Mark K. Ferguson
The need for esophagectomy for managing gastroesophageal reflux disease (GERD) arises in a small minority of patients who experience severe complications of reflux or from antireflux surgery. When surgery other than routine fundoplication is necessary for correction of reflux complications, a variety of esophageal-preserving operations is available that minimizes operative risks compared with those associated with esophagectomy. Preservation of esophageal function is an important indication for use of such procedures, because no reconstructive organ can replicate esophageal peristaltic function. In addition, avoidance of esophagectomy helps preserve gastric reservoir and digestive capacities, and eliminates the risk of intrathoracic alimentary tract redundancy that frequently accompanies esophageal reconstructive procedures. Such redundancy can lead to food stasis, early satiety, and weight loss, and contributes to the risk of postprandial aspiration. Because many reconstructive operations include an anastomosis to the cervical esopha-gus,avoidance of esophagectomy helps preserve swallowing function that can otherwise be altered by injury to regional nerves that coordinate deglutition or by the development of an anastomotic stricture.
Examples of esophageal-preserving operations for reflux-associated problems include patch esophagoplasty operations for treatment of intractable strictures, acid suppression and alkaline diversion for management of primary duodenogastric reflux (see Chapter 12), and esophageal lengthening (gastroplasty) operations for esophageal shortening (see Chapter 13). In some patients, Barrett's esophagus, a complication of reflux, has progressed to highgrade dysplasia or superficial cancer. In such situations, endoscopic mucosal resection or ablative procedures utilizing cautery or laser energy can be used to reduce the risk of invasive cancer while preserving the esophagus. When these procedures are not appropriate for a patient with severe complications of reflux or prior anti-reflux surgery, esophagectomy may be the only therapeutic option remaining.
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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.