SURGICAL-MANAGEMENT OF ESOPHAGEAL DISORDERS

Decreased lower esophageal sphincter resistance and contamination of the refluxate with duodenal contents predispose to the development of mucosal injury in patients with gastroesophageal reflux disease. These patients do not receive long-term benefit from medical management. Restoration of lower esophageal sphincter resistance by a surgical antireflux procedure is the best method for reflux control in this situation. A short 360-degrees fundoplication around the lower esophageal sphincter constructed over a 60F bougie achieves this goal with minimal side effects and provides relief of reflux symptoms in over 90% of patients for at least 10 years. In experienced hands, the morbidity associated with the laparotomy can be further reduced by performing the procedure laparoscopically. Excellent long-term results can be achieved with myotomy as the primary form of treatment in patients with achalasia. Laparoscopic or thoracoscopic myotomy of the lower esophageal sphincter will further decrease the reluctance of gastroenterologists to refer patients with achalasia for a surgical myotomy. In many centers of the Western world, adenocarcinoma of the esophagus now equals or outnumbers squamous cell carcinoma. Endosonography markedly improves the preoperative staging and identification of patients in whom a curative resection can be performed. En-block resection in patients with early tumors of the distal esophagus appears to have the best potential for long-term survival. The value of cervical lymphadenectomy and multimodality treatment of esophageal cancer needs to be established in randomized prospective trials. A colon interposition provides better functional long-term results as an esophageal substitute than a gastric pull-up.