Cardiovascular and Thoracic Surgery

Tests

An endoscopy is usually the first step in evaluation. This is an outpatient test performed under sedation in which a flexible telescope is passed through your mouth and down your esophagus into your stomach. The telescope permits the physician performing the test to look at the lining of the esophagus and take a small bite of tissue, or biopsy, of any areas that look suspicious. The tissue is looked at under a microscope to determine whether there is cancer present. Other common tests include an x-ray of the esophagus and stomach or a computed tomography, or a CT scan, of the chest and abdomen to get a picture of the lungs, liver, and other organs surrounding the esophagus.

Tests

For patients who are found to have cancer spread to other organs or who, for some other reason, can't have surgery, combined chemotherapy and radiotherapy is the most common treatment. 

Treatment/procedure options:

If diet changes and medication are not having any effect on heartburn and regurgitation, you may be a candidate for minimally invasive surgery to strengthen the lower esophageal sphincter, the muscle that opens and closes to let food pass from the esophagus to the stomach.

Laparoscopic anti-reflux surgery is a minimally-invasive procedure that corrects gastroesophageal reflux by reducing the hiatal hernia, reconstructing the esophageal hiatus and reinforcing the lower esophageal sphincter.

During laparoscopy, five or six small punctures are made in the abdomen permitting insertion of a telescope for viewing and instruments to do the operation. This can be accomplished in some patients on an outpatient basis or with just one overnight stay in the hospital. If laparoscopy is not feasible, the operation is performed through an open abdominal incision or an incision on the left side of the chest. These larger operations require a hospital stay of at least several days.

The aims of surgery for GERD are to correct any hernia which might exist and to wrap a portion of the stomach around the esophagus, thus creating a new valve mechanism to prevent reflux. If complications of GERD exist, such as scarring or ulcer formation, these are also corrected at the same time. The likelihood of having a successful operation that relieves symptoms of GERD sufficiently so that no medications are necessary is about 95%.

Patients who have laparoscopic anti-reflux surgery generally experience less pain and scarring after surgery, have a quicker recovery, and less risk of infection than those who have traditional anti-reflux surgery.

Treatment/procedure options:

Surgery for hiatal hernia involves gently pushing the stomach or other organs back into place through the diaphragmatic opening (hiatus) and repairing this opening to close and tighten it and prevent future herniation. The surgeon stitches the hiatus to create a snug entry at the gastroesophageal juncture. The team may use special surgical mesh to help reinforce larger areas when it closes the diaphragm. To prevent the stomach from migrating upwards during healing, the surgeon may also suture the stomach to connective tissue in the abdomen, or place into the stomach a feeding tube that exits through the skin of the abdomen.

During this minimally invasive, laparoscopic procedure, the surgeon makes several very small incisions in the abdomen, through which the team inserts the scope and laparoscopic instruments. Surgery for hiatal hernias serves to reinforce the position and function of the esophageal sphincter, thus helping to address symptoms of reflux. In the same operation, the surgical team will sometimes also combine the fundoplication procedure used to treat severe reflux, for patients who may need an additional step in addressing a reflux condition. In this procedure, the surgeon wraps the upper portion of the stomach around the stomach-esophageal connection to tighten the separation between the two areas.

Patients who undergo laparoscopic surgery will spend at least one night in the hospital compared with patients who undergo open surgery, who will need to stay several nights in the hospital. Most patients are mobile the day after their surgery, are able to resume activities within a week, and are able to make a complete recovery within two to three weeks (twice this for open surgery). Strenuous exertion, though must be avoided for several months. This minimally invasive approach results in less scarring and pain, faster healing, and quicker recovery.

Tests:

People who have difficulty swallowing should undergo endoscopy to ensure that no cancer exists as an explanation for this symptom. Endoscopy is performed on an outpatient basis under sedation. The physician passes a small, flexible telescope through the mouth, down the esophagus and into the stomach, providing an opportunity to assess the lining and muscular activity of the esophagus and stomach. Motility problems are sometimes suspected if the physician identifies a muscular narrowing at the level of the valve between the esophagus and stomach, changes in the appearance of the lining of the esophagus, or the finding of retained food in the esophagus.

Many patients who have a suspected esophageal motility disorder undergo an X-ray of the esophagus. This is done while the patient swallows a thick liquid that is visible under X-rays, creating a picture of the lining of the esophagus and stomach. Discoordinated muscular activity within the esophagus can sometimes be seen using this test.

One of the best tests to evaluate for achalasia and other esophageal motility disorders is manometry. This test is performed on an outpatient basis. A small tube is passed down the patient's nose and into the stomach. As it is gradually withdrawn, the patient is instructed to swallow sips of water, permitting the technician who performs the test to measure the strength and coordination of contractions of the esophageal muscles. Some motility disorders, including achalasia, have very characteristic abnormalities of esophageal muscle function that are evident using this test.

Treatment/procedure options:

People who have difficulty swallowing should undergo endoscopy to ensure that no cancer exists as an explanation for this symptom. Endoscopy is performed on an outpatient basis under sedation. The physician passes a small, flexible telescope through the mouth, down the esophagus and into the stomach, providing an opportunity to assess the lining and muscular activity of the esophagus and stomach. Motility problems are sometimes suspected if the physician identifies a muscular narrowing at the level of the valve between the esophagus and stomach, changes in the appearance of the lining of the esophagus, or the finding of retained food in the esophagus.

Many patients who have a suspected esophageal motility disorder undergo an X-ray of the esophagus. This is done while the patient swallows a thick liquid that is visible under X-rays, creating a picture of the lining of the esophagus and stomach. Discoordinated muscular activity within the esophagus can sometimes be seen using this test.

