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Surgery_Schwartz_6902 | Surgery_Schwartz | the sphincter due to compensation by a vigorously contracting esophageal body. Eventually, all three components of the sphincter fail, allowing unrestricted reflux of gastric juice into the esophagus and overwhelming its normal clearance mechanisms. This leads to esophageal mucosal injury with progressive deterioration of esophageal contractility, as is commonly seen in patients with strictures and BE. The loss of esophageal clearance increases the potential for regurgitation into the pharynx with aspiration.Brunicardi_Ch25_p1009-p1098.indd 103301/03/19 6:03 PM 1034SPECIFIC CONSIDERATIONSPART II70Prevalence%Gastric reflux(n = 22)Mixed reflux(n = 31)6050403020100A20151050% TimepH<4BpH4–7pH>7Figure 25-29. A. Prevalence of reflux types in 53 patients with gastroesophageal reflux disease. B. Esophageal luminal pH dur-ing bilirubin exposure. (Reproduced with permission from Kauer WK, Peters JH, DeMeester TR, etal: Mixed reflux of gastric and duodenal juices is more harmful to the | Surgery_Schwartz. the sphincter due to compensation by a vigorously contracting esophageal body. Eventually, all three components of the sphincter fail, allowing unrestricted reflux of gastric juice into the esophagus and overwhelming its normal clearance mechanisms. This leads to esophageal mucosal injury with progressive deterioration of esophageal contractility, as is commonly seen in patients with strictures and BE. The loss of esophageal clearance increases the potential for regurgitation into the pharynx with aspiration.Brunicardi_Ch25_p1009-p1098.indd 103301/03/19 6:03 PM 1034SPECIFIC CONSIDERATIONSPART II70Prevalence%Gastric reflux(n = 22)Mixed reflux(n = 31)6050403020100A20151050% TimepH<4BpH4–7pH>7Figure 25-29. A. Prevalence of reflux types in 53 patients with gastroesophageal reflux disease. B. Esophageal luminal pH dur-ing bilirubin exposure. (Reproduced with permission from Kauer WK, Peters JH, DeMeester TR, etal: Mixed reflux of gastric and duodenal juices is more harmful to the |
Surgery_Schwartz_6903 | Surgery_Schwartz | B. Esophageal luminal pH dur-ing bilirubin exposure. (Reproduced with permission from Kauer WK, Peters JH, DeMeester TR, etal: Mixed reflux of gastric and duodenal juices is more harmful to the esophagus than gastric juice alone. The need for surgical therapy re-emphasized, Ann Surg. 1995 Oct;222(4):525-531.)350300250200150100500123pH4567891018:00Time06:00Bile acid conc. umol/l0Figure 25-28. Sample bile acid concentration and esophageal pH plotted against time to obtain detailed profiles; in this case showing both significant bile acid (vertical bars) and acid (linear plot) reflux. (Reproduced with permission from Nehra D, Watt P, Pye JK, et al. Automated oesophageal reflux sampler: a new device used to moni-tor bile acid reflux in patients with gastroesophageal reflux disease, J Med Eng Technol. 1997 Jan-Feb;21(1):1-9.)The potential injurious components that reflux into the esophagus include gastric secretions such as acid and pepsin, as well as biliary and pancreatic secretions that | Surgery_Schwartz. B. Esophageal luminal pH dur-ing bilirubin exposure. (Reproduced with permission from Kauer WK, Peters JH, DeMeester TR, etal: Mixed reflux of gastric and duodenal juices is more harmful to the esophagus than gastric juice alone. The need for surgical therapy re-emphasized, Ann Surg. 1995 Oct;222(4):525-531.)350300250200150100500123pH4567891018:00Time06:00Bile acid conc. umol/l0Figure 25-28. Sample bile acid concentration and esophageal pH plotted against time to obtain detailed profiles; in this case showing both significant bile acid (vertical bars) and acid (linear plot) reflux. (Reproduced with permission from Nehra D, Watt P, Pye JK, et al. Automated oesophageal reflux sampler: a new device used to moni-tor bile acid reflux in patients with gastroesophageal reflux disease, J Med Eng Technol. 1997 Jan-Feb;21(1):1-9.)The potential injurious components that reflux into the esophagus include gastric secretions such as acid and pepsin, as well as biliary and pancreatic secretions that |
Surgery_Schwartz_6904 | Surgery_Schwartz | 1997 Jan-Feb;21(1):1-9.)The potential injurious components that reflux into the esophagus include gastric secretions such as acid and pepsin, as well as biliary and pancreatic secretions that regurgitate from the duodenum into the stomach. There is a considerable body of experimental evidence to indicate that maximal epithelial injury occurs during exposure to bile salts combined with acid and pepsin. These studies have shown that while acid alone does minimal damage to the esophageal mucosa, the combination of acid and pepsin is highly deleterious. Similarly, the reflux of duodenal juice alone does little damage to the mucosa, although the combination of duodenal juice and gastric acid is particu-larly noxious.Complications of gastroesophageal reflux such as esopha-gitis, stricture, and Barrett’s metaplasia occur in the presence of two predisposing factors: a mechanically defective LES and an increased esophageal exposure to fluid containing duodenal content that includes bile and | Surgery_Schwartz. 1997 Jan-Feb;21(1):1-9.)The potential injurious components that reflux into the esophagus include gastric secretions such as acid and pepsin, as well as biliary and pancreatic secretions that regurgitate from the duodenum into the stomach. There is a considerable body of experimental evidence to indicate that maximal epithelial injury occurs during exposure to bile salts combined with acid and pepsin. These studies have shown that while acid alone does minimal damage to the esophageal mucosa, the combination of acid and pepsin is highly deleterious. Similarly, the reflux of duodenal juice alone does little damage to the mucosa, although the combination of duodenal juice and gastric acid is particu-larly noxious.Complications of gastroesophageal reflux such as esopha-gitis, stricture, and Barrett’s metaplasia occur in the presence of two predisposing factors: a mechanically defective LES and an increased esophageal exposure to fluid containing duodenal content that includes bile and |
Surgery_Schwartz_6905 | Surgery_Schwartz | Barrett’s metaplasia occur in the presence of two predisposing factors: a mechanically defective LES and an increased esophageal exposure to fluid containing duodenal content that includes bile and pancreatic juice. The duodenal origin of esophageal contents in patients with an increased exposure to a pH >7 has previously been confirmed by esopha-geal aspiration studies (Fig. 25-28). Studies have clarified and expanded these observations by measuring esophageal bilirubin exposure over a 24-hour period as a marker for the presence of duodenal juice. Direct measurement of esophageal bilirubin exposure as a marker for duodenal juice has shown that 58% of patients with GERD have increased esophageal exposure to duodenal juice and that this exposure occurs most commonly when the esophageal pH is between 4 and 7 (Fig. 25-29). These earlier studies have been confirmed by other studies that mea-sure volume reflux using impedance technology (Fig. 25-30).If reflux of gastric juice is allowed to | Surgery_Schwartz. Barrett’s metaplasia occur in the presence of two predisposing factors: a mechanically defective LES and an increased esophageal exposure to fluid containing duodenal content that includes bile and pancreatic juice. The duodenal origin of esophageal contents in patients with an increased exposure to a pH >7 has previously been confirmed by esopha-geal aspiration studies (Fig. 25-28). Studies have clarified and expanded these observations by measuring esophageal bilirubin exposure over a 24-hour period as a marker for the presence of duodenal juice. Direct measurement of esophageal bilirubin exposure as a marker for duodenal juice has shown that 58% of patients with GERD have increased esophageal exposure to duodenal juice and that this exposure occurs most commonly when the esophageal pH is between 4 and 7 (Fig. 25-29). These earlier studies have been confirmed by other studies that mea-sure volume reflux using impedance technology (Fig. 25-30).If reflux of gastric juice is allowed to |
Surgery_Schwartz_6906 | Surgery_Schwartz | between 4 and 7 (Fig. 25-29). These earlier studies have been confirmed by other studies that mea-sure volume reflux using impedance technology (Fig. 25-30).If reflux of gastric juice is allowed to persist and sustained or repetitive esophageal injury occurs, two sequelae can result. First, a luminal stricture can develop from submucosal and even-tually intramural fibrosis. Second, the tubular esophagus may become replaced with columnar epithelium. The columnar epi-thelium is resistant to acid and is associated with the alleviation of the complaint of heartburn. This columnar epithelium often becomes intestinalized, identified histologically by the presence 100Prevalence of patients with increased bilirubin806040200Normalsubjectsn = 25No mucosalinjuryn = 16Erosiveesophagitisn = 10Barrett’sesophagusn = 27Figure 25-30. Prevalence of abnormal esophageal bilirubin expo-sure in healthy subjects and in patients with gastroesophageal reflux disease with varied degrees of mucosal injury. (*P | Surgery_Schwartz. between 4 and 7 (Fig. 25-29). These earlier studies have been confirmed by other studies that mea-sure volume reflux using impedance technology (Fig. 25-30).If reflux of gastric juice is allowed to persist and sustained or repetitive esophageal injury occurs, two sequelae can result. First, a luminal stricture can develop from submucosal and even-tually intramural fibrosis. Second, the tubular esophagus may become replaced with columnar epithelium. The columnar epi-thelium is resistant to acid and is associated with the alleviation of the complaint of heartburn. This columnar epithelium often becomes intestinalized, identified histologically by the presence 100Prevalence of patients with increased bilirubin806040200Normalsubjectsn = 25No mucosalinjuryn = 16Erosiveesophagitisn = 10Barrett’sesophagusn = 27Figure 25-30. Prevalence of abnormal esophageal bilirubin expo-sure in healthy subjects and in patients with gastroesophageal reflux disease with varied degrees of mucosal injury. (*P |
Surgery_Schwartz_6907 | Surgery_Schwartz | = 27Figure 25-30. Prevalence of abnormal esophageal bilirubin expo-sure in healthy subjects and in patients with gastroesophageal reflux disease with varied degrees of mucosal injury. (*P <.03 vs. all other groups; **P <.03 vs. healthy subjects.) (Reproduced with permis-sion from Kauer WK, Peters JH, DeMeester TR, et al: Mixed reflux of gastric and duodenal juices is more harmful to the esophagus than gastric juice alone. The need for surgical therapy re-emphasized, Ann Surg. 1995 Oct;222(4):525-531.)Brunicardi_Ch25_p1009-p1098.indd 103401/03/19 6:03 PM 1035ESOPHAGUS AND DIAPHRAGMATIC HERNIACHAPTER 25of goblet cells. This specialized IM is currently required for the diagnosis of BE. Endoscopically, BE can be quiescent or associ-ated with complications of esophagitis, stricture, Barrett’s ulcer-ation, and dysplasia. The complications associated with BE may be due to the continuous irritation from refluxed duodenogastric juice. This continued injury is pH dependent and may be | Surgery_Schwartz. = 27Figure 25-30. Prevalence of abnormal esophageal bilirubin expo-sure in healthy subjects and in patients with gastroesophageal reflux disease with varied degrees of mucosal injury. (*P <.03 vs. all other groups; **P <.03 vs. healthy subjects.) (Reproduced with permis-sion from Kauer WK, Peters JH, DeMeester TR, et al: Mixed reflux of gastric and duodenal juices is more harmful to the esophagus than gastric juice alone. The need for surgical therapy re-emphasized, Ann Surg. 1995 Oct;222(4):525-531.)Brunicardi_Ch25_p1009-p1098.indd 103401/03/19 6:03 PM 1035ESOPHAGUS AND DIAPHRAGMATIC HERNIACHAPTER 25of goblet cells. This specialized IM is currently required for the diagnosis of BE. Endoscopically, BE can be quiescent or associ-ated with complications of esophagitis, stricture, Barrett’s ulcer-ation, and dysplasia. The complications associated with BE may be due to the continuous irritation from refluxed duodenogastric juice. This continued injury is pH dependent and may be |
Surgery_Schwartz_6908 | Surgery_Schwartz | Barrett’s ulcer-ation, and dysplasia. The complications associated with BE may be due to the continuous irritation from refluxed duodenogastric juice. This continued injury is pH dependent and may be modi-fied by medical therapy. The incidence of metaplastic Barrett’s epithelium becoming dysplastic and progressing to adenocarci-noma is approximately 0.2% to 0.5% per year.An esophageal stricture can be associated with severe esophagitis or BE. In the latter situation, it occurs at the site of maximal inflammatory injury (i.e., the columnar-squamous epi-thelial interface). Patients who have a stricture in the absence of Barrett’s esophagus should have the presence of gastroesopha-geal reflux documented before the presence of the stricture is ascribed to reflux esophagitis. In patients with normal acid exposure and no endoscopic or CT evidence of cancer, the stric-ture may be a result of a drug-induced chemical injury, the latter resulting from the lodgment of a capsule or tablet in the | Surgery_Schwartz. Barrett’s ulcer-ation, and dysplasia. The complications associated with BE may be due to the continuous irritation from refluxed duodenogastric juice. This continued injury is pH dependent and may be modi-fied by medical therapy. The incidence of metaplastic Barrett’s epithelium becoming dysplastic and progressing to adenocarci-noma is approximately 0.2% to 0.5% per year.An esophageal stricture can be associated with severe esophagitis or BE. In the latter situation, it occurs at the site of maximal inflammatory injury (i.e., the columnar-squamous epi-thelial interface). Patients who have a stricture in the absence of Barrett’s esophagus should have the presence of gastroesopha-geal reflux documented before the presence of the stricture is ascribed to reflux esophagitis. In patients with normal acid exposure and no endoscopic or CT evidence of cancer, the stric-ture may be a result of a drug-induced chemical injury, the latter resulting from the lodgment of a capsule or tablet in the |
Surgery_Schwartz_6909 | Surgery_Schwartz | normal acid exposure and no endoscopic or CT evidence of cancer, the stric-ture may be a result of a drug-induced chemical injury, the latter resulting from the lodgment of a capsule or tablet in the distal esophagus. In such patients, dilation usually corrects the prob-lem of dysphagia. It is also possible for drug-induced injuries to occur in patients who have underlying esophagitis and a distal esophageal stricture secondary to gastroesophageal reflux. In this situation, a long, string-like stricture progressively devel-ops as a result of repetitive caustic injury from capsule or tablet lodgment on top of an initial reflux stricture. These strictures are often resistant to dilation. The incidence of this problem has lessened since the introduction of proton pump inhibitor medication.Metaplastic (Barrett’s Esophagus) and Neoplastic (Adenocarcinoma) ComplicationsThe condition whereby the tubular esophagus is lined with columnar epithelium rather than squamous epithelium was first | Surgery_Schwartz. normal acid exposure and no endoscopic or CT evidence of cancer, the stric-ture may be a result of a drug-induced chemical injury, the latter resulting from the lodgment of a capsule or tablet in the distal esophagus. In such patients, dilation usually corrects the prob-lem of dysphagia. It is also possible for drug-induced injuries to occur in patients who have underlying esophagitis and a distal esophageal stricture secondary to gastroesophageal reflux. In this situation, a long, string-like stricture progressively devel-ops as a result of repetitive caustic injury from capsule or tablet lodgment on top of an initial reflux stricture. These strictures are often resistant to dilation. The incidence of this problem has lessened since the introduction of proton pump inhibitor medication.Metaplastic (Barrett’s Esophagus) and Neoplastic (Adenocarcinoma) ComplicationsThe condition whereby the tubular esophagus is lined with columnar epithelium rather than squamous epithelium was first |
Surgery_Schwartz_6910 | Surgery_Schwartz | (Barrett’s Esophagus) and Neoplastic (Adenocarcinoma) ComplicationsThe condition whereby the tubular esophagus is lined with columnar epithelium rather than squamous epithelium was first described by Norman Barrett in 1950. He incorrectly believed it to be congenital in origin. It is now realized that it is an acquired abnormality, occurs in 10% to 15% of patients with GERD, and represents the end stage of the natural history of this disease. It is also distinctly different from the congenital condition in which islands of gastric fundic epithelium are found in the upper half of the esophagus.The definition of BE has evolved considerably over the past decade. Traditionally, BE was identified by the presence of columnar mucosa extending at least 3 cm into the esophagus. It is now recognized that the specialized, intestinal-type epi-thelium, or intestinal metaplasia (IM) found in the Barrett’s mucosa, is the only tissue predisposed to malignant degenera-tion. Consequently, the | Surgery_Schwartz. (Barrett’s Esophagus) and Neoplastic (Adenocarcinoma) ComplicationsThe condition whereby the tubular esophagus is lined with columnar epithelium rather than squamous epithelium was first described by Norman Barrett in 1950. He incorrectly believed it to be congenital in origin. It is now realized that it is an acquired abnormality, occurs in 10% to 15% of patients with GERD, and represents the end stage of the natural history of this disease. It is also distinctly different from the congenital condition in which islands of gastric fundic epithelium are found in the upper half of the esophagus.The definition of BE has evolved considerably over the past decade. Traditionally, BE was identified by the presence of columnar mucosa extending at least 3 cm into the esophagus. It is now recognized that the specialized, intestinal-type epi-thelium, or intestinal metaplasia (IM) found in the Barrett’s mucosa, is the only tissue predisposed to malignant degenera-tion. Consequently, the |
Surgery_Schwartz_6911 | Surgery_Schwartz | recognized that the specialized, intestinal-type epi-thelium, or intestinal metaplasia (IM) found in the Barrett’s mucosa, is the only tissue predisposed to malignant degenera-tion. Consequently, the diagnosis of BE is presently made given any length of endoscopically identifiable columnar mucosa that proves, on biopsy, to show IM. Although long segments of columnar mucosa without IM do occur, they are uncommon and might be congenital in origin.The hallmark of IM is the presence of intestinal goblet cells. There is a high prevalence of biopsy-demonstrated IM at the cardia, on the gastric side of the squamocolumnar junction, in the absence of endoscopic evidence of a CLE. Evidence is accumulating that these patches of what appears to be Barrett’s in the cardia have a similar malignant potential as in the longer segments, and are precursors for carcinoma of the cardia.The long-term relief of symptoms remains the primary rea-son for performing antireflux surgery in patients with BE. | Surgery_Schwartz. recognized that the specialized, intestinal-type epi-thelium, or intestinal metaplasia (IM) found in the Barrett’s mucosa, is the only tissue predisposed to malignant degenera-tion. Consequently, the diagnosis of BE is presently made given any length of endoscopically identifiable columnar mucosa that proves, on biopsy, to show IM. Although long segments of columnar mucosa without IM do occur, they are uncommon and might be congenital in origin.The hallmark of IM is the presence of intestinal goblet cells. There is a high prevalence of biopsy-demonstrated IM at the cardia, on the gastric side of the squamocolumnar junction, in the absence of endoscopic evidence of a CLE. Evidence is accumulating that these patches of what appears to be Barrett’s in the cardia have a similar malignant potential as in the longer segments, and are precursors for carcinoma of the cardia.The long-term relief of symptoms remains the primary rea-son for performing antireflux surgery in patients with BE. |
Surgery_Schwartz_6912 | Surgery_Schwartz | potential as in the longer segments, and are precursors for carcinoma of the cardia.The long-term relief of symptoms remains the primary rea-son for performing antireflux surgery in patients with BE. Heal-ing of esophageal mucosal injury and the prevention of disease progression are important secondary goals. In this regard, patients with BE are no different than the broader population of patients with gastroesophageal reflux. They should be con-sidered for antireflux surgery when patient data suggest severe disease or predict the need for long-term medical management. Most patients with BE are symptomatic. Although it has been argued that some patients with BE may not have symptoms, careful history taking will reveal the presence of symptoms in most, if not all, patients.Patients with BE have a spectrum of disease ranging from visually identifiable but short segments, to long segments of classic BE. In general, however, they represent a relatively severe stage of gastroesophageal | Surgery_Schwartz. potential as in the longer segments, and are precursors for carcinoma of the cardia.The long-term relief of symptoms remains the primary rea-son for performing antireflux surgery in patients with BE. Heal-ing of esophageal mucosal injury and the prevention of disease progression are important secondary goals. In this regard, patients with BE are no different than the broader population of patients with gastroesophageal reflux. They should be con-sidered for antireflux surgery when patient data suggest severe disease or predict the need for long-term medical management. Most patients with BE are symptomatic. Although it has been argued that some patients with BE may not have symptoms, careful history taking will reveal the presence of symptoms in most, if not all, patients.Patients with BE have a spectrum of disease ranging from visually identifiable but short segments, to long segments of classic BE. In general, however, they represent a relatively severe stage of gastroesophageal |
Surgery_Schwartz_6913 | Surgery_Schwartz | BE have a spectrum of disease ranging from visually identifiable but short segments, to long segments of classic BE. In general, however, they represent a relatively severe stage of gastroesophageal reflux, usually with markedly increased esophageal acid exposure, deficient LES characteris-tics, poor esophageal body function, and a high prevalence of duodenogastroesophageal reflux. Gastric hypersecretion occurs in 44% of patients. Most will require long-term PPI therapy for relief of symptoms and control of coexistent esophageal muco-sal injury. Given such profound deficits in esophageal physi-ology, antireflux surgery is an excellent means of long-term control of reflux symptoms for most patients with BE.The typical complications in BE include ulceration in the columnar-lined segment, stricture formation, and a dysplasia-cancer sequence. Barrett’s ulceration is unlike the erosive ulceration of reflux esophagitis in that it more closely resem-bles peptic ulceration in the stomach or | Surgery_Schwartz. BE have a spectrum of disease ranging from visually identifiable but short segments, to long segments of classic BE. In general, however, they represent a relatively severe stage of gastroesophageal reflux, usually with markedly increased esophageal acid exposure, deficient LES characteris-tics, poor esophageal body function, and a high prevalence of duodenogastroesophageal reflux. Gastric hypersecretion occurs in 44% of patients. Most will require long-term PPI therapy for relief of symptoms and control of coexistent esophageal muco-sal injury. Given such profound deficits in esophageal physi-ology, antireflux surgery is an excellent means of long-term control of reflux symptoms for most patients with BE.The typical complications in BE include ulceration in the columnar-lined segment, stricture formation, and a dysplasia-cancer sequence. Barrett’s ulceration is unlike the erosive ulceration of reflux esophagitis in that it more closely resem-bles peptic ulceration in the stomach or |
