The
GALE
ENCYCLOPEDIA
of
S
urgery
V O L U M E
G - O
A N T H O N Y J . S E N A G O R E , M . D . , E X E C U T I V E A D V I S O R
C L E V E L A N D C L I N I C F O U N D AT I O N
The
GALE
ENCYCLOPEDIA
of
S
urgery
A G U I D E F O R P A T I E N T S A N D C A R E G I V E R S
Gale Encyclopedia of Surgery: A Guide for Patients and Caregivers Anthony J. Senagore MD, Executive Adviser
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LIBRARY OF CONGRESS CATALOGING-IN-PUBLICATION DATA
Gale encyclopedia of surgery : a guide for patients and caregivers / Anthony J. Senagore, [editor].
p. cm.
Includes bibliographical references and index.
ISBN 0-7876-7721-3 (set : hc) — ISBN 0-7876-7722-1 (v. 1) — ISBN 0-7876-7723-X (v. 2) — ISBN 0-7876-9123-2 (v. 3)
Surgery—Encyclopedias. 2. Surgery—Popular works. I. Senagore, Anthony J.,
1958-RD17.G34 2003
CONTENTS
List of Entries . . . vii
Introduction . . . xiii
Contributors . . . xv
Entries Volume 1: A-F . . . 1
Volume 2: G-O . . . 557
Volume 3: P-Z. . . 1079
Glossary . . . 1577
Organizations Appendix . . . 1635
A
Abdominal ultrasound Abdominal wall defect repair Abdominoplasty
Abortion, induced
Abscess incision and drainage Acetaminophen
Adenoidectomy
Admission to the hospital Adrenalectomy
Anticoagulant and antiplatelet drugs Antihypertensive drugs
Cerebrospinal fluid (CSF) analysis Cervical cerclage
Blood donation and registry Blood pressure measurement Blood salvage
Bloodless surgery Bone grafting
Complete blood count Cone biopsy
Corneal transplantation Coronary artery bypass graft
surgery Discharge from the hospital Disk removal
Diuretics
Do not resuscitate order (DNR)
E
Ear, nose, and throat surgery Echocardiography
Elective surgery Electrocardiography Electroencephalography Electrolyte tests
Electrophysiology study of the heart Emergency surgery
Hammer, claw, and mallet toe surgery
Hand surgery Health care proxy Health history
Ileostomy
Intensive care unit equipment Intestinal obstruction repair
Laser in-situ keratomileusis (LASIK) Laser iridotomy
Needle bladder neck suspension Nephrectomy
Obstetric and gynecologic surgery Omphalocele repair
Maze procedure for atrial fibrillation
Minimally invasive heart surgery Mitral valve repair
Myringotomy and ear tubes
Pelvic ultrasound Penile prostheses Pericardiocentesis Peripheral endarterectomy Peripheral vascular bypass surgery Peritoneovenous shunt
Planning a hospital stay Plastic, reconstructive, and
cosmetic surgery Pneumonectomy Portal vein bypass
Positron emission tomography (PET) Post-surgical pain Red blood cell indices Reoperation
Talking to the doctor Tarsorrhaphy Transurethral resection of the
prostate
Sclerotherapy for varicose veins Scopolamine patch
Second opinion Second-look surgery Sedation, conscious Segmentectomy
Urinalysis
Urinary anti-infectives Urologic surgery Uterine stimulants
V
Vagal nerve stimulation
W
Webbed finger or toe repair Weight management White blood cell count and
differential Wound care Wound culture Wrist replacement Vagotomy
Vascular surgery Vasectomy Vasovasostomy
Vein ligation and stripping Venous thrombosis prevention Ventricular assist device Ventricular shunt
Vertical banded gastroplasty Vital signs
The Gale Encyclopedia of Surgeryis a medical ref-erence product designed to inform and educate readers about a wide variety of surgeries, tests, drugs, and other medical topics. The Gale Group believes the product to be comprehensive, but not necessarily definitive. While the Gale Group has made substantial efforts to provide information that is accurate, comprehensive, and up-to-date, the Gale Group makes no representations or
ranties of any kind, including without limitation, war-ranties of merchantability or fitness for a particular pur-pose, nor does it guarantee the accuracy, comprehensive-ness, or timeliness of the information contained in this product. Readers should be aware that the universe of medical knowledge is constantly growing and changing, and that differences of medical opinion exist among au-thorities.
PLEASE READ—
The Gale Encyclopedia of Surgery: A Guide for Patients and Caregivers is a unique and invaluable source of information for anyone who is considering undergoing a surgical procedure, or has a loved one in that situation. This collection of 465 entries provides in-depth coverage of specific surgeries, diagnostic tests, drugs, and other related entries. The book gives detailed information on 265 surgeries; most include step-by-step illustrations to enhance the reader’s under-standing of the procedure itself. Entries on related top-ics, including anesthesia, second opinions, talking to the doctor, admission to the hospital, and preparing for surgery, give lay readers knowledge of surgery prac-tices in general. Sidebars provide information on who performs the surgery and where, and on questions to ask the doctor.
This encyclopedia minimizes medical jargon and uses language that laypersons can understand, while still providing detailed coverage that will benefit health sci-ence students.
Entries on surgeries follow a standardized format that provides information at a glance. Rubrics include:
Definition Purpose Demographics Description
Diagnosis/Preparation Aftercare
Risks
Normal results
Morbidity and mortality rates Alternatives
Resources
Inclusion criteria
A preliminary list of surgeries and related topics was compiled from a wide variety of sources, including professional medical guides and textbooks, as well as consumer guides and encyclopedias. Final selection of
topics to include was made by the executive adviser in conjunction with the Gale editor.
About the Executive Adviser
The Executive Adviser for the Gale Encyclopedia of Surgery was Anthony J. Senagore, MD, MS, FACS, FASCRS. He has published a number of professional ar-ticles and is the Krause/Lieberman Chair in Laparoscop-ic Colorectal Surgery, and Staff Surgeon, Department of Colorectal Surgery at the Cleveland Clinic Foundation in Cleveland, Ohio.
About the contributors
The essays were compiled by experienced medical writers, including physicians, pharmacists, nurses, and other health care professionals. The adviser reviewed the completed essays to ensure that they are appropriate, up-to-date, and medically accurate. Illustrations were also reviewed by a medical doctor.
How to use this book
The Gale Encyclopedia of Surgeryhas been de-signed with ready reference in mind.
• Straight alphabetical arrangementof topics allows users to locate information quickly.
