation, and mechanical haemostasis. The optimal choice of the endoscopic technique depends on the bleeding source, the endoscopists’ skills, the available equipment, the patient's clinical condition and costs. Endoscopic stenting has become the palliative treatment of choice for many patients with malignant oesophageal obstruction. However, the procedure is associated with a high incidence of complications. Stenting is widely used as a first line treatment option in patients that are not suitable for surgery and those with limited survival. Stents consist of a flexible framework of wire mesh, and are either uncovered or covered. Some have anti-reflux valves as an option.

Obesity is a complex multi-system disorder, which is increasingly recognized as one of the greatest challenges faced by health care systems throughout the world. Obesity is classified on the basis of both the BMI and the fat distribution. Surgical bariatric procedures can achieve up to 50% weight loss and this is sustained for a longer period of time. The procedures, although not without risk, are relatively safe with low morbidity and mortality rates. A key marker for increased risk of perioperative complications is central obesity. The presence of obstructive sleep apnoea is an independent marker of risk that leads to the doubling of postoperative respiratory and cardiac complications. Obese patients will have a markedly different volume of distribution of drugs as a result of the adipose tissue. To compensate for these changes drug dosing in obese patients is based on a combination of adjusted body weight, total body weight, ideal body weight and lean body mass. Adequate time and preparation is essential to provide safe conditions to anaesthetise obese patients. There are specific considerations for the intra-operative anaesthetic management of obese individuals, which need to be adhered to for the safe conduct and reversal of anaesthesia. Most patients presenting for bariatric surgery can be discharged to a ward environment. However, some patients carry an increased risk and as such may be required to be cared for in a high dependency or an intensive care unit. In addition, a number of patients may require specific measures for safe hospital discharge.

Obesity is a complex condition, one with serious social and psychological dimensions, that affects virtually all age and socioeconomic groups. It is a consequence of abundance, convenience and underlying biology. Preventing obesity requires changes in the environment and organisational behaviour, as well as changes in groups, family and individual behaviour. Treatment strategies vary in different centres and treatment sectors. Non-surgical management consists of diet, exercise, psychology and pharmacology. Non-surgical management can achieve weight loss. Anti-obesity drugs may be effective as adjunctive therapy to diet and physical activity in those subjects who struggle to lose weight despite following an appropriate weight loss programme. The problem with non-surgical treatment is of long-term sustainability. Bariatric surgery is the only management, which has long-term sustainability of weight loss and reversal of comorbidities. However, it is not applicable to all obese patients. Both restrictive and malabsorptive procedures have a relatively high success rate in weight loss and improvement of blood sugar control. However, these procedures have many pitfalls and complications. Experienced bariatric surgeons in high-volume centres have achieved minimal morbidity and mortality after weight loss surgery. Patient selection and preparation is key to success. Special anaesthetic considerations and modifications must be adhered to. The choice of procedure for any individual patient is a complex process and depends on many factors. Follow-up after bariatric surgery must be rigorous to monitor and correct micronutrient deficiency and provide psychological support to patients who have had to change their life style albeit to a healthier existence.