Surgery_Schwartz_6914 | Surgery_Schwartz | formation, and a dysplasia-cancer sequence. Barrett’s ulceration is unlike the erosive ulceration of reflux esophagitis in that it more closely resem-bles peptic ulceration in the stomach or duodenum, and has the same propensity to bleed, penetrate, or perforate. Fortunately, this complication occurs very rarely. The strictures found in BE occur at the squamocolumnar junction, and they are typically higher than peptic strictures in the absence of BE. Ulceration and stricture in association with BE were commonly reported before 1975, but with the advent of potent acid suppression medication, they have become less common. In contrast, the complication of adenocarcinoma developing in Barrett’s mucosa has become more common. Adenocarcinoma developing in Bar-rett’s mucosa was considered a rare tumor before 1975. Today, it occurs at approximately 0.2% to 0.5% per year of follow-up, which represents a risk 40 times that of the general popula-tion. Most, if not all, cases of adenocarcinoma of | Surgery_Schwartz. formation, and a dysplasia-cancer sequence. Barrett’s ulceration is unlike the erosive ulceration of reflux esophagitis in that it more closely resem-bles peptic ulceration in the stomach or duodenum, and has the same propensity to bleed, penetrate, or perforate. Fortunately, this complication occurs very rarely. The strictures found in BE occur at the squamocolumnar junction, and they are typically higher than peptic strictures in the absence of BE. Ulceration and stricture in association with BE were commonly reported before 1975, but with the advent of potent acid suppression medication, they have become less common. In contrast, the complication of adenocarcinoma developing in Barrett’s mucosa has become more common. Adenocarcinoma developing in Bar-rett’s mucosa was considered a rare tumor before 1975. Today, it occurs at approximately 0.2% to 0.5% per year of follow-up, which represents a risk 40 times that of the general popula-tion. Most, if not all, cases of adenocarcinoma of |
Surgery_Schwartz_6915 | Surgery_Schwartz | tumor before 1975. Today, it occurs at approximately 0.2% to 0.5% per year of follow-up, which represents a risk 40 times that of the general popula-tion. Most, if not all, cases of adenocarcinoma of the esophagus arise in Barrett’s epithelium (Fig. 25-31). About one-third of all patients with BE present with malignancy.The long-term risk of progression to dysplasia and ade-nocarcinoma, although not the driving force behind the deci-sion to perform antireflux surgery, is a significant concern for both patient and physician. Although to date, there have been no prospective randomized studies documenting that antireflux surgery has an effect on the risk of progression to dysplasia and carcinoma, complete control of reflux of gastric juice into the esophagus is clearly a desirable goal.Respiratory ComplicationsA significant proportion of patients with GERD will have associated respiratory symptoms. These patients may have laryngopharyngeal reflux-type symptoms, adult-onset asthma, or | Surgery_Schwartz. tumor before 1975. Today, it occurs at approximately 0.2% to 0.5% per year of follow-up, which represents a risk 40 times that of the general popula-tion. Most, if not all, cases of adenocarcinoma of the esophagus arise in Barrett’s epithelium (Fig. 25-31). About one-third of all patients with BE present with malignancy.The long-term risk of progression to dysplasia and ade-nocarcinoma, although not the driving force behind the deci-sion to perform antireflux surgery, is a significant concern for both patient and physician. Although to date, there have been no prospective randomized studies documenting that antireflux surgery has an effect on the risk of progression to dysplasia and carcinoma, complete control of reflux of gastric juice into the esophagus is clearly a desirable goal.Respiratory ComplicationsA significant proportion of patients with GERD will have associated respiratory symptoms. These patients may have laryngopharyngeal reflux-type symptoms, adult-onset asthma, or |
Surgery_Schwartz_6916 | Surgery_Schwartz | ComplicationsA significant proportion of patients with GERD will have associated respiratory symptoms. These patients may have laryngopharyngeal reflux-type symptoms, adult-onset asthma, or even idiopathic pulmonary fibrosis. These symptoms and organ injury may occur in isolation or in conjunction with typi-cal reflux symptoms such as heartburn and regurgitation. Sev-eral studies have demonstrated that up to 50% of patients with asthma have either endoscopically evident esophagitis or abnor-mal distal esophageal acid exposure. These findings support a causal relationship between GERD and aerodigestive symptoms and complications in a proportion of patients.3Brunicardi_Ch25_p1009-p1098.indd 103501/03/19 6:03 PM 1036SPECIFIC CONSIDERATIONSPART IIABFigure 25-31. Photomicrographs. A. Barrett’s epithelium with severe dysplasia. (×200.) Note nuclear irregularity, stratification, and loss of polarity. B. Barrett’s epithelium with intramucosal carcinoma. (×66.) Note malignant cells in the | Surgery_Schwartz. ComplicationsA significant proportion of patients with GERD will have associated respiratory symptoms. These patients may have laryngopharyngeal reflux-type symptoms, adult-onset asthma, or even idiopathic pulmonary fibrosis. These symptoms and organ injury may occur in isolation or in conjunction with typi-cal reflux symptoms such as heartburn and regurgitation. Sev-eral studies have demonstrated that up to 50% of patients with asthma have either endoscopically evident esophagitis or abnor-mal distal esophageal acid exposure. These findings support a causal relationship between GERD and aerodigestive symptoms and complications in a proportion of patients.3Brunicardi_Ch25_p1009-p1098.indd 103501/03/19 6:03 PM 1036SPECIFIC CONSIDERATIONSPART IIABFigure 25-31. Photomicrographs. A. Barrett’s epithelium with severe dysplasia. (×200.) Note nuclear irregularity, stratification, and loss of polarity. B. Barrett’s epithelium with intramucosal carcinoma. (×66.) Note malignant cells in the |
Surgery_Schwartz_6917 | Surgery_Schwartz | epithelium with severe dysplasia. (×200.) Note nuclear irregularity, stratification, and loss of polarity. B. Barrett’s epithelium with intramucosal carcinoma. (×66.) Note malignant cells in the mucosa (upper arrow), but not invading the muscularis mucosae (bottom arrow). (Reproduced with permission from Zuidema GD, Orringer MB: Shackelford’s Surgery of the Alimentary Tract, 3rd ed. Vol 1. Philadelphia, PA: Elsevier/Saunders; 1991.)Etiology of Reflux-Induced Respiratory Symptoms. There are two mechanisms that have been proposed as the cause of reflux-induced respiratory symptoms. The reflux theory sug-gests that these symptoms are the direct result of laryngopha-ryngeal exposure and aspiration of gastric contents. The reflex theory suggests that the vagal-mediated afferent fibers result in bronchoconstriction during episodes of distal esophageal acidification. The evidence supporting a mechanism of direct exposure to the aerodigestive system is based in clinical studies that have | Surgery_Schwartz. epithelium with severe dysplasia. (×200.) Note nuclear irregularity, stratification, and loss of polarity. B. Barrett’s epithelium with intramucosal carcinoma. (×66.) Note malignant cells in the mucosa (upper arrow), but not invading the muscularis mucosae (bottom arrow). (Reproduced with permission from Zuidema GD, Orringer MB: Shackelford’s Surgery of the Alimentary Tract, 3rd ed. Vol 1. Philadelphia, PA: Elsevier/Saunders; 1991.)Etiology of Reflux-Induced Respiratory Symptoms. There are two mechanisms that have been proposed as the cause of reflux-induced respiratory symptoms. The reflux theory sug-gests that these symptoms are the direct result of laryngopha-ryngeal exposure and aspiration of gastric contents. The reflex theory suggests that the vagal-mediated afferent fibers result in bronchoconstriction during episodes of distal esophageal acidification. The evidence supporting a mechanism of direct exposure to the aerodigestive system is based in clinical studies that have |
Surgery_Schwartz_6918 | Surgery_Schwartz | in bronchoconstriction during episodes of distal esophageal acidification. The evidence supporting a mechanism of direct exposure to the aerodigestive system is based in clinical studies that have documented a strong correlation between idiopathic pulmonary fibrosis and hiatal hernia. In addition, the presence of GERD was demonstrated to be highly associated with several pulmonary diseases in a recent Department of Veteran Affairs multivariate analysis. Next, with ambulatory pH testing, acid exposure within the proximal esophagus is more frequently identified in patients with gastroesophageal reflux and respi-ratory symptoms than in patients who have gastroesophageal reflux symptoms alone. These findings are supported by scinti-graphic studies, which have demonstrated aspiration of ingested radioisotope in patients with both gastroesophageal reflux and pulmonary symptoms. In animal studies, tracheal instillation of acid has been demonstrated to profoundly increase airway resis-tance. | Surgery_Schwartz. in bronchoconstriction during episodes of distal esophageal acidification. The evidence supporting a mechanism of direct exposure to the aerodigestive system is based in clinical studies that have documented a strong correlation between idiopathic pulmonary fibrosis and hiatal hernia. In addition, the presence of GERD was demonstrated to be highly associated with several pulmonary diseases in a recent Department of Veteran Affairs multivariate analysis. Next, with ambulatory pH testing, acid exposure within the proximal esophagus is more frequently identified in patients with gastroesophageal reflux and respi-ratory symptoms than in patients who have gastroesophageal reflux symptoms alone. These findings are supported by scinti-graphic studies, which have demonstrated aspiration of ingested radioisotope in patients with both gastroesophageal reflux and pulmonary symptoms. In animal studies, tracheal instillation of acid has been demonstrated to profoundly increase airway resis-tance. |
Surgery_Schwartz_6919 | Surgery_Schwartz | radioisotope in patients with both gastroesophageal reflux and pulmonary symptoms. In animal studies, tracheal instillation of acid has been demonstrated to profoundly increase airway resis-tance. Finally, in patients who have undergone multichannel intraluminal impedance testing with a catheter configured to detect laryngopharyngeal reflux, a correlation between proxi-mal fluid movement and laryngopharyngeal symptoms, such as cough, can be demonstrated.The reflex mechanism is supported by the bronchocon-striction that occurs with the infusion of acid into the distal esophagus. There is a shared embryologic origin of the tracheo-esophageal tract and vagus nerve, and this reflex is thought to be an afferent fiber–mediated reflex that protects the aerodigestive system from the aspiration of refluxate. In patients with respira-tory symptoms and documented gastroesophageal reflux with-out proximal esophageal acid exposure, pulmonary symptoms will often times significantly improve or | Surgery_Schwartz. radioisotope in patients with both gastroesophageal reflux and pulmonary symptoms. In animal studies, tracheal instillation of acid has been demonstrated to profoundly increase airway resis-tance. Finally, in patients who have undergone multichannel intraluminal impedance testing with a catheter configured to detect laryngopharyngeal reflux, a correlation between proxi-mal fluid movement and laryngopharyngeal symptoms, such as cough, can be demonstrated.The reflex mechanism is supported by the bronchocon-striction that occurs with the infusion of acid into the distal esophagus. There is a shared embryologic origin of the tracheo-esophageal tract and vagus nerve, and this reflex is thought to be an afferent fiber–mediated reflex that protects the aerodigestive system from the aspiration of refluxate. In patients with respira-tory symptoms and documented gastroesophageal reflux with-out proximal esophageal acid exposure, pulmonary symptoms will often times significantly improve or |
Surgery_Schwartz_6920 | Surgery_Schwartz | of refluxate. In patients with respira-tory symptoms and documented gastroesophageal reflux with-out proximal esophageal acid exposure, pulmonary symptoms will often times significantly improve or completely resolve after undergoing laparoscopic fundoplication. It is likely that both of the proposed mechanisms work simultaneously to cause these symptoms in the face of GERD.The most difficult clinical challenge in formulating a treat-ment plan for reflux-associated respiratory symptoms resides in establishing the diagnosis. Although the diagnosis may be straightforward in patients with predominately typical reflux symptoms and secondary respiratory complaints, a substan-tial number of patients will have respiratory symptoms that dominate the clinical scenario. Typical gastroesophageal reflux Brunicardi_Ch25_p1009-p1098.indd 103601/03/19 6:03 PM 1037ESOPHAGUS AND DIAPHRAGMATIC HERNIACHAPTER 25symptoms, such as heartburn and regurgitation, may often be completely absent only to be | Surgery_Schwartz. of refluxate. In patients with respira-tory symptoms and documented gastroesophageal reflux with-out proximal esophageal acid exposure, pulmonary symptoms will often times significantly improve or completely resolve after undergoing laparoscopic fundoplication. It is likely that both of the proposed mechanisms work simultaneously to cause these symptoms in the face of GERD.The most difficult clinical challenge in formulating a treat-ment plan for reflux-associated respiratory symptoms resides in establishing the diagnosis. Although the diagnosis may be straightforward in patients with predominately typical reflux symptoms and secondary respiratory complaints, a substan-tial number of patients will have respiratory symptoms that dominate the clinical scenario. Typical gastroesophageal reflux Brunicardi_Ch25_p1009-p1098.indd 103601/03/19 6:03 PM 1037ESOPHAGUS AND DIAPHRAGMATIC HERNIACHAPTER 25symptoms, such as heartburn and regurgitation, may often be completely absent only to be |
Surgery_Schwartz_6921 | Surgery_Schwartz | Brunicardi_Ch25_p1009-p1098.indd 103601/03/19 6:03 PM 1037ESOPHAGUS AND DIAPHRAGMATIC HERNIACHAPTER 25symptoms, such as heartburn and regurgitation, may often be completely absent only to be uncovered with objective esopha-geal physiology testing. Traditionally, the diagnosis of reflux-induced respiratory injury is established using ambulatory dual probe pH monitoring, with one probe positioned within the dis-tal esophagus and the other at a proximal location. Proximal probe positioning has included multiple locations such as the trachea, pharynx, and proximal esophagus. Although ambu-latory esophageal pH monitoring allows a direct correlation between esophageal acidification and respiratory symptoms, sensitivity of this testing modality is poor, and the temporal rela-tionship between laryngeal or pulmonary symptoms and reflux events is complex. In addition, as the refluxed gastric fluid trav-els proximally, it may be neutralized by saliva and therefore go undetected with pH | Surgery_Schwartz. Brunicardi_Ch25_p1009-p1098.indd 103601/03/19 6:03 PM 1037ESOPHAGUS AND DIAPHRAGMATIC HERNIACHAPTER 25symptoms, such as heartburn and regurgitation, may often be completely absent only to be uncovered with objective esopha-geal physiology testing. Traditionally, the diagnosis of reflux-induced respiratory injury is established using ambulatory dual probe pH monitoring, with one probe positioned within the dis-tal esophagus and the other at a proximal location. Proximal probe positioning has included multiple locations such as the trachea, pharynx, and proximal esophagus. Although ambu-latory esophageal pH monitoring allows a direct correlation between esophageal acidification and respiratory symptoms, sensitivity of this testing modality is poor, and the temporal rela-tionship between laryngeal or pulmonary symptoms and reflux events is complex. In addition, as the refluxed gastric fluid trav-els proximally, it may be neutralized by saliva and therefore go undetected with pH |
Surgery_Schwartz_6922 | Surgery_Schwartz | laryngeal or pulmonary symptoms and reflux events is complex. In addition, as the refluxed gastric fluid trav-els proximally, it may be neutralized by saliva and therefore go undetected with pH monitoring. Impedance testing may also be used to detect the movement of fluid throughout the entire esophageal column regardless of pH content.Treatment. Once the diagnosis is established, treatment may be initiated with either PPI therapy or antireflux surgery. A trial of high-dose PPI therapy may help establish that reflux is partly or completely responsible for the respiratory symptoms. It is important to note that the persistence of symptoms in the face of aggressive PPI treatment does not necessarily rule out reflux as a possible cofactor or sole etiology.Although there is probably some element of a placebo effect, relief of respiratory symptoms can be anticipated in up to 50% of patients with reflux-induced asthma treated with anti-secretory medications. However, when examined | Surgery_Schwartz. laryngeal or pulmonary symptoms and reflux events is complex. In addition, as the refluxed gastric fluid trav-els proximally, it may be neutralized by saliva and therefore go undetected with pH monitoring. Impedance testing may also be used to detect the movement of fluid throughout the entire esophageal column regardless of pH content.Treatment. Once the diagnosis is established, treatment may be initiated with either PPI therapy or antireflux surgery. A trial of high-dose PPI therapy may help establish that reflux is partly or completely responsible for the respiratory symptoms. It is important to note that the persistence of symptoms in the face of aggressive PPI treatment does not necessarily rule out reflux as a possible cofactor or sole etiology.Although there is probably some element of a placebo effect, relief of respiratory symptoms can be anticipated in up to 50% of patients with reflux-induced asthma treated with anti-secretory medications. However, when examined |
Surgery_Schwartz_6923 | Surgery_Schwartz | some element of a placebo effect, relief of respiratory symptoms can be anticipated in up to 50% of patients with reflux-induced asthma treated with anti-secretory medications. However, when examined objectively, <15% of patients can be expected to have improvement in their pulmonary function with medical therapy. In properly selected patients, antireflux surgery improves respiratory symptoms in nearly 90% of children and 70% of adults with asthma and reflux disease. Improvements in pulmonary function can be demonstrated in around 30% of patients. Uncontrolled studies of the two forms of therapy (PPI and surgery) and the evidence from the two randomized controlled trials of medical vs. sur-gical therapy indicate that surgical valve reconstruction is the most effective therapy for reflux-induced asthma. The superi-ority of the surgery over PPI is most noticeable in the supine position, which corresponds with the nadir of PPI blood levels and resultant acid breakthrough and is the time | Surgery_Schwartz. some element of a placebo effect, relief of respiratory symptoms can be anticipated in up to 50% of patients with reflux-induced asthma treated with anti-secretory medications. However, when examined objectively, <15% of patients can be expected to have improvement in their pulmonary function with medical therapy. In properly selected patients, antireflux surgery improves respiratory symptoms in nearly 90% of children and 70% of adults with asthma and reflux disease. Improvements in pulmonary function can be demonstrated in around 30% of patients. Uncontrolled studies of the two forms of therapy (PPI and surgery) and the evidence from the two randomized controlled trials of medical vs. sur-gical therapy indicate that surgical valve reconstruction is the most effective therapy for reflux-induced asthma. The superi-ority of the surgery over PPI is most noticeable in the supine position, which corresponds with the nadir of PPI blood levels and resultant acid breakthrough and is the time |
Surgery_Schwartz_6924 | Surgery_Schwartz | asthma. The superi-ority of the surgery over PPI is most noticeable in the supine position, which corresponds with the nadir of PPI blood levels and resultant acid breakthrough and is the time in the circadian cycle when asthma symptoms are at their worst.In asthmatic patients with an esophageal motility disorder, performing an antireflux operation will not prevent the regur-gitation and possible aspiration of swallowed liquid or food “upstream” to the valve reconstruction. It is critical that esopha-geal body function be considered prior to surgical intervention in this patient population.Medical Therapy for Gastroesophageal Reflux Disease. With the widespread availability of over-the-counter antisecre-tory medications, most patients with mild or moderate symp-toms will carry self-medication. When initially identified with mild symptoms of uncomplicated GERD, patients can be placed on 12 weeks of simple antacids before diagnostic testing is initi-ated. This approach may successfully | Surgery_Schwartz. asthma. The superi-ority of the surgery over PPI is most noticeable in the supine position, which corresponds with the nadir of PPI blood levels and resultant acid breakthrough and is the time in the circadian cycle when asthma symptoms are at their worst.In asthmatic patients with an esophageal motility disorder, performing an antireflux operation will not prevent the regur-gitation and possible aspiration of swallowed liquid or food “upstream” to the valve reconstruction. It is critical that esopha-geal body function be considered prior to surgical intervention in this patient population.Medical Therapy for Gastroesophageal Reflux Disease. With the widespread availability of over-the-counter antisecre-tory medications, most patients with mild or moderate symp-toms will carry self-medication. When initially identified with mild symptoms of uncomplicated GERD, patients can be placed on 12 weeks of simple antacids before diagnostic testing is initi-ated. This approach may successfully |
Surgery_Schwartz_6925 | Surgery_Schwartz | When initially identified with mild symptoms of uncomplicated GERD, patients can be placed on 12 weeks of simple antacids before diagnostic testing is initi-ated. This approach may successfully and completely resolve the symptoms. Patients should be counseled to elevate the head of the bed; avoid tight-fitting clothing; eat small, frequent meals; avoid eating the nighttime meal immediately prior to bedtime; and avoid alcohol, coffee, chocolate, and peppermint, which are known to reduce resting LES pressure and may aggravate symptoms.Used in combination with simple antacids, alginic acid may augment the relief of symptoms by creating a physical bar-rier to reflux, as well as by acid reduction. Alginic acid reacts with sodium bicarbonate in the presence of saliva to form a highly viscous solution that floats like a raft on the surface of the gastric contents. When reflux occurs, this protective layer is refluxed into the esophagus, and acts as a protective barrier against the noxious | Surgery_Schwartz. When initially identified with mild symptoms of uncomplicated GERD, patients can be placed on 12 weeks of simple antacids before diagnostic testing is initi-ated. This approach may successfully and completely resolve the symptoms. Patients should be counseled to elevate the head of the bed; avoid tight-fitting clothing; eat small, frequent meals; avoid eating the nighttime meal immediately prior to bedtime; and avoid alcohol, coffee, chocolate, and peppermint, which are known to reduce resting LES pressure and may aggravate symptoms.Used in combination with simple antacids, alginic acid may augment the relief of symptoms by creating a physical bar-rier to reflux, as well as by acid reduction. Alginic acid reacts with sodium bicarbonate in the presence of saliva to form a highly viscous solution that floats like a raft on the surface of the gastric contents. When reflux occurs, this protective layer is refluxed into the esophagus, and acts as a protective barrier against the noxious |
Surgery_Schwartz_6926 | Surgery_Schwartz | solution that floats like a raft on the surface of the gastric contents. When reflux occurs, this protective layer is refluxed into the esophagus, and acts as a protective barrier against the noxious gastric contents. Medications to promote gastric emptying, such as metoclopramide or domperidone, are beneficial in early disease but of little value in more severe disease.In patients with persistent symptoms, the mainstay of medical therapy is acid suppression. High-dosage regimens of hydrogen potassium PPIs, such as omeprazole (up to 40 mg/d), can reduce gastric acidity by as much as 80% to 90%. This usu-ally heals mild esophagitis. In severe esophagitis, healing may occur in only one-half of the patients. In patients who reflux a combination of gastric and duodenal juice, acid-suppression therapy may give relief of symptoms, while still allowing mixed reflux to occur. This can allow persistent mucosal damage in an asymptomatic patient. Unfortunately, within 6 months of discontinuation | Surgery_Schwartz. solution that floats like a raft on the surface of the gastric contents. When reflux occurs, this protective layer is refluxed into the esophagus, and acts as a protective barrier against the noxious gastric contents. Medications to promote gastric emptying, such as metoclopramide or domperidone, are beneficial in early disease but of little value in more severe disease.In patients with persistent symptoms, the mainstay of medical therapy is acid suppression. High-dosage regimens of hydrogen potassium PPIs, such as omeprazole (up to 40 mg/d), can reduce gastric acidity by as much as 80% to 90%. This usu-ally heals mild esophagitis. In severe esophagitis, healing may occur in only one-half of the patients. In patients who reflux a combination of gastric and duodenal juice, acid-suppression therapy may give relief of symptoms, while still allowing mixed reflux to occur. This can allow persistent mucosal damage in an asymptomatic patient. Unfortunately, within 6 months of discontinuation |