• Bold-faced termswithin entries and See also termsat the end of entries direct the reader to related articles. • Cross-referencesplaced throughout the encyclopedia
direct readers from alternate names and related topics to entries.
• A list of Key termsis provided where appropriate to define unfamiliar terms or concepts.
• A sidebar describing Who performs the procedure and where it is performedis listed with every surgery entry. • A list of Questions to ask the doctor is provided wherever appropriate to help facilitate discussion with the patient’s physician.
• The Resources section directs readers to additional sources of medical information on a topic. Books, peri-odicals, organizations, and internet sources are listed. • A Glossaryof terms used throughout the text is
col-lected in one easy-to-use section at the back of book. • A valuable Organizations appendixcompiles useful
contact information for various medical and surgical organizations.
• A comprehensive General indexguides readers to all topics mentioned in the text.
Graphics
The Gale Encyclopedia of Surgerycontains over 230 full-color illustrations, photos, and tables. This includes
over 160 step-by-step illustrations of surgeries. These il-lustrations were specially created for this product to en-hance a layperson’s understanding of surgical procedures.
Licensing
The Gale Encyclopedia of Surgeryis available for li-censing. The complete database is provided in a fielded format and is deliverable on such media as disk or CD-ROM. For more information, contact Gale’s Business Development Group at 1-800-877-GALE, or visit our website at www.gale.com/bizdev.
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Gallbladder removal
see
Cholecystectomy
Gallbladder ultrasound
see
Abdominal
ultrasound
Gallstone removal
Definition
Also known as cholelithotomy, gallstone removal is a procedure that rids the gallbladder of calculus buildup.
Purpose
The gallbladder is not a vital organ. It is located on the right side of the abdomen underneath the liver. The gallbladder’s function is to store bile, concentrate it, and release it during digestion. Bile is supposed to retain all of its chemicals in solution, but commonly one of them crystallizes and forms sandy or gravel-like particles, and finally gallstones. The formation of gallstones causes gallbladder disease (cholelithiasis).
Chemicals in bile will form crystals as the gallblad-der draws water out of the bile. The solubility of these chemicals is based on the concentration of three chemi-cals: bile acids, phospholipids, and cholesterol. If the chemicals are out of balance, one or the other will not re-main in solution. Dietary fat and cholesterol are also im-plicated in crystal formation.
As the bile crystals aggregate to form stones, they move about, eventually occluding the outlet and prevent-ing the gallbladder from emptyprevent-ing. This blockage results in irritation, inflammation, and sometimes infection (cholecystitis) of the gallbladder. The pattern is usually one of intermittent obstruction due to stones moving in and out of the way. Meanwhile, the gallbladder becomes more and more scarred. Sometimes infection fills the gall-bladder with pus, which is a serious complication.
Occasionally, a gallstone will travel down the cystic duct into the common bile duct and get stuck there. This blockage will back bile up into the liver as well as the gallbladder. If the stone sticks at the ampulla of Vater (a narrowing in the duct leading to the pancreas), the pan-creas will also be blocked and will develop pancreatitis.
Gallstones will cause a sudden onset of pain in the upper abdomen. Pain will last for 30 minutes to several hours. Pain may move to the right shoulder blade. Nau-sea with or without vomiting may accompany the pain.
Demographics
Gallstones are approximately two times more com-mon in females than in males. Overweight women in their middle years constitute the vast majority of patients with gallstones in every racial or ethnic group. An esti-mated 10% of the general population has gallstones. The prevalence for women between ages 20 and 55 varies from 5–20%, and is higher after age 50 (25–30%). The prevalence for males is approximately half that for women in a given age group. Certain people, in particular the Pima tribe of Native Americans in Arizona, have a ge-netic predisposition to forming gallstones. Scandinavians also have a higher than average incidence of this disease.
There seems to be a strong genetic correlation with gallstone disease, since stones are more than four times as likely to occur among first-degree relatives. Since gallstones rarely dissolve spontaneously, the prevalence increases with age. Obesity is a well-known risk factor since overweight causes chemical abnormalities that lead to increased levels of cholesterol. Gallstones are also as-sociated with rapid weight loss secondary to dieting. Pregnancy is a risk factor since increased estrogen levels result in an increased cholesterol secretion and abnormal changes in bile. However, while an increase in dietary cholesterol is not a risk factor, an increase in triglyc-erides is positively associated with a higher incidence of gallstones. Diabetes mellitus is also believed to be a risk factor for gallstone development.
Description
Surgery to remove the entire gallbladder with all its stones is usually the best treatment, provided the patient is able to tolerate the procedure. A relatively new technique of removing the gallbladder using a laparoscope has re-sulted in quicker recovery and much smaller surgical inci-sions than the 6-in (15-cm) gash under the right ribs that had previously been the standard procedure; however, not everyone is a candidate for this approach. If the procedure is not expected to have complications, laparoscopic chole-cystectomyis performed. Laparoscopic surgery requires a space in the surgical area for visualization and instrument manipulation. The laparoscope with attached video cam-era is inserted. Sevcam-eral other instruments are inserted through the abdomen (into the surgical field) to assist the surgeon to maneuver around the nearby organs during surgery. The surgeon must take precautions not to acci-dentally harm anatomical structures in the liver. Once the cystic artery has been divided and the gallbladder dissect-ed from the liver, the gallbladder can be removdissect-ed.
If the gallbladder is extremely diseased (inflamed, infected, or has large gallstones), the abdominal ap-proach (open cholecystectomy) is recommended. This surgery is usually performed with an incision in the upper midline of the abdomen or on the right side of the abdomen below the rib (right subcostal incision).
If a stone is lodged in the bile ducts, additional surgery must be done to remove it. After surgery, the sur-geon will ordinarily insert a drain to collect bile until the system is healed. The drain can also be used to inject contrast material and take x rays during or after surgery.
A procedure called endoscopic retrograde cholan-giopancreatoscopy (ERCP) allows the removal of some bile duct stones through the mouth, throat, esophagus, stomach, duodenum, and biliary system without the need for surgical incisions. ERCP can also be used to inject contrast agents into the biliary system, providing finely detailed pictures.
Patients with symptomatic cholelithiasis can be treated with certain medications called oral bile acid
litholysis or oral dissolution therapy. This technique is especially effective for dissolving small cholesterol-composed gallstones. Current research indicates that the success rate for oral dissolution treatment is 70–80% with floating stones (those predominantly composed of cholesterol). Approximately 10–20% of patients who re-ceive medication-induced litholysis can have a recur-rence within the first two or three years after treatment completion.
