Bariatric Surgery

Bariatric surgery refers to a group of invasive procedures used to surgically reduce the size of the stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach to produce early satiety, decrease food intake (restrictive type) and/or alter digestion, and artificially induce malabsorption Malabsorption Malabsorption involves many disorders in which there is an inability of the gut to absorb nutrients from dietary intake, potentially including water and/or electrolytes. A closely related term, maldigestion is the inability to break down large molecules of food into their smaller constituents. Malabsorption and maldigestion can affect macronutrients (fats, proteins, and carbohydrates), micronutrients (vitamins and minerals), or both. Malabsorption and Maldigestion of nutrients (malabsorptive type). The ultimate goal of bariatric surgery is drastic weight loss. Bariatric surgery is currently the only modality that provides significant long-term weight loss in morbidly obese individuals and cures or significantly improves obesity Obesity Obesity is a condition associated with excess body weight, specifically with the deposition of excessive adipose tissue. Obesity is considered a global epidemic. Major influences come from the western diet and sedentary lifestyles, but the exact mechanisms likely include a mixture of genetic and environmental factors. Obesity-related complications. The 2 modalities currently in wide use are the Roux-en-Y gastric bypass and sleeve gastrectomy.

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Surgical Anatomy

Definition

Bariatric surgery is a group of invasive procedures that can be used to either surgically reduce the size of the stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach or reroute the intestines with the ultimate goal of drastic weight loss by restricting food intake or altering the absorption of food.

Anatomy

It is important to review the anatomy of the stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach to more easily locate and recognize it within the abdominal cavity, as well as to promptly control bleeding during surgery.

Anatomical landmarks of the stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach:

  • Has 2 curvatures (lesser and greater)
  • Cardia: 
    • Entrance of the stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach
    • Originates from the z-line and creates the angle of His or angle of the cardiac orifice (angle between the fundus and abdominal esophagus Esophagus The esophagus is a muscular tube-shaped organ of around 25 centimeters in length that connects the pharynx to the stomach. The organ extends from approximately the 6th cervical vertebra to the 11th thoracic vertebra and can be divided grossly into 3 parts: the cervical part, the thoracic part, and the abdominal part. Esophagus)
    • A crucial landmark in construction of the gastric pouch 
  • Fundus: a dome-shaped region located at the highest point of the stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach
  • Body: 
    • The main section of the stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach
    • Extends from the fundus to the pylorus
    • Bordered by the lesser and greater curvatures
  • Pylorus: 
    • Connects to the duodenum
    • Contains the pyloric sphincter
    • Consists of a wide pyloric antrum and narrow pyloric canal
Stomach anatomy

Anatomy of the stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach

Image by BioDigital, edited by Lecturio
Stomach in situ

The stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach in situ

Image by BioDigital, edited by Lecturio

Arterial supply:

  • Left gastric artery: main supply to the gastric pouch in a gastric bypass
  • Right gastric artery
  • Right and left gastroepiploic (gastro-omental) arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries
  • Splenic artery
  • Short gastric arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries
  • Posterior gastric artery

Venous drainage:

  • Homonymous veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins that accompany the arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries
  • Right and left gastric veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins drain into the portal vein.
  • Left gastroepiploic vein drains into the splenic vein.
  • Right gastroepiploic vein drains into the superior mesenteric vein.

Innervation:

  • Parasympathetic innervation: anterior and posterior vagal trunk
  • Sympathetic innervation: greater splanchnic nerve and gastric branches from the celiac plexus
Blood supply and innervation of the stomach

Blood supply and innervation of the stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach

Image by BioDigital, edited by Lecturio

Indications and Contraindications

Eligibility criteria

Bariatric surgery is a type of surgical management indicated in patients with morbid obesity Obesity Obesity is a condition associated with excess body weight, specifically with the deposition of excessive adipose tissue. Obesity is considered a global epidemic. Major influences come from the western diet and sedentary lifestyles, but the exact mechanisms likely include a mixture of genetic and environmental factors. Obesity in whom lifestyle modifications (e.g., diet and exercise), psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy, and pharmacotherapy have failed.