Surgery_Schwartz_6927 | Surgery_Schwartz | therapy may give relief of symptoms, while still allowing mixed reflux to occur. This can allow persistent mucosal damage in an asymptomatic patient. Unfortunately, within 6 months of discontinuation of any form of medical therapy for GERD, 80% of patients have a recurrence of symptoms, and 40% of individuals with daily GERD eventually develop symptoms that “breakthrough” adequately dosed PPIs. Once initiated, most patients with GERD will require lifelong treatment with PPIs, both to relieve symptoms and to control any coexistent esophagitis or stricture. Although control of symptoms has his-torically served as the endpoint of therapy, the wisdom of this approach has recently been questioned, particularly in patients with BE. Evidence suggesting that reflux control may prevent the development of adenocarcinoma and lead to regression of dysplastic and nondysplastic Barrett’s segments has led many to consider control of reflux, and not symptom control, a better therapeutic endpoint. | Surgery_Schwartz. therapy may give relief of symptoms, while still allowing mixed reflux to occur. This can allow persistent mucosal damage in an asymptomatic patient. Unfortunately, within 6 months of discontinuation of any form of medical therapy for GERD, 80% of patients have a recurrence of symptoms, and 40% of individuals with daily GERD eventually develop symptoms that “breakthrough” adequately dosed PPIs. Once initiated, most patients with GERD will require lifelong treatment with PPIs, both to relieve symptoms and to control any coexistent esophagitis or stricture. Although control of symptoms has his-torically served as the endpoint of therapy, the wisdom of this approach has recently been questioned, particularly in patients with BE. Evidence suggesting that reflux control may prevent the development of adenocarcinoma and lead to regression of dysplastic and nondysplastic Barrett’s segments has led many to consider control of reflux, and not symptom control, a better therapeutic endpoint. |
Surgery_Schwartz_6928 | Surgery_Schwartz | of adenocarcinoma and lead to regression of dysplastic and nondysplastic Barrett’s segments has led many to consider control of reflux, and not symptom control, a better therapeutic endpoint. However, this hypothesis remains contro-versial. It should be noted that complete control of reflux using PPIs can be difficult, as has been highlighted by studies of acid breakthrough while on PPI therapy and of persistent reflux fol-lowing antireflux surgery. Castell, Triadafilopoulos, and others have shown that 40% to 80% of patients with BE continue to have abnormal esophageal acid exposure despite up to 20 mg twice daily of PPIs. Ablation trials have shown that mean doses of 56 mg of omeprazole were necessary to normalize 24-hour esophageal pH studies. It is likely that antireflux surgery results in more reproducible and reliable elimination of reflux of both acid and duodenal contents, although long-term outcome studies suggest that as many as 25% of postfundoplication patients will have | Surgery_Schwartz. of adenocarcinoma and lead to regression of dysplastic and nondysplastic Barrett’s segments has led many to consider control of reflux, and not symptom control, a better therapeutic endpoint. However, this hypothesis remains contro-versial. It should be noted that complete control of reflux using PPIs can be difficult, as has been highlighted by studies of acid breakthrough while on PPI therapy and of persistent reflux fol-lowing antireflux surgery. Castell, Triadafilopoulos, and others have shown that 40% to 80% of patients with BE continue to have abnormal esophageal acid exposure despite up to 20 mg twice daily of PPIs. Ablation trials have shown that mean doses of 56 mg of omeprazole were necessary to normalize 24-hour esophageal pH studies. It is likely that antireflux surgery results in more reproducible and reliable elimination of reflux of both acid and duodenal contents, although long-term outcome studies suggest that as many as 25% of postfundoplication patients will have |
Surgery_Schwartz_6929 | Surgery_Schwartz | in more reproducible and reliable elimination of reflux of both acid and duodenal contents, although long-term outcome studies suggest that as many as 25% of postfundoplication patients will have persistent pathologic esophageal acid exposure confirmed by positive 24-hour pH studies.Suggested Therapeutic Approach. Traditionally a stepwise approach is used for the treatment of GERD. First-line therapy entails antisecretory medication, usually PPIs, in most patients. Failure of medication to adequately control GERD symptoms suggests either that the patient may have relatively severe dis-ease or a non-GERD cause for his or her symptoms. Endoscopic examination at this stage of the patient’s evaluation is recom-mended and will provide the opportunity to assess the degree of mucosal injury and presence of BE. Treatment options for these patients entails either long term PPI use vs. antireflux surgery. Laparoscopic antireflux surgery in these patients achieves long-term control of symptoms | Surgery_Schwartz. in more reproducible and reliable elimination of reflux of both acid and duodenal contents, although long-term outcome studies suggest that as many as 25% of postfundoplication patients will have persistent pathologic esophageal acid exposure confirmed by positive 24-hour pH studies.Suggested Therapeutic Approach. Traditionally a stepwise approach is used for the treatment of GERD. First-line therapy entails antisecretory medication, usually PPIs, in most patients. Failure of medication to adequately control GERD symptoms suggests either that the patient may have relatively severe dis-ease or a non-GERD cause for his or her symptoms. Endoscopic examination at this stage of the patient’s evaluation is recom-mended and will provide the opportunity to assess the degree of mucosal injury and presence of BE. Treatment options for these patients entails either long term PPI use vs. antireflux surgery. Laparoscopic antireflux surgery in these patients achieves long-term control of symptoms |
Surgery_Schwartz_6930 | Surgery_Schwartz | presence of BE. Treatment options for these patients entails either long term PPI use vs. antireflux surgery. Laparoscopic antireflux surgery in these patients achieves long-term control of symptoms in 85% to 90%. The measurement Brunicardi_Ch25_p1009-p1098.indd 103701/03/19 6:03 PM 1038SPECIFIC CONSIDERATIONSPART IIof esophageal acid exposure via 24-hour pH should be under-taken when patients are considered for surgery. The status of the LES and esophageal body function with esophageal manom-etry should also be performed at this stage. These studies will serve to establish the diagnosis and assess esophageal body dysfunction.Surgical Therapy for Gastroesophageal Reflux DiseaseSelection of Patients for Surgery. Studies of the natural history of GERD indicate that most patients have a relatively benign form of the disease that is responsive to lifestyle changes and dietary and medical therapy and do not need surgical treat-ment. Approximately 25% to 50% of the patients with GERD | Surgery_Schwartz. presence of BE. Treatment options for these patients entails either long term PPI use vs. antireflux surgery. Laparoscopic antireflux surgery in these patients achieves long-term control of symptoms in 85% to 90%. The measurement Brunicardi_Ch25_p1009-p1098.indd 103701/03/19 6:03 PM 1038SPECIFIC CONSIDERATIONSPART IIof esophageal acid exposure via 24-hour pH should be under-taken when patients are considered for surgery. The status of the LES and esophageal body function with esophageal manom-etry should also be performed at this stage. These studies will serve to establish the diagnosis and assess esophageal body dysfunction.Surgical Therapy for Gastroesophageal Reflux DiseaseSelection of Patients for Surgery. Studies of the natural history of GERD indicate that most patients have a relatively benign form of the disease that is responsive to lifestyle changes and dietary and medical therapy and do not need surgical treat-ment. Approximately 25% to 50% of the patients with GERD |
Surgery_Schwartz_6931 | Surgery_Schwartz | a relatively benign form of the disease that is responsive to lifestyle changes and dietary and medical therapy and do not need surgical treat-ment. Approximately 25% to 50% of the patients with GERD have persistent or progressive disease, and it is this patient pop-ulation that is best suited to surgical therapy. In the past, the presence of esophagitis and a structurally defective LES were the primary indications for surgical treatment, and many inter-nists and surgeons were reluctant to recommend operative pro-cedures in their absence. However, one should not be deterred from considering antireflux surgery in a symptomatic patient with or without esophagitis or a defective sphincter, provided the disease process has been objectively documented by 24-hour pH monitoring. This is particularly true in patients who have become dependent upon therapy with PPIs, or require increasing doses to control their symptoms. It is important to note that a good response to medical therapy in this | Surgery_Schwartz. a relatively benign form of the disease that is responsive to lifestyle changes and dietary and medical therapy and do not need surgical treat-ment. Approximately 25% to 50% of the patients with GERD have persistent or progressive disease, and it is this patient pop-ulation that is best suited to surgical therapy. In the past, the presence of esophagitis and a structurally defective LES were the primary indications for surgical treatment, and many inter-nists and surgeons were reluctant to recommend operative pro-cedures in their absence. However, one should not be deterred from considering antireflux surgery in a symptomatic patient with or without esophagitis or a defective sphincter, provided the disease process has been objectively documented by 24-hour pH monitoring. This is particularly true in patients who have become dependent upon therapy with PPIs, or require increasing doses to control their symptoms. It is important to note that a good response to medical therapy in this |
Surgery_Schwartz_6932 | Surgery_Schwartz | true in patients who have become dependent upon therapy with PPIs, or require increasing doses to control their symptoms. It is important to note that a good response to medical therapy in this group of patients pre-dicts an excellent outcome following antireflux surgery.In general, the key indications for antireflux surgery are (a) objectively proven gastroesophageal reflux disease, and (b) typical symptoms of gastroesophageal reflux disease (heartburn and/or regurgitation) despite adequate medical management, or (c) a younger patient unwilling to take lifelong medication. In addition, a structurally defective LES can also predict which patients are more likely to fail with medical therapy. Patients with normal sphincter pressures tend to remain well controlled with medical therapy, whereas patients with a structurally defec-tive LES may not respond as well to medical therapy, and often develop recurrent symptoms within 1 to 2 years of beginning therapy. Such patients should be | Surgery_Schwartz. true in patients who have become dependent upon therapy with PPIs, or require increasing doses to control their symptoms. It is important to note that a good response to medical therapy in this group of patients pre-dicts an excellent outcome following antireflux surgery.In general, the key indications for antireflux surgery are (a) objectively proven gastroesophageal reflux disease, and (b) typical symptoms of gastroesophageal reflux disease (heartburn and/or regurgitation) despite adequate medical management, or (c) a younger patient unwilling to take lifelong medication. In addition, a structurally defective LES can also predict which patients are more likely to fail with medical therapy. Patients with normal sphincter pressures tend to remain well controlled with medical therapy, whereas patients with a structurally defec-tive LES may not respond as well to medical therapy, and often develop recurrent symptoms within 1 to 2 years of beginning therapy. Such patients should be |
Surgery_Schwartz_6933 | Surgery_Schwartz | whereas patients with a structurally defec-tive LES may not respond as well to medical therapy, and often develop recurrent symptoms within 1 to 2 years of beginning therapy. Such patients should be considered for an antireflux operation, regardless of the presence or absence of endoscopic esophagitis.Young patients with documented reflux disease with or without a defective LES are also excellent candidates for anti-reflux surgery. They usually will require long-term medical therapy for control of their symptoms, and some will go on to develop complications of the disease. An analysis of the cost of therapy based on data from the Veterans Administration Coop-erative trial indicates that surgery has a cost advantage over medical therapy in patients <49 years of age.Severe endoscopic esophagitis in a symptomatic patient with a structurally defective LES is also an indication for early surgical therapy. These patients are prone to breakthrough of their symptoms while receiving medical | Surgery_Schwartz. whereas patients with a structurally defec-tive LES may not respond as well to medical therapy, and often develop recurrent symptoms within 1 to 2 years of beginning therapy. Such patients should be considered for an antireflux operation, regardless of the presence or absence of endoscopic esophagitis.Young patients with documented reflux disease with or without a defective LES are also excellent candidates for anti-reflux surgery. They usually will require long-term medical therapy for control of their symptoms, and some will go on to develop complications of the disease. An analysis of the cost of therapy based on data from the Veterans Administration Coop-erative trial indicates that surgery has a cost advantage over medical therapy in patients <49 years of age.Severe endoscopic esophagitis in a symptomatic patient with a structurally defective LES is also an indication for early surgical therapy. These patients are prone to breakthrough of their symptoms while receiving medical |
Surgery_Schwartz_6934 | Surgery_Schwartz | in a symptomatic patient with a structurally defective LES is also an indication for early surgical therapy. These patients are prone to breakthrough of their symptoms while receiving medical therapy. Symptoms and mucosal injury can be controlled in such patients, but careful monitoring is required, and increasing dosages of PPIs are nec-essary. In everyday clinical practice, however, such treatment can be both difficult and impractical, and, in such cases, antire-flux surgery can be considered early, especially if PPI therapy is problematic.The development of a stricture in a patient represents a fail-ure of medical therapy, and it is also an indication for a surgical antireflux procedure. In addition, strictures are often associated with a structurally defective sphincter and loss of esophageal contractility. Before proceeding with surgical treatment, malig-nancy and a drug-related etiology of the stricture should be excluded, and the stricture should be progressively dilated up to | Surgery_Schwartz. in a symptomatic patient with a structurally defective LES is also an indication for early surgical therapy. These patients are prone to breakthrough of their symptoms while receiving medical therapy. Symptoms and mucosal injury can be controlled in such patients, but careful monitoring is required, and increasing dosages of PPIs are nec-essary. In everyday clinical practice, however, such treatment can be both difficult and impractical, and, in such cases, antire-flux surgery can be considered early, especially if PPI therapy is problematic.The development of a stricture in a patient represents a fail-ure of medical therapy, and it is also an indication for a surgical antireflux procedure. In addition, strictures are often associated with a structurally defective sphincter and loss of esophageal contractility. Before proceeding with surgical treatment, malig-nancy and a drug-related etiology of the stricture should be excluded, and the stricture should be progressively dilated up to |
Surgery_Schwartz_6935 | Surgery_Schwartz | contractility. Before proceeding with surgical treatment, malig-nancy and a drug-related etiology of the stricture should be excluded, and the stricture should be progressively dilated up to a 50 to 60F bougie. When the stricture is fully dilated, the relief of dysphagia is evaluated, and esophageal manometry is performed to determine the adequacy of peristalsis in the distal esophagus. If dysphagia is relieved and the amplitude of esopha-geal contractions is adequate, an antireflux procedure should be performed; if there is a global loss of esophageal contractility, caution should be exercised in performing an antireflux proce-dure with a complete fundoplication, and a partial fundoplica-tion should be considered.Barrett’s CLE is commonly associated with a severe structural defect of the LES and often poor contractility of the esophageal body. Patients with BE are at risk of the development of an adenocarcinoma. Whilst surgeons would like to think that an antireflux procedure can | Surgery_Schwartz. contractility. Before proceeding with surgical treatment, malig-nancy and a drug-related etiology of the stricture should be excluded, and the stricture should be progressively dilated up to a 50 to 60F bougie. When the stricture is fully dilated, the relief of dysphagia is evaluated, and esophageal manometry is performed to determine the adequacy of peristalsis in the distal esophagus. If dysphagia is relieved and the amplitude of esopha-geal contractions is adequate, an antireflux procedure should be performed; if there is a global loss of esophageal contractility, caution should be exercised in performing an antireflux proce-dure with a complete fundoplication, and a partial fundoplica-tion should be considered.Barrett’s CLE is commonly associated with a severe structural defect of the LES and often poor contractility of the esophageal body. Patients with BE are at risk of the development of an adenocarcinoma. Whilst surgeons would like to think that an antireflux procedure can |
Surgery_Schwartz_6936 | Surgery_Schwartz | the LES and often poor contractility of the esophageal body. Patients with BE are at risk of the development of an adenocarcinoma. Whilst surgeons would like to think that an antireflux procedure can reduce the risk of progression to cancer, the evidence supporting this is relatively weak, and for now Barrett’s esophagus should be considered to be evidence that the patient has gastroesophageal reflux, and progression to antireflux surgery is indicated for the treatment of reflux symptoms, not cancer progression. If, however, high grade dysplasia or intramucosal carcinoma is found on mucosal biopsy specimens, treatment should then be directed at the BE and the lesion, using either evaluation endoscopic ablation, endoscopic resection, or esophageal resection.The majority of patients requiring treatment for reflux have a relatively mild form of disease and will respond to antise-cretory medications. Patients with more severe forms of disease, particularly those who develop persistent or | Surgery_Schwartz. the LES and often poor contractility of the esophageal body. Patients with BE are at risk of the development of an adenocarcinoma. Whilst surgeons would like to think that an antireflux procedure can reduce the risk of progression to cancer, the evidence supporting this is relatively weak, and for now Barrett’s esophagus should be considered to be evidence that the patient has gastroesophageal reflux, and progression to antireflux surgery is indicated for the treatment of reflux symptoms, not cancer progression. If, however, high grade dysplasia or intramucosal carcinoma is found on mucosal biopsy specimens, treatment should then be directed at the BE and the lesion, using either evaluation endoscopic ablation, endoscopic resection, or esophageal resection.The majority of patients requiring treatment for reflux have a relatively mild form of disease and will respond to antise-cretory medications. Patients with more severe forms of disease, particularly those who develop persistent or |
Surgery_Schwartz_6937 | Surgery_Schwartz | treatment for reflux have a relatively mild form of disease and will respond to antise-cretory medications. Patients with more severe forms of disease, particularly those who develop persistent or progressive disease, should be considered for definitive therapy. Laparoscopic fun-doplication will provide a long-term cure in the majority of these patients, with minimal discomfort and an early return to normal activity.Preoperative Evaluation. Before proceeding with an antire-flux operation, several factors should be evaluated. The clinical symptoms should be consistent with the diagnosis of gastro-esophageal reflux. Patients presenting with the typical symp-toms of heartburn and/or regurgitation which have responded, at least partly, to PPI therapy, will generally do well following surgery, whereas patients with atypical symptoms have a less predictable response. Reflux should also be objectively con-firmed by either the presence of ulcerative esophagitis or an abnormal 24-hour pH | Surgery_Schwartz. treatment for reflux have a relatively mild form of disease and will respond to antise-cretory medications. Patients with more severe forms of disease, particularly those who develop persistent or progressive disease, should be considered for definitive therapy. Laparoscopic fun-doplication will provide a long-term cure in the majority of these patients, with minimal discomfort and an early return to normal activity.Preoperative Evaluation. Before proceeding with an antire-flux operation, several factors should be evaluated. The clinical symptoms should be consistent with the diagnosis of gastro-esophageal reflux. Patients presenting with the typical symp-toms of heartburn and/or regurgitation which have responded, at least partly, to PPI therapy, will generally do well following surgery, whereas patients with atypical symptoms have a less predictable response. Reflux should also be objectively con-firmed by either the presence of ulcerative esophagitis or an abnormal 24-hour pH |
Surgery_Schwartz_6938 | Surgery_Schwartz | whereas patients with atypical symptoms have a less predictable response. Reflux should also be objectively con-firmed by either the presence of ulcerative esophagitis or an abnormal 24-hour pH study.The propulsive force of the body of the esophagus should be evaluated by esophageal manometry to determine if it has sufficient power to propel a bolus of food through a newly reconstructed valve. Patients with normal peristaltic contrac-tions can be considered for a 360° Nissen fundoplication or a partial fundoplication, depending on patient and surgeon pref-erences. When peristalsis is absent, a partial fundoplication is probably the procedure of choice, but only if achalasia has been ruled out.Hiatal anatomy should also be assessed. In patients with smaller hiatal hernias, endoscopy evaluation usually provides sufficient information. However, when patients present with a very large hiatus hernia or for revision surgery after previous antireflux surgery, contrast radiology provides | Surgery_Schwartz. whereas patients with atypical symptoms have a less predictable response. Reflux should also be objectively con-firmed by either the presence of ulcerative esophagitis or an abnormal 24-hour pH study.The propulsive force of the body of the esophagus should be evaluated by esophageal manometry to determine if it has sufficient power to propel a bolus of food through a newly reconstructed valve. Patients with normal peristaltic contrac-tions can be considered for a 360° Nissen fundoplication or a partial fundoplication, depending on patient and surgeon pref-erences. When peristalsis is absent, a partial fundoplication is probably the procedure of choice, but only if achalasia has been ruled out.Hiatal anatomy should also be assessed. In patients with smaller hiatal hernias, endoscopy evaluation usually provides sufficient information. However, when patients present with a very large hiatus hernia or for revision surgery after previous antireflux surgery, contrast radiology provides |
