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Esophageal surgery including functional diagnostics

Team of doctors:
Univ.-Prof. Dr. Heinz Wykypiel, FEBS/FEBTS UGI
Priv.-Doz.ⁱⁿ Dr.ⁱⁿ Katrin Kienzl-Wagner
Dr.ⁱⁿ Fergül Cakar-Beck
Dr. Philipp Gehwolf, FEBS/FEBTS UGI

Diagnostik
Mo - Fr 11.00 - 15.00
Tel. +43 (0)50 504 22950

In the case of chronic complaints, a precise clarification of the underlying clinical picture is necessary in order to make the right therapeutic decisions. In contrast to others, we carry out the following examinations, especially before operations:

• Gastroscopy (including histological analysis),
• Pressure measurement in the esophagus (manometry),
• Acid measurement in the oesophagus (pH measurement),
• Reflux measurement in the oesophagus (impedance measurement).
• Quality of life measurement and symptom analysis

For gastroscopy a sedation (sleeping injection) can be administered at the patient's request, but not for manometry or pH-metry. For manometry, a thin pressure probe is inserted into the oesophagus via the nose (local anesthesia of the nasal mucosa using a gel). This examination provides information about the function of the esophageal closure apparatus and the peristalsis of the esophagus (pumping function).

The duration of the examination is about ½ hour. For pH measurement (or impedance measurement) a thin probe is also inserted through the nose into the oesophagus. This probe is connected to a small, portable computer which records the acid reflux. The duration of the examination is 24 hours.

All examinations performed by us are performed on an outpatient basis.

Reflux Illness

The reflux disease is the most common disease of the upper digestive tract in the industrialized world. About 10% of the adult population suffers from it. The disease usually begins with the formation of a hiatus hernia (diaphragmatic hernia = shifting of a part of the stomach into the chest). The main symptoms are heartburn and belching of stomach contents often up to the mouth. Swallowing difficulties, pain in the pit of the stomach, pain behind the breastbone as well as a feeling of tightness (globus sensation) in the throat are other common complaints. Night-time coughing fits, hoarseness and chronic bronchitis are also common. The backflow of stomach contents into the esophagus sometimes causes severe inflammation, later scarring and constriction of the esophagus. Occasionally, severe, long years of untreated disease can also result in esophageal cancer.

Therapy of reflux disease
The therapy of reflux disease is initially carried out with medication. For this purpose, drugs are administered which restrict the production of stomach acid (proton pump blocker). These drugs must usually be taken permanently, since the underlying sphincter weakness in the lower esophagus is not eliminated. When the medication is discontinued, reflux problems usually reoccur.
Patient brochure on nutrition and behavior in reflux disease

Surgical therapy is indicated if the drug therapy is not effective or in case of a large diaphragmatic hernia > 5 cm, in case of massive belching