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Controversies in the Definition of Barrett Esophagus

Esophageal adenocarcinoma (EAC) is a highly lethal disease associated with a survival of less than 20% at 5 years. The American Cancer Society estimates that 16,940 new esophageal cancer cases will be diagnosed in the United States in 2017, the majority from EAC, with 15,690 cancer-related deaths. The incidence of EAC has been climbing for more than 40 years at a rate greater than any other…

Mesh at the Hiatus

Crural repair and reduction of hiatal hernia (HH) are paramount to the success of an antireflux surgery. Case series from the early laparoscopic era (i.e., the 1990s) reported an unacceptably high recurrence rate of HHs. In addition, some patients were found to be naturally predisposed to hernia formation, and recurring hernias were thought to be due in part to inherent defects in healing. Simultaneously, the routine…

Collis Gastroplasty for a Foreshortened Esophagus

Normally, several centimeters of the distal esophagus and the gastroesophageal junction (GEJ) lie below the hiatus within the abdomen. When the GEJ, the fundus of the stomach, or both migrate into the chest above the hiatus, a hiatal hernia is present. Intrinsic to the repair of a hiatal hernia is the need to bring the GEJ, stomach, and distal esophagus back into the abdomen. However, since…

Diaphragmatic Relaxing Incisions for Crural Tension During Hiatal Hernia Repair

Laparoscopic repair of a large hiatal hernia with a widened hiatus is challenging and objective hernia recurrence rates are high. In a recent randomized trial, the recurrence rate exceeded 50% at 5 years after laparoscopic paraesophageal hernia. Tension on the repair of any hernia contributes to an increased risk for recurrence. This was first recognized for inguinal hernias and led to the incorporation of relaxing incisions…

Open Paraesophageal Hernia Repair

Hiatal hernia (HH) was first recognized more than 400 years ago. In 1610 Ambrose Paré described a patient with the stomach herniating through the esophageal hiatus. Bowditch was the first to report repair of an HH in 1853, and Akerlund first reported paraesophageal herniation in 1926. In 1945 Harrington described the first series of patients who underwent HH repair. In 1951 Allison was the first to…

Laparoscopic Paraesophageal Hernia Repair: Technique, Outcomes, and Management of Complications

Pathophysiology, Incidence, and Clinical Presentation In normal esophageal anatomy the gastroesophageal junction (GEJ) is located below the hiatal orifice. It is held in place by both the phrenoesophageal ligaments and an aggregate of posterior attachments between the GEJ and cardia of the stomach. The phrenoesophageal ligament is formed from the fascia transversalis on the abdominal aspect of the diaphragm and the endothoracic fascia on the thoracic…

Paraesophageal Hernia: Etiology, Presentation, and Indications for Repair

Paraesophageal hernias are the results of defects in the diaphragmatic hiatus. Widening of the hiatus between the left and right diaphragmatic crura provides the pathway for upward displacement of abdominal contents into the mediastinum. Paraesophageal hernias are an increasingly common type of hiatal hernia. They can be associated with life-threatening complications such as gastric volvulus leading to necrosis or perforation of the stomach. Due to these…

Esophageal Complications of Bariatric Procedures

Over the last three decades bariatric surgery moved from open to laparoscopic procedures, with all the benefits of minimally invasive surgery. All existing restrictive bariatric procedures may affect the esophagus over time, with the possibility of mild or sometimes severe complications. Depending on the procedure performed, the esophagus can be affected minimally or severely. The gold standard of bariatric surgery is still the laparoscopic Roux en-Y…

Management of Failed Fundoplications, End-Stage Gastroesophageal Reflux Disease, and Scleroderma

Patients with recurrent, persistent, or new symptoms after antireflux surgery can be a challenging problem for the foregut surgeon. Determining who will benefit from reoperation and what operation to perform requires that the surgeon be able to interpret a host of preoperative studies and be familiar with the common methods of failure associated with antireflux procedures. When reoperation is contemplated, the anticipated functional outcome must be…

Options to Address Delayed Gastric Emptying in Gastroesophageal Reflux Disease

Gastroparesis is described as delayed gastric emptying (DGE) without evidence of mechanical outlet obstruction. Common symptoms of gastroparesis include chronic nausea, emesis, abdominal pain, early satiety, and bloating. Abdominal pain can be significant and is associated with narcotic dependence in some patients. The true prevalence of this potentially debilitating disease is unknown, but it has been estimated to affect up to 4% of the population. Some…

