The first critical step after meeting a patient with a complex benign foregut problem is a careful evaluation. Upper endoscopy done by the surgeon or at a minimum viewed by the surgeon as it is being done is indispensable for assessing the situation and developing a strategy. Often a motility study is helpful if the status of the esophageal body is in question, and a video esophagram provides invaluable information in these patients about the presence or absence of a stricture, esophageal bolus transport, and the presence and reducibility of a hiatal hernia. Selectively used tests include gastric emptying scans, 24-hour pH monitoring, impedance testing, barium small-bowel follow-through, and abdominal ultrasound or computed tomography scan. A cardiopulmonary evaluation is also advisable in this patient population before embarking on complex foregut surgery.
If esophageal resection is likely to be necessary then the method of reconstruction needs to be determined, and when considering a colon interposition then evaluation with colonoscopy and potentially a visceral arteriogram is recommended. Colonoscopy or an air-contrast barium radiographic study should be performed before use of the colon as an esophageal substitute to rule out polyps, malignancy, or evidence of either inflammatory disease or significant diver-ticulosis in the area of the colon to be used. Careful consideration should be given before using a colon graft in the presence of any of these abnormalities with the exception of a polyp that has been completely excised. Routine angiography, although not essential, does provide information about anatomic variations that may be present, but most importantly confirms patency of the colonic vessels and the marginal arcade.3 Most surgeons prefer to use the transverse colon based on the ascending branch of the left colic artery. A stenosis at the origin of the inferior mesenteric artery alters the choice, and either a different graft or use of the ascending colon based on the middle colic vessels would be advisable under such circumstances. Although intraoperative examination of the vascular integrity of the graft can in most circumstances determine the suitability of the graft, it is time-saving to know preoperatively if there are problems so that a suitable strategy can be prepared.
Operative intervention is undertaken only after a complete assessment of the problem and a frank discussion with the patient about the issues, options, and pros and cons of various therapies have been completed. It is imperative that the surgeon and patient are aligned on the goals of the procedure and the anticipated outcome. Often it is helpful to review all of the patient's symptoms and clarify whether or not that symptom is likely to change or be relieved with the therapy because commonly some symptoms in these complex patients are unrelated to the foregut process. Unrealistic expectations by the patient may lead to dissatisfaction despite what is otherwise a complete success from a surgical standpoint. Furthermore, great caution should be used in regard to promises of pain relief unless there is a clear anatomic or physiologic explanation for the pain which will be corrected by the surgical procedure. Upper abdominal pain seems to be a particularly prominent component of the collection of symptoms often encountered in middle-aged females with a complex foregut problem, and frank discussions before reoperation about the necessity of weaning off narcotics is a critical aspect of the evaluation and care of these patients.
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