Early Surgical Therapy

The first operations performed at least in part for possible gastroesophageal reflux problems were for correction of hiatal hernias, usually giant paraesophageal hernias. Hedblom11 stated that the first operation for a clinically diagnosed hiatal hernia was by Naumann in 1888, but the stomach could not be reduced into the abdomen and the patient died. By the time of Harrington's10 report in 1928, successful surgery for hiatal hernia had been accomplished in dozens of patients. The standard operation included hernia reduction, plication of the hernia orifice,suturing of the formerly herniated stomach to the abdominal wall to help prevent recurrent hernia, and paralysis of the diaphragm by phrenic nerve injury. Large series of operated patients were subsequently reported, although a careful distinction among posttraumatic, esophageal hiatal, and other diaphragmatic hernias was not always carefully observed.45

Bypass operations for peptic esophageal stricture were first successfully performed in the early 1900s. Skin tubes were initially constructed for this purpose, but surgeons quickly adopted jejunal interposition, colon interposition, and gastric pull-up operations to bridge the gap between the cervical esophagus and the abdominal gastrointestinal tract. In 1934, Ochsner and Owens46 summarized the results of all esophageal bypass and reconstructive operations performed until that time for both malignant and benign obstruction. The reconstructive conduit was located in the antesternal or substernal plane, as reconstruction in the bed of the resected esophagus had not been successfully accomplished at that time. In summarizing results in 240 patients, the authors noted several striking features: the mortality of attempted reconstruction/bypass was 37%, the likelihood of completing the reconstruction was barely >50%, and only about 40% of patients were considered to have good functional results. They recommended that such surgery should be used only in cases of impermeable benign stricture. Subsequent experience with esophagectomy and bowel interposition yielded more favorable results, although complication and mortality rates were still high.47,48 These less-than-satisfactory results led to direct approaches to peptic esophageal strictures aimed at preservation of esophageal function rather than bypass or resection of the esophagus. Such approaches were made possible by the preoperative diagnosis of a benign stricture enabled by the development of endoscopy, and by the development of endo-tracheal positive pressure ventilation which permitted elective thoracic surgery. Esophagoplasty for peptic stricture was initially performed by opening the stricture longitudinally and then closing the defect transversely, which had the effect of widening the lumen in the region of the stricture.49-51 This completely

MANAGING FAILED ANTI-REFLUX THERAPY

Endoscopic Stricturoplasty

Figure 2.6. One method of treating a nondilatable stricture was to perform a stricturoplasty as initially described by Thal in 1965. The stricture was opened lengthwise, partially closed horizontally, and the stomach was brought up and sewn over the open esophageal lumen. The illustrated version used a partial-thickness skin graft as an overlay patch on the gastric serosa to prevent acid erosion through this susceptible tissue, which was a frequent complication of the original version. (Reprinted with permission from Thal.54)

Figure 2.6. One method of treating a nondilatable stricture was to perform a stricturoplasty as initially described by Thal in 1965. The stricture was opened lengthwise, partially closed horizontally, and the stomach was brought up and sewn over the open esophageal lumen. The illustrated version used a partial-thickness skin graft as an overlay patch on the gastric serosa to prevent acid erosion through this susceptible tissue, which was a frequent complication of the original version. (Reprinted with permission from Thal.54)

destroyed the anti-reflux mechanism and created a small iatrogenic hiatal hernia, both of which usually dramatically worsened the patient's reflux problems. As an alternative technique, patch esophagoplasty was introduced as a substitute for closing the longitudinal esophageal defect transversely. Materials used experimentally and clinically for the patch included fascia, skin, dermal grafts, pedicled intercostal muscle, pericardium, diaphragm, and omentum.52 The introduction of the fundic patch esophagoplasty by Thal et al.53 simplified the operation and had the additional benefit of reinforcing the anti-reflux mechanism with a partial gastric wrap across the esophagogastric junction (Figure 2.6). Results of the operation were gratifying, with >80% of patients reporting good outcomes.54,55

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Herbal Remedies For Acid Reflux

Herbal Remedies For Acid Reflux

Gastroesophageal reflux disease is the medical term for what we know as acid reflux. Acid reflux occurs when the stomach releases its liquid back into the esophagus, causing inflammation and damage to the esophageal lining. The regurgitated acid most often consists of a few compoundsbr acid, bile, and pepsin.

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