Extracorporeal shock wave lithotripsyis a treat-ment in which shock waves are generated in water by lithotripters (devices that produce the waves). There are several types of lithotripters available for gallbladder re-moval. One specific lithotripter involves the use of piezoelectric crystals, which allow the shock waves to be accurately focused on a small area to disrupt a stone. This procedure does not generally require analgesia (or anesthesia). Damage to the gallbladder and associated structures (such as the cystic duct) must be present for stone removal after the shock waves break up the stone. Typically, repeated shock wave treatments are necessary to completely remove gallstones. The success rate of the fragmentation of the gallstone and urinary clearance is inversely proportional to stone size and number: patients with a small solitary stone have the best outcome, with high rates of stone clearance (95% are cleared within 12–18 months), while patients with multiple stones are at risk for poor clearance rates. Complications of shock wave lithotripsy include inflammation of the pancreas (pancreatitis) and acute cholecystitis.
A method called contact dissolution of gallstone re-moval involves direct entry (via a percutaneous transhe-patic catheter) of a chemical solvent (such as methyl ter-tiary-butyl ether, MTBE). MTBE is rapidly removed un-changed from the body via the respiratory system (ex-haled air). Side effects in persons receiving contact dissolution therapy include foul-smelling breath, dysp-nea (difficulty breathing), vomiting, and drowsiness. Treatment with MTBE can be successful in treating cho-lesterol gallstones regardless of the number and size of stones. Studies indicate that the success rate for dissolu-tion is well over 95% in persons who receive direct chemical infusions that can last five to 12 hours.
Diagnosis/Preparation
Diagnostically, gallstone disease, which can lead to gallbladder removal, is divided into four diseases: biliary colic, acute cholecystitis, choledocholithiasis, and cholangitis. Biliary colic is usually caused by intermit-tent cystic duct obstruction by a stone (without any flammation), causing a severe, poorly localized, and in-tensifying pain on the upper right side of the abdomen.
Gallstone r
WHERE IS IT PERFORMED?
These painful attacks can persist from days to months in patients with biliary colic.
Persons affected with acute cholecystitis caused by an impacted stone in the cystic duct also suffer from gallbladder infection in approximately 50% of cases. These people have moderately severe pain in the upper right portion of the abdomen that lasts longer than six hours. Pain with acute cholecystitis can also extend to the shoulder or back. Since there may be infection inside the gallbladder, the patient may also have fever. On the right side of the abdomen below the last rib, there is usu-ally tenderness with inspiratory (breathing in) arrest (Murphy’s sign). In about 33% of cases of acute chole-cystitis, the gallbladder may be felt with palpation (clini-cian feeling abdomen for tenderness). Mild jaundice can be present in about 20% of cases.
Persons with choledocholithiasis, or intermittent ob-struction of the common bile duct, often do not have symptoms; but if present, they are indistinguishable from the symptoms of biliary colic.
A more severe form of gallstone disease is cholangi-tis, which causes stone impaction in the common bile duct. In about 70% of cases, these patients present with Charcot’s triad (pain, jaundice, and fever). Patients with cholangitis may have chills, mild pain, lethargy, and delirium, which indicate that infection has spread to the bloodstream (bacteremia). The majority of patients with cholangitis will have fever (95%), tenderness in the upper right side of the abdomen, and jaundice (80%).
In addition to a physical examination, preparation for laboratory (blood) and special tests is essential to gallstone diagnosis. Patients with biliary colic may have elevated bilirubin and should have an ultrasound study to visualize the gallbladder and associated structures. An increase in the white blood cell count (leukocytosis) can be expected for both acute cholecystitis and cholangitis (seen in 80% of cases). Ultrasound testing is recom-mended for acute cholecystitis patients, whereas ERCP is the test usually indicated to assist in a definitive diag-nosis for both choledocholithiasis and cholangitis. Pa-tients with either biliary colic or choledocholithiasis are treated with elective laparoscopic cholecystectomy. Open cholecystectomy is recommended for acute chole-cystitis. For cholangitis, emergency ERCP is indicated for stone removal. ERCP therapy can remove stones pro-duced by gallbladder disease.
Aftercare
Without a gallbladder, stones rarely recur. Patients who have continued symptoms after their gallbladder is removed may need an ERCP to detect residual stones or damage to the bile ducts caused by the original stones.
Occasionally, the ampulla of Vater is too tight for bile to flow through and causes symptoms until it is opened up.
Risks
The most common medical treatment for gallstones is the surgical removal of the gallbladder (cholecsytecto-my). Risks associated with gallbladder removal are low, but include damage to the bile ducts, residual gallstones in the bile ducts, or injury to the surrounding organs. With laparoscopic cholecystectomy, the bile duct dam-age rate is approximately 0.5%.
Normal results
Most patients undergoing laparoscopic cholecystec-tomy may go home the same day of surgery, and may im-mediately return to normal activities and a normal diet, while most patients who undergo open cholecystectomy must remain in the hospital for five to seven days. After one week, they may resume a normal diet, and in four to six weeks they can expect to return to normal activities.
Morbidity and mortality rates
Cholecystectomy is generally a safe procedure, with an overall mortality rate of 0.1–0.3%. The operative mor-tality rates for open cholecystectomy in males is 0.11% for males aged 30, and 13.84% for males aged 81–90 years. Women seem to tolerate the procedure better than males since mortality rates in females are approximately half those in men for all age groups. The improved tech-nique of laparoscopic cholecystectomy accounts for 90% of all cholecystectomies performed in the United States; the improved technique reduces time missed away from work, patient hospitalization, and postoperative pain.
Alternatives
There are no other acceptable alternatives for gall-stone removal besides surgery, shock wave fragmenta-tion, or chemical dissolution.
See alsoCholecystectomy.
Gallstone r
emo
va
l
QUESTIONS TO ASK
THE DOCTOR
• How long must I remain in the hospital fol-lowing gallstone removal?
• How do I care for the my incision site? • How soon can I return to normal activities
Resources
BOOKS
Bennett, J. Claude, and Fred Plum, eds. Cecil Textbook of Med-icine.Philadelphia: W. B. Saunders Co., 1996.
Bilhartz, Lyman E., and Jay D. Horton. “Gallstone Disease and Its Complications.” In Sleisenger & Fordtran’s Gastroin-testinal and Liver Disease,edited by Mark Feldman, et al. Philadelphia: W. B. Saunders Co., 1998.
Fauci, Anthony S., et al., editors. Harrison’s Principles of In-ternal Medicine.New York: McGraw-Hill, 1997.
Feldman, Mark, editor. Sleisenger & Fordtran’s Gastrointesti-nal and Liver Disease,7th Edition. St. Louis: Elsevier Science, 2002.
