Surgery and Treatment for Diseases of the Esophagus | Dr. Richard Battafarano Q&A

Author: Johns Hopkins Medicine

Well, there are two main categories of diseases of the esophagus. The first is benign disease of the esophagus, and the most common of that is hiatal hernia, with gastroesophageal reflux disease or heartburn. And in those patients, the initial treatment is medicines.

And if the patients are well-treated with medicines we don't offer surgery. But there's a small but very real group of patients with gastroesophageal reflux disease and a hiatal hernia that don't respond well to the medicines. And so the operation then would be to return the stomach and the esophagus back into the abdomen where it belongs, and then perform a fundoplication, a fundoplication in order to really mechanically prevent reflux disease. The second large category is patients with esophageal cancer. And unfortunately, that's an increasing problem in the United States, so we're seeing it more and more. And in that setting, where the goal is to treat the tumor and remove it completely, and then restore continuity between the remaining esophagus that we save and the portion of the stomach that we save also.

Well, I think in the area of benign esophageal diseases, it's very important that we work closely with our gastroenterologist. Of course, many people who have reflex disease can be treated with medications and may never require an operation. And so we use a multi-disciplinary treatment plan in that setting.

In the setting of esophageal cancer, we often work very, very closely not only with the gastroenterologist, who often will find the tumor at the time of endoscopy or stage it at the time of endoscopy. But we also work closely with our radiation oncologist and our medical oncologist to be sure that we can come up with a multi-disciplinary care plan that fits each individual patient. Well, for the benign diseases such as gastroesphageal reflux disease and hiatal hernia, we try whenever possible to use minimally invasive approaches. And we use a laparoscopic approach in which we use four openings, all about the size of our finger, through which we place instruments and a camera so we can see what we're doing.

Surgery and Treatment for Diseases of the Esophagus | Dr. Richard Battafarano Q&A

We mobilize the hernia down from the center of the chest into the abdomen, where the stomach should belong. And then, again, using the same minimally invasive techniques, we can perform the fundoplication and create a barrier for reflux in these patients. Well, I think as long as we can recreate the same operation that we would do open using minimally invasive techniques, then every patient, in a sense, could be a candidate for minimally invasive surgery. Essentially, in those patients that have a small hiatal hernia or a medium hiatal hernia associated with gastroesophageal reflux disease, we perform that procedure laparascopically. We're able to repair the hernia and actually create a fundoplication in a very, very standard manner. And so that would probably be the most common minimally invasive esophageal procedure that we use.

We're increasingly using minimally invasive techniques for the care of cancer patients, esophageal cancer patients by actually recreating the abdominal portion of an esophagectomy, using a transabdominal laparoscopic approach. And then we remove the remaining portion of the esophagus and create the reconstruction between the remaining esophagus and the stomach tube that we create through the right chest, using video-assisted, minimally invasive techniques. Well, essentially most patients who have minimally invasive surgery have less pain and also are able to leave the hospital a little sooner because of some of the pain control issues that can be managed more easily as an outpatient.

However, every candidate for minimally invasive surgery, we as surgeons have to approach it in a way that we perform the same operation minimally invasively that we would do open, that minimum invasive operations can't be a substitute for a good open operation. And so as long as we feel we can recreate the same operation with minimally invasive techniques, then we try to apply it on as many people as possible.

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