  • BMI > 40 kg/m2
  • BMI > 35 kg/m2 with complications of obesity Obesity Obesity is a condition associated with excess body weight, specifically with the deposition of excessive adipose tissue. Obesity is considered a global epidemic. Major influences come from the western diet and sedentary lifestyles, but the exact mechanisms likely include a mixture of genetic and environmental factors. Obesity (e.g., diabetes mellitus Diabetes mellitus Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus, hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension, obstructive sleep apnea Obstructive sleep apnea Obstructive sleep apnea (OSA) is a disorder characterized by recurrent obstruction of the upper airway during sleep, causing hypoxia and fragmented sleep. Obstructive sleep apnea is due to a partial or complete collapse of the upper airway and is associated with snoring, restlessness, sleep interruption, and daytime somnolence. Obstructive Sleep Apnea)
  • Previous failure of diet therapy
  • Psychiatric stability without alcohol use or the consumption of illicit drugs
  • Patients who are aware of the implications of surgery and the dietary changes that are required
  • Patients who are motivated
  • Underlying medical problems are not contraindications for surgery.

Contraindications

Relative:

  • Patients > 65 years of age
  • Children and adolescents (surgery is delayed until they have reached maximal pubertal growth)
  • Underlying medical conditions (e.g., cardiac or respiratory diseases)
  • Pre-existing GERD GERD Gastroesophageal reflux disease (GERD) occurs when the stomach acid frequently flows back into the esophagus. This backwash (acid reflux) can irritate the lining of the esophagus, causing symptoms such as retrosternal burning pain (heartburn). Gastroesophageal Reflux Disease for gastric sleeve (but not for gastric bypass)

Absolute:

  • Inability to ambulate
  • Prader-Willi syndrome Prader-Willi syndrome Prader-Willi syndrome (PWS) is a rare autosomal neurodevelopmental genetic disorders mapped to a specific region of chromosome 15 attributed to genomic imprinting. A paternally derived chromosome 15 with this deletion results in 15q11-13 paternal deletion syndrome, or PWS. Prader-Willi Syndrome and Angelman Syndrome

Procedure

Preoperative preparation

  • Prior fasting/bowel rest (nil per os, nothing by mouth) for 8 hours
  • Explanation of the procedure to the patient and obtaining informed consent
  • Laboratory workup:
    • CBC: platelet count > 50,000
    • PTT and PT within acceptable ranges
    • Renal function: serum creatinine and BUN within acceptable ranges
  • Anticoagulants Anticoagulants Anticoagulants are drugs that retard or interrupt the coagulation cascade. The primary classes of available anticoagulants include heparins, vitamin K-dependent antagonists (e.g., warfarin), direct thrombin inhibitors, and factor Xa inhibitors. Anticoagulants are withheld before the procedure.
  • Deep vein thrombosis Deep vein thrombosis Deep vein thrombosis (DVT) usually occurs in the deep veins of the lower extremities. The affected veins include the femoral, popliteal, iliofemoral, and pelvic veins. Proximal DVT is more likely to cause a pulmonary embolism (PE) and is generally considered more serious. Deep Vein Thrombosis ( DVT DVT Deep vein thrombosis (DVT) usually occurs in the deep veins of the lower extremities. The affected veins include the femoral, popliteal, iliofemoral, and pelvic veins. Proximal DVT is more likely to cause a pulmonary embolism (PE) and is generally considered more serious. Deep Vein Thrombosis) prophylaxis: 
    • Enoxaparin
    • Compression stockings
  • Antibiotic prophylaxis: 1st-generation cephalosporins Cephalosporins Cephalosporins are a group of bactericidal beta-lactam antibiotics (similar to penicillins) that exert their effects by preventing bacteria from producing their cell walls, ultimately leading to cell death. Cephalosporins are categorized by generation and all drug names begin with "cef-" or "ceph-." Cephalosporins (cefazolin) 
    • Dose must be appropriate to the patient’s weight.
    • Prophylaxis is continued for 24 hours after the procedure.
  • Continuous monitoring:
    • HR
    • BP
    • Oxygen saturation 
    • ECG ECG An electrocardiogram (ECG) is a graphic representation of the electrical activity of the heart plotted against time. Adhesive electrodes are affixed to the skin surface allowing measurement of cardiac impulses from many angles. The ECG provides 3-dimensional information about the conduction system of the heart, the myocardium, and other cardiac structures. Normal Electrocardiogram (ECG)
  • Anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. Anesthesiology: History and Basic Concepts: The procedure is usually performed under general anesthesia.