Hoffmann, Alan F. “Bile Secretion and the Enterohepatic Cir-culation of Bile Acids.” In Sleisenger & Fordtran’s Gas-trointestinal and Liver Disease,edited by Mark Feldman, et al. Philadelphia: W. B. Saunders Co., 1998.
Mulvihill, Sean J. “Surgical Management of Gallstone Disease and Postoperative Complications.” In Sleisenger & Ford-tran’s Gastrointestinal and Liver Disease,edited by Mark Feldman, et al. Philadelphia: W. B. Saunders Co., 1997. Noble, John. Textbook of Primary Care Medicine,3rd Edition.
St. Louis. Mosby, Inc., 2001.
Paumgartner, Gustav. “Non-Surgical Management of Gallstone Disease.” In Sleisenger & Fordtran’s Gastrointestinal and Liver Disease,edited by Mark Feldman, et al. Philadel-phia: W. B. Saunders Co., 1998.
Sabiston Textbook of Surgery,16th Edition. Philadelphia: W. B. Saunders Co., 2001.
Laith Farid Gulli, MD Nicole Mallory, MS, PA-C J. Polsdorfer, MD
Ganglion cyst removal
DefinitionGanglion cyst removal, or ganglionectomy, is the re-moval of a fluid-filled sac on the skin of the wrist, finger, or sole of the foot. The cyst is attached to a tendon or a joint through its fibers and contains synovial fluid, which is the clear liquid that lubricates the joints and tendons of the body. The surgical procedure is performed in a doc-tor’s office. It entails aspiration, or draining fluid from the cyst with a large hypodermic needle. The cyst may also be excised (removed by cutting).
Purpose
Ganglion cysts are sacs that contain the synovial fluid found in joints and tendons. They are the most common forms of soft tissue growth on the hand and are distin-guished by their sticky liquid contents. The cystic structures are attached to tendon sheaths via a long thin tube-like arm. About 65% of ganglion cysts occur on the upper surface of the wrist, with another 20%–25% on the volar (palm) sur-face of the hand. Most of the remaining 10%–15% of gan-glion cysts occur on the sheath of the flexor tendon. In a few cases, the cysts emerge on the sole of the foot.
Ganglion cysts have appeared in medical writing from the time of Hippocrates (c. 460–c. 375 B. C.). Their exact cause is unknown. There are some indications, however, that ganglion cysts result from trauma to or de-terioration of the tissue lining in the joints that secretes synovial fluid.
Ganglion c
yst r
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KEY TERMS
Bilirubin—A pigment released from red blood cells.
Cholecystectomy—Surgical removal of the
gall-bladder.
Cholelithotomy—Surgical incision into the gall-bladder to remove stones.
Contrast agent—A substance that causes shadows on x rays (or other images of the body).
Cystic artery—An artery that brings oxygenated blood to the gallbladder.
Endoscope—An instrument designed to enter
body cavities.
Jaundice—A yellow discoloration of the skin and eyes due to excess bile that is not removed by the liver.
Laparoscopy—Surgery performed through small
incisions with pencil-sized instruments.
Triglycerides—Chemicals made up mostly of fat
that can form deposits in tissues and cause health risks or disease.
WHO PERFORMS
THE PROCEDURE AND
WHERE IS IT PERFORMED?
Ganglion c
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Ganglion cyst
A.
B.
C.
D.
Ganglion cyst
Sutures
Ganglion cyst
Ganglion cyst removal
A ganglion cyst is usually attached to a tendon or muscle in the wrist or finger (A). To remove it, the skin is cut open (B), the growth is removed (C), and the skin is sutured closed (D). (Illustration by GGS Inc.)
tendons of the hand or finger only when they are large. Many people do not seek medical attention for gan-glion cysts unless they cause pain, affect the move-Ganglion cysts can emerge quite quickly, and can
ment of the nearby tendons, or become particularly un-sightly.
An old traditional treatment for a ganglion cyst was to hit it with a Bible, since the cysts can burst when struck. Today, cysts are removed surgically by aspiration but often reappear. Surgical excision is the most reliable treatment for ganglion cysts, but aspiration is the more common form of therapy.
Demographics
Ganglion cysts account for 50%–70% of all soft tis-sue tumors of the hand and wrist. They are most likely to occur in adults between the ages of 20 and 50, with the female: male ratio being about 3: 1. Most ganglion cysts are visible; however, some are occult (hidden). Occult cysts may be diagnosed because the patient feels pain in that part of the hand or has noticed that the tendon can-not move normally. In about 10% of cases, there is asso-ciated trauma.
Description
Patients are given a local or regional anesthetic in a doctor’s office. Two methods are used to remove the cysts. Most physicians use the more conservative proce-dure, which is known as aspiration.
Aspiration
• An 18- or 22-gauge needle attached to a 20–30-mL sy-ringe is inserted into the cyst. The doctor removes the fluid slowly by suction.
• The doctor may inject a corticosteroid medication into the joint after the fluid has been withdrawn.
• A compression dressing is applied to the site.
• The patient remains in the office for about 30 minutes.
Excision
Some ganglion cysts are so large that the doctor rec-ommends excision. This procedure also takes place in the physician’s office with local or regional anesthetic.
Excision of a ganglion cyst is performed as follows:
• The physician palpates, or feels, the borders of the sac with the fingers and marks the sac and its periphery.
• The sac is cut away with a scalpel.
• The doctor closes the incision with sutures and applies a bandage.
• The patient is asked to remain in the office for at least 30 minutes.
Diagnosis/Preparation
Ganglion cysts are fairly easy to diagnose because they are usually visible and pliable to the touch. They are distinguished from other growths by their location near tendons or joints and by their fluid consistency. Ganglion cysts are sometimes confused with a carpal boss (a bony, non-mobile spur on the top of the wrist), but can usually be distinguished by the fact that they can be moved and are usually less painful for the patient.
The doctor may schedule one or more imaging stud-ies of the hand and wrist. An x-ray may reveal bone or joint abnormalities. Ultrasound may be used to diagnose the presence of occult cysts.
Aftercare
Patients should avoid strenuous physical activity for at least 48 hours after surgery and report any signs of in-fection or inflammation to their physician. A follow-up appointment should be scheduled within three weeks of aspiration or excision. Excision may result in some stiff-ness after the surgery and some difficulties in flexing the hand because of scar tissue formation.
Risks
Aspiration has very few complications as a treat-ment for ganglion cysts; the most common aftereffects are infection or a reaction to the cortisone injection. Complications of excision include some stiffness in the hand and scar formation. Ganglion cysts recur after exci-sion in about 5–15% of cases, usually because the cyst was not completely removed.