Surgery_Schwartz_6939 | Surgery_Schwartz | usually provides sufficient information. However, when patients present with a very large hiatus hernia or for revision surgery after previous antireflux surgery, contrast radiology provides better anatomical information. The concept of anatomic shortening of the esoph-agus is controversial, with divergent opinions held about how Brunicardi_Ch25_p1009-p1098.indd 103801/03/19 6:03 PM 1039ESOPHAGUS AND DIAPHRAGMATIC HERNIACHAPTER 25DistentionFigure 25-32. A graphic illustration of the shortening of the lower esophageal sphincter that occurs as the sphincter is “taken up” by the cardia as the stomach distends.common this problem is. Believers claim that anatomic short-ening of the esophagus compromises the ability of the surgeon to perform an adequate repair without tension and that this can lead to an increased incidence of breakdown or thoracic displace-ment of the repair. Some of those who hold this view claim that esophageal shortening is present when a barium swallow X-ray | Surgery_Schwartz. usually provides sufficient information. However, when patients present with a very large hiatus hernia or for revision surgery after previous antireflux surgery, contrast radiology provides better anatomical information. The concept of anatomic shortening of the esoph-agus is controversial, with divergent opinions held about how Brunicardi_Ch25_p1009-p1098.indd 103801/03/19 6:03 PM 1039ESOPHAGUS AND DIAPHRAGMATIC HERNIACHAPTER 25DistentionFigure 25-32. A graphic illustration of the shortening of the lower esophageal sphincter that occurs as the sphincter is “taken up” by the cardia as the stomach distends.common this problem is. Believers claim that anatomic short-ening of the esophagus compromises the ability of the surgeon to perform an adequate repair without tension and that this can lead to an increased incidence of breakdown or thoracic displace-ment of the repair. Some of those who hold this view claim that esophageal shortening is present when a barium swallow X-ray |
Surgery_Schwartz_6940 | Surgery_Schwartz | this can lead to an increased incidence of breakdown or thoracic displace-ment of the repair. Some of those who hold this view claim that esophageal shortening is present when a barium swallow X-ray identifies a sliding hiatal hernia that will not reduce in the upright position or that measures more than 5 cm in length at endoscopy. When such identification is made, these surgeons usually add a gastroplasty to the antireflux procedure. Others claim that esoph-ageal shortening is overdiagnosed and rarely seen, and that the morbidity of adding a gastroplasty outweighs any benefits. These surgeons would recommend a standard antireflux procedure in all patients undergoing primary surgery.Principles of Surgical Therapy. The primary goal of anti-reflux surgery is to safely create a new antireflux valve at the gastroesophageal junction, while preserving the patient’s abil-ity to swallow normally and to belch to relieve gaseous disten-tion. Regardless of the choice of the procedure, this goal | Surgery_Schwartz. this can lead to an increased incidence of breakdown or thoracic displace-ment of the repair. Some of those who hold this view claim that esophageal shortening is present when a barium swallow X-ray identifies a sliding hiatal hernia that will not reduce in the upright position or that measures more than 5 cm in length at endoscopy. When such identification is made, these surgeons usually add a gastroplasty to the antireflux procedure. Others claim that esoph-ageal shortening is overdiagnosed and rarely seen, and that the morbidity of adding a gastroplasty outweighs any benefits. These surgeons would recommend a standard antireflux procedure in all patients undergoing primary surgery.Principles of Surgical Therapy. The primary goal of anti-reflux surgery is to safely create a new antireflux valve at the gastroesophageal junction, while preserving the patient’s abil-ity to swallow normally and to belch to relieve gaseous disten-tion. Regardless of the choice of the procedure, this goal |
Surgery_Schwartz_6941 | Surgery_Schwartz | valve at the gastroesophageal junction, while preserving the patient’s abil-ity to swallow normally and to belch to relieve gaseous disten-tion. Regardless of the choice of the procedure, this goal can be achieved if attention is paid to some basic principles when reconstructing the antireflux mechanism. First, the operation should create a flap valve which prevents regurgitation of gas-tric contents into the esophagus. This will result in an increase in the pressure of the distal esophageal sphincter region. Follow-ing a Nissen fundoplication the expected increase is to a level twice the resting gastric pressure (i.e., 12 mmHg for a gastric pressure of 6 mmHg). The extent of the pressure rise is often less following a partial fundoplication, although with all types of fundoplication the length of the reconstructed valve should be at least 3 cm. This not only augments sphincter characteristics in patients in whom they are reduced before surgery but also prevents unfolding of a normal | Surgery_Schwartz. valve at the gastroesophageal junction, while preserving the patient’s abil-ity to swallow normally and to belch to relieve gaseous disten-tion. Regardless of the choice of the procedure, this goal can be achieved if attention is paid to some basic principles when reconstructing the antireflux mechanism. First, the operation should create a flap valve which prevents regurgitation of gas-tric contents into the esophagus. This will result in an increase in the pressure of the distal esophageal sphincter region. Follow-ing a Nissen fundoplication the expected increase is to a level twice the resting gastric pressure (i.e., 12 mmHg for a gastric pressure of 6 mmHg). The extent of the pressure rise is often less following a partial fundoplication, although with all types of fundoplication the length of the reconstructed valve should be at least 3 cm. This not only augments sphincter characteristics in patients in whom they are reduced before surgery but also prevents unfolding of a normal |
Surgery_Schwartz_6942 | Surgery_Schwartz | length of the reconstructed valve should be at least 3 cm. This not only augments sphincter characteristics in patients in whom they are reduced before surgery but also prevents unfolding of a normal sphincter in response to gastric distention (Fig. 25-32). Preoperative and postoperative esopha-geal manometry measurements have shown that the resting sphincter pressure and the overall sphincter length can be surgi-cally augmented over preoperative values, and that the change in the former is a function of the degree of gastric wrap around the esophagus (Fig. 25-33). However, the aim of any fundopli-cation is to create a loose wrap and to maintain the position of the gastric fundus close to the distal intra-abdominal esophagus, in a flap valve arrangement. The efficacy of this relies on the close relationship between the fundus and the esophagus, not the “tightness” of the wrap.Second, the operation should place an adequate length of the distal esophageal sphincter in the | Surgery_Schwartz. length of the reconstructed valve should be at least 3 cm. This not only augments sphincter characteristics in patients in whom they are reduced before surgery but also prevents unfolding of a normal sphincter in response to gastric distention (Fig. 25-32). Preoperative and postoperative esopha-geal manometry measurements have shown that the resting sphincter pressure and the overall sphincter length can be surgi-cally augmented over preoperative values, and that the change in the former is a function of the degree of gastric wrap around the esophagus (Fig. 25-33). However, the aim of any fundopli-cation is to create a loose wrap and to maintain the position of the gastric fundus close to the distal intra-abdominal esophagus, in a flap valve arrangement. The efficacy of this relies on the close relationship between the fundus and the esophagus, not the “tightness” of the wrap.Second, the operation should place an adequate length of the distal esophageal sphincter in the |
Surgery_Schwartz_6943 | Surgery_Schwartz | relies on the close relationship between the fundus and the esophagus, not the “tightness” of the wrap.Second, the operation should place an adequate length of the distal esophageal sphincter in the positive-pressure 051015˜ P mmHg 20240Degree of wrapY = 4.63 + .023 (x)P < .01BelseyHillN=15NissenN=15N=15360Figure 25-33. The relationship between the augmentation of sphincter pressure over preoperative pressure (ΔP) and the degree of gastric fundic wrap in three different antireflux procedures. (Repro-duced with permission from O’Sullivan GC, DeMeester TR, Joels-son BE, et al: Interaction of lower esophageal sphincter pressure and length of sphincter in the abdomen as determinants of gastro-esophageal competence, Am J Surg. 1982 Jan;143(1):40-47.)environment of the abdomen by a method that ensures its response to changes in intra-abdominal pressure. The permanent restoration of 2 or more cm of abdominal esophagus ensures the preservation of the relationship between the fundus and the | Surgery_Schwartz. relies on the close relationship between the fundus and the esophagus, not the “tightness” of the wrap.Second, the operation should place an adequate length of the distal esophageal sphincter in the positive-pressure 051015˜ P mmHg 20240Degree of wrapY = 4.63 + .023 (x)P < .01BelseyHillN=15NissenN=15N=15360Figure 25-33. The relationship between the augmentation of sphincter pressure over preoperative pressure (ΔP) and the degree of gastric fundic wrap in three different antireflux procedures. (Repro-duced with permission from O’Sullivan GC, DeMeester TR, Joels-son BE, et al: Interaction of lower esophageal sphincter pressure and length of sphincter in the abdomen as determinants of gastro-esophageal competence, Am J Surg. 1982 Jan;143(1):40-47.)environment of the abdomen by a method that ensures its response to changes in intra-abdominal pressure. The permanent restoration of 2 or more cm of abdominal esophagus ensures the preservation of the relationship between the fundus and the |
Surgery_Schwartz_6944 | Surgery_Schwartz | ensures its response to changes in intra-abdominal pressure. The permanent restoration of 2 or more cm of abdominal esophagus ensures the preservation of the relationship between the fundus and the esophagus. All of the popular antireflux procedures increase the length of the sphincter exposed to abdominal pressure by an average of at least 1 cm.Third, the operation should allow the reconstructed car-dia to relax on deglutition. In normal swallowing, a vagally mediated relaxation of the distal esophageal sphincter and the gastric fundus occurs. The relaxation lasts for approximately 10 seconds and is followed by a rapid recovery to the former tonicity. To ensure relaxation of the sphincter, three factors are important: (a) Only the fundus of the stomach should be used to buttress the sphincter, because it is known to relax in con-cert with the sphincter; (b) the gastric wrap should be properly placed around the sphincter and not incorporate a portion of the stomach or be placed around | Surgery_Schwartz. ensures its response to changes in intra-abdominal pressure. The permanent restoration of 2 or more cm of abdominal esophagus ensures the preservation of the relationship between the fundus and the esophagus. All of the popular antireflux procedures increase the length of the sphincter exposed to abdominal pressure by an average of at least 1 cm.Third, the operation should allow the reconstructed car-dia to relax on deglutition. In normal swallowing, a vagally mediated relaxation of the distal esophageal sphincter and the gastric fundus occurs. The relaxation lasts for approximately 10 seconds and is followed by a rapid recovery to the former tonicity. To ensure relaxation of the sphincter, three factors are important: (a) Only the fundus of the stomach should be used to buttress the sphincter, because it is known to relax in con-cert with the sphincter; (b) the gastric wrap should be properly placed around the sphincter and not incorporate a portion of the stomach or be placed around |
Surgery_Schwartz_6945 | Surgery_Schwartz | because it is known to relax in con-cert with the sphincter; (b) the gastric wrap should be properly placed around the sphincter and not incorporate a portion of the stomach or be placed around the stomach itself, because the body of the stomach does not relax with swallowing; and (c) damage to the vagal nerves during dissection of the thoracic esophagus should be avoided because it may result in failure of the sphincter to relax.Fourth, the fundoplication should not increase the resis-tance of the relaxed sphincter to a level that exceeds the peri-staltic power of the body of the esophagus. The resistance of the relaxed sphincter depends on the degree, length, and diameter of the gastric fundic wrap, and on the variation in intra-abdominal pressure. A 360° gastric wrap should be no longer than 2 cm and constructed over a large (50 to 60F) bougie. This will ensure that the relaxed sphincter will have an adequate diameter with minimal resistance. A bougie is not necessary when | Surgery_Schwartz. because it is known to relax in con-cert with the sphincter; (b) the gastric wrap should be properly placed around the sphincter and not incorporate a portion of the stomach or be placed around the stomach itself, because the body of the stomach does not relax with swallowing; and (c) damage to the vagal nerves during dissection of the thoracic esophagus should be avoided because it may result in failure of the sphincter to relax.Fourth, the fundoplication should not increase the resis-tance of the relaxed sphincter to a level that exceeds the peri-staltic power of the body of the esophagus. The resistance of the relaxed sphincter depends on the degree, length, and diameter of the gastric fundic wrap, and on the variation in intra-abdominal pressure. A 360° gastric wrap should be no longer than 2 cm and constructed over a large (50 to 60F) bougie. This will ensure that the relaxed sphincter will have an adequate diameter with minimal resistance. A bougie is not necessary when |
Surgery_Schwartz_6946 | Surgery_Schwartz | no longer than 2 cm and constructed over a large (50 to 60F) bougie. This will ensure that the relaxed sphincter will have an adequate diameter with minimal resistance. A bougie is not necessary when construct-ing a partial wrap.Fifth, the operation should ensure that the fundoplication can be placed in the abdomen without undue tension and main-tained there by approximating the crura of the diaphragm above the repair. Leaving the fundoplication in the thorax converts a sliding hernia into a PEH, with all the complications associ-ated with that condition. Maintaining the repair in the abdomen Brunicardi_Ch25_p1009-p1098.indd 103901/03/19 6:03 PM 1040SPECIFIC CONSIDERATIONSPART IIunder tension predisposes to an increased incidence of recur-rence. How common this problem is encountered is disputed, with some surgeons advocating lengthening the esophagus by gastroplasty and constructing a partial fundoplication, and oth-ers claiming that this issue is now rarely encountered.Procedure | Surgery_Schwartz. no longer than 2 cm and constructed over a large (50 to 60F) bougie. This will ensure that the relaxed sphincter will have an adequate diameter with minimal resistance. A bougie is not necessary when construct-ing a partial wrap.Fifth, the operation should ensure that the fundoplication can be placed in the abdomen without undue tension and main-tained there by approximating the crura of the diaphragm above the repair. Leaving the fundoplication in the thorax converts a sliding hernia into a PEH, with all the complications associ-ated with that condition. Maintaining the repair in the abdomen Brunicardi_Ch25_p1009-p1098.indd 103901/03/19 6:03 PM 1040SPECIFIC CONSIDERATIONSPART IIunder tension predisposes to an increased incidence of recur-rence. How common this problem is encountered is disputed, with some surgeons advocating lengthening the esophagus by gastroplasty and constructing a partial fundoplication, and oth-ers claiming that this issue is now rarely encountered.Procedure |
Surgery_Schwartz_6947 | Surgery_Schwartz | disputed, with some surgeons advocating lengthening the esophagus by gastroplasty and constructing a partial fundoplication, and oth-ers claiming that this issue is now rarely encountered.Procedure Selection. A laparoscopic approach is now used routinely in all patients undergoing primary antireflux surgery. Some surgeons advocate the use of a single antireflux procedure for all patients, whereas others advocate a tailored approach. Advocates of the laparoscopic Nissen fundoplication as the pro-cedure of choice for a primary antireflux repair would generally apply this procedure in all patients with normal or near normal esophageal motility, and they would reserve a partial fundopli-cation for use in individuals with poor esophageal body motility. Others, based on the good longer-term outcomes now reported following partial fundoplication procedures, advocate the rou-tine application of a partial fundoplication procedure, thereby avoiding any concerns about constructing a | Surgery_Schwartz. disputed, with some surgeons advocating lengthening the esophagus by gastroplasty and constructing a partial fundoplication, and oth-ers claiming that this issue is now rarely encountered.Procedure Selection. A laparoscopic approach is now used routinely in all patients undergoing primary antireflux surgery. Some surgeons advocate the use of a single antireflux procedure for all patients, whereas others advocate a tailored approach. Advocates of the laparoscopic Nissen fundoplication as the pro-cedure of choice for a primary antireflux repair would generally apply this procedure in all patients with normal or near normal esophageal motility, and they would reserve a partial fundopli-cation for use in individuals with poor esophageal body motility. Others, based on the good longer-term outcomes now reported following partial fundoplication procedures, advocate the rou-tine application of a partial fundoplication procedure, thereby avoiding any concerns about constructing a |
Surgery_Schwartz_6948 | Surgery_Schwartz | outcomes now reported following partial fundoplication procedures, advocate the rou-tine application of a partial fundoplication procedure, thereby avoiding any concerns about constructing a fundoplication in individuals with poor esophageal motility.Experience and randomized studies have shown that both the Nissen fundoplication and various partial fundoplication procedures are all effective and durable antireflux repairs that generate an excellent outcome in approximately 90% of patients at longer-term follow-up.Primary Antireflux RepairsNissen Fundoplication. The most common antireflux proce-dure is the Nissen fundoplication. In the past, this procedure has been performed through an open abdominal or a chest incision, but with the development of laparoscopic approaches primary antireflux surgery is now routinely undertaken using the laparo-scope. Rudolph Nissen described this procedure as a 360° fun-doplication around the lower esophagus for a distance of 4 to 5 cm, without | Surgery_Schwartz. outcomes now reported following partial fundoplication procedures, advocate the rou-tine application of a partial fundoplication procedure, thereby avoiding any concerns about constructing a fundoplication in individuals with poor esophageal motility.Experience and randomized studies have shown that both the Nissen fundoplication and various partial fundoplication procedures are all effective and durable antireflux repairs that generate an excellent outcome in approximately 90% of patients at longer-term follow-up.Primary Antireflux RepairsNissen Fundoplication. The most common antireflux proce-dure is the Nissen fundoplication. In the past, this procedure has been performed through an open abdominal or a chest incision, but with the development of laparoscopic approaches primary antireflux surgery is now routinely undertaken using the laparo-scope. Rudolph Nissen described this procedure as a 360° fun-doplication around the lower esophagus for a distance of 4 to 5 cm, without |
Surgery_Schwartz_6949 | Surgery_Schwartz | surgery is now routinely undertaken using the laparo-scope. Rudolph Nissen described this procedure as a 360° fun-doplication around the lower esophagus for a distance of 4 to 5 cm, without division of the short gastric blood vessels. Although this provided good control of reflux, it was associated with a number of side effects that have encouraged modifica-tions of the procedure as originally described. These include using only the gastric fundus to envelop the esophagus in a fash-ion analogous to a Witzel jejunostomy, sizing the fundoplication with a large (50 to 60F) bougie, limiting the length of the fun-doplication to 1 to 2 cm, and dividing the short gastric vessels. The essential elements necessary for the performance of a trans-abdominal fundoplication are common to both the laparoscopic and open procedures and include the following:1. Hiatal dissection and preservation of both vagi along their entire length2. Circumferential esophageal mobilization3. Hiatal closure, usually | Surgery_Schwartz. surgery is now routinely undertaken using the laparo-scope. Rudolph Nissen described this procedure as a 360° fun-doplication around the lower esophagus for a distance of 4 to 5 cm, without division of the short gastric blood vessels. Although this provided good control of reflux, it was associated with a number of side effects that have encouraged modifica-tions of the procedure as originally described. These include using only the gastric fundus to envelop the esophagus in a fash-ion analogous to a Witzel jejunostomy, sizing the fundoplication with a large (50 to 60F) bougie, limiting the length of the fun-doplication to 1 to 2 cm, and dividing the short gastric vessels. The essential elements necessary for the performance of a trans-abdominal fundoplication are common to both the laparoscopic and open procedures and include the following:1. Hiatal dissection and preservation of both vagi along their entire length2. Circumferential esophageal mobilization3. Hiatal closure, usually |
Surgery_Schwartz_6950 | Surgery_Schwartz | and open procedures and include the following:1. Hiatal dissection and preservation of both vagi along their entire length2. Circumferential esophageal mobilization3. Hiatal closure, usually posterior to the esophagus4. Creation of a short and floppy fundoplication over an esoph-ageal dilatorIn addition, many surgeons also routinely divide the short gastric blood vessels, although this step is not universally applied, and the results of several randomized trials have failed to show that this step yields any benefit.The laparoscopic approach to fundoplication has now replaced the open abdominal Nissen fundoplication as the pro-cedure of choice. Five ports are usually used (Fig. 25-34), and dissection is begun by incising the gastrohepatic omentum above and below the hepatic branch of the anterior vagus nerve, which is usually preserved. The circumference of the diaphragmatic L R Figure 25-34. Patient positioning and trocar placement for lap-aroscopic antireflux surgery. The patient | Surgery_Schwartz. and open procedures and include the following:1. Hiatal dissection and preservation of both vagi along their entire length2. Circumferential esophageal mobilization3. Hiatal closure, usually posterior to the esophagus4. Creation of a short and floppy fundoplication over an esoph-ageal dilatorIn addition, many surgeons also routinely divide the short gastric blood vessels, although this step is not universally applied, and the results of several randomized trials have failed to show that this step yields any benefit.The laparoscopic approach to fundoplication has now replaced the open abdominal Nissen fundoplication as the pro-cedure of choice. Five ports are usually used (Fig. 25-34), and dissection is begun by incising the gastrohepatic omentum above and below the hepatic branch of the anterior vagus nerve, which is usually preserved. The circumference of the diaphragmatic L R Figure 25-34. Patient positioning and trocar placement for lap-aroscopic antireflux surgery. The patient |
Surgery_Schwartz_6951 | Surgery_Schwartz | anterior vagus nerve, which is usually preserved. The circumference of the diaphragmatic L R Figure 25-34. Patient positioning and trocar placement for lap-aroscopic antireflux surgery. The patient is placed with the head elevated approximately 30° in the modified lithotomy position. The surgeon stands between the patient’s legs, and the procedure is completed using five abdominal access ports.hiatus is dissected and the esophagus is mobilized by careful dis-section of the anterior and posterior soft tissues within the hiatus. The esophagus is held anterior and to the left and the hiatal pillars are approximated with interrupted nonabsorbable sutures, starting posteriorly and working anteriorly. A tension-free fundoplication should be constructed. This can usually be achieved either with or without division of the short gastric blood vessels, accord-ing to surgeon preference. If the vessels are divided, the upper one-third of the greater curvature is mobilized by sequentially | Surgery_Schwartz. anterior vagus nerve, which is usually preserved. The circumference of the diaphragmatic L R Figure 25-34. Patient positioning and trocar placement for lap-aroscopic antireflux surgery. The patient is placed with the head elevated approximately 30° in the modified lithotomy position. The surgeon stands between the patient’s legs, and the procedure is completed using five abdominal access ports.hiatus is dissected and the esophagus is mobilized by careful dis-section of the anterior and posterior soft tissues within the hiatus. The esophagus is held anterior and to the left and the hiatal pillars are approximated with interrupted nonabsorbable sutures, starting posteriorly and working anteriorly. A tension-free fundoplication should be constructed. This can usually be achieved either with or without division of the short gastric blood vessels, accord-ing to surgeon preference. If the vessels are divided, the upper one-third of the greater curvature is mobilized by sequentially |
