Surgery of the upper gastrointestinal (GI) tract deals with the diseases of the esophagus and the stomach. Lately, with the establishment of the laparoscopic and robotic techniques, treatment of such diseases has become friendly, atraumatic and well tolerated by the patients. The most frequent medical conditions of the upper GI tract that require surgical treatment are the following:
Gastroesophageal Reflux and Hiatal Hernia
As gastroesophageal reflux (GERD) is defined the condition in which the content of the stomach refluxes to the esophagus. Hiatal hernia is the protrusion of part of the stomach through the hiatus (opening of the diaphragm through which passes the esophagus) to the thoracic cavity. These two conditions can exist independently or simultaneously, causing similar symptoms including acidic reflux and retrosternal burning and satiety.
At the lower part of the esophagus there is a complex muscular formation, the Lower Esophageal Sphincter (LES). LES formats a one-way valve which allows the passage of food from the esophagus to the stomach and not vice-versa. LES closes spontaneously after swallowing, preventing the reflux of the gastric fluids, which have much lower pH and high acidic concentration. In case of GERD, LES malfunctions, allowing thus the acidic content of the stomach to reflux in the esophagus, which is not protected from acidity, causing esophagitis, strictures, ulcers, bleeding, dysplasia and progressively malignant transformation and cancer.
Treatment of GERD is both conservative and surgical. Initially, dietary modifications, weight loss, reduce of smoking and alcohol consumption and avoiding lying down after meals are advised. In addition, drugs are prescribed to reduce the acidic production of the stomach.
Surgical treatment is indicated in patients that do not respond well in conservative management, or present with recurrent symptoms after stopping medication. Surgical treatment is called fundoplication, it is very efficient in the treatment of GERD and surgically identical with the surgical treatment of hiatal hernia.
During fundoplication we reverse and repair the hiatal hernia, we narrow with stitches the wide hiatus and we create a new valve in the lower esophagus by wrapping the upper part of the stomach around the lower part of the esophagus. This procedure is nowadays performed with the laparoscopic and robotic technique, and according to the circumferential extend of the wrap, there are several variations, Nissen, Toupet, Dor etc.
Esophageal achalasia is a motility disorder in which the lower part of the esophagus is not able to fulfil the peristaltic movements to primarily push forward the food to the stomach, while the lower esophageal sphincter is in continuous spasm.
The symptoms that usually cause are::
- Dysphagia, where the patients find hard to swallow food and feel that it is stuck somewhere in the esophagus.
- Reflux, once the food cannot be passed to the stomach and it accumulates in the esophagus, from where it returns to the mouth like a small vomiting. When this happens at night, aspiration is common, pneumonia or even pneumonic abscess can occur.
- Weight loss because of the malnutrition and the difficulty in oral food intake.
Initially, endoscopic treatment is applied, by means of pneumatic dilations, intending to widen the lower part of the esophagus. The duration and the quality of the relief is usually not satisfactory. Most recently, the botulinum toxin (botox) is used, to paralyse the lower esophageal sphincter, also with temporary and mild relief. When the symptoms are intense, surgical treatment is applied, which is the permanent treatment of the disease.
The procedure is called Heller’s myotomy, in which the muscular fibres of the lower esophagus are cut, and sometimes is followed by fundoplication to avoid acidic gastric reflux. Heller’s myotomy is the procedure of choice for the treatment of achalasia. It can be performed either with the laparoscopic or the robotic technique, offering immediate and permanent relief.
The other benign diseases of the esophagus and the stomach, such as diverticula and fibromyomas are treated mostly with the robotic, laparoscopic and thoracoscopic approach. The same stands for the malignant diseases. On the other hand, the cancer of the esophagus and the stomach which is in a relatively advanced stage is treated mainly with conservative or open surgical approach which seems to have better results in these specific cases.