Normal results
Aspirated ganglion cysts disappear and cause no further symptoms in 27–67% of cases. They may,
how-Ganglion c
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QUESTIONS TO ASK
THE DOCTOR
• May I continue to exerciseand continue my other regular activities with this cyst?
• Would you recommend removal rather than aspiration?
• How effective is aspiration in preventing these cysts from recurring?
Ferri, Fred F. Ferri’s Clinical Advisor: Instant Diagnosis and Treatment. St. Louis, MO: Mosby, Inc., 2003.
Ruddy, Shaun, et al. Kelly’s Textbook of Rheumatology, 6th ed. Philadelphia, PA: W.B. Saunders, 2001.
PERIODICALS
Tallia, A. F., and D. A. Cardone. “Diagnostic and Therapeutic Injection of the Wrist and Hand Region.”American Fami-ly Physician67 (February 15, 2003): 745-750.
OTHER
MDConsult.com. Ganglion Cyst Removal (Ganglionectomy). <www.mdconsult.com.>
Nancy McKenzie, PhD
Gastrectomy
DefinitionGastrectomy is the surgical removal of all or part of the stomach.
Purpose
Gastrectomy is performed most commonly to treat the following conditions:
• stomach cancer
• bleeding gastric ulcer
• perforation of the stomach wall
• noncancerous polyps
Demographics
Stomach cancer was the most common form of can-cer worldwide in the 1970s and early 1980s, and the in-cidence rates have always shown substantial variation in different countries. Rates are currently highest in Japan and eastern Asia, but other areas of the world have high incidence rates, including Eastern European countries and parts of Latin America. Incidence rates are generally lower in Western Europe and the United States.
Gastrointestinal diseases (including gastric ulcers) affect an estimated 25–30% of the world’s population. In the United States, 60 million adults experience gastroin-testinal reflux at least once a month, and 25 million adults suffer daily from heartburn, a condition that may evolve into ulcers.
Description
Gastrectomy for cancer
Removal of the tumor, often with removal of the surrounding lymph nodes, is the only curative treatment ever, reoccur and require repeated aspiration. Aspiration
combined with an injection of cortisone has more suc-cess than aspiration by itself. Excision is a much more reliable procedure, however, and the stiffness that the pa-tient may experience after the procedure eventually goes away. The formation of a small scar is normal.
Morbidity and mortality rates
The only risks for ganglion cyst removal are infec-tions or inflammation due to the cortisone injection. There is a small risk of damage to nearby nerves or blood vessels.
Alternatives
Alternatives to aspiration and excision in the treat-ment of ganglion cysts include watchful waiting and rest-ing the affected hand or foot. It is quite common for gan-glion cysts to fade away without any surgical treatment.
Resources
BOOKS
“Common Hand Disorders.” Section 5, Chapter 61 in The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Sta-tion, NJ: Merck Research Laboratories, 1999.
Gastr
ectom
y
KEY TERMS
Aspiration—A surgical procedure in which the
physician uses a thick needle to draw fluid from a joint or from a sac produced by a growth or by in-fection.
Cyst—An abnormal saclike growth in the body
that contains liquid or a semisolid material. Excision—Removal by cutting.
Ganglion—A knot or knot-like mass; it can refer either to groups of nerve cells outside the central nervous system or to cysts that form on the sheath of a tendon.
Ganglionectomy—Surgery to excise a ganglion
cyst.
Occult—Hidden; concealed from the doctor’s di-rect observation. Some ganglion cysts are occult. Synovial fluid—A transparent alkaline fluid re-sembling the white of an egg. It is secreted by the synovial membranes that line the joints and ten-don sheaths.
for various forms of gastric (stomach) cancer. For many patients, this entails removing not only the tumor, but part of the stomach as well. The extent to which lymph nodes should also be removed is a subject of debate, but some studies show additional survival benefits associat-ed with removal of a greater number of lymph nodes.
Gastrectomy, either total or subtotal (also called par-tial), is the treatment of choice for gastric adenocarcino-mas, primary gastric lymphomas (originating in the stomach), and the rare leiomyosarcomas (also called gas-tric sarcomas). Adenocarcinomas are by far the most common form of stomach cancer and are less curable than the relatively uncommon lymphomas, for which gastrectomy offers good chances of survival.
General anesthesia is used to ensure that the patient does not experience pain and is not conscious during the operation. When the anesthesia has taken hold, a urinary catheter is usually inserted to monitor urine output. A thin nasogastric tube is inserted from the nose down into the stomach. The abdomen is cleansed with an antiseptic solu-tion. The surgeon makes a large incision from just below the breastbone down to the navel. If the lower end of the stomach is diseased, the surgeon places clamps on either end of the area, and that portion is excised. The upper part of the stomach is then attached to the small intestine. If the upper end of the stomach is diseased, the end of the esophagus and the upper part of the stomach are clamped together. The diseased part is removed, and the lower part of the stomach is attached to the esophagus.
After gastrectomy, the surgeon may reconstruct the altered portions of the digestive tract so that it may con-tinue to function. Several different surgical techniques are used, but, generally speaking, the surgeon attaches any remaining portion of the stomach to the small intestine.
Gastrectomy for gastric cancer is almost always done using the traditional open surgery technique, which requires a wide incision to open the abdomen. However, some surgeons use a laparoscopic technique that requires
only a small incision. The laparoscope is connected to a tiny video camera that projects a picture of the abdomi-nal contents onto a monitor for the surgeon’s viewing. The stomach is operated on through this incision.
The potential benefits of laparoscopic surgery in-clude less postoperative pain, decreased hospitalization, and earlier return to normal activities. The use of laparo-scopic gastrectomy is limited, however. Only patients with early-stage gastric cancers or those whose surgery is intended only for palliation (pain and symptomatic re-lief rather than cure) are considered for this minimally invasive technique. It can only be performed by surgeons experienced in this type of surgery.
Gastrectomy for ulcers
Gastrectomy is also occasionally used in the treat-ment of severe peptic ulcer disease or its complications. While the vast majority of peptic ulcers (gastric ulcers in the stomach or duodenal ulcers in the duodenum) are managed with medication, partial gastrectomy is some-times required for peptic ulcer patients who have compli-cations. These include patients who do not respond satis-factorily to medical therapy; those who develop a bleed-ing or perforated ulcer; and those who develop pyloric obstruction, a blockage to the exit from the stomach.