Surgery_Schwartz_6952 | Surgery_Schwartz | with or without division of the short gastric blood vessels, accord-ing to surgeon preference. If the vessels are divided, the upper one-third of the greater curvature is mobilized by sequentially dissecting and dividing these vessels, commencing distally and working proximally. Following complete fundal mobilization, the posterior wall of the fundus is brought behind the esophagus to the right side, and the anterior wall of the fundus is brought anterior to the esophagus. The fundic lips are manipulated to allow the fundus to envelop the esophagus without twisting. A 50 to 60F bougie is passed to properly size the fundoplication, and it is sutured using nonabsorbable sutures. Some surgeons use a single U-stitch of 2-0 polypropylene buttressed with felt pledgets (Fig. 25-35), and others use 2-4 interrupted sutures.Brunicardi_Ch25_p1009-p1098.indd 104001/03/19 6:03 PM 1041ESOPHAGUS AND DIAPHRAGMATIC HERNIACHAPTER 25Posterior Partial Fundoplication. Partial fundoplications were | Surgery_Schwartz. with or without division of the short gastric blood vessels, accord-ing to surgeon preference. If the vessels are divided, the upper one-third of the greater curvature is mobilized by sequentially dissecting and dividing these vessels, commencing distally and working proximally. Following complete fundal mobilization, the posterior wall of the fundus is brought behind the esophagus to the right side, and the anterior wall of the fundus is brought anterior to the esophagus. The fundic lips are manipulated to allow the fundus to envelop the esophagus without twisting. A 50 to 60F bougie is passed to properly size the fundoplication, and it is sutured using nonabsorbable sutures. Some surgeons use a single U-stitch of 2-0 polypropylene buttressed with felt pledgets (Fig. 25-35), and others use 2-4 interrupted sutures.Brunicardi_Ch25_p1009-p1098.indd 104001/03/19 6:03 PM 1041ESOPHAGUS AND DIAPHRAGMATIC HERNIACHAPTER 25Posterior Partial Fundoplication. Partial fundoplications were |
Surgery_Schwartz_6953 | Surgery_Schwartz | use 2-4 interrupted sutures.Brunicardi_Ch25_p1009-p1098.indd 104001/03/19 6:03 PM 1041ESOPHAGUS AND DIAPHRAGMATIC HERNIACHAPTER 25Posterior Partial Fundoplication. Partial fundoplications were developed as an alternative to the Nissen procedure in an attempt to minimize the risk of postfundoplication side effects, such as dysphagia, inability to belch, and flatulence. The commonest approach has been a posterior partial or Toupet fundoplication. Some surgeons use this type of procedure for all patients present-ing for antireflux surgery, whereas others apply a tailored approach in which a partial fundoplication is constructed in patients with impaired esophageal motility, in which the propulsive force of the esophagus is thought to be insufficient to overcome the outflow obstruction of a complete fundoplication. The Toupet posterior partial fundoplication consists of a 270° gastric fundoplication around the distal 4 cm of esophagus (Fig. 25-36). It is usually stabilized by | Surgery_Schwartz. use 2-4 interrupted sutures.Brunicardi_Ch25_p1009-p1098.indd 104001/03/19 6:03 PM 1041ESOPHAGUS AND DIAPHRAGMATIC HERNIACHAPTER 25Posterior Partial Fundoplication. Partial fundoplications were developed as an alternative to the Nissen procedure in an attempt to minimize the risk of postfundoplication side effects, such as dysphagia, inability to belch, and flatulence. The commonest approach has been a posterior partial or Toupet fundoplication. Some surgeons use this type of procedure for all patients present-ing for antireflux surgery, whereas others apply a tailored approach in which a partial fundoplication is constructed in patients with impaired esophageal motility, in which the propulsive force of the esophagus is thought to be insufficient to overcome the outflow obstruction of a complete fundoplication. The Toupet posterior partial fundoplication consists of a 270° gastric fundoplication around the distal 4 cm of esophagus (Fig. 25-36). It is usually stabilized by |
Surgery_Schwartz_6954 | Surgery_Schwartz | of a complete fundoplication. The Toupet posterior partial fundoplication consists of a 270° gastric fundoplication around the distal 4 cm of esophagus (Fig. 25-36). It is usually stabilized by anchoring the wrap posteriorly to the hiatal rim.Anterior Partial Fundoplication. An alternative approach to partial fundoplication is to construct an anterior partial fundopli-cation. Following posterior hiatal repair, the anterior fundus is rolled over the front of the esophagus and sutured to the hiatal rim and the esophageal wall. Division of the short gastric vessels Figure 25-35. A. Laparoscopic Nissen fundoplication is performed with a five-trocar technique. B. The liver retractor is affixed to a mechani-cal arm to hold it in place throughout the operation. C. After division of the gastrohepatic omentum above the hepatic branch of the vagus (pars flaccida), the surgeon places a blunt atraumatic grasper beneath the phrenoesophageal ligament. D. After completion of the crural closure, an | Surgery_Schwartz. of a complete fundoplication. The Toupet posterior partial fundoplication consists of a 270° gastric fundoplication around the distal 4 cm of esophagus (Fig. 25-36). It is usually stabilized by anchoring the wrap posteriorly to the hiatal rim.Anterior Partial Fundoplication. An alternative approach to partial fundoplication is to construct an anterior partial fundopli-cation. Following posterior hiatal repair, the anterior fundus is rolled over the front of the esophagus and sutured to the hiatal rim and the esophageal wall. Division of the short gastric vessels Figure 25-35. A. Laparoscopic Nissen fundoplication is performed with a five-trocar technique. B. The liver retractor is affixed to a mechani-cal arm to hold it in place throughout the operation. C. After division of the gastrohepatic omentum above the hepatic branch of the vagus (pars flaccida), the surgeon places a blunt atraumatic grasper beneath the phrenoesophageal ligament. D. After completion of the crural closure, an |
Surgery_Schwartz_6955 | Surgery_Schwartz | omentum above the hepatic branch of the vagus (pars flaccida), the surgeon places a blunt atraumatic grasper beneath the phrenoesophageal ligament. D. After completion of the crural closure, an atraumatic grasper is placed right to left behind the gastroesophageal junction. The grasper is withdrawn, pulling the posterior aspect of the gastric fundus behind the esophagus. E. Once the suture positions are chosen, the first stitch (2-0 silk, 20 cm long) is introduced through the 10-mm trocar, and the needle is passed first through the left limb of the fundus, then the esophagus (2.5 cm above the gastroesophageal junction), then through the right limb of the fundus. F. Final position of the fundoplication.Brunicardi_Ch25_p1009-p1098.indd 104101/03/19 6:03 PM 1042SPECIFIC CONSIDERATIONSPART IIFigure 25-36. Completed laparoscopic posterior partial (Toupet) fundoplication. The fundoplication does not cover the anterior sur-face of the esophagus, and it is stabilized by suturing the | Surgery_Schwartz. omentum above the hepatic branch of the vagus (pars flaccida), the surgeon places a blunt atraumatic grasper beneath the phrenoesophageal ligament. D. After completion of the crural closure, an atraumatic grasper is placed right to left behind the gastroesophageal junction. The grasper is withdrawn, pulling the posterior aspect of the gastric fundus behind the esophagus. E. Once the suture positions are chosen, the first stitch (2-0 silk, 20 cm long) is introduced through the 10-mm trocar, and the needle is passed first through the left limb of the fundus, then the esophagus (2.5 cm above the gastroesophageal junction), then through the right limb of the fundus. F. Final position of the fundoplication.Brunicardi_Ch25_p1009-p1098.indd 104101/03/19 6:03 PM 1042SPECIFIC CONSIDERATIONSPART IIFigure 25-36. Completed laparoscopic posterior partial (Toupet) fundoplication. The fundoplication does not cover the anterior sur-face of the esophagus, and it is stabilized by suturing the |
Surgery_Schwartz_6956 | Surgery_Schwartz | 25-36. Completed laparoscopic posterior partial (Toupet) fundoplication. The fundoplication does not cover the anterior sur-face of the esophagus, and it is stabilized by suturing the fundus to the side of the esophagus, and posteriorly to the right hiatal pillar.is never needed when constructing this type of fundoplication. Various degrees of anterior partial fundoplication have been described—90°, 120°, 180°. The anterior 180° partial fundopli-cation (Fig. 25-37) provides a more robust fundoplication and achieves an excellent longer-term outcome in approximately 90% of patients at follow-up of at least 10 years. With this procedure, the fundus and esophagus are sutured to the right side of the hiatal rim to create a flap valve at the gastroesophageal junction and to stabilize a 3 to 4 cm length of intra-abdominal esophagus.Collis Gastroplasty. When a shortened esophagus is encoun-tered, many surgeons choose to add an esophageal lengthening procedure before fundoplication, to reduce | Surgery_Schwartz. 25-36. Completed laparoscopic posterior partial (Toupet) fundoplication. The fundoplication does not cover the anterior sur-face of the esophagus, and it is stabilized by suturing the fundus to the side of the esophagus, and posteriorly to the right hiatal pillar.is never needed when constructing this type of fundoplication. Various degrees of anterior partial fundoplication have been described—90°, 120°, 180°. The anterior 180° partial fundopli-cation (Fig. 25-37) provides a more robust fundoplication and achieves an excellent longer-term outcome in approximately 90% of patients at follow-up of at least 10 years. With this procedure, the fundus and esophagus are sutured to the right side of the hiatal rim to create a flap valve at the gastroesophageal junction and to stabilize a 3 to 4 cm length of intra-abdominal esophagus.Collis Gastroplasty. When a shortened esophagus is encoun-tered, many surgeons choose to add an esophageal lengthening procedure before fundoplication, to reduce |
Surgery_Schwartz_6957 | Surgery_Schwartz | length of intra-abdominal esophagus.Collis Gastroplasty. When a shortened esophagus is encoun-tered, many surgeons choose to add an esophageal lengthening procedure before fundoplication, to reduce the tension on the gastroesophageal junction, believing this will minimize the risk of failure due to postoperative hiatus hernia. The commonest approach to this is the Collis gastroplasty. This entails using a stapler to divide the cardia and upper stomach, parallel to the lesser curvature of Figure 25-37. Completed laparoscopic anterior 180° partial fun-doplication. The fundoplication fully covers the anterior surface of the esophagus, and it is stabilized by suturing the fundus to the right side of the esophagus, and to the right hiatal pillar. Unlike the Nissen procedure, the fundus is not pulled behind the esophagus.the stomach, thereby creating a gastric tube in continuity with the esophagus, and effectively lengthening the esophagus by several centimeters. Laparoscopic techniques for | Surgery_Schwartz. length of intra-abdominal esophagus.Collis Gastroplasty. When a shortened esophagus is encoun-tered, many surgeons choose to add an esophageal lengthening procedure before fundoplication, to reduce the tension on the gastroesophageal junction, believing this will minimize the risk of failure due to postoperative hiatus hernia. The commonest approach to this is the Collis gastroplasty. This entails using a stapler to divide the cardia and upper stomach, parallel to the lesser curvature of Figure 25-37. Completed laparoscopic anterior 180° partial fun-doplication. The fundoplication fully covers the anterior surface of the esophagus, and it is stabilized by suturing the fundus to the right side of the esophagus, and to the right hiatal pillar. Unlike the Nissen procedure, the fundus is not pulled behind the esophagus.the stomach, thereby creating a gastric tube in continuity with the esophagus, and effectively lengthening the esophagus by several centimeters. Laparoscopic techniques for |
Surgery_Schwartz_6958 | Surgery_Schwartz | behind the esophagus.the stomach, thereby creating a gastric tube in continuity with the esophagus, and effectively lengthening the esophagus by several centimeters. Laparoscopic techniques for Collis gastroplasty have been described (Fig. 25-38). Following gastroplasty a fundoplica-tion is constructed, with the highest suture is placed on the native esophagus when constructing a Nissen fundoplication. Not all sur-geons choose to undertake a Collis procedure, however, as there is controversy about the actual incidence of the shortened esophagus and widely divergent views are held about how often this prob-lem is encountered. In addition, some surgeons have questioned the wisdom of creating an amotile tube of gastric wall, which can secrete acid, and then placing a Nissen fundoplication below this.Outcome After Fundoplication. Studies of long-term outcome following both open and laparoscopic fundoplication document the ability of laparoscopic fundoplication to relieve typical reflux | Surgery_Schwartz. behind the esophagus.the stomach, thereby creating a gastric tube in continuity with the esophagus, and effectively lengthening the esophagus by several centimeters. Laparoscopic techniques for Collis gastroplasty have been described (Fig. 25-38). Following gastroplasty a fundoplica-tion is constructed, with the highest suture is placed on the native esophagus when constructing a Nissen fundoplication. Not all sur-geons choose to undertake a Collis procedure, however, as there is controversy about the actual incidence of the shortened esophagus and widely divergent views are held about how often this prob-lem is encountered. In addition, some surgeons have questioned the wisdom of creating an amotile tube of gastric wall, which can secrete acid, and then placing a Nissen fundoplication below this.Outcome After Fundoplication. Studies of long-term outcome following both open and laparoscopic fundoplication document the ability of laparoscopic fundoplication to relieve typical reflux |
Surgery_Schwartz_6959 | Surgery_Schwartz | below this.Outcome After Fundoplication. Studies of long-term outcome following both open and laparoscopic fundoplication document the ability of laparoscopic fundoplication to relieve typical reflux symptoms (heartburn, regurgitation, and dysphagia) in more than Figure 25-35. (Continued )Brunicardi_Ch25_p1009-p1098.indd 104201/03/19 6:03 PM 1043ESOPHAGUS AND DIAPHRAGMATIC HERNIACHAPTER 25Figure 25-38. A. After removal of the fat pad and release of tension on the Penrose drain, the gastroesophageal junction (GES) retracts to the level of the hiatus. The interior end of the staple line is marked 2/5 cm below the angle of His. B. The first horizontal firing of the stapler occurs by maximally articulating the stapler to the left, aiming toward the previously marked spot adjacent to the dilator. C. The vertical staple line is created by a single firing of the GIA placed parallel and flush against the 48F dilator. D. The highest Nissen fundoplication suture is placed on the native | Surgery_Schwartz. below this.Outcome After Fundoplication. Studies of long-term outcome following both open and laparoscopic fundoplication document the ability of laparoscopic fundoplication to relieve typical reflux symptoms (heartburn, regurgitation, and dysphagia) in more than Figure 25-35. (Continued )Brunicardi_Ch25_p1009-p1098.indd 104201/03/19 6:03 PM 1043ESOPHAGUS AND DIAPHRAGMATIC HERNIACHAPTER 25Figure 25-38. A. After removal of the fat pad and release of tension on the Penrose drain, the gastroesophageal junction (GES) retracts to the level of the hiatus. The interior end of the staple line is marked 2/5 cm below the angle of His. B. The first horizontal firing of the stapler occurs by maximally articulating the stapler to the left, aiming toward the previously marked spot adjacent to the dilator. C. The vertical staple line is created by a single firing of the GIA placed parallel and flush against the 48F dilator. D. The highest Nissen fundoplication suture is placed on the native |
Surgery_Schwartz_6960 | Surgery_Schwartz | dilator. C. The vertical staple line is created by a single firing of the GIA placed parallel and flush against the 48F dilator. D. The highest Nissen fundoplication suture is placed on the native esophagus, and the second suture tucks in the apex of the staple line.90% of patients at follow-up intervals averaging 2 to 3 years and 80% to 90% of patients 5 years or more following surgery. This includes evidence-based reviews of antireflux surgery, pro-spective randomized trials comparing antireflux surgery to PPI therapy and open to laparoscopic fundoplication and analysis of U.S. national trends in use and outcomes. Postoperative pH stud-ies indicate that more than 90% of patients will normalize their pH tracings. The results of laparoscopic fundoplication compare favorably with those of the “modern” era of open fundoplica-tion. They also indicate the less predictable outcome of atypical reflux symptoms (cough, asthma, laryngitis) after surgery, being relieved in only two-thirds of | Surgery_Schwartz. dilator. C. The vertical staple line is created by a single firing of the GIA placed parallel and flush against the 48F dilator. D. The highest Nissen fundoplication suture is placed on the native esophagus, and the second suture tucks in the apex of the staple line.90% of patients at follow-up intervals averaging 2 to 3 years and 80% to 90% of patients 5 years or more following surgery. This includes evidence-based reviews of antireflux surgery, pro-spective randomized trials comparing antireflux surgery to PPI therapy and open to laparoscopic fundoplication and analysis of U.S. national trends in use and outcomes. Postoperative pH stud-ies indicate that more than 90% of patients will normalize their pH tracings. The results of laparoscopic fundoplication compare favorably with those of the “modern” era of open fundoplica-tion. They also indicate the less predictable outcome of atypical reflux symptoms (cough, asthma, laryngitis) after surgery, being relieved in only two-thirds of |
Surgery_Schwartz_6961 | Surgery_Schwartz | the “modern” era of open fundoplica-tion. They also indicate the less predictable outcome of atypical reflux symptoms (cough, asthma, laryngitis) after surgery, being relieved in only two-thirds of patients.The goal of surgical treatment for GERD is to relieve the symptoms of reflux by reestablishing the gastroesophageal barrier. The challenge is to accomplish this without inducing dysphagia or other untoward side effects. Dysphagia, existing before surgery, usually improves following laparoscopic fun-doplication. Temporary dysphagia is common after surgery and generally resolves within 3 months, but it can take up to 12 months in some individuals, and dysphagia sufficient to require ongoing dietary modification persists in up to 5% of individuals following Nissen fundoplication. Other side effects common to antireflux surgery include the inability to belch and vomit and increased flatulence. Most patients cannot vomit through an intact wrap, though this is rarely clinically | Surgery_Schwartz. the “modern” era of open fundoplica-tion. They also indicate the less predictable outcome of atypical reflux symptoms (cough, asthma, laryngitis) after surgery, being relieved in only two-thirds of patients.The goal of surgical treatment for GERD is to relieve the symptoms of reflux by reestablishing the gastroesophageal barrier. The challenge is to accomplish this without inducing dysphagia or other untoward side effects. Dysphagia, existing before surgery, usually improves following laparoscopic fun-doplication. Temporary dysphagia is common after surgery and generally resolves within 3 months, but it can take up to 12 months in some individuals, and dysphagia sufficient to require ongoing dietary modification persists in up to 5% of individuals following Nissen fundoplication. Other side effects common to antireflux surgery include the inability to belch and vomit and increased flatulence. Most patients cannot vomit through an intact wrap, though this is rarely clinically |
Surgery_Schwartz_6962 | Surgery_Schwartz | Other side effects common to antireflux surgery include the inability to belch and vomit and increased flatulence. Most patients cannot vomit through an intact wrap, though this is rarely clinically relevant. Most patients are unable to belch gas from the stomach in the first 3 to 6 months after fundoplication, but 80% to 90% regain the ability to belch normally beyond the first 12 months of fol-low-up. Hyperflatulence is a common and noticeable problem, likely related to increased air swallowing that is present in most patients with reflux disease, aggravated by the inability to belch in some patients.Brunicardi_Ch25_p1009-p1098.indd 104301/03/19 6:03 PM 1044SPECIFIC CONSIDERATIONSPART IIRandomized Controlled Trials Addressing Surgical Technique Division of the Short Gastric Blood Vessels Originally, Nissen’s description of a total fundoplication entailed a 360° fundoplication during which the short gastric blood vessels were left intact. However, with reports of troublesome | Surgery_Schwartz. Other side effects common to antireflux surgery include the inability to belch and vomit and increased flatulence. Most patients cannot vomit through an intact wrap, though this is rarely clinically relevant. Most patients are unable to belch gas from the stomach in the first 3 to 6 months after fundoplication, but 80% to 90% regain the ability to belch normally beyond the first 12 months of fol-low-up. Hyperflatulence is a common and noticeable problem, likely related to increased air swallowing that is present in most patients with reflux disease, aggravated by the inability to belch in some patients.Brunicardi_Ch25_p1009-p1098.indd 104301/03/19 6:03 PM 1044SPECIFIC CONSIDERATIONSPART IIRandomized Controlled Trials Addressing Surgical Technique Division of the Short Gastric Blood Vessels Originally, Nissen’s description of a total fundoplication entailed a 360° fundoplication during which the short gastric blood vessels were left intact. However, with reports of troublesome |
Surgery_Schwartz_6963 | Surgery_Schwartz | Vessels Originally, Nissen’s description of a total fundoplication entailed a 360° fundoplication during which the short gastric blood vessels were left intact. However, with reports of troublesome postoperative dysphagia, division of these vessels—to achieve full fundal mobilization and thereby ensure a loose fundoplication—was promoted and has entered common practice. The evidence sup-porting dividing these vessels has been based on the outcomes from uncontrolled case series of patients undergoing Nissen fundoplication either with vs. without division of the short gas-tric vessels. However, the results from these studies have been conflicting, with different proponents reporting good results irrespective of whether these vessels have been divided or not. To address this issue, six randomized trials that enrolled a total of 438 patients have been reported. None of these trials demon-strated any differences for the postoperative dysphagia or recur-rent gastro-esophageal reflux. | Surgery_Schwartz. Vessels Originally, Nissen’s description of a total fundoplication entailed a 360° fundoplication during which the short gastric blood vessels were left intact. However, with reports of troublesome postoperative dysphagia, division of these vessels—to achieve full fundal mobilization and thereby ensure a loose fundoplication—was promoted and has entered common practice. The evidence sup-porting dividing these vessels has been based on the outcomes from uncontrolled case series of patients undergoing Nissen fundoplication either with vs. without division of the short gas-tric vessels. However, the results from these studies have been conflicting, with different proponents reporting good results irrespective of whether these vessels have been divided or not. To address this issue, six randomized trials that enrolled a total of 438 patients have been reported. None of these trials demon-strated any differences for the postoperative dysphagia or recur-rent gastro-esophageal reflux. |
