Uncontrolled pathologic gastroesophageal reflux can lead to transmural esophageal inflam mation culminating in intractable peptic esophageal stricture and esophageal shortening. This results in ongoing severe reflux symptoms accompanied by dysphagia and weight loss. The incidence of peptic stricture in the era of effective acid suppression medications is estimated to be 1-5% of patients with esophagitis.20 Initial management of early peptic stricture consists of a careful clinical evaluation including endoscopy with biopsy to rule out cancer, determine whether Barrett's esophagus exists, and obtain a histologic diagnosis. Standard therapy includes intensive acid suppression and dilation, and is successful in about 75% of patients. However, long-term follow-up of such patients is often inadequate, and the true outcomes of medical therapy are not known.21 Patients with recurrent stricture or ongoing symptoms of reflux in the setting of optimal medical therapy are candidates for anti-reflux surgery. Surgical options include standard partial or total fundoplication, or fundoplication combined with a gastroplasty as an esophageal lengthening procedure. The latter option is often necessary because of esophageal shortening. In rare situations, patch esophagoplasty or antrectomy and Roux-en-Y reconstruction as acid suppression and bile diversion may be indicated.
Indications for esophagectomy in the setting of peptic stricture are fortunately rare. They include nondilatable stricture, perforation during dilation of a stricture, inability to confirm that a stricture is benign, and multiple failed fundo-plication operations in the presence of a stricture. The definition of a nondilatable stricture varies, but generally includes strictures for which adequate-sized dilators cannot be passed, failure of resolution of dysphagia after dilation, increasingly frequent dilations to relieve dys-phagia, and strictures requiring dilation that have suffered previous perforation. Nondilat-able strictures represent the most common indication for esophagectomy in patients with benign strictures.
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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.