SURGERY FOR BENIGN ESOPHAGEAL DISEASE

Daniel T. Dempsey, MD

Professor of Surgery

University of Pennsylvania

SURGICAL BENIGN ESOPHAGEAL DISEASE

• GERD

• HIATAL HERNIA

• ACHALASIA

• DIVERTICULA (ZENKER’S AND EPIPHRENIC)

• PERFORATION/CAUSTIC INGESTION

• TUMORS/CYSTS

PREOPERATIVE EVALUATION

• History and physical examination

• EGD

• Manometry

• R/O gastrinoma and h.pylori

• pH testing*

• Gastric emptying scan*

• Upper GI series*

• Gastroenterologist and surgeon team

LAPAROSCOPIC FUNDOPLICATION

NISSEN TOUPET

Dor Fundoplication

Catarci: Ann Surg, Volume 239(3).March 2004.325-337

PARTIAL VS TOTAL FUNDOPLICATION

INCIDENCE AND SEVERITY OF HEARTBURN, LAF v LNF

5 YEAR FOLLOW UP. BROEDERS ET AL, ANN SURG, 2013

DYSPHAGIA AFTER FUNDOPLICATION (LAF v LNF)

5 YEAR DILATION AND REOPERATION: LAF v LNF

LONGTERM HEARTBURN: LAF vs LPR

Broeders et al , Annals of Surgery, 2011

LONGTERM REOPERATION: LAF vs LPF

Jamieson, Ann Surg 2008

LAPAROSCOPIC FUNDOPLICATION:PREDICTORS OF SUBOPTIMAL OUTCOME

• Abnormal esophageal motility

• No heartburn or regurgitation

• Age > 65 years

BMI and GERD in ADULT WOMEN

Jacobson, NEJM, 2006

Inpatient Mortality

0.0%

0.1%

0.2%

0.3%

0.4%

0.5%

0.6%

0.7%

0.8%

0.9%

1.0%

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Year

Inp

atie

nt m

ort

ality

Antireflux Surgery Gastric Bypass Surgery

PARAESOPHAGEAL HIATAL HERNIA

Oelschlager: Ann Surg, Volume 244(4).October 2006.481-490

HIATAL REINFORCEMENT WITH BIOPROSTHESIS

Primary (39) SIS (33)

Symptom⁎ Mean ± SD p Value† Mean ± SD p Value†

Heartburn −3.6 ± 4.0 <0.001 −3.2 ± 4.6 0.002

Regurgitation −4.3 ± 3.5 <0.001 −4.2 ± 4.0 <0.001

Dysphagia −1.0 ± 4.3 0.200 −2.0 ± 3.2 0.009

Chest pain −3.2 ± 4.1 <0.001 −3.8 ± 3.6 <0.001

Abdominal pain

−1.9 ± 3.8 0.007 −1.8 ± 3.5 0.020

Bloating −1.6 ± 3.6 0.020 −2.7 ± 3.2 0.000

Postprandial pain

−2.9 ± 3.3 <0.001 −3.6 ± 3.7 <0.001

Early satiety

Recurrent hernia

−1.2 ± 2.7

59%

0.020 −2.6 ± 3.1

54%

<0.001

Biologic Prosthesis to Prevent Recurrence after Laparoscopic Paraesophageal Hernia Repair: Long-term Follow-up from a Multicenter, Prospective, Randomized Trial (5 years)

Journal of the American College of SurgeonsVolume 213, Issue 4, October 2011, Pages 461-468

Smith: Ann Surg, Volume 241(6).June 2005.861-871

REVISIONAL ANTIREFLUX OPERATION

Pennathur et al, Ann Thor Surg, 2010

PATTERNS OF FAILURE AFTER FUNDOPLICATION

SHORT ESOPHAGUS

• Contributes to recurrent HH and wrap slippage

• Most common in type 3 and 4 HH

• Incidence 0%-20%

• Esophageal Length Index (ELI)<19.5

– Endoscopic length (cm) divided by

– Patient height (M)

– Yano et al, Surg Endosc, 2009

Transthoracic Hiatal Hernia Repair with Collis

WEDGE FUNDECTOMY

COLLIS-NISSEN FOR SHORT ESOPHAGUS

Achalasia: “Northwestern Classification”

Kaplan–Meier Curves for the Rate of Treatment Success.

Boeckxstaens GE et al. N Engl J Med 2011;364:1807-1816.

HELLER DOR PRCEDURE FOR ACHALASIA

Richards, Ann Surg, 2004

Kurian…..Swanstrom, JAMA Surgery, 2013

ESOPHAGOMYOTOMY FOR ACHALASIA

• Abdominal approach w/hemiwrap

• Laparoscopic >95%

• Good results: 85-90% @ 5 years

• End stage disease may do worse

• Life long acid suppression

Zenker’s Diverticulum

Question 1

A 68-year-old man presents due to symptoms of heartburn and regurgitation. He has a history

of numerous abdominal surgeries, including a recent exploratory laparotomy for bowel

obstruction that was notable for significant adhesions. After workup with barium swallow and

esophagogastroscopy, he is diagnosed with a hiatal hernia. Due to his significant operative

history, a transthoracic hiatal hernia repair is planned.

