What percentage of patients should be expected to have relief of symptoms at 5 years out from antireflux surgery?
Studies of long-term outcome following both open and laparoscopic fundoplication document the ability of laparoscopic fundoplication to relieve typical reflux symptoms (heartburn, regurgitation, and dysphagia) in more than 90% of patients at follow-up intervals averaging 2 to 3 years and 80 to 90% of patients 5 years or more following surgery. This includes evidence-based reviews of antireflux surgery, prospective randomized trials comparing antireflux surgery to PPI therapy and open to laparoscopic fundoplication and analysis ofU.S. national trends in use and outcomes.
An upward dislocation ofboth the cardia and gastric fundus is which type of hiatal hernia?
With the advent of clinical radiology, it became evident that a diaphragmatic hernia was a relatively common abnormality and was not always accompanied by symptoms. Three types of esophageal hiatal hernia were identified: (a) the sliding hernia, type I, characterized by an upward dislocation of the cardia in the posterior mediastinum; (b) the rolling or paraesophageal hernia (PEH), type II, characterized by an upward dislocation of the gastric fundus alongside a normally positioned cardia; and (c) the combined sliding-rolling or mixed hernia, type III, characterized by an upward dislocation of both the cardia and the gastric fundus. The end stage of type I and type II hernias occurs when the whole stomach migrates up into the chest by rotating 180° around its longitudinal axis, with the cardia and pylorus as fixed points. In this situation the abnormality is usually referred to as an intrathoracic stomach (Fig. below). In some taxonomies, a type IV hiatal hernia is declared when an additional organ, usually the colon, herniates as well. Type II-IV hiatal hernias are also referred to as paraesophageal hernia (PEH), as a portion of the stomach is situated adjacent to the esophagus, above the GEJ.
Radiogram of an intrathoracic stomach. This is the end stage of a large hiatal hernia regardless of its initial classification. Note that the stomach has rotated 180° around its longitudinal axis, with the cardia and pylorus as fixed points.
The most common form of esophageal cancer diagnosed in the United States is:
Adenocarcinoma of the esophagus, once an unusual malignancy, is diagnosed with increasing frequency and now accounts for more than 50% of esophageal cancer in most Western countries. The shift in the epidemiology of esophageal cancer from predominantly squamous carcinoma seen in association with smoking and alcohol, to adenocarcinoma in the setting of BE, is one of the most dramatic changes that have occurred in the history of human neoplasia. Although esophageal carcinoma is a relatively uncommon malignancy, its prevalence is exploding, largely secondary to the well-established association between gastroesophageal reflux, BE, and esophageal adenocarcinoma. Once a nearly uniformly lethal disease, survival has improved slightly because of advances in the understanding of its molecular biology, screening and surveillance practices, improved staging, minimally invasive surgical techniques, and neoadjuvant therapy.
Squamous cell carcinomas of the esophagus most commonly occur:
It is estimated that 8% of the primary malignant tumors of the esophagus occur in the cervical portion. They are almost always squamous cell cancer, with a rare adenocarcinoma arising from a congenital inlet patch of columnar lining. These tumors, particularly those in the postcricoid area, represent a separate pathologic entity for two reasons: (a) They are more common in women and appear to be a unique entity in this regard; and (b) the efferent lymphatics from the cervical esophagus drain completely differently from those of the thoracic esophagus. The latter drain directly into the para tracheal and deep cervical or internal jugular lymph nodes (LNs) with minimal flow in a longitudinal direction. Except in advanced disease, it is unusual for intrathoracic LNs to be involved.
The preoperative test most heavily correlated with the ability to tolerate an esophagectomy is:
Patients undergoing esophageal resection should have sufficient cardiopulmonary reserve to tolerate the proposed procedure. The respiratory function is best assessed with the forced expiratory volume in 1 second, which ideally should be 2 L or more. Any patient with a forced expiratory volume in 1 second of < 1 .25 L is a poor candidate for thoracotomy, because he or she has a 40% risk of dying from respiratory insufficiency within 4 years. In patients with poor pulmonary reserve, the transhiatal esophagectomy should be considered, as the pulmonary morbidity of this operation is less than is seen following thoracotomy. Clinical evaluation and electrocardiogram are not sufficient indicators of cardiac reserve. Echocardiography and dipyridamole-thallium imaging provide accurate information on wall motion, ejection fraction, and myocardial blood flow. A defect on thallium imaging may require further evaluation with preoperative coronary angiography. A resting ejection fraction of <40%, particularly if there is no increase with exercise, is an ominous sign. In the absence of invasive testing, observed stair-climbing is an economical (albeit not quantitative) method of assessing cardiopulmonary reserve. Most individuals who can climb three flights of stairs without stopping will do well with two-field open esophagectomy, especially if an epidural catheter is used for postoperative pain relief.
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