The surgical procedure for severe ulcer disease is also called an antrectomy, a limited form of gastrecto-my in which the antrum, a portion of the stomach, is re-moved. For duodenal ulcers, antrectomy may be com-bined with other surgical procedures that are aimed at re-ducing the secretion of gastric acid, which is associated with ulcer formation. This additional surgery is com-monly a vagotomy, surgery on the vagus nerve that dis-ables the acid-producing portion of the stomach.
Diagnosis/Preparation
Before undergoing gastrectomy, patients require a variety of such tests as x rays, computed tomography (CT) scans, ultrasonography, or endoscopic biopsies (mi-croscopic examination of tissue) to confirm the diagnosis and localize the tumor or ulcer. Laparoscopymay be done to diagnose a malignancy or to determine the extent of a tumor that is already diagnosed. When a tumor is strongly suspected, laparoscopy is often performed im-mediately before the surgery to remove the tumor; this method avoids the need to anesthetize the patient twice and sometimes avoids the need for surgery altogether if the tumor found on laparoscopy is deemed inoperable.
Aftercare
After gastrectomy surgery, patients are taken to the recovery unit and vital signsare closely monitored by
Gastr
ectom
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WHO PERFORMS
THE PROCEDURE AND
WHERE IS IT PERFORMED?
Gastr
ectom
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Gastrectomy
A.
B.
C.
E.
D. Spleen
Pyloric vein
Sub pyloric lymph nodes
Stomach
Stomach
Gastrosplenic ligament
Splenocolic ligament
Traction suture
Pylorus
Esophagus
Duodenum
Clamp
Stomach
Upper portion of stomach
Jejunum
the nursing staff until the anesthesia wears off. Patients commonly feel pain from the incision, and pain medica-tion is prescribed to provide relief, usually delivered in-travenously. Upon waking from anesthesia, patients have an intravenous line, a urinary catheter, and a nasogastric tube in place. They cannot eat or drink immediately fol-lowing surgery. In some cases, oxygen is delivered through a mask that fits over the mouth and nose. The nasogastric tube is attached to intermittent suction to keep the stomach empty. If the whole stomach has been removed, the tube goes directly to the small intestine and remains in place until bowel function returns, which can take two to three days and is monitored by listening with a stethoscopefor bowel sounds. A bowel movement is also a sign of healing. When bowel sounds return, the patient can drink clear liquids. If the liquids are tolerat-ed, the nasogastric tube is removed and the diet is gradu-ally changed from liquids to soft foods, and then to more solid foods. Dietary adjustments may be necessary, as certain foods may now be difficult to digest. Overall, gastrectomy surgery usually requires a recuperation time of several weeks.
Risks
Surgery for peptic ulcer is effective, but it may result in a variety of postoperative complications. Following gastrectomy surgery, as many as 30% of patients have significant symptoms. An operation called highly selec-tive vagotomy is now preferred for ulcer management, and is safer than gastrectomy.
After a gastrectomy, several abnormalities may de-velop that produce symptoms related to food intake. They happen largely because the stomach, which serves
as a food reservoir, has been reduced in its capacity by the surgery. Other surgical procedures that often accom-pany gastrectomy for ulcer disease can also contribute to later symptoms. These procedures include vagotomy, which lessens acid production and slows stomach empty-ing; and pyloroplasty, which enlarges the opening be-tween the stomach and small intestine to facilitate emp-tying of the stomach.
Some patients experience lightheadedness, heart palpitations or racing heart, sweating, and nausea and vomiting after a meal. These may be symptoms of “dumping syndrome,” as food is rapidly dumped into the small intestine from the stomach. Dumping syn-drome is treated by adjusting the diet and pattern of eat-ing, for example, eating smaller, more frequent meals and limiting liquids.
Patients who have abdominal bloating and pain after eating, frequently followed by nausea and vomiting, may have what is called the “afferent loop syndrome.” This is treated by surgical correction. Patients who have early satiety (feeling of fullness after eating), abdominal dis-comfort, and vomiting may have bile reflux gastritis (also called bilious vomiting), which is also surgically correctable. Many patients also experience weight loss.
Reactive hypoglycemia is a condition that results when blood sugar levels become too high after a meal, stimulating the release of insulin, occurring about two hours after eating. A high-protein diet and smaller meals are advised.
Ulcers recur in a small percentage of patients after surgery for peptic ulcer, usually in the first few years. Further surgery is usually necessary.
Vitamin and mineral supplementation is necessary after gastrectomy to correct certain deficiencies, especial-ly vitamin B12, iron, and folate. Vitamin D and calcium
are also needed to prevent and treat the bone problems that often occur. These include softening and bending of the bones, which can produce pain and osteoporosis, a loss of bone mass. According to one study, the risk for spinal fractures may be as high as 50% after gastrectomy.
Normal results
Overall survival after gastrectomy for gastric cancer varies greatly by the stage of disease at the time of surgery. For early gastric cancer, the five-year survival rate is as high as 80–90%; for late-stage disease, the prognosis is bad. For gastric adenocarcinomas that are amenable to gastrectomy, the five-year survival rate is 10–30%, depending on the location of the tumor. The prognosis for patients with gastric lymphoma is better, with five-year survival rates reported at 40–60%.
Gastr
ectom
y
QUESTIONS TO ASK
THE DOCTOR
• What happens on the day of surgery? • What type of anesthesia will be used?
• How long will it take to recover from the surgery?
• When can I expect to return to work and/or resume normal activities?
• What are the risks associated with a gastrec-tomy?
• How many gastrectomies do you perform in a year?
nal and Liver Disease,edited by Mark Feldman et al. Philadelphia: W. B. Saunders Co., 1998.
PERIODICALS
Fujiwara, M., et al. “Laparoscopy-Assisted Distal Gastrectomy with Systemic Lymph Node Dissection for Early Gastric Carcinoma: A Review of 43 Cases.”Journal of the Ameri-can College of Surgeons196 (January 2003): 75–81. Iseki, J., et al. “Feasibility of Central Gastrectomy for Gastric
Cancer.”Surgery133 (January 2003): 75–81.
Kim, Y. W., H. S. Han, and G. D. Fleischer. “Hand-Assisted Laparoscopic Total Gastrectomy.”Surgical Laparoscopy, Endoscopy & Percutaneous Techniques 13 (February 2003): 26–30.
Kono, K., et al. “Improved Quality of Life with Jejunal Pouch Reconstruction after Total Gastrectomy.”American Jour-nal of Surgery185 (February 2003): 150–154.
