Treatment of Esophageal Diseases
Treatment of Esophageal Cancer
NYPH/Columbia, offers a multidisciplinary approach to treatment of esophageal cancer. Our team of specialists from multiple disciplines, including gastroenterology, surgery, oncology, and radiation therapy, work together to create diagnostic and treatment plans for patients. Patients with early stage tumors can be treated by a combination of minimally invasive techniques that can include endoscopic mucosal resection (EMR), photodynamic therapy (PDT) or minimally invasive surgery. Patients with more advanced tumors are encouraged to undergo multimodality therapy with chemotherapy and radiation therapy followed by surgery. Preoperative therapy increases the likelihood of complete removal of the tumor, and increases cure rate.
We perform many of our esophageal resections for cancer using laparoscopy or thoracoscopy. These minimally invasive approaches can significantly reduce the post operative convalescence, and speed recovery. Not all patients are candidates for this, but our considerable experience with open surgery enables us to select appropriate patients for minimally invasive procedures.
Treatment for GERD
For those patients in whom a medical regimen has not been successful, anti-reflux surgery can offer gratifying, durable results with relief of GERD. While GERD can have several causes, surgery is most effective for those patients whose GERD is caused by a defective lower esophageal sphincter (LES), the muscle connecting the esophagus with the stomach. In general, more than 90% of patients who undergo surgery have no reflux after surgery. Fundoplication, done as either an open or a laparoscopic procedure, treats the reflux by making a new valve mechanism at the lower esophagus as a barrier to reflux. Several new minimally invasive procedures are available that enable the patient to return home the same day and return normal activity.
Surgery for GERD: Fundoplication
Fundoplication, involves constructing a new "valve" between the esophagus and the stomach by wrapping the upper portion of the stomach (the fundus) around the lowest port of the esophagus. As the stomach becomes distended during a meal, the wrap compresses the lower esophagus, preventing reflux. Fundoplication also involves repair of a hiatal hernia (if present). For patients who have other problems contributing to or accompanying their GERD, such as a swallowing disorder, a shortened esophagus, or gastric outlet obstruction, there are variations to this surgery so that there is a better overall control of symptoms.
|Fundus(top of stomach) is wrapped around esophagus.||Nissen Procedure:Full wrap around LES|
The two types of fundoplication are most commonly performed are the Nissen and the Toupet. Nissen fundoplication involves wrapping the fundus completely around the esophagus (360°), producing a short, loose wrap. In Toupet fundoplication, the fundus is wrapped only part of the way around the esophagus (270°), producing a short, even looser wrap. The type of operation is chosen based on the severity of reflux and complications involved, as well as the function of the esophagus. While the Toupet results in less difficulty with gas bloat syndrome and swallowing, the Nissen procedure is the most effective for controlling reflux. Therefore, the Toupet is generally best for patients whose reflux is less severe.
Fundoplication is done as either an open or a laparoscopic procedure. The open procedure involves an incision of about 8 inches in the abdomen, while the laparoscopic approach is a minimally invasive technique producing 4 to 5 half inch incisions. Although the laparoscopic approach offers many advantages over the open technique, such as a quicker recovery and less complications, it may not be appropriate for some patients, including those who have had previous abdominal surgery or who have some pre-existing medical conditions. In addition, some patients may have to be converted from the laparoscopic procedure to the open technique during surgery. However, this is uncommon and most patients (95%) can undergo the laparoscopic procedure without difficulty.
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