Surgery_Schwartz_6964 | Surgery_Schwartz | randomized trials that enrolled a total of 438 patients have been reported. None of these trials demon-strated any differences for the postoperative dysphagia or recur-rent gastro-esophageal reflux. However, in the three largest of the six trials an increased incidence of flatulence and bloating symptoms, as well as greater difficulty with belching, was seen in patients in whom the short gastric vessels were divided.A recent meta-analysis from Engstrom et al, generated by combining the raw data from Australian and Swedish trials, eval-uated a larger cohort of 201 patients, with 12 years of follow-up in 170, and also confirmed equivalent reflux control but found more abdominal bloating after division of the short gastric ves-sels. Overall, these trials fail to support the belief that dividing the short gastric vessels improves any outcome following Nissen fun-doplication. The trials actually suggest that dividing the vessels increases the complexity of the procedure and leads to a | Surgery_Schwartz. randomized trials that enrolled a total of 438 patients have been reported. None of these trials demon-strated any differences for the postoperative dysphagia or recur-rent gastro-esophageal reflux. However, in the three largest of the six trials an increased incidence of flatulence and bloating symptoms, as well as greater difficulty with belching, was seen in patients in whom the short gastric vessels were divided.A recent meta-analysis from Engstrom et al, generated by combining the raw data from Australian and Swedish trials, eval-uated a larger cohort of 201 patients, with 12 years of follow-up in 170, and also confirmed equivalent reflux control but found more abdominal bloating after division of the short gastric ves-sels. Overall, these trials fail to support the belief that dividing the short gastric vessels improves any outcome following Nissen fun-doplication. The trials actually suggest that dividing the vessels increases the complexity of the procedure and leads to a |
Surgery_Schwartz_6965 | Surgery_Schwartz | the short gastric vessels improves any outcome following Nissen fun-doplication. The trials actually suggest that dividing the vessels increases the complexity of the procedure and leads to a poorer outcome due to the increase in bloating symptoms.Nissen vs. Posterior Partial Fundoplication Eleven randomized trials have compared Nissen vs. posterior partial fundoplication. Some of the trials contributed little to the pool of evidence, as they are either small or underpowered, and failed to show significant outcome differences. The larger trials, however, have consistently demonstrated equivalent reflux control, but they also show a reduced incidence of wind-related side-effects (flatulence, bloating, and inability to belch) following posterior partial fundoplication procedures, although less dysphagia fol-lowing a posterior fundoplication was only demonstrated in 2 of the 11 trials. Lundell et al reported the outcomes of Nissen vs. Toupet partial fundoplication in a trial that | Surgery_Schwartz. the short gastric vessels improves any outcome following Nissen fun-doplication. The trials actually suggest that dividing the vessels increases the complexity of the procedure and leads to a poorer outcome due to the increase in bloating symptoms.Nissen vs. Posterior Partial Fundoplication Eleven randomized trials have compared Nissen vs. posterior partial fundoplication. Some of the trials contributed little to the pool of evidence, as they are either small or underpowered, and failed to show significant outcome differences. The larger trials, however, have consistently demonstrated equivalent reflux control, but they also show a reduced incidence of wind-related side-effects (flatulence, bloating, and inability to belch) following posterior partial fundoplication procedures, although less dysphagia fol-lowing a posterior fundoplication was only demonstrated in 2 of the 11 trials. Lundell et al reported the outcomes of Nissen vs. Toupet partial fundoplication in a trial that |
Surgery_Schwartz_6966 | Surgery_Schwartz | less dysphagia fol-lowing a posterior fundoplication was only demonstrated in 2 of the 11 trials. Lundell et al reported the outcomes of Nissen vs. Toupet partial fundoplication in a trial that enrolled 137 patients with reported follow-up to 18 years. Reflux control and dyspha-gia symptoms were similar, but flatulence was commoner after Nissen fundoplication at some medium-term follow-up time points, and revision surgery was more common following Nissen fundoplication, mainly to correct postoperative paraoesophageal herniation. At 18 years follow-up, success rates of more than 80% were reported for both procedures, as well as no significant differences in the incidence of side effects. The data from this trial suggested that the mechanical side effects following Nis-sen fundoplication progressively improve with very long-term follow-up. Strate et al reported 2-year follow-up in a trial that enrolled 200 patients. Approximately 85% of each group was satisfied with the clinical | Surgery_Schwartz. less dysphagia fol-lowing a posterior fundoplication was only demonstrated in 2 of the 11 trials. Lundell et al reported the outcomes of Nissen vs. Toupet partial fundoplication in a trial that enrolled 137 patients with reported follow-up to 18 years. Reflux control and dyspha-gia symptoms were similar, but flatulence was commoner after Nissen fundoplication at some medium-term follow-up time points, and revision surgery was more common following Nissen fundoplication, mainly to correct postoperative paraoesophageal herniation. At 18 years follow-up, success rates of more than 80% were reported for both procedures, as well as no significant differences in the incidence of side effects. The data from this trial suggested that the mechanical side effects following Nis-sen fundoplication progressively improve with very long-term follow-up. Strate et al reported 2-year follow-up in a trial that enrolled 200 patients. Approximately 85% of each group was satisfied with the clinical |
Surgery_Schwartz_6967 | Surgery_Schwartz | progressively improve with very long-term follow-up. Strate et al reported 2-year follow-up in a trial that enrolled 200 patients. Approximately 85% of each group was satisfied with the clinical outcome, but dysphagia was signifi-cantly more common following Nissen fundoplication (19 vs. 8 patients).Other trials (Guérin et al–140 patients, Booth et al–127, Khan et al–121, Shaw et al–100) also report similar reflux control within the first few years of follow-up. Only Booth et al demonstrated less dysphagia following posterior fundoplica-tion. Subgroup analysis in 3 trials (Booth, Shaw, Zornig) did not reveal differences between patients with vs. without poor pre-operative oesophageal motility. Overall these trials suggest that some side-effects, mainly wind-related issues, are less common following posterior partial fundoplication. However, the hypoth-esis that dysphagia is less of a problem following posterior par-tial fundoplication has only been substantiated in 2 of 11 | Surgery_Schwartz. progressively improve with very long-term follow-up. Strate et al reported 2-year follow-up in a trial that enrolled 200 patients. Approximately 85% of each group was satisfied with the clinical outcome, but dysphagia was signifi-cantly more common following Nissen fundoplication (19 vs. 8 patients).Other trials (Guérin et al–140 patients, Booth et al–127, Khan et al–121, Shaw et al–100) also report similar reflux control within the first few years of follow-up. Only Booth et al demonstrated less dysphagia following posterior fundoplica-tion. Subgroup analysis in 3 trials (Booth, Shaw, Zornig) did not reveal differences between patients with vs. without poor pre-operative oesophageal motility. Overall these trials suggest that some side-effects, mainly wind-related issues, are less common following posterior partial fundoplication. However, the hypoth-esis that dysphagia is less of a problem following posterior par-tial fundoplication has only been substantiated in 2 of 11 |
Surgery_Schwartz_6968 | Surgery_Schwartz | less common following posterior partial fundoplication. However, the hypoth-esis that dysphagia is less of a problem following posterior par-tial fundoplication has only been substantiated in 2 of 11 trials.Nissen vs. Anterior Fundoplication Six trials have evaluated Nissen vs. anterior partial fundoplication variants. Four have assessed Nissen vs. anterior 180° partial fundoplication (Watson et al–107 patients, Baigrie et al–161, Cao et al–100, Raue et al–64). These trials all demonstrated equivalent reflux control, but less dysphagia and less wind-related side effects after anterior 180° partial fundoplication at up to 5 years follow-up. Only the study from Watson et al has reported follow-up to 10 years, and at late follow-up in their trial there were no significant outcome differences for the two procedures, with equivalent control of reflux, and no differences for side effects due to a progressive decline in dysphagia as follow-up extended beyond 5 years.Two trials compared | Surgery_Schwartz. less common following posterior partial fundoplication. However, the hypoth-esis that dysphagia is less of a problem following posterior par-tial fundoplication has only been substantiated in 2 of 11 trials.Nissen vs. Anterior Fundoplication Six trials have evaluated Nissen vs. anterior partial fundoplication variants. Four have assessed Nissen vs. anterior 180° partial fundoplication (Watson et al–107 patients, Baigrie et al–161, Cao et al–100, Raue et al–64). These trials all demonstrated equivalent reflux control, but less dysphagia and less wind-related side effects after anterior 180° partial fundoplication at up to 5 years follow-up. Only the study from Watson et al has reported follow-up to 10 years, and at late follow-up in their trial there were no significant outcome differences for the two procedures, with equivalent control of reflux, and no differences for side effects due to a progressive decline in dysphagia as follow-up extended beyond 5 years.Two trials compared |
Surgery_Schwartz_6969 | Surgery_Schwartz | for the two procedures, with equivalent control of reflux, and no differences for side effects due to a progressive decline in dysphagia as follow-up extended beyond 5 years.Two trials compared laparoscopic anterior 90° partial fundoplication vs. Nissen fundoplication (Watson et al–112 patients, Spence et al–79). In both of these trials, side-effects were less common following anterior 90° fundoplication, but this was offset by a slightly higher incidence of recurrent reflux at up to 5 years follow-up. Satisfaction with the overall outcome was similar for both fundoplication variants.Anterior vs. Posterior Partial Fundoplication Two ran-domized trials have directly compared anterior vs. posterior partial fundoplication. Hagedorn et al randomized 95 patients to undergo either Toupet vs. anterior 120° partial fundoplica-tion, and Khan et al enrolled 103 patients to anterior 180° vs. posterior partial fundoplication. Both studies demonstrated bet-ter reflux control, offset by more side | Surgery_Schwartz. for the two procedures, with equivalent control of reflux, and no differences for side effects due to a progressive decline in dysphagia as follow-up extended beyond 5 years.Two trials compared laparoscopic anterior 90° partial fundoplication vs. Nissen fundoplication (Watson et al–112 patients, Spence et al–79). In both of these trials, side-effects were less common following anterior 90° fundoplication, but this was offset by a slightly higher incidence of recurrent reflux at up to 5 years follow-up. Satisfaction with the overall outcome was similar for both fundoplication variants.Anterior vs. Posterior Partial Fundoplication Two ran-domized trials have directly compared anterior vs. posterior partial fundoplication. Hagedorn et al randomized 95 patients to undergo either Toupet vs. anterior 120° partial fundoplica-tion, and Khan et al enrolled 103 patients to anterior 180° vs. posterior partial fundoplication. Both studies demonstrated bet-ter reflux control, offset by more side |
Surgery_Schwartz_6970 | Surgery_Schwartz | 120° partial fundoplica-tion, and Khan et al enrolled 103 patients to anterior 180° vs. posterior partial fundoplication. Both studies demonstrated bet-ter reflux control, offset by more side effects following posterior partial fundoplication. The anterior 120° partial fundoplication performed by Hagedorn et al was similar to the anterior 90° vari-ant described above. However, the outcomes following this pro-cedure were much worse in this trial than the outcomes in other studies, with the average exposure time to acid (pH <4%–5.6%) following anterior fundoplication in their study unusually high compared to other studies. Khan et al only reported 6 months follow-up, and longer-term outcomes are awaited before draw-ing firm conclusions. The overall results from all eight trials that included an anterior fundoplication variant suggest that this type of fundoplication achieves satisfactory reflux control, with less dysphagia and other side-effects, yielding a good overall outcome. | Surgery_Schwartz. 120° partial fundoplica-tion, and Khan et al enrolled 103 patients to anterior 180° vs. posterior partial fundoplication. Both studies demonstrated bet-ter reflux control, offset by more side effects following posterior partial fundoplication. The anterior 120° partial fundoplication performed by Hagedorn et al was similar to the anterior 90° vari-ant described above. However, the outcomes following this pro-cedure were much worse in this trial than the outcomes in other studies, with the average exposure time to acid (pH <4%–5.6%) following anterior fundoplication in their study unusually high compared to other studies. Khan et al only reported 6 months follow-up, and longer-term outcomes are awaited before draw-ing firm conclusions. The overall results from all eight trials that included an anterior fundoplication variant suggest that this type of fundoplication achieves satisfactory reflux control, with less dysphagia and other side-effects, yielding a good overall outcome. |
Surgery_Schwartz_6971 | Surgery_Schwartz | included an anterior fundoplication variant suggest that this type of fundoplication achieves satisfactory reflux control, with less dysphagia and other side-effects, yielding a good overall outcome. However, the reduced incidence of troublesome side-effects is traded off against a higher risk of recurrent reflux.Outcome of Antireflux Surgery in Patients With Barrett’s Esophagus. Few studies have focused on the alleviation of symp-toms after antireflux surgery in patients with BE (Table 25-7). Those that are available document excellent to good results in 72% to 95% of patients at 5 years following surgery. Several nonrandomized studies have compared medical and surgical therapy and report better outcomes after antireflux surgery. Par-rilla and colleagues reported the only randomized trial to evaluate this issue. They enrolled 101 patients over 18 years, and median follow-up was 6 years. Medical therapy consisted of 20 mg of omeprazole (PPI) twice daily since 1992 in all medically | Surgery_Schwartz. included an anterior fundoplication variant suggest that this type of fundoplication achieves satisfactory reflux control, with less dysphagia and other side-effects, yielding a good overall outcome. However, the reduced incidence of troublesome side-effects is traded off against a higher risk of recurrent reflux.Outcome of Antireflux Surgery in Patients With Barrett’s Esophagus. Few studies have focused on the alleviation of symp-toms after antireflux surgery in patients with BE (Table 25-7). Those that are available document excellent to good results in 72% to 95% of patients at 5 years following surgery. Several nonrandomized studies have compared medical and surgical therapy and report better outcomes after antireflux surgery. Par-rilla and colleagues reported the only randomized trial to evaluate this issue. They enrolled 101 patients over 18 years, and median follow-up was 6 years. Medical therapy consisted of 20 mg of omeprazole (PPI) twice daily since 1992 in all medically |
Surgery_Schwartz_6972 | Surgery_Schwartz | to evaluate this issue. They enrolled 101 patients over 18 years, and median follow-up was 6 years. Medical therapy consisted of 20 mg of omeprazole (PPI) twice daily since 1992 in all medically treated patients, and surgical therapy consisted of an open Nissen Brunicardi_Ch25_p1009-p1098.indd 104401/03/19 6:03 PM 1045ESOPHAGUS AND DIAPHRAGMATIC HERNIACHAPTER 25Table 25-7Symptomatic outcome of surgical therapy for Barrett’s esophagusAUTHORYEARNO. OF PATIENTS% EXCELLENT TO GOOD RESPONSEMEAN FOLLOW-UP, YEARSStarnes19848752Williamson199037923DeMeester199035773McDonald199611382.26.5Ortiz19963290.65fundoplication. The symptomatic outcome in the two groups was nearly identical, although esophagitis and/or stricture persisted in 20% of the medically treated patients, compared to only 3% to 7% of patients following antireflux surgery. About 15% of patients had abnormal acid exposure after surgery. Although pH data were not routinely collected in patients on PPI therapy, in the subgroup | Surgery_Schwartz. to evaluate this issue. They enrolled 101 patients over 18 years, and median follow-up was 6 years. Medical therapy consisted of 20 mg of omeprazole (PPI) twice daily since 1992 in all medically treated patients, and surgical therapy consisted of an open Nissen Brunicardi_Ch25_p1009-p1098.indd 104401/03/19 6:03 PM 1045ESOPHAGUS AND DIAPHRAGMATIC HERNIACHAPTER 25Table 25-7Symptomatic outcome of surgical therapy for Barrett’s esophagusAUTHORYEARNO. OF PATIENTS% EXCELLENT TO GOOD RESPONSEMEAN FOLLOW-UP, YEARSStarnes19848752Williamson199037923DeMeester199035773McDonald199611382.26.5Ortiz19963290.65fundoplication. The symptomatic outcome in the two groups was nearly identical, although esophagitis and/or stricture persisted in 20% of the medically treated patients, compared to only 3% to 7% of patients following antireflux surgery. About 15% of patients had abnormal acid exposure after surgery. Although pH data were not routinely collected in patients on PPI therapy, in the subgroup |
Surgery_Schwartz_6973 | Surgery_Schwartz | 7% of patients following antireflux surgery. About 15% of patients had abnormal acid exposure after surgery. Although pH data were not routinely collected in patients on PPI therapy, in the subgroup of 12 patients that did have 24-hour monitoring on treat-ment, 3 of 12 (25%) had persistently high esophageal acid expo-sure, and most (75%) had persistently high bilirubin exposure.The common belief that Barrett’s epithelium cannot be reversed by antireflux surgery may not be correct. Within the control arm of a randomized trial of ablation vs. surveillance, Bright and associates identified approximately 50% regression in the length of Barrett’s esophagus in 20 patients within the control arm of a randomized trial of ablation vs. surveillance.Current data indicate that patients with BE should remain in an endoscopic surveillance program following antireflux surgery. Biopsy specimens should be reviewed by a patholo-gist with expertise in the field. If low-grade dysplasia is con-firmed, | Surgery_Schwartz. 7% of patients following antireflux surgery. About 15% of patients had abnormal acid exposure after surgery. Although pH data were not routinely collected in patients on PPI therapy, in the subgroup of 12 patients that did have 24-hour monitoring on treat-ment, 3 of 12 (25%) had persistently high esophageal acid expo-sure, and most (75%) had persistently high bilirubin exposure.The common belief that Barrett’s epithelium cannot be reversed by antireflux surgery may not be correct. Within the control arm of a randomized trial of ablation vs. surveillance, Bright and associates identified approximately 50% regression in the length of Barrett’s esophagus in 20 patients within the control arm of a randomized trial of ablation vs. surveillance.Current data indicate that patients with BE should remain in an endoscopic surveillance program following antireflux surgery. Biopsy specimens should be reviewed by a patholo-gist with expertise in the field. If low-grade dysplasia is con-firmed, |
Surgery_Schwartz_6974 | Surgery_Schwartz | remain in an endoscopic surveillance program following antireflux surgery. Biopsy specimens should be reviewed by a patholo-gist with expertise in the field. If low-grade dysplasia is con-firmed, biopsy specimens should be repeated after 12 weeks of high-dose acid suppression therapy. If high-grade dysplasia or intramucosal cancer is evident on more than one biopsy speci-men, then treatment is escalated. Treatment options include endoscopic mucosal resection, endoscopic ablation of the BE, or esophageal resection. Esophageal resection is advisable when an invasive cancer (stage T1b or deeper) is present, or for mul-tifocal long segment BE in younger and fit patients in whom endoscopic treatments are unlikely to be adequate. Endoscopic mucosal resection allows smaller intramucosal tumors to be removed with clear pathology margins, and it can be used as a “big biopsy” to obtain better pathological staging, and even to excise shorter segments of BE in a piecemeal fashion. Ablation, | Surgery_Schwartz. remain in an endoscopic surveillance program following antireflux surgery. Biopsy specimens should be reviewed by a patholo-gist with expertise in the field. If low-grade dysplasia is con-firmed, biopsy specimens should be repeated after 12 weeks of high-dose acid suppression therapy. If high-grade dysplasia or intramucosal cancer is evident on more than one biopsy speci-men, then treatment is escalated. Treatment options include endoscopic mucosal resection, endoscopic ablation of the BE, or esophageal resection. Esophageal resection is advisable when an invasive cancer (stage T1b or deeper) is present, or for mul-tifocal long segment BE in younger and fit patients in whom endoscopic treatments are unlikely to be adequate. Endoscopic mucosal resection allows smaller intramucosal tumors to be removed with clear pathology margins, and it can be used as a “big biopsy” to obtain better pathological staging, and even to excise shorter segments of BE in a piecemeal fashion. Ablation, |
Surgery_Schwartz_6975 | Surgery_Schwartz | to be removed with clear pathology margins, and it can be used as a “big biopsy” to obtain better pathological staging, and even to excise shorter segments of BE in a piecemeal fashion. Ablation, commonly using radiofrequency ablation, has been shown at short-term follow-up in a randomized trial to reduce the rate of progression from high grade dysplasia to invasive cancer by approximately 50%. However, following any endoscopic treatment, patients need to continue with close endoscopic sur-veillance as recurrence can occur and the longer-term outcome following these treatments remains uncertain. Early detection and treatment have been shown to decrease the mortality rate from esophageal cancer in these patients.If the dysplasia is reported as lower grade or indetermi-nant, then inflammatory change that is often confused with dysplasia should be suppressed by a course of acid suppression therapy in high doses for 2 to 3 months, followed by rebiopsy of the Barrett’s segment.Reoperation | Surgery_Schwartz. to be removed with clear pathology margins, and it can be used as a “big biopsy” to obtain better pathological staging, and even to excise shorter segments of BE in a piecemeal fashion. Ablation, commonly using radiofrequency ablation, has been shown at short-term follow-up in a randomized trial to reduce the rate of progression from high grade dysplasia to invasive cancer by approximately 50%. However, following any endoscopic treatment, patients need to continue with close endoscopic sur-veillance as recurrence can occur and the longer-term outcome following these treatments remains uncertain. Early detection and treatment have been shown to decrease the mortality rate from esophageal cancer in these patients.If the dysplasia is reported as lower grade or indetermi-nant, then inflammatory change that is often confused with dysplasia should be suppressed by a course of acid suppression therapy in high doses for 2 to 3 months, followed by rebiopsy of the Barrett’s segment.Reoperation |
Surgery_Schwartz_6976 | Surgery_Schwartz | change that is often confused with dysplasia should be suppressed by a course of acid suppression therapy in high doses for 2 to 3 months, followed by rebiopsy of the Barrett’s segment.Reoperation for Failed Antireflux Repairs. Failure of an antireflux procedure occurs when, after the repair, the patient is unable to swallow normally, experiences upper abdominal dis-comfort during and after meals, or has recurrence or persistence of reflux symptoms. The assessment of these symptoms and the selection of patients who need further surgery are challenging problems. Functional assessment of patients who have recur-rent, persistent, or emergent new symptoms following a primary antireflux repair is critical to identifying the cause of the failure. Analysis of patients requiring reoperation after a previous anti-reflux procedure shows that placement of the wrap around the stomach is the most frequent cause for failure after open proce-dures, while herniation of the repair into the chest is | Surgery_Schwartz. change that is often confused with dysplasia should be suppressed by a course of acid suppression therapy in high doses for 2 to 3 months, followed by rebiopsy of the Barrett’s segment.Reoperation for Failed Antireflux Repairs. Failure of an antireflux procedure occurs when, after the repair, the patient is unable to swallow normally, experiences upper abdominal dis-comfort during and after meals, or has recurrence or persistence of reflux symptoms. The assessment of these symptoms and the selection of patients who need further surgery are challenging problems. Functional assessment of patients who have recur-rent, persistent, or emergent new symptoms following a primary antireflux repair is critical to identifying the cause of the failure. Analysis of patients requiring reoperation after a previous anti-reflux procedure shows that placement of the wrap around the stomach is the most frequent cause for failure after open proce-dures, while herniation of the repair into the chest is |