Endoscopic Management of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is defined by the reflux of gastric fluid into the esophagus causing troublesome symptoms and/or complications, such as mucosal inflammation and metaplasia. Functional disturbances of the lower esophageal sphincter (LES), along with anatomic abnormalities of the esophagogastric junction (EGJ) such as hiatal hernia, allow the reflux of gastric fluid up into the esophagus. Treatment of GERD is focused on providing relief of…

Magnetic Sphincter Augmentation for Gastroesophageal Reflux Disease

The continuous search for the ideal antireflux procedure reflects a widely held perception among surgeons, gastroenterologists, and patients that therapy for gastroesophageal reflux disease (GERD) remains unsatisfactory. About 30% to 40% of patients are resistant or only partial responders to proton pump inhibitor (PPI) therapy, and even high-dose escalation may be inadequate to maintain individuals in a symptom-free state with a mechanically defective lower esophageal sphincter…

Fundoplication for Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is the most common disorder of the esophagus and gastroesophageal junction. While transient reflux of stomach contents into the esophagus occurs physiologically, according to the Montreal Classification, the criteria for GERD are met when reflux causes troublesome symptoms and/or complications. With 60% of American adults reporting intermittent heartburn symptoms, GERD is a serious health concern in the Western world. For the 20%…

Acid-Suppression Therapy for Gastroesophageal Reflux Disease and the Therapeutic Gap

Over the past 40 years, there has been a remarkable evolution in our understanding of the pathophysiology, clinical manifestations, and treatment strategies underlying gastroesophageal reflux disease (GERD). Initially synonymous with esophagitis and presence of hiatal hernias, we now understand that reflux disease is a much more complicated and often nuanced diagnosis to make, wherein a myriad of potential nonspecific symptoms and absence of suitable biomarkers can…

Respiratory Complications of Gastroesophageal Reflux Disease

Gastroesophageal reflux (GER) refers to the reflux of stomach contents into the esophagus. GER can occur physiologically, particularly in the postprandial state. When reflux is of small volume for limited durations and limited to the distal esophagus, this retrograde flow of stomach contents is generally of minor medical importance. In this chapter, the repercussions of reflux of gastric contents into the airway will be reviewed. In…

Etiology and Natural History of Gastroesophageal Reflux Disease and Predictors of Progressive Disease

Gastroesophageal reflux disease (GERD) is the most common foregut disease in the world and accounts for approximately 75% of all esophageal pathology. The majority of affected patients have mild disease and are successfully managed with lifestyle modification and acid suppression medication. Fortunately, progression to erosive disease occurs in only 13% of patients over 5 years. Unfortunately, progression to Barrett esophagus (BE), the premalignant lesion for adenocarcinoma…

Gastroesophageal Reflux Disease: Definition and Scope of the Problem in the United States of America and Worldwide

Gastroesophageal reflux disease (GERD) is among the most common diseases seen by both primary care and gastrointestinal (GI) specialists worldwide. Its prevalence is increasing, with reflux symptoms ranging from 10% to 30% of the population of Western countries. Compared to the numbers reported in North America, the prevalence of weekly GERD symptoms is slightly lower in Europe (8.8% to 25.9%) and substantially lower in Asia (approximately…

Endoscopic and Surgical Therapies for Achalasia

With an estimated annual incidence of 1 in 100,000 and prevalence of 10 in 100,000, achalasia is a rare, primary motility disorder of the esophagus, defined by absence of normal peristalsis and failure of swallow-induced relaxation of the lower esophageal sphincter (LES). The first described treatment for “cardiospasm” in the 1600s was self-dilatation with oral passage of a whale rib-bone with an attached sponge. In 1937…

Epidemiology, Diagnosis, and Medical Management of Achalasia

Achalasia is a rare esophageal disorder presenting primarily with dysphagia, characterized by well-defined esophageal motor abnormalities. This chapter addresses the epidemiology, pathophysiology, and diagnosis of achalasia, as well as the medical therapeutic options for this disorder. Epidemiology Epidemiologic data originate mostly from Western populations and vary among studies. The incidence rate ranges from a low of 0.03/100,000 per year to 1.63/100,000 per year, with the majority…

Surgical Management of Mid- and Distal Esophageal Diverticula

Diverticular diseases of the esophagus consist of variations of outpouchings of one or more layers of the gut wall that are epithelial lined. These outpouchings can be found along the entire length of the esophagus. They are described by their location along the esophagus: pharyngoesophageal, mid-esophagus, and epiphrenic. Often these diverticula are asymptomatic, but when they are symptomatic, they create a significant constellation of symptoms that…