Which of the following is true?

A) The short gastric arteries must be divided along both the greater and the lesser curvature to

mobilize the stomach

B) If there is tension on the esophagus when the stomach is reduced, Collis gastroplasty should

be performed

C) During dissection of the hernia sac, it should be incised perpendicular to the esophagus

D) Left thoracotomy should be performed with incision in the left fourth or fifth interspace

E) Stitches should be placed so that the crura are approximated tightly around the esophagus

A 50-year-old man is taken to the operating room for laparoscopic Nissen

fundoplication for gastroesophageal reflux disease (GERD).

Which of the following is true regarding operative technique?

A) The wrap should be 2.5 cm or greater in length on completion

B) The body of the stomach is used to form the wrap

C) Division of the short gastric vessels is not necessary

D) Placement of a bougie during wrap creation helps avoid an excessively tight wrap

E) The patient should be placed in the steep Trendelenberg position

Question 3

A 48-year-old woman presents with a history of heartburn that has been only

partially relieved with proton pump inhibitors (PPIs). She has been referred for

possible laparoscopic Nissen fundoplication.

Which of the following is true regarding preoperative assessment of these

patients?

A) All patients with GERD will have evidence of mucosal damage on endoscopy

B) Esophageal manometry can be used to confirm the diagnosis of GERD

C) Patients who have not responded to PPIs are more likely to have significant

and abnormal reflux

D) GERD severity can be assessed using ambulatory pH monitoring

E) Typical symptoms of heartburn and regurgitation are highly sensitive and

specific for the diagnosis of GERD

Question 4

A 65-year-old woman presents for possible fundoplication after

being diagnosed with GERD. Esophageal manometry testing

shows abnormal peristalsis.

Which of the following is true regarding partial and full

fundoplication?

A) The wrap in a partial fundoplication extends 180 to 200° around the esophagus B) Partial and full fundoplication are equally effective for control of reflux C) Patients with weak peristalsis are more likely to have dysphagia if a total fundoplication is performed D) The right and left sides of the wrap are separately sutured to the esophagus during partial fundoplicationE) All patients with abnormal manometry should undergo partial rather than full fundoplication

Question 5

A 60-year-old man presents with persistent heartburn and

dysphagia 8 weeks after laparoscopic Nissen fundoplication.

Which of the following is true regarding persistent postoperative

symptoms?

A) A wrap that is too short can cause postoperative dysphagia B) Persistent heartburn is always indicative of persistent reflux, and PPIs should be restarted C) Revision can be completed without completely taking down the previous wrap D) Dysphagia is an expected postoperative complication that can persist for up to 12 weeksE) Barium swallow should be completed to visualize the anatomy of the esophagogastric junction

A 54-year-old woman presents with severe gastroesophageal reflux disease (GERD) that has been only partially relieved with proton pump inhibitors

(PPIs). She has been referred for possible laparoscopic Nissen fundoplication.

Which of the following is true regarding preoperative evaluation of patients prior to antireflux procedures?

• A) Patients who have not responded to PPIs are more likely to have significant and abnormal reflux

• B) All patients with GERD will have evidence of mucosal damage on endoscopy

• C) Typical symptoms of heartburn and regurgitation are highly sensitive and specific for the diagnosis of GERD

• D) GERD severity can be assessed using ambulatory pH monitoring

• E) Esophageal manometry can be used to confirm the diagnosis of GERD

The patient in the previous question undergoes esophageal manometry testing, which shows abnormal peristalsis.

Which of the following is true regarding partial and full fundoplication?

• A) The wrap in a partial fundoplication extends 180 to 210°around the esophagus

• B) Patients with weak peristalsis are more likely to have dysphagia if a total fundoplication is performed

• C) Partial and full fundoplication are equally effective for control of reflux

• D) The right and left sides of the wrap are separately sutured to the esophagus during partial fundoplication

• E) All patients with abnormal manometry should undergo partial rather than full fundoplication

Instead, the esophageal manometry in the patient in the previous two questions is found to be normal. She is planned for Nissenfundoplication.

Which of the following is true regarding operative technique?

• A) The patient should be placed in the steep Trendelenburgposition

• B) Division of the short gastric vessels is not necessary

• C) The body of the stomach is used to form the wrap

• D) The wrap should be greater than 2.5 cm in length on completion

• E) Placement of a bougie during wrap creation helps avoid an excessively tight wrap

Ten weeks after undergoing laparoscopic Nissen fundoplication, the patient in the preceding questions returns with persistent reflux symptoms and dysphagia.

Which of the following is true regarding complications of antirefluxprocedures?

• A) Dysphagia is an expected postoperative complication that can persist for up to 12 weeks

• B) Persistent heartburn is always indicative of persistent reflux, and PPIs should be restarted

• C) Barium swallow should be completed to visualize the anatomy of the esophagogastric junction in patients with persistent dysphagia

• D) A wrap that is too short can cause postoperative dysphagia

• E) Revision can be completed without completely taking down the previous wrap

THANK YOU