Surgery_Schwartz_6977 | Surgery_Schwartz | a previous anti-reflux procedure shows that placement of the wrap around the stomach is the most frequent cause for failure after open proce-dures, while herniation of the repair into the chest is the most frequent cause of failure after a laparoscopic procedure. Partial or complete breakdown of the fundoplication and construction of a too-tight a fundoplication or overnarrowing the esophageal hiatus occurs with both open and closed procedures.Patients who have recurrence of heartburn and regurgitation without dysphagia and have good esophageal motility are most amenable to reoperation, and they can be expected to have an excellent outcome. When dysphagia is the cause of failure, the sit-uation can be more difficult to manage. If the dysphagia occurred immediately following the repair, it is usually due to a technical failure, most commonly a misplaced fundoplication around the upper stomach, or overnarrowing of the esophageal diaphragmatic hiatus and reoperation is usually | Surgery_Schwartz. a previous anti-reflux procedure shows that placement of the wrap around the stomach is the most frequent cause for failure after open proce-dures, while herniation of the repair into the chest is the most frequent cause of failure after a laparoscopic procedure. Partial or complete breakdown of the fundoplication and construction of a too-tight a fundoplication or overnarrowing the esophageal hiatus occurs with both open and closed procedures.Patients who have recurrence of heartburn and regurgitation without dysphagia and have good esophageal motility are most amenable to reoperation, and they can be expected to have an excellent outcome. When dysphagia is the cause of failure, the sit-uation can be more difficult to manage. If the dysphagia occurred immediately following the repair, it is usually due to a technical failure, most commonly a misplaced fundoplication around the upper stomach, or overnarrowing of the esophageal diaphragmatic hiatus and reoperation is usually |
Surgery_Schwartz_6978 | Surgery_Schwartz | repair, it is usually due to a technical failure, most commonly a misplaced fundoplication around the upper stomach, or overnarrowing of the esophageal diaphragmatic hiatus and reoperation is usually satisfactory. When dysphagia is associated with poor motility and multiple previous repairs, fur-ther revision fundoplication is unlikely to be successful, and in otherwise fit patients it is appropriate to seriously consider esopha-geal resection. With each reoperation, the esophagus is damaged further, and the chance of preserving function is decreased. Also, blood supply is reduced, and ischemic necrosis of the esophagus can occur after several previous mobilizations.GIANT DIAPHRAGMATIC (HIATAL) HERNIASWith the advent of clinical radiology, it became evident that a diaphragmatic hernia was a relatively common abnormality and was not always accompanied by symptoms. Three types of esophageal hiatal hernia were identified: (a) the sliding hernia, type I, characterized by an upward | Surgery_Schwartz. repair, it is usually due to a technical failure, most commonly a misplaced fundoplication around the upper stomach, or overnarrowing of the esophageal diaphragmatic hiatus and reoperation is usually satisfactory. When dysphagia is associated with poor motility and multiple previous repairs, fur-ther revision fundoplication is unlikely to be successful, and in otherwise fit patients it is appropriate to seriously consider esopha-geal resection. With each reoperation, the esophagus is damaged further, and the chance of preserving function is decreased. Also, blood supply is reduced, and ischemic necrosis of the esophagus can occur after several previous mobilizations.GIANT DIAPHRAGMATIC (HIATAL) HERNIASWith the advent of clinical radiology, it became evident that a diaphragmatic hernia was a relatively common abnormality and was not always accompanied by symptoms. Three types of esophageal hiatal hernia were identified: (a) the sliding hernia, type I, characterized by an upward |
Surgery_Schwartz_6979 | Surgery_Schwartz | was a relatively common abnormality and was not always accompanied by symptoms. Three types of esophageal hiatal hernia were identified: (a) the sliding hernia, type I, characterized by an upward dislocation of the cardia in the posterior mediastinum (Fig. 25-39A); (b) the roll-ing or PEH, type II, characterized by an upward dislocation of the gastric fundus alongside a normally positioned cardia (Fig. 25-39B); and (c) the combined sliding-rolling or mixed hernia, type III, characterized by an upward dislocation of both the cardia and the gastric fundus (Fig. 25-39C). The end stage of type I and type II hernias occurs when the whole stomach migrates up into the chest by rotating 180° around its longitu-dinal axis, with the cardia and pylorus as fixed points. In this situation, the abnormality is usually referred to as an intratho-racic stomach (Fig. 25-39D). In some taxonomies, a type IV hiatal hernia is declared when an additional organ, usually the colon, herniates as well. Types | Surgery_Schwartz. was a relatively common abnormality and was not always accompanied by symptoms. Three types of esophageal hiatal hernia were identified: (a) the sliding hernia, type I, characterized by an upward dislocation of the cardia in the posterior mediastinum (Fig. 25-39A); (b) the roll-ing or PEH, type II, characterized by an upward dislocation of the gastric fundus alongside a normally positioned cardia (Fig. 25-39B); and (c) the combined sliding-rolling or mixed hernia, type III, characterized by an upward dislocation of both the cardia and the gastric fundus (Fig. 25-39C). The end stage of type I and type II hernias occurs when the whole stomach migrates up into the chest by rotating 180° around its longitu-dinal axis, with the cardia and pylorus as fixed points. In this situation, the abnormality is usually referred to as an intratho-racic stomach (Fig. 25-39D). In some taxonomies, a type IV hiatal hernia is declared when an additional organ, usually the colon, herniates as well. Types |
Surgery_Schwartz_6980 | Surgery_Schwartz | is usually referred to as an intratho-racic stomach (Fig. 25-39D). In some taxonomies, a type IV hiatal hernia is declared when an additional organ, usually the colon, herniates as well. Types II–IV hiatal hernias are also referred to as paraesophageal hernia (PEH), as a portion of the stomach is situated adjacent to the esophagus, above the gastroesophageal junction.Incidence and EtiologyThe true incidence of a hiatal hernia is difficult to determine because of the absence of symptoms in a large number of patients who are subsequently shown to have a hernia. When radiographic examinations are done in response to GI symptoms, Brunicardi_Ch25_p1009-p1098.indd 104501/03/19 6:03 PM 1046SPECIFIC CONSIDERATIONSPART IICDBAFigure 25-39. A. Radiogram of a type I (sliding) hiatal hernia. B. Radiogram of a type II (rolling or paraesophageal) hernia. C. Radiogram of a type III (combined sliding-rolling or mixed) hernia. D. Radiogram of an intrathoracic stomach. This is the end stage of a | Surgery_Schwartz. is usually referred to as an intratho-racic stomach (Fig. 25-39D). In some taxonomies, a type IV hiatal hernia is declared when an additional organ, usually the colon, herniates as well. Types II–IV hiatal hernias are also referred to as paraesophageal hernia (PEH), as a portion of the stomach is situated adjacent to the esophagus, above the gastroesophageal junction.Incidence and EtiologyThe true incidence of a hiatal hernia is difficult to determine because of the absence of symptoms in a large number of patients who are subsequently shown to have a hernia. When radiographic examinations are done in response to GI symptoms, Brunicardi_Ch25_p1009-p1098.indd 104501/03/19 6:03 PM 1046SPECIFIC CONSIDERATIONSPART IICDBAFigure 25-39. A. Radiogram of a type I (sliding) hiatal hernia. B. Radiogram of a type II (rolling or paraesophageal) hernia. C. Radiogram of a type III (combined sliding-rolling or mixed) hernia. D. Radiogram of an intrathoracic stomach. This is the end stage of a |
Surgery_Schwartz_6981 | Surgery_Schwartz | Radiogram of a type II (rolling or paraesophageal) hernia. C. Radiogram of a type III (combined sliding-rolling or mixed) hernia. D. Radiogram of an intrathoracic stomach. This is the end stage of a large hiatal hernia regardless of its initial classification. Note that the stomach has rotated 180° around its longitudinal axis, with the cardia and pylorus as fixed points. (Reproduced with permission from Nyhus LM, Condon RE: Hernia, 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1989.)Brunicardi_Ch25_p1009-p1098.indd 104601/03/19 6:03 PM 1047ESOPHAGUS AND DIAPHRAGMATIC HERNIACHAPTER 25the incidence of a sliding hiatal hernia is seven times higher than that of a PEH. The PEH is also known as the giant hiatal hernia. Over time the pressure gradient between the abdomen and chest enlarges the hiatal hernia. In many cases the type 1 sliding hernia will evolve into a type III mixed hernia. Type II hernias are quite rare. The age distribution of patients with PEHs is | Surgery_Schwartz. Radiogram of a type II (rolling or paraesophageal) hernia. C. Radiogram of a type III (combined sliding-rolling or mixed) hernia. D. Radiogram of an intrathoracic stomach. This is the end stage of a large hiatal hernia regardless of its initial classification. Note that the stomach has rotated 180° around its longitudinal axis, with the cardia and pylorus as fixed points. (Reproduced with permission from Nyhus LM, Condon RE: Hernia, 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1989.)Brunicardi_Ch25_p1009-p1098.indd 104601/03/19 6:03 PM 1047ESOPHAGUS AND DIAPHRAGMATIC HERNIACHAPTER 25the incidence of a sliding hiatal hernia is seven times higher than that of a PEH. The PEH is also known as the giant hiatal hernia. Over time the pressure gradient between the abdomen and chest enlarges the hiatal hernia. In many cases the type 1 sliding hernia will evolve into a type III mixed hernia. Type II hernias are quite rare. The age distribution of patients with PEHs is |
Surgery_Schwartz_6982 | Surgery_Schwartz | and chest enlarges the hiatal hernia. In many cases the type 1 sliding hernia will evolve into a type III mixed hernia. Type II hernias are quite rare. The age distribution of patients with PEHs is significantly different from that observed in sliding hiatal hernias. The median age of the former is 61 years old; of the latter, 48 years old. PEHs are more likely to occur in women by a ratio of 4:1.Structural deterioration of the phrenoesophageal mem-brane over time may explain the higher incidence of hiatal her-nias in the older age group. These changes involve thinning of the upper fascial layer of the phrenoesophageal membrane (i.e., the supradiaphragmatic continuation of the endothoracic fascia) and loss of elasticity in the lower fascial layer (i.e., the infra-diaphragmatic continuation of the transversalis fascia). Conse-quently, the phrenoesophageal membrane yields to stretching in the cranial direction due to the persistent intra-abdominal pres-sure and the tug of esophageal | Surgery_Schwartz. and chest enlarges the hiatal hernia. In many cases the type 1 sliding hernia will evolve into a type III mixed hernia. Type II hernias are quite rare. The age distribution of patients with PEHs is significantly different from that observed in sliding hiatal hernias. The median age of the former is 61 years old; of the latter, 48 years old. PEHs are more likely to occur in women by a ratio of 4:1.Structural deterioration of the phrenoesophageal mem-brane over time may explain the higher incidence of hiatal her-nias in the older age group. These changes involve thinning of the upper fascial layer of the phrenoesophageal membrane (i.e., the supradiaphragmatic continuation of the endothoracic fascia) and loss of elasticity in the lower fascial layer (i.e., the infra-diaphragmatic continuation of the transversalis fascia). Conse-quently, the phrenoesophageal membrane yields to stretching in the cranial direction due to the persistent intra-abdominal pres-sure and the tug of esophageal |
Surgery_Schwartz_6983 | Surgery_Schwartz | of the transversalis fascia). Conse-quently, the phrenoesophageal membrane yields to stretching in the cranial direction due to the persistent intra-abdominal pres-sure and the tug of esophageal shortening on swallowing. Inter-estingly, the stretching and thinning occurs more anteriorly and posteriorly, with fixation of the left crus of the diaphragm to the stomach at the 3 o’clock position, as viewed from the foot. This creates an anterior and posterior hernia sac, the latter of which is often filled with epiphrenic and retroperitoneal fat. These obser-vations point to the conclusion that the development of a hiatal hernia is an age-related phenomenon secondary to repetitive upward stretching of the phrenoesophageal membrane.Clinical ManifestationsThe clinical presentation of a giant hiatal (paraesophageal) her-nia differs from that of a sliding hernia. There is usually a higher prevalence of symptoms of dysphagia and postprandial fullness with PEHs, but the typical symptoms of | Surgery_Schwartz. of the transversalis fascia). Conse-quently, the phrenoesophageal membrane yields to stretching in the cranial direction due to the persistent intra-abdominal pres-sure and the tug of esophageal shortening on swallowing. Inter-estingly, the stretching and thinning occurs more anteriorly and posteriorly, with fixation of the left crus of the diaphragm to the stomach at the 3 o’clock position, as viewed from the foot. This creates an anterior and posterior hernia sac, the latter of which is often filled with epiphrenic and retroperitoneal fat. These obser-vations point to the conclusion that the development of a hiatal hernia is an age-related phenomenon secondary to repetitive upward stretching of the phrenoesophageal membrane.Clinical ManifestationsThe clinical presentation of a giant hiatal (paraesophageal) her-nia differs from that of a sliding hernia. There is usually a higher prevalence of symptoms of dysphagia and postprandial fullness with PEHs, but the typical symptoms of |
Surgery_Schwartz_6984 | Surgery_Schwartz | hiatal (paraesophageal) her-nia differs from that of a sliding hernia. There is usually a higher prevalence of symptoms of dysphagia and postprandial fullness with PEHs, but the typical symptoms of heartburn and regurgi-tation present in sliding hiatal hernias can also occur. Both are caused by gastroesophageal reflux secondary to an underlying mechanical deficiency of the cardia. The symptoms of dysphagia and postprandial fullness in patients with a PEH are explained by the compression of the adjacent esophagus by a distended cardia, or twisting of the GEJ by the torsion of the stomach that occurs as it becomes progressively displaced in the chest. The postprandial fullness or retrosternal chest pain is a thought to be a result of distension of the stomach with gas or food in the hiatal hernia. Many patients with sliding hernias and reflux symptoms will lose the reflux symptoms when the hernia evolves into the paraesophageal variety. This can be explained by the recreation of the | Surgery_Schwartz. hiatal (paraesophageal) her-nia differs from that of a sliding hernia. There is usually a higher prevalence of symptoms of dysphagia and postprandial fullness with PEHs, but the typical symptoms of heartburn and regurgi-tation present in sliding hiatal hernias can also occur. Both are caused by gastroesophageal reflux secondary to an underlying mechanical deficiency of the cardia. The symptoms of dysphagia and postprandial fullness in patients with a PEH are explained by the compression of the adjacent esophagus by a distended cardia, or twisting of the GEJ by the torsion of the stomach that occurs as it becomes progressively displaced in the chest. The postprandial fullness or retrosternal chest pain is a thought to be a result of distension of the stomach with gas or food in the hiatal hernia. Many patients with sliding hernias and reflux symptoms will lose the reflux symptoms when the hernia evolves into the paraesophageal variety. This can be explained by the recreation of the |
Surgery_Schwartz_6985 | Surgery_Schwartz | hernia. Many patients with sliding hernias and reflux symptoms will lose the reflux symptoms when the hernia evolves into the paraesophageal variety. This can be explained by the recreation of the cardiophrenic angle when the stomach herniates along-side the GEJ or becomes twisted in the sac. Repair of the hernia without addressing the reflux can create extremely bothersome heartburn. Respiratory complications are frequently associated with a PEH and consist of dyspnea and recurrent pneumonia from aspiration. New research demonstrates that the cause of dyspnea in the presence of a giant PEH is more likely to be left atrial compression, decreasing cardiac output, than a restrictive pulmonary effect, as has been hypothesized for many years.Approximately one-third of patients with a PEH are found to be anemic, which is due to recurrent bleeding from ulceration of the gastric mucosa in the herniated portion of the stomach, even if ulcerations are not detected at the time of endoscopy. The | Surgery_Schwartz. hernia. Many patients with sliding hernias and reflux symptoms will lose the reflux symptoms when the hernia evolves into the paraesophageal variety. This can be explained by the recreation of the cardiophrenic angle when the stomach herniates along-side the GEJ or becomes twisted in the sac. Repair of the hernia without addressing the reflux can create extremely bothersome heartburn. Respiratory complications are frequently associated with a PEH and consist of dyspnea and recurrent pneumonia from aspiration. New research demonstrates that the cause of dyspnea in the presence of a giant PEH is more likely to be left atrial compression, decreasing cardiac output, than a restrictive pulmonary effect, as has been hypothesized for many years.Approximately one-third of patients with a PEH are found to be anemic, which is due to recurrent bleeding from ulceration of the gastric mucosa in the herniated portion of the stomach, even if ulcerations are not detected at the time of endoscopy. The |
Surgery_Schwartz_6986 | Surgery_Schwartz | to be anemic, which is due to recurrent bleeding from ulceration of the gastric mucosa in the herniated portion of the stomach, even if ulcerations are not detected at the time of endoscopy. The association of anemia and PEH is best proven by fixing the hernia. Anemia is corrected in >90% of patients with this condition. With time, more and more stomach migrates into the chest and can cause intermittent foregut obstruction due to the rotation that has occurred. In contrast, many patients with PEH are asymptomatic or complain of minor symptoms. However, the presence of a PEH can be life-threatening in that the hernia can lead to sudden catastrophic events, such as excessive bleed-ing or volvulus with acute gastric obstruction or infarction. With mild dilatation of the stomach, the gastric blood supply can be markedly reduced, causing gastric ischemia, ulceration, perfora-tion, and sepsis. The probability of incarceration/strangulation is not well known, although recent studies suggest | Surgery_Schwartz. to be anemic, which is due to recurrent bleeding from ulceration of the gastric mucosa in the herniated portion of the stomach, even if ulcerations are not detected at the time of endoscopy. The association of anemia and PEH is best proven by fixing the hernia. Anemia is corrected in >90% of patients with this condition. With time, more and more stomach migrates into the chest and can cause intermittent foregut obstruction due to the rotation that has occurred. In contrast, many patients with PEH are asymptomatic or complain of minor symptoms. However, the presence of a PEH can be life-threatening in that the hernia can lead to sudden catastrophic events, such as excessive bleed-ing or volvulus with acute gastric obstruction or infarction. With mild dilatation of the stomach, the gastric blood supply can be markedly reduced, causing gastric ischemia, ulceration, perfora-tion, and sepsis. The probability of incarceration/strangulation is not well known, although recent studies suggest |
Surgery_Schwartz_6987 | Surgery_Schwartz | blood supply can be markedly reduced, causing gastric ischemia, ulceration, perfora-tion, and sepsis. The probability of incarceration/strangulation is not well known, although recent studies suggest that the lifetime risk is less than 5%, making this concern an insufficient concern for routine repair of the asymptomatic PEH.The symptoms of sliding hiatal hernias are usually due to functional abnormalities associated with gastroesophageal reflux and include heartburn, regurgitation, and dysphagia. These patients have a mechanically defective LES, giving rise to the reflux of gastric juice into the esophagus and the symp-toms of heartburn and regurgitation. The symptom of dysphagia occurs from the presence of mucosal edema, Schatzki’s ring, stricture, or the inability to organize peristaltic activity in the body of the esophagus as a consequence of the disease.There is a group of patients with sliding hiatal hernias not associated with reflux disease who have dysphagia without any | Surgery_Schwartz. blood supply can be markedly reduced, causing gastric ischemia, ulceration, perfora-tion, and sepsis. The probability of incarceration/strangulation is not well known, although recent studies suggest that the lifetime risk is less than 5%, making this concern an insufficient concern for routine repair of the asymptomatic PEH.The symptoms of sliding hiatal hernias are usually due to functional abnormalities associated with gastroesophageal reflux and include heartburn, regurgitation, and dysphagia. These patients have a mechanically defective LES, giving rise to the reflux of gastric juice into the esophagus and the symp-toms of heartburn and regurgitation. The symptom of dysphagia occurs from the presence of mucosal edema, Schatzki’s ring, stricture, or the inability to organize peristaltic activity in the body of the esophagus as a consequence of the disease.There is a group of patients with sliding hiatal hernias not associated with reflux disease who have dysphagia without any |
Surgery_Schwartz_6988 | Surgery_Schwartz | activity in the body of the esophagus as a consequence of the disease.There is a group of patients with sliding hiatal hernias not associated with reflux disease who have dysphagia without any obvious endoscopic or manometric explanation. Video barium radiograms have shown that the cause of dysphagia in these patients is an obstruction of the swallowed bolus by diaphrag-matic impingement on the herniated stomach. Manometrically, this is reflected by a double-humped high-pressure zone at the GEJ. The first pressure rise is due to diaphragmatic impinge-ment on the herniated stomach, and the second is due to the true distal esophageal sphincter. These patients usually have a mechanically competent sphincter, but the impingement of the diaphragm on the stomach can result in propelling the contents of the supradiaphragmatic portion of the stomach up into the esophagus and pharynx, resulting in complaints of pharyngeal regurgitation and aspiration. Consequently, this abnormality is often | Surgery_Schwartz. activity in the body of the esophagus as a consequence of the disease.There is a group of patients with sliding hiatal hernias not associated with reflux disease who have dysphagia without any obvious endoscopic or manometric explanation. Video barium radiograms have shown that the cause of dysphagia in these patients is an obstruction of the swallowed bolus by diaphrag-matic impingement on the herniated stomach. Manometrically, this is reflected by a double-humped high-pressure zone at the GEJ. The first pressure rise is due to diaphragmatic impinge-ment on the herniated stomach, and the second is due to the true distal esophageal sphincter. These patients usually have a mechanically competent sphincter, but the impingement of the diaphragm on the stomach can result in propelling the contents of the supradiaphragmatic portion of the stomach up into the esophagus and pharynx, resulting in complaints of pharyngeal regurgitation and aspiration. Consequently, this abnormality is often |