ORGANIZATIONS
American College of Gastroenterology. 4900-B South 31st St., Arlington, VA 22206. (703) 820-7400. <www.acg.gi.org>. American Gastroenterological Association (AGA). 4930 Del Ray Avenue, Bethesda, MD 20814. (301) 654-2055. <www.gastro.org>.
OTHER
Mayo Clinic Online: Gastrectomy.<www.mayohealth.com >.
Caroline A. Helwick Monique Laberge, PhD
Gastric acid inhibitors
DefinitionGastric acid inhibitors are medications that reduce the production of stomach acid. They are different from antacids, which act on stomach acid after it has been pro-duced and released into the stomach.
Purpose
Gastric acid inhibitors are used to treat conditions that are either caused or made worse by the presence of acid in the stomach. These conditions include gastric ul-cers; gastroesophageal reflux disease (GERD); and Zollinger-Ellison syndrome, which is marked by atypical gastric ulcers and excessive amounts of stomach acid. Gastric acid inhibitors are also widely used to protect the stomach from drugs or conditions that may cause stom-ach ulcers. Medications that may cause ulcers include steroid compounds and nonsteroidal anti-inflammato-ry drugs(NSAIDs), which are often used to treat arthri-tis. Gastric acid inhibitors offer some protection against Most studies have shown that patients can have an
acceptable quality of life after gastrectomy for a poten-tially curable gastric cancer. Many patients will maintain a healthy appetite and eat a normal diet. Others may lose weight and not enjoy meals as much. Some studies show that patients who have total gastrectomies have more dis-ease-related or treatment-related symptoms after surgery and poorer physical function than patients who have subtotal gastrectomies. There does not appear to be much difference, however, in emotional status or social activity level between patients who have undergone total versus subtotal gastrectomies.
Morbidity and mortality rates
Depending on the extent of surgery, the risk for postoperative death after gastrectomy for gastric cancer has been reported as 1–3% and the risk of non-fatal com-plications as 9–18%. Overall, gastric cancer incidence and mortality rates have been declining for several decades in most areas of the world.
Resources
BOOKS
“Disorders of the Stomach and Duodenum.” In The Merck Man-ual.Whitehouse Station, NJ: Merck & Co., Inc., 1992. “Stomach and Duodenum: Complications of Surgery for Peptic
Ulcer Disease.” In Sleisenger & Fordtran’s
Gastrointesti-Gastric acid inhibitors
KEY TERMS
Adenocarcinoma—A form of cancer that involves
cells from the lining of the walls of many different organs of the body.
Antrectomy—A surgical procedure for ulcer dis-ease in which the antrum, a portion of the stom-ach, is removed.
Laparoscopy—The examination of the inside of
the abdomen through a lighted tube, sometimes accompanied by surgery.
Leiomyosarcoma—A malignant tumor of smooth
muscle origin. Can occur almost anywhere in the body, but is most frequent in the uterus and gas-trointestinal tract.
Lymphoma—Malignant tumor of lymphoblasts
de-rived from B lymphocytes, a type of white blood cell. Most commonly affects children in tropical Africa.
the stress ulcers that are associated with some types of illness and with surgery.
Description
There are two types of gastric acid inhibitors, H2
-re-ceptor blockers and proton pump inhibitors. H2-receptor
blockers are a type of antihistamine. Histamine, in addi-tion to its well-known effects in colds and allergies, also stimulates the stomach to produce more acid. The recep-tors (nerve endings) that respond to the presence of hist-amine are called H2receptors, to distinguish them from
the H1receptors involved in causing allergy symptoms.
The most common H2-receptor blockers are cimetidine
(Tagamet), famotidine (Pepcid), nizatidine (Axid), and ranitidine (Zantac).
The proton pump inhibitors (PPIs) are drugs that block an enzyme called hydrogen/potassium adenosine triphosphatase in the cells lining the stomach. Blocking this enzyme stops the production of stomach acid. These drugs are more effective in reducing stomach acid than the H2-receptor blockers. The PPIs include such
medica-tions as omeprazole (Prilosec), esomeprazole (Nexium), lansoprazole (Prevacid), pantoprazole (Protonix) and rabeprazole (AcipHex).
Recommended dosages
The recommended dosage depends on the specific drug; the purpose for which it is being used; and the route of administration, whether oral or intravenous. Patients should check with the physician who prescribed the med-ication or the pharmacist who dispensed it. If the drug is an over-the-counter preparation, patients should read the package labeling carefully, and discuss the correct use of the drug with their physician or pharmacist. This precau-tion is particularly important with regard to the H2
-recep-tor blockers, because they are available in over-the-counter (OTC) formulations as well as prescription strength. The two are not interchangeable; OTC H2
-re-ceptor blockers are only half as strong as the lowest avail-able dose of prescription-strength versions of these drugs.
Patients should not use the over-the-counter prepa-rations as an alternative to seeking professional care. For some conditions, particularly stomach ulcers, acid-in-hibiting drugs may relieve the symptoms, but will not cure the underlying problems, which require both acid reduction and antibiotic therapy.
Gastric acid inhibitors work best when they are taken regularly, so that the amounts of stomach acid are kept low at all times. Patients should check the package directions or ask the physician or pharmacist for instruc-tions on the best way to take the medicine.
Precautions
There are relatively few adverse reactions when gas-tric acid inhibitors are used for one to two doses before or just after surgery, The side effects listed below are most often seen with long-term use.
H2-receptor blockers
Although the H2-receptor blockers are very safe
drugs, they are capable of causing thrombocytopenia, a disorder in which there are too few platelets in the blood. This deficiency may cause bleeding problems, since platelets are essential for blood clotting. Platelet defi-ciencies can only be recognized by blood tests; there are no symptoms that the patient can see or feel. In addition to affecting platelet levels, the H2-receptor blockers may
cause changes in heart rate, making the heart beat either faster or slower than normal. Patients should call a physician immediately if any of these signs occur:
• tingling of the fingers or toes
• difficulty breathing
• difficulty swallowing
• swelling of the face or lips
• rapid heartbeat
• slow heartbeat
In addition to these signs, the H2-receptor blockers
may cause the following unwanted reactions:
• headache
• diarrhea
• dizziness
• drowsiness
• nausea
• depression
• skin rash
• vomiting
In addition, cimetidine is an inhibitor of male sex hormones; it may cause loss of libido, breast tenderness and enlargement, and impotence.
Ranitidine may cause loss of hair or severe skin rashes that require prompt medical attention. In rare cases, this drug may cause a reduction in the white blood cell count.