Types and steps of the procedures

Roux-en-Y gastric-bypass technique:

Gastric bypass is both restrictive (reduces the size of the stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach) and malabsorptive (reroutes the intestines to alter food absorption). A laparoscopic approach is generally preferred because of shorter recovery and hospital stay.

  1. The hepatogastric ligament is dissected perigastrically to avoid injury to the nerve of Latarjet. 
  2. The 20–30-mL gastric pouch is fashioned based on the lesser curvature of the stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach, providing the restrictive component.
  3. The Roux limb is brought up to the gastric pouch by any of the following paths:
    • Antecolic/antegastric
    • Retrocolic/retrogastric (shortest path)
    • Retrocolic/antegastric
  4. The Roux limb is anastomosed with the gastric pouch using non-absorbable sutures or staples.
  5. To prevent herniation, the following defects are closed:
    • Peterson’s defect (space between the limbs of the small intestine Small intestine The small intestine is the longest part of the GI tract, extending from the pyloric orifice of the stomach to the ileocecal junction. The small intestine is the major organ responsible for chemical digestion and absorption of nutrients. It is divided into 3 segments: the duodenum, the jejunum, and the ileum. Small Intestine, the transverse mesocolon, and the retroperitoneum)
    • Intermesenteric defect (space within the mesenteric pouch)
    • Defect in the transverse mesocolon
Roux-en-y gastric bypass

Roux-en-Y gastric bypass

Image by Lecturio.

Gastric sleeve technique:

The goal is to create a smaller, tube-shaped stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach along the lesser curvature with a volume of approximately 60–100 mL. This procedure is most commonly performed laparoscopically.

  1. The short gastric vessels along the greater curvature are transected.
  2. The phrenoesophageal ligament and gastroesophageal fat pad are divided to expose the left diaphragm Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. Diaphragm
  3. The greater curvature of the stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach is released and an elastic bougie (a long plastic tube used to calibrate the size of the sleeve) is inserted. 
  4. A linear cutting stapler is moved parallel to the lesser curve of the stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach, starting at the antrum and progressing towards the fundus, while being careful to not impinge on the incisura.
  5. At the fundus, the linear stapler is moved medially to the angle of His, and the greater curvature is completely resected to create the gastric sleeve.
  6. The remnant stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach is then removed.
Gastric sleeve

Gastric sleeve

Image by Lecturio.

Post-operative care Post-operative care After any procedure performed in the operating room, all patients must undergo close observation at least in the recovery room. After larger procedures and for patients who require hospitalization, observation must continue on the surgical ward. The primary intent of this practice is the early detection of postoperative complications. Postoperative Care