Surgery_Schwartz_6989 | Surgery_Schwartz | of the supradiaphragmatic portion of the stomach up into the esophagus and pharynx, resulting in complaints of pharyngeal regurgitation and aspiration. Consequently, this abnormality is often confused with typical GERD. Surgical reduction of the hernia results in relief of the dysphagia in 91% of patients.DiagnosisA chest X-ray with the patient in the upright position can diag-nose a hiatal hernia if it shows an air-fluid level behind the car-diac shadow. This is usually caused by a PEH or an intrathoracic stomach. The accuracy of the upper GI barium study in detect-ing a paraesophageal hiatal hernia is greater than for a sliding hernia because the latter can often spontaneously reduce. The paraesophageal hiatal hernia is a permanent herniation of the stomach into the thoracic cavity, so a barium swallow provides the diagnosis in virtually every case. Attention should be focused on the position of the GEJ, when seen, to differentiate it from a type II hernia (see Fig. 25-39B and C). | Surgery_Schwartz. of the supradiaphragmatic portion of the stomach up into the esophagus and pharynx, resulting in complaints of pharyngeal regurgitation and aspiration. Consequently, this abnormality is often confused with typical GERD. Surgical reduction of the hernia results in relief of the dysphagia in 91% of patients.DiagnosisA chest X-ray with the patient in the upright position can diag-nose a hiatal hernia if it shows an air-fluid level behind the car-diac shadow. This is usually caused by a PEH or an intrathoracic stomach. The accuracy of the upper GI barium study in detect-ing a paraesophageal hiatal hernia is greater than for a sliding hernia because the latter can often spontaneously reduce. The paraesophageal hiatal hernia is a permanent herniation of the stomach into the thoracic cavity, so a barium swallow provides the diagnosis in virtually every case. Attention should be focused on the position of the GEJ, when seen, to differentiate it from a type II hernia (see Fig. 25-39B and C). |
Surgery_Schwartz_6990 | Surgery_Schwartz | a barium swallow provides the diagnosis in virtually every case. Attention should be focused on the position of the GEJ, when seen, to differentiate it from a type II hernia (see Fig. 25-39B and C). Fiber-optic esophagos-copy is useful in the diagnosis and classification of a hiatal hernia because the scope can be retroflexed. In this position, a sliding hiatal hernia can be identified by noting a gastric pouch lined with rugal folds extending above the impression caused by the crura of the diaphragm, or measuring at least 2 cm between the crura, identified by having the patient sniff, and the squamoco-lumnar junction on withdrawal of the scope (Fig. 25-40). A PEH is identified on retroversion of the scope by noting a separate orifice adjacent to the GEJ into which gastric rugal folds ascend. A sliding-rolling or mixed hernia can be identified by noting a gastric pouch lined with rugal folds above the diaphragm, with the GEJ entering about midway up the side of the | Surgery_Schwartz. a barium swallow provides the diagnosis in virtually every case. Attention should be focused on the position of the GEJ, when seen, to differentiate it from a type II hernia (see Fig. 25-39B and C). Fiber-optic esophagos-copy is useful in the diagnosis and classification of a hiatal hernia because the scope can be retroflexed. In this position, a sliding hiatal hernia can be identified by noting a gastric pouch lined with rugal folds extending above the impression caused by the crura of the diaphragm, or measuring at least 2 cm between the crura, identified by having the patient sniff, and the squamoco-lumnar junction on withdrawal of the scope (Fig. 25-40). A PEH is identified on retroversion of the scope by noting a separate orifice adjacent to the GEJ into which gastric rugal folds ascend. A sliding-rolling or mixed hernia can be identified by noting a gastric pouch lined with rugal folds above the diaphragm, with the GEJ entering about midway up the side of the |
Surgery_Schwartz_6991 | Surgery_Schwartz | rugal folds ascend. A sliding-rolling or mixed hernia can be identified by noting a gastric pouch lined with rugal folds above the diaphragm, with the GEJ entering about midway up the side of the pouch.Brunicardi_Ch25_p1009-p1098.indd 104701/03/19 6:03 PM 1048SPECIFIC CONSIDERATIONSPART IIFigure 25-40. Endoscopic view through a retroflexed fiber-optic gastroscope showing the shaft of the scope (arrow) coming down through a sliding hernia. Note the gastric rugal folds extending above the impression caused by the crura of the diaphragm. (Repro-duced with permission from Nyhus LM, Condon RE: Hernia, 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1989.)PathophysiologyPhysiologic testing with 24-hour esophageal pH monitoring has shown increased esophageal exposure to acid gastric juice in 60% of the patients with a paraesophageal hiatal hernia, com-pared with the observed 71% incidence in patients with a sliding hiatal hernia. It is now recognized that paraesophageal hiatal | Surgery_Schwartz. rugal folds ascend. A sliding-rolling or mixed hernia can be identified by noting a gastric pouch lined with rugal folds above the diaphragm, with the GEJ entering about midway up the side of the pouch.Brunicardi_Ch25_p1009-p1098.indd 104701/03/19 6:03 PM 1048SPECIFIC CONSIDERATIONSPART IIFigure 25-40. Endoscopic view through a retroflexed fiber-optic gastroscope showing the shaft of the scope (arrow) coming down through a sliding hernia. Note the gastric rugal folds extending above the impression caused by the crura of the diaphragm. (Repro-duced with permission from Nyhus LM, Condon RE: Hernia, 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1989.)PathophysiologyPhysiologic testing with 24-hour esophageal pH monitoring has shown increased esophageal exposure to acid gastric juice in 60% of the patients with a paraesophageal hiatal hernia, com-pared with the observed 71% incidence in patients with a sliding hiatal hernia. It is now recognized that paraesophageal hiatal |
Surgery_Schwartz_6992 | Surgery_Schwartz | juice in 60% of the patients with a paraesophageal hiatal hernia, com-pared with the observed 71% incidence in patients with a sliding hiatal hernia. It is now recognized that paraesophageal hiatal her-nia can be associated with pathologic gastroesophageal reflux.Physiologic studies have also shown that the competency of the cardia depends on an interrelationship between distal esophageal sphincter pressure, the length of the sphincter that is exposed to the positive-pressure environment of the abdomen, and the overall length of the sphincter. A deficiency in any one of these manometric characteristics of the sphincter is associated with incompetency of the cardia regardless of whether a hernia is present. Patients with a PEH who have an incompetent cardia have been shown to have a distal esophageal sphincter with nor-mal pressure, but a shortened overall length and displacement outside the positive-pressure environment of the abdomen. One might expect esophageal body function to be | Surgery_Schwartz. juice in 60% of the patients with a paraesophageal hiatal hernia, com-pared with the observed 71% incidence in patients with a sliding hiatal hernia. It is now recognized that paraesophageal hiatal her-nia can be associated with pathologic gastroesophageal reflux.Physiologic studies have also shown that the competency of the cardia depends on an interrelationship between distal esophageal sphincter pressure, the length of the sphincter that is exposed to the positive-pressure environment of the abdomen, and the overall length of the sphincter. A deficiency in any one of these manometric characteristics of the sphincter is associated with incompetency of the cardia regardless of whether a hernia is present. Patients with a PEH who have an incompetent cardia have been shown to have a distal esophageal sphincter with nor-mal pressure, but a shortened overall length and displacement outside the positive-pressure environment of the abdomen. One might expect esophageal body function to be |
Surgery_Schwartz_6993 | Surgery_Schwartz | esophageal sphincter with nor-mal pressure, but a shortened overall length and displacement outside the positive-pressure environment of the abdomen. One might expect esophageal body function to be diminished with the esophagus “accordioned” up into the chest. Surprisingly, esophageal peristalsis in patients with PEH is normal in 88%.TreatmentThe treatment of paraesophageal hiatal hernia is largely surgi-cal. Controversial aspects include: (a) indications for repair, (b) diaphragmatic repair, (c) role of fundoplication, and (d) exis-tence and treatment of the short esophagus.Indications and Surgical Approach. The presence of a paraesophageal hiatal hernia has traditionally been consid-ered an indication for surgical repair. This recommendation is largely based upon two clinical observations. First, retrospec-tive studies have shown a significant incidence of catastrophic, life-threatening complications of bleeding, infarction, and per-foration in patients being followed with known | Surgery_Schwartz. esophageal sphincter with nor-mal pressure, but a shortened overall length and displacement outside the positive-pressure environment of the abdomen. One might expect esophageal body function to be diminished with the esophagus “accordioned” up into the chest. Surprisingly, esophageal peristalsis in patients with PEH is normal in 88%.TreatmentThe treatment of paraesophageal hiatal hernia is largely surgi-cal. Controversial aspects include: (a) indications for repair, (b) diaphragmatic repair, (c) role of fundoplication, and (d) exis-tence and treatment of the short esophagus.Indications and Surgical Approach. The presence of a paraesophageal hiatal hernia has traditionally been consid-ered an indication for surgical repair. This recommendation is largely based upon two clinical observations. First, retrospec-tive studies have shown a significant incidence of catastrophic, life-threatening complications of bleeding, infarction, and per-foration in patients being followed with known |
Surgery_Schwartz_6994 | Surgery_Schwartz | First, retrospec-tive studies have shown a significant incidence of catastrophic, life-threatening complications of bleeding, infarction, and per-foration in patients being followed with known paraesophageal herniation. Second, emergency repair carries a high mortality. In the classic report of Skinner and Belsey, six of 21 patients with a PEH, treated medically because of minimal symptoms, died from the complications of strangulation, perforation, exsangui-nating hemorrhage, or acute dilatation of the herniated intratho-racic stomach. For the most part, these catastrophes occurred without warning. Others have reported similar findings.Recent studies suggest that catastrophic complications may be somewhat less common. Allen and colleagues followed 23 patients for a median of 78 months with only four patients pro-gressively worsening. There was a single mortality secondary to aspiration that occurred during a barium swallow examination to investigate progressive symptoms. Although | Surgery_Schwartz. First, retrospec-tive studies have shown a significant incidence of catastrophic, life-threatening complications of bleeding, infarction, and per-foration in patients being followed with known paraesophageal herniation. Second, emergency repair carries a high mortality. In the classic report of Skinner and Belsey, six of 21 patients with a PEH, treated medically because of minimal symptoms, died from the complications of strangulation, perforation, exsangui-nating hemorrhage, or acute dilatation of the herniated intratho-racic stomach. For the most part, these catastrophes occurred without warning. Others have reported similar findings.Recent studies suggest that catastrophic complications may be somewhat less common. Allen and colleagues followed 23 patients for a median of 78 months with only four patients pro-gressively worsening. There was a single mortality secondary to aspiration that occurred during a barium swallow examination to investigate progressive symptoms. Although |
Surgery_Schwartz_6995 | Surgery_Schwartz | with only four patients pro-gressively worsening. There was a single mortality secondary to aspiration that occurred during a barium swallow examination to investigate progressive symptoms. Although emergency repairs had a median hospital stay of 48 days compared to a stay of 9 days in those having elective repair, there were only three cases of gastric strangulation in 735 patient-years of follow-up.If surgery is delayed and repair is done on an emergency basis, operative mortality is high, compared to <1% for an elec-tive repair. With this in mind, patients with a PEH are generally counseled to have elective repair of their hernia, particularly if they are symptomatic. Watchful waiting of asymptomatic PEHs may be an acceptable option.The surgical approach to repair of a paraesophageal hiatal hernia may be either transabdominal (laparoscopic or open) or transthoracic. Each has its advantages and disadvantages. A transthoracic approach facilitates complete esophageal mobi-lization | Surgery_Schwartz. with only four patients pro-gressively worsening. There was a single mortality secondary to aspiration that occurred during a barium swallow examination to investigate progressive symptoms. Although emergency repairs had a median hospital stay of 48 days compared to a stay of 9 days in those having elective repair, there were only three cases of gastric strangulation in 735 patient-years of follow-up.If surgery is delayed and repair is done on an emergency basis, operative mortality is high, compared to <1% for an elec-tive repair. With this in mind, patients with a PEH are generally counseled to have elective repair of their hernia, particularly if they are symptomatic. Watchful waiting of asymptomatic PEHs may be an acceptable option.The surgical approach to repair of a paraesophageal hiatal hernia may be either transabdominal (laparoscopic or open) or transthoracic. Each has its advantages and disadvantages. A transthoracic approach facilitates complete esophageal mobi-lization |
Surgery_Schwartz_6996 | Surgery_Schwartz | hiatal hernia may be either transabdominal (laparoscopic or open) or transthoracic. Each has its advantages and disadvantages. A transthoracic approach facilitates complete esophageal mobi-lization but is rarely used because the access trauma and postopera-tive pain are significantly greater than a laparoscopic approach.The transabdominal approach facilitates reduction of the volvulus that is often associated with PEHs. Although some degree of esophageal mobilization can be accomplished tran-shiatally, complete mobilization to the aortic arch is difficult or impossible without risk of injury to the vagal nerves.Laparoscopic repair of PEH would appear to have become the standard approach. Laparoscopic repair of a pure type II, or mixed type III PEH is an order of magnitude more difficult than a standard laparoscopic Nissen fundoplication. Most would rec-ommend that these procedures are best avoided until the surgeon has accumulated considerable experience with laparoscopic antireflux | Surgery_Schwartz. hiatal hernia may be either transabdominal (laparoscopic or open) or transthoracic. Each has its advantages and disadvantages. A transthoracic approach facilitates complete esophageal mobi-lization but is rarely used because the access trauma and postopera-tive pain are significantly greater than a laparoscopic approach.The transabdominal approach facilitates reduction of the volvulus that is often associated with PEHs. Although some degree of esophageal mobilization can be accomplished tran-shiatally, complete mobilization to the aortic arch is difficult or impossible without risk of injury to the vagal nerves.Laparoscopic repair of PEH would appear to have become the standard approach. Laparoscopic repair of a pure type II, or mixed type III PEH is an order of magnitude more difficult than a standard laparoscopic Nissen fundoplication. Most would rec-ommend that these procedures are best avoided until the surgeon has accumulated considerable experience with laparoscopic antireflux |
Surgery_Schwartz_6997 | Surgery_Schwartz | than a standard laparoscopic Nissen fundoplication. Most would rec-ommend that these procedures are best avoided until the surgeon has accumulated considerable experience with laparoscopic antireflux surgery. There are several reasons for this. First, the vertical and horizontal volvulus of the stomach often associated with PEHs makes identification of the anatomy, in particular the location of the esophagus, difficult. Second, dissection of a large PEH sac may result in significant bleeding if the surgeon deviates from the correct plane of dissection between the peri-toneal sac and the endothoracic fascia. Finally, redundant tissue present at the GEJ following dissection of the sac frustrates the creation of a fundoplication. This tissue, which includes the epi-phrenic fat pad and hernia sac should be removed at the time of PEH repair. Mindful of these difficulties, and given appropriate experience, patients with PEH may be approached laparoscopi-cally, with expectation of success in | Surgery_Schwartz. than a standard laparoscopic Nissen fundoplication. Most would rec-ommend that these procedures are best avoided until the surgeon has accumulated considerable experience with laparoscopic antireflux surgery. There are several reasons for this. First, the vertical and horizontal volvulus of the stomach often associated with PEHs makes identification of the anatomy, in particular the location of the esophagus, difficult. Second, dissection of a large PEH sac may result in significant bleeding if the surgeon deviates from the correct plane of dissection between the peri-toneal sac and the endothoracic fascia. Finally, redundant tissue present at the GEJ following dissection of the sac frustrates the creation of a fundoplication. This tissue, which includes the epi-phrenic fat pad and hernia sac should be removed at the time of PEH repair. Mindful of these difficulties, and given appropriate experience, patients with PEH may be approached laparoscopi-cally, with expectation of success in |
Surgery_Schwartz_6998 | Surgery_Schwartz | sac should be removed at the time of PEH repair. Mindful of these difficulties, and given appropriate experience, patients with PEH may be approached laparoscopi-cally, with expectation of success in the majority.Diaphragmatic RepairIt has been shown that PEH repair has a relatively high incidence of recurrence (10–40%) when the crura is closed primarily with permanent suture. Techniques to reduce hernia recurrence con-tinue to evolve. Most surgeons believe that recurrence may be reduced with the use of synthetic or biologic mesh to reinforce the standard crural closure. Randomized controlled studies have 4Brunicardi_Ch25_p1009-p1098.indd 104801/03/19 6:04 PM 1049ESOPHAGUS AND DIAPHRAGMATIC HERNIACHAPTER 25demonstrated a reduction in PEH recurrence rate when mesh was used. Nonabsorbable synthetic mesh must be used carefully and not in a keyhole fashion at the hiatus because of a potential risk of esophagus or gastric erosion and mesh infection. Bio-logic mesh (acellular porcine | Surgery_Schwartz. sac should be removed at the time of PEH repair. Mindful of these difficulties, and given appropriate experience, patients with PEH may be approached laparoscopi-cally, with expectation of success in the majority.Diaphragmatic RepairIt has been shown that PEH repair has a relatively high incidence of recurrence (10–40%) when the crura is closed primarily with permanent suture. Techniques to reduce hernia recurrence con-tinue to evolve. Most surgeons believe that recurrence may be reduced with the use of synthetic or biologic mesh to reinforce the standard crural closure. Randomized controlled studies have 4Brunicardi_Ch25_p1009-p1098.indd 104801/03/19 6:04 PM 1049ESOPHAGUS AND DIAPHRAGMATIC HERNIACHAPTER 25demonstrated a reduction in PEH recurrence rate when mesh was used. Nonabsorbable synthetic mesh must be used carefully and not in a keyhole fashion at the hiatus because of a potential risk of esophagus or gastric erosion and mesh infection. Bio-logic mesh (acellular porcine |
Surgery_Schwartz_6999 | Surgery_Schwartz | synthetic mesh must be used carefully and not in a keyhole fashion at the hiatus because of a potential risk of esophagus or gastric erosion and mesh infection. Bio-logic mesh (acellular porcine dermis, acellular human dermis, porcine small intestinal submucosa) has become more widely used, but these meshes are significantly more expensive than synthetic mesh, and the only randomized study supporting bio-logic mesh usage failed to demonstrate superiority over suture alone after 5 years of rigorous follow-up.Role of Fundoplication in Giant Hiatal Hernia Repair. Controversy remains as to whether to perform an antireflux procedure at all, in selected cases only, or in all patients. Most advocate the routine addition of an antireflux procedure follow-ing repair of the hernia defect. There are several reasons for this. Physiologic testing with 24-hour esophageal pH monitoring has shown increased esophageal exposure to acid gastric juice in 60% to 70% of patients with a paraesophageal | Surgery_Schwartz. synthetic mesh must be used carefully and not in a keyhole fashion at the hiatus because of a potential risk of esophagus or gastric erosion and mesh infection. Bio-logic mesh (acellular porcine dermis, acellular human dermis, porcine small intestinal submucosa) has become more widely used, but these meshes are significantly more expensive than synthetic mesh, and the only randomized study supporting bio-logic mesh usage failed to demonstrate superiority over suture alone after 5 years of rigorous follow-up.Role of Fundoplication in Giant Hiatal Hernia Repair. Controversy remains as to whether to perform an antireflux procedure at all, in selected cases only, or in all patients. Most advocate the routine addition of an antireflux procedure follow-ing repair of the hernia defect. There are several reasons for this. Physiologic testing with 24-hour esophageal pH monitoring has shown increased esophageal exposure to acid gastric juice in 60% to 70% of patients with a paraesophageal |
Surgery_Schwartz_7000 | Surgery_Schwartz | are several reasons for this. Physiologic testing with 24-hour esophageal pH monitoring has shown increased esophageal exposure to acid gastric juice in 60% to 70% of patients with a paraesophageal hiatal hernia, nearly identical to the observed 71% incidence in patients with a sliding hiatal hernia. Furthermore, there is no relation between the symptoms experienced by the patient with a PEH and the competency of the cardia. Finally, dissection of the gastro-esophageal esophagus may lead to postoperative reflux despite a negative preoperative pH score.The Short Esophagus and PEHGiant PEH can be associated with a short esophagus in up to 5% to 20% of patients as a result of chronic cephalad displacement of the GEJ. The presence of a short esophagus increases the dif-ficulty of laparoscopic PEH repair. Approximately 10% to 20% of surgical failures with PEH repair is due to the lack of recogni-tion of a short esophagus. Preoperative results of barium swallow and | Surgery_Schwartz. are several reasons for this. Physiologic testing with 24-hour esophageal pH monitoring has shown increased esophageal exposure to acid gastric juice in 60% to 70% of patients with a paraesophageal hiatal hernia, nearly identical to the observed 71% incidence in patients with a sliding hiatal hernia. Furthermore, there is no relation between the symptoms experienced by the patient with a PEH and the competency of the cardia. Finally, dissection of the gastro-esophageal esophagus may lead to postoperative reflux despite a negative preoperative pH score.The Short Esophagus and PEHGiant PEH can be associated with a short esophagus in up to 5% to 20% of patients as a result of chronic cephalad displacement of the GEJ. The presence of a short esophagus increases the dif-ficulty of laparoscopic PEH repair. Approximately 10% to 20% of surgical failures with PEH repair is due to the lack of recogni-tion of a short esophagus. Preoperative results of barium swallow and |
Surgery_Schwartz_7001 | Surgery_Schwartz | of laparoscopic PEH repair. Approximately 10% to 20% of surgical failures with PEH repair is due to the lack of recogni-tion of a short esophagus. Preoperative results of barium swallow and esophagogastroduodenoscopy may provide an indication of short esophagus, but no combination of preoperative clinical vari-ables reliably predict the presence of short esophagus, defined as the failure to achieve 2.5 cm of intra-abdominal esophagus with standard mediastinal dissection techniques. Hence, the diagno-sis of this entity continues to be made definitively only in the operating room. Collis gastroplasty achieves esophageal length-ening by creation of a neoesophagus using the gastric cardia. The totally laparoscopic approach to the short esophagus has evolved from a method using an end-to-end anastomosis circular stapler to the current approach that uses a linear stapler creating a sta-pled wedge gastroplasty. Elements of importance in fashioning the fundoplication after Collis gastroplasty | Surgery_Schwartz. of laparoscopic PEH repair. Approximately 10% to 20% of surgical failures with PEH repair is due to the lack of recogni-tion of a short esophagus. Preoperative results of barium swallow and esophagogastroduodenoscopy may provide an indication of short esophagus, but no combination of preoperative clinical vari-ables reliably predict the presence of short esophagus, defined as the failure to achieve 2.5 cm of intra-abdominal esophagus with standard mediastinal dissection techniques. Hence, the diagno-sis of this entity continues to be made definitively only in the operating room. Collis gastroplasty achieves esophageal length-ening by creation of a neoesophagus using the gastric cardia. The totally laparoscopic approach to the short esophagus has evolved from a method using an end-to-end anastomosis circular stapler to the current approach that uses a linear stapler creating a sta-pled wedge gastroplasty. Elements of importance in fashioning the fundoplication after Collis gastroplasty |
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