Before using H2-receptor blockers, people with any
of these medical problems should make sure their physi-cians are aware of their conditions:
• kidney disease
• liver disease
• medical conditions associated with confusion or dizzi-ness
Proton pump inhibitors
The proton pump inhibitors are also very safe, but have been associated with rare but severe skin reactions. Patients should be sure to report any rash or change in the appearance of the skin when taking these drugs. The following adverse reactions are also possible:
• stomach cramps
• weakness
• chest pain
• constipation
• diarrhea
• dizziness
• drowsiness
• gas pains
• headache
• nausea with or without vomiting
• itching
• blood in urine
The PPIs make some people feel drowsy, dizzy, lightheaded, or less alert. Anyone who takes these drugs should not drive, use heavy machinery, or do anything else that requires full alertness until they have found out how the drugs affect them.
Before using proton pump inhibitors, people with liver disease should make sure their physicians are aware of their condition.
Taking gastric acid reducers with certain other drugs may affect the way the drugs work or may increase the chance of side effects.
Side effects
The most common side effects of both types of gas-tric acid reducer are mild diarrhea, nausea, vomiting, stomach or abdominal pain, dizziness, drowsiness, light-headedness, nervousness, sleep problems, and headache. The frequency of each type of problem varies with the specific drug selected and the dose. These problems usu-ally go away as the body adjusts to the drug and do not require medical treatment unless they are bothersome.
Serious side effects are uncommon with these med-ications, but may occur. Patients should consult a physi-cian immediately if they notice any of the following:
• skin rash or such other skin problems as itching, peel-ing, hives, or redness
• fever
• agitation or confusion
• hallucinations
• shakiness or tremors
• seizures or convulsions
• tingling in the fingers or toes
• pain at the injection site that lasts for some time after the injection
• pain in the calves that spreads to the heels
• swelling of the calves or lower legs
• swelling of the face or neck
• difficulty swallowing
• rapid heartbeat
• shortness of breath
• loss of consciousness
Other side effects may occur in rare instances. Any-one who has unusual symptoms after taking gastric acid inhibitors should get in touch with his or her physician.
Interactions
Gastric acid inhibitors may interact with other medi-cines. When an interaction occurs, the effects of one or both of the drugs may change or the risk of side effects may be increased. Anyone who takes gastric acid in-hibitors should give their physician a list of all the other medicines that he or she is taking.
Of the drugs in this class, cimetidine has the highest number of drug interactions, and specialized reference works should be consulted for guidance about this med-ication.
The drugs that may interact with H2-receptor
block-ers include:
• itraconazole (Sporanox)
• ketoconazole (Nizoral)
• warfarin (Coumadin)
• dofetilide (Tikosyn)
• drugs given to open the airway (bronchodilators), in-cluding aminophylline, theophylline (Theo-Dur and other brands), and oxtriphylline (Choledyl and other brands)
Drugs that may interact with proton pump inhibitors include:
• itraconazole (Sporanox)
• ketoconazole (Nizoral)
• phenytoin (Dilantin) and other anticonvulsant drugs
• cilostazol (Pletal)
• voriconazole (Vfend)
The preceding lists do not include every drug that may interact with gastric acid inhibitors. Patients should be careful to consult a physician or pharmacist before combining gastric acid inhibitors with any other pre-scription or nonprepre-scription (over-the-counter) medicine.
Resources
BOOKS
“Factors Affecting Drug Response: Drug Interactions.” Section 22, Chapter 301 in The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 1999.
“Peptic Ulcer Disease.” Section 3, Chapter 23 in The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 1999.
Reynolds, J. E. F., ed. Martindale: The Extra Pharmacopoeia, 31st ed. London, UK: The Pharmaceutical Press, 1996.
Wilson, Billie Ann, RN, PhD, Carolyn L. Stang, PharmD, and Margaret T. Shannon, RN, PhD. Nurses Drug Guide 2000. Stamford, CT: Appleton and Lange, 1999.
ORGANIZATIONS
American Society of Health-System Pharmacists (ASHP). 7272 Wisconsin Avenue, Bethesda, MD 20814. (301) 657-3000. <www.ashp.org>.
United States Food and Drug Administration (FDA). 5600 Fishers Lane, Rockville, MD 20857-0001. (888) INFO-FDA. <www.fda.gov>.
OTHER
<www.nlm.nih.gov/medlineplus/druginfo/medmaster/a682256. html>.
<www.nlm.nih.gov/medlineplus/druginfo/medmaster/a601106. html>.
<www.nlm.nih.gov/medlineplus/druginfo/uspdi/500275.html>. <www.nlm.nih.gov/medlineplus/druginfo/uspdi/202283.html>. <www.nlm.nih.gov/medlineplus/druginfo/uspdi/202283.html>.
Samuel Uretsky, PharmD
Gastric bypass
DefinitionA gastric bypass is a surgical procedure that creates a very small stomach; the rest of the stomach is removed. The small intestine is attached to the new stomach, al-lowing the lower part of the stomach to be bypassed.
Purpose
Gastric bypass surgery is intended to treat obesity, a condition characterized by an increase in body weight beyond the skeletal and physical requirements of a per-son, resulting in excessive weight gain. The rationale for gastric bypass surgery is that by making the stom-ach smaller a person suffering from obesity will eat less and thus gain less weight. The operation restricts food intake and reduces the feeling of hunger while provid-ing a sensation of fullness (satiety) in the new smaller stomach.
Demographics
Obesity affects nearly one-third of the adult Ameri-can population (approximately 60 million people). The number of overweight and obese Americans has steadily increased since 1960, and the trend has not slowed down in recent years. Currently, 64.5% of adult Americans (about 127 million) are considered overweight or obese. Each year, obesity contributes to at least 300,000 deaths
Gastric b
ypass
KEY TERMS
Enzyme—A biological compound that causes
changes in other compounds.
Gastroesophageal reflux disease (GERD)—A
con-dition in which the contents of the stomach flow backward into the esophagus. There is no known single cause.
Nonsteroidal anti-inflammatory drugs (NSAIDs)— Drugs that relieve pain and reduce inflammation but are not related chemically to cortisone. Com-mon drugs in this class are aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve, Naprosyn), keto-profen (Orudis), and several others.
Platelets—Disk-shaped structures found in blood that play an active role in blood clotting. Platelets are also known as thrombocytes.
Receptor—A sensory nerve ending that responds
to chemical or other stimuli of various kinds. Stress ulcers—Stomach ulcers that occur in con-nection with some types of physical injury, includ-ing burns and invasive surgical procedures.
Thrombocytopenia—A disorder characterized by
a drop in the number of platelets in the blood.
Zollinger-Ellison syndrome—A condition marked