  • Observation in the recovery room for 6 hours and later in the wards
  • Same-day discharge is possible.
  • Special diet plan with small frequent meals to avoid vomiting, food intolerance, and dumping syndrome
  • Careful follow-up of patients by a multidisciplinary team is necessary:
    • Monitoring of weight loss
    • Vigilance for malnutrition Malnutrition Malnutrition is a clinical state caused by an imbalance or deficiency of calories and/or micronutrients and macronutrients. The 2 main manifestations of acute severe malnutrition are marasmus (total caloric insufficiency) and kwashiorkor (protein malnutrition with characteristic edema). Malnutrition in children in resource-limited countries and vitamin deficiencies
  • Plastic surgery: Aesthetic procedures may be indicated to remove excess skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin from the abdomen, thighs, and arms after drastic weight loss.
  • Prognosis:
    • Greatest extent of weight loss occurs during the 1st postoperative year.
    • Gastric bypass provides slightly better-maintained weight loss at 5 years than the gastric sleeve.
    • Best means to cure obesity Obesity Obesity is a condition associated with excess body weight, specifically with the deposition of excessive adipose tissue. Obesity is considered a global epidemic. Major influences come from the western diet and sedentary lifestyles, but the exact mechanisms likely include a mixture of genetic and environmental factors. Obesity-related complications: improves or cures type 2 diabetes, hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension, and hyperlipidemia
    • Significant number of patients develop gallstones secondary to rapid weight loss:
      • If symptomatic, cholecystectomy Cholecystectomy Cholecystectomy is a surgical procedure performed with the goal of resecting and extracting the gallbladder. It is one of the most common abdominal surgeries performed in the Western world. Cholecystectomy is performed for symptomatic cholelithiasis, cholecystitis, gallbladder polyps > 0.5 cm, porcelain gallbladder, choledocholithiasis and gallstone pancreatitis, and rarely, for gallbladder cancer. Cholecystectomy: Approaches and Technique is indicated
      • Some surgeons advocate prophylactic cholecystectomy Cholecystectomy Cholecystectomy is a surgical procedure performed with the goal of resecting and extracting the gallbladder. It is one of the most common abdominal surgeries performed in the Western world. Cholecystectomy is performed for symptomatic cholelithiasis, cholecystitis, gallbladder polyps > 0.5 cm, porcelain gallbladder, choledocholithiasis and gallstone pancreatitis, and rarely, for gallbladder cancer. Cholecystectomy: Approaches and Technique at the time of bariatric surgery.

Complications

Bariatric surgery, like any invasive procedure, has inherent risks and complications.

Roux-en-Y gastric bypass

  • Anastomotic leak:
    • May lead to intra-abdominal abscess, peritonitis, and sepsis Sepsis Organ dysfunction resulting from a dysregulated systemic host response to infection separates sepsis from uncomplicated infection. The etiology is mainly bacterial and pneumonia is the most common known source. Patients commonly present with fever, tachycardia, tachypnea, hypotension, and/or altered mentation. Sepsis and Septic Shock
    • Potentially life-threatening complication
  • Bleeding along the suture or staple lines
  • Anastomotic stenosis (results in obstruction)
  • Marginal ulcers: form at the GI anastomosis usually on the intestinal side, as a result of unopposed exposure to gastric acid
  • Gastro-gastric fistula: fistula formation between the gastric pouch and gastric remnant
  • Nutritional deficiencies:
    • Result from exclusion of the large portion of the stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach and inadequate absorption due to intestinal bypass
    • Common deficiencies: vitamin B12 Vitamin B12 Folate and vitamin B12 are 2 of the most clinically important water-soluble vitamins. Deficiencies can present with megaloblastic anemia, GI symptoms, neuropsychiatric symptoms, and adverse pregnancy complications, including neural tube defects. Folate and Vitamin B12, folate, iron, zinc, copper, calcium, vitamin D
  • Dumping syndrome:
    • Caused by rapid movement of large amounts of food from a small stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach into the intestine
    • Usually associated with foods rich in simple sugars and starches
    • Presents as bloating, abdominal discomfort, and diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea
    • Can also be associated with tachycardia and hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension due to massive fluid influx into the intestinal lumen

Gastric sleeve

  • Gastroesophageal reflux: due to increased pressure within a narrow, tubular stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach
  • Leakage along the staple line
  • Bleeding from the staple line

References

  1. Hardwick, R. (2018). The esophagus Esophagus The esophagus is a muscular tube-shaped organ of around 25 centimeters in length that connects the pharynx to the stomach. The organ extends from approximately the 6th cervical vertebra to the 11th thoracic vertebra and can be divided grossly into 3 parts: the cervical part, the thoracic part, and the abdominal part. Esophagus, stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach, and duodenum. In Garden, O. James. http://dx.doi.org/10.1016/B978-0-7020-6859-1.00013-3
  2. Lyo, V., Husain, F.A. (2021). Roux-en-Y gastric bypass and sleeve gastrectomy. In Delaney, Conor P. et al. (Ed.), Netter’s Surgical Anatomy and Approaches. http://dx.doi.org/10.1016/B978-0-323-67346-4.00010-4 
  3. Standring, S. (2021). Abdominal oesophagus and stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach. In Standring, Susan (Ed.), Gray’s Anatomy (pp. 1160–1172.e1). http://dx.doi.org/10.1016/B978-0-7020-7705-0.00063-X

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