Esophagus
Surgery
Surgery for Hiatal Hernia, Reflux or Achalasia
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The esophagus is a muscular tube through which food descends from the mouth, through the diaphragm to the stomach. Muscles actively propel each mouthful of food (a process called peristalsis) so that humans can swallow, even upside-down! Normal swallowing needs coordinated propulsion by the muscles of the esophagus followed by relaxation of a valve at the lower end, the lower esophageal sphincter or LES. The lower part of the esophagus is protected from stomach acid by muscles that tighten the entrance into the stomach, and by other factors that create a valve effect
When the upper part of the stomach resides in the chest above the diaphragm this is called a hiatal hernia. The hiatus (where the esophagus passes through the diaphragm) is widely stretched. Many people have a hiatal hernia but no symptoms. Depending on the degree, if much of the stomach is twisted where it lies in the chest, a more dangerous paraesophageal hernia exists with the risk of strangulation of the stomach.
Gastroesophageal reflux disease (GERD or reflux) occurs because of a failure of the normal mechanisms that protect the esophagus from the corrosive effects of acid and other stomach juices. Although heartburn is a common symptom of this disorder, ulcers, bleeding and narrowing (stricture) of the lower esophagus can still occur with little or no symptoms.
Long-standing reflux or hiatal hernia can cause normal peristalsis to deteriorate. This is detected by a test called manometry and many patients considering surgery for reflux will need to undergo this examination.
This is a rare disorder of unknown cause. Achalasia occurs when the nerves supplying the muscle of the last inch or so of the esophagus disappear. This results in failure of the muscle to relax completely. Normal peristalsis in the esophagus is absent and patients complain of difficulty swallowing, regurgitation and chest pain. As time goes by the esophagus begins to dilate and twist till it resembles a large passive bag in which food and fluid accumulate because they cannot pass normally into the stomach. Eventually this results in weight loss and nutritional depletion. Because there is no known cure for achalasia, treatment is aimed at loosening the tight zone in the lower esophagus to allow food to pass through more easily.
Conventional surgery is a treatment option for these disorders and has been revolutionized by the development of laparoscopic techniques. Because there is no organ to remove, and only stitches to insert, this surgery can be performed through tiny incisions. Great precision is made possible by the magnification provided by the video system.
For patients with symptoms of reflux, a 24 hour pH study measures how long and how often the esophagus is exposed to acid, and the correlation between acid exposure and symptoms such as heartburn. This allows the surgeon to identify patients unlikely to benefit from an operation. After surgery is performed, the same test measures the effect of the operation for comparison with the preoperative values. Manometry measures the pressure waves in the esophagus and is usually performed in patients with long-standing reflux, or when achalasia is suspected. All patients must have had an endoscopy in the 6-12 months before surgery to rule out the presence of a tumor of the esophagus or upper stomach which can mimic some of the symptoms of these otherwise benign disorders.
No specific preparation is required for this surgery. Routine laboratory tests, EKG and a chest X-ray will be performed. Surgery is performed on the day of admission and can last from 11/2 - 4 hours, depending on the complexity of the case.
General anesthesia is required. The upper abdomen is inflated with gas and five small incisions are made for instruments to perform the surgery.
If the problem is reflux, the lower esophagus is dissected and the upper part of the stomach is partially or completely wrapped around it to create a valve (or wrap-see picture).
For paraesophageal hernia, the lining of the hernia is removed, the stomach is returned to the abdomen and the diaphragm is repaired. A wrap may be performed to prevent reflux.
In achalasia the muscle on the front of the esophagus is split surgically to remove the high pressure zone. Endoscopy of the inside of the esophagus is performed simultaneously to check that the muscle split (or esophagomyotomy) is adequate. An anti-reflux procedure normally completes the procedure to prevent regurgitation from stomach into the esophagus.
As with any laparoscopic operation, if it cannot be completed safely, it may be necessary to convert to a conventional procedure. The chance of this is only about 1%.
The following day, a limited barium swallow examination is performed to record the position of the stomach and the esophagus as it passes through the hiatus. If all is well, food is commenced immediately and you will be discharged later in the day. Painkillers by mouth should be sufficient at this stage and for the next day or two. Lengthy use of Percocet or Tylenol 3 will cause constipation and should be avoided after the first 2 to 3 doses.
It is common to experience some minor swallowing discomfort or difficulty for up to a month after the surgery. This is due to swelling of the operated tissues and almost always goes away without treatment.
In general any medication that you take for reflux such as Prilosec, Zantac etc. can be discontinued once the surgery is over.
It should be possible for you to eat a normal diet, but foods that tend to remain in large lumps when swallowed such as poorly chewed steak, tough breads or bagels, may stick and should be avoided. Note, in patients with achalasia, a puree diet will be necessary for 10 days after the operation to lower the chance of damaging the lining of the esophagus weakened by the myotomy.
Because you will now have a loose, one-way valve at the LES, you may experience a change in the way you belch. You may pass more gas from below and generally feel more "gassy". To minimize these effects you should eat slowly, chew each mouthful well and avoid carbonated beverages. If you remain comfortable after drinking gassy liquids there is no reason to abstain!
In the days following discharge, abdominal pain, vomiting, fever or absence of gas and normal bowel movements should be reported. Progressive difficulty or complete inability to swallow may indicate a problem with the wrap and evaluation by the surgeon is necessary. Recurrence of reflux may mean that the wrap has come loose. In our experience injury to adjacent organs such as the spleen or the stomach is very uncommon.
Surgery for reflux is very effective in 90-95% of cases. This means that a small number of patients will have a less satisfactory result and further evaluation with barium X-ray, manometry and 24 hour pH testing may be necessary.
Whether performed by conventional or laparoscopic surgery, paraesophageal hernia can recur in 10-15% of cases. We have had to reoperate on a small number of patients to correct this problem.
The results of surgery for achalasia depend on how much damage has occurred to the wall of the esophagus prior to operation.
We are constantly refining techniques to make laparoscopic surgery more safe and effective and to collect data concerning the longer term results. At intervals after your procedure one of our research assistants may call to check on your progress.