One of the best tests to evaluate for achalasia and other esophageal motility disorders is manometry. This test is performed on an outpatient basis. A small tube is passed down the patient's nose and into the stomach. As it is gradually withdrawn, the patient is instructed to swallow sips of water, permitting the technician who performs the test to measure the strength and coordination of contractions of the esophageal muscles. Some motility disorders, including achalasia, have very characteristic abnormalities of esophageal muscle function that are evident using this test.

Surgery is recommended for many patients with achalasia. The operation is designed to cut the muscles of the valve between the esophagus and stomach, permitting food to pass from the esophagus into the stomach. The operation has been performed since early in the 20th century with good results. For much of this time was done through an open incision in the abdomen or through an incision in the left side of the chest between the ribs. These types of incisions often required hospitalization of up to a week for adequate recovery. Since the early 1990s the operation has been done using minimally invasive telescopic techniques that permit patients to go home much earlier, often the day after surgery. Almost 95 percent of patients who have surgery for achalasia experience relief of symptoms for many years after the operation.

Two types of treatment are performed under sedation using endoscopic guidance. One, known as pneumatic dilation, involves placing a balloon in the swallowing passage at the level of the valve between the esophagus and stomach. This balloon is forcefully expanded, tearing the muscles of the valve so that the valve no longer obstructs passage of food from the esophagus into the stomach. This has a 75 percent chance of relieving symptoms for a period of years, but has a 3 percent risk of rupturing the esophagus. If esophageal rupture occurs, then emergency surgery is necessary to repair the rupture and then treat the achalasia surgically.

The other type of treatment that is performed under endoscopic guidance is botulinum toxin, or Botox, injection. This toxin paralyzes the muscles of the valve between the esophagus and stomach, permitting food to pass from the esophagus into the stomach. Over 60 percent of people who have this therapy get substantial relief of symptoms for at least one year.

It should be understood that, since physicians don't know the underlying cause for achalasia, it's not possible to restore the function of the esophagus completely to normal. Most patients will have some residual symptoms after successful therapy but should be able to carry on a nearly normal lifestyle.

Treatment/procedure options:

Surgery is the standard treatment for symptomatic esophageal duplication cysts A minimally invasive approach to surgery for esophageal duplication cysts is less invasive than open surgery, resulting in reduced risk of infections, shorter hospital stay and quicker recovery time.

During the procedure, your surgeon will insert a breathing tube and then make three or four small incisions in the chest area. He or she will insert a tiny camera as well as small surgical tools into these incisions using catheters. While viewing a screen of detailed images of your esophagus, your surgeon will guide the movement of the instruments using the computer console. The duplication cyst(s) will be located, separated from muscle fibers, and removed from your esophagus. Your surgeon will close the incisions when the resection is complete.

With minimally invasive surgery, you will likely remain in the hospital for 1 to 2 days, and full recovery may take 2 to 3 weeks, as opposed to open surgery, which can take up to 6 weeks. It is important to follow your doctor's orders in regards to post-procedure eating, drinking and medications.

Tests:

The tests most commonly used to diagnose and evaluate esophageal diverticulum include:

• Barium swallow: The patient swallows a barium preparation (liquid or other form) and its movement through the esophagus is evaluated using X-ray technology.
• Gastrointestinal endoscopy: A flexible, narrow tube called an endoscope is passed through the gastrointestinal tract and projects images of the inside onto a screen.
• Esophageal manometry: This test measures the timing and strength of esophagus contractions and muscular valve relaxations.
• 24-h pHmetry: A test to check for the presence of gastroesophageal reflux disease (GERD).

Treatment/procedure options:

Cases of esophageal diverticulum that cause minor symptoms can be treated through lifestyle changes, such as eating a bland diet, chewing food thoroughly, and drinking plenty of water after meals. If symptoms become severe, several types of surgery are available to remove the diverticula, repair the defects and relieve a patient’s symptoms and improve their quality of life.

Treatment of diverticula require:

• An examination of the diverticula;
• Repair of the weakened wall; and
• Relief of obstruction

The type of surgical treatment recommended depends on the size and location of diverticula, and include:

• Cricopharyngeal myotomy: Used in the removal of small diverticula, this surgical treatment can be completed using an open or minimally invasive approach, known as transoral robotic surgery. During transoral robotic surgery, the robot's precise wrist-like action allows surgical removal of the tumor by working in multiple directions in tight spaces with the capability to work around corners. Guiding the surgery from the command console, the surgeon uses 3-D imaging and instruments attached to the robotic arms, which improves precision
• Diverticulopexy with cricopharyngeal myotomy: Used to remove larger diverticula, this procedure involves turning the diverticular sac upside down and suspending it by suturing it to the esophageal wall.
• Diverticulectomy and cricopharyngeal myotomy: Diverticulectomy for the treatment of Zenker's diverticula (the most common type of diverticula of the esophagus; Zenker’s diverticula are usually located in the back of the throat, just above the esophagus) has been performed for almost a century. Involving a complete excision of the diverticular sac, this procedure is recommended for diverticula greater than 4 centimeters in size.
• Endoscopic diverticulotomy (Dohlman procedure): This procedure divides the septum between the cervical esophagus and the diverticular pouch. By dividing the septum, food can freely drain from the pouch to the esophagus.

Minimally invasive (Laparoscopic) approaches, such as endoscopic diverticulotomy, offer patients many benefits, including:

• Limited number of small scars instead of one large abdominal scar
• Shorter hospital stay
• Reduced postoperative pain
• Shorter recovery time
• Quicker return to daily activities, including a regular diet

Your health care team will discuss the possible risks and benefits of each procedure with you.