Modern surgical options for diseases of the esophagus

Diseases of the esophagus affect millions of people around the world and in most cases, they can be cured without subjecting the sufferer to surgical interventions, simply by taking medication and lifestyle changes. But there are also diseases of the esophagus for which surgical treatment is one-way.

In recent decades, surgeons have devoted themselves to perfecting techniques to make them safer for the patient, with the ultimate goal of a faster recovery and, in the case of cancer, a longer survival. In the Western world, general surgery is changing shape as diseases of specific organs are treated by specialized doctors. In this context, esophageal surgery is a separate entity. It is a specialization of general surgery that deals with the treatment of all surgical diseases related to the esophagus, both benign and cases when we have to deal with a neoplasm of this organ.

The role of the esophagus is to promote food from the mouth to the stomach. This procedure is carried out with the help of the two clamps present at its two ends, which guide the food to the stomach and close after ingestion, preventing the food from returning to the mouth.

Disturbances in swallowing, temporary or chronic, are in the majority of cases the result of achalasia and gastroesophageal reflux disease (GI). Rarely, they can be caused by other causes, such as muscle or neurological problems, injuries or cancer.

Achalasia is a condition in which the esophagus loses the ability to promote solid or liquid food into the stomach. The lower esophageal sphincter remains closed during swallowing, so food regresses and the patient experiences dysphagia. The treatment, depending on the patient, can initially be endoscopic by the gastroenterologist specialist, either with botox injections inside the sphincter, or by dilating the sphincter with a balloon. In cases where the above treatments fail, the definitive treatment is surgery, which is called esophago-myotomy according to Heller. Its purpose is to completely cross the muscle fibers of the lower esophageal sphincter so that it can relax and the food ends up in the stomach. Heller myotomy is performed laparoscopically, with 4-5 millimeter incisions, resulting in minimizing postoperative pain and blood loss. Laparoscopic myotomy has very high success rates (95%), while patients experience minimal discomfort, as they are only hospitalized for 24 hours and return to their daily activities in 3-5 days.

However, the most common cause of damage to the esophagus is gastroesophageal reflux disease (GI). It is a digestive disorder resulting from the chronic reduction of gastric acids or stomach contents into the esophagus, which causes irritation and ultimately damage to its mucous membrane. Treatment of gastroesophageal reflux is mainly conservative, with the administration of medication and lifestyle changes. When these measures do not work, surgery is the only definitive treatment.

In recent years, the most prevalent intervention for the treatment of COPD is Nissen obturation, which gives the solution to persistent gastroesophageal reflux disease. It concerns the correction of the possible existing diaphragmatic hernia and the strengthening of the lower esophageal sphincter, through the folding of the upper part of the stomach called the dome, around the lower part of the esophagus and throughout its circumference (bulloplasty 360o). The operation is performed laparoscopically through small holes in the abdomen and the use of a thin instrument that carries a microscopic camera (laparoscope). A section of the stomach wraps around the valve that separates the esophagus from the stomach. This strengthens the sphincter and prevents stomach acids from rising into the esophagus. It is a safe and effective procedure that requires a 24-hour hospital stay and can be performed on patients of all ages.

However, 5-10% of people with gastroesophageal reflux disease may develop a condition called Barret's esophagus, the existence of which over time increases the chances of developing esophageal cancer by 30 to 40 times. This is a preneoplastic lesion, which in fact is the most serious complication of reflux disease. The condition, of course, also occurs in people without COPD, with men at higher risk than women. Treatment of Barrett's Esophagus depends on the degree of dysplasia, with a high degree requiring surgical treatment in the form of esophagectomy.

In cases where esophageal cancer occurs, treatment is now only done in specialized centers, due to its difficult anatomical location and the complexity of the surgeries that accompany the treatment of these tumors, in order to achieve the best possible results for the patient, with the highest degree of safety. In addition, the treatment plan is individualized for each patient, since apart from surgery, which is the main means of treatment, the majority will need chemotherapy either before or after surgery, or even radiotherapy in some cases. To this end, all such cases are discussed in specialized oncology councils, in the presence of doctors and other specialties, following specific protocols, in order to make the best possible decision for each patient individually.

All patients who do not experience distant metastases or peritoneal implants are candidates for surgery for the purpose of healing. The type of surgery depends on the exact anatomical localization and extension of the disease. In any case, the esophagus or part of it is removed and replaced by a part of the stomach that joins the remaining part of the esophagus, depending on the type of operation, either in the chest or cervix. In the case where there is a previous operation on the stomach, the large intestine can be used to replace the esophagus.

What is more important, however, is the fact that esophageal cancer is very aggressive, infiltrating surrounding tissues and metastasizing to neighboring lymph nodes in about 75%. Therefore, radical resection of the cancer with extensive lymphatic cleansing, both in the upper abdomen and in the chest, which presupposes access by both abdominal incision and thoracotomy, is necessary. Surgical excision of esophageal cancer in the form of esophagectomy alone is not an adequate surgical treatment of the disease if it is not complemented by extensive lymphatic cleansing.

Advances in how to treat esophageal neoplasms with modern combination therapies, the care of cancer patients by specialized surgeons and, above all, the radical surgical exclusion of the disease with extensive lymphatic cleansing, have significantly prolonged the life of people with esophageal cancer. Statistics show that at least half of patients survive for five years, while when a timely diagnosis is made the rate reaches 70%!

In recent years, the most prevalent intervention for the treatment of COPD is Nissen obturation, which gives the solution to persistent gastroesophageal reflux disease.

He writes:

DR. EMMANUEL ZACHARAKIS MD, PHD, FRCS (ENG)

Assistant Professor, Imperial College London,

Director of Upper Digestive Surgery Clinic

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Source: https://www.metropolitan-general.gr/el/blog/258-%CF%83%CF%8D%CE%B3%CF%87%CF%81%CE%BF%CE%BD%CE%B5%CF%82-%CF%87%CE%B5%CE%B9%CF%81%CE%BF%CF%85%CF%81%CE%B3%CE%B9%CE%BA%CE%AD%CF%82-%CE%B5%CF%80%CE%B9%CE%BB%CE%BF%CE%B3%CE%AD%CF%82-%CE%B3%CE%B9%CE%B1-%CF%84%CE%B9%CF%82-%CF%80%CE%B1%CE%B8%CE%AE%CF%83%CE%B5%CE%B9%CF%82-%CF%84%CE%BF%CF%85-%CE%BF%CE%B9%CF%83%CE%BF%CF%86%CE%AC%CE%B3%CE%BF%CF%85?fbclid=IwY2xjawEe1lVleHRuA2FlbQIxMAABHTY_37x3ndXdBscYhRyeQgoMaVwi9502IA_wyPHQ4iTxQCW_9oW3CWrRUw_aem_PBdOJMYE0J3oKlp1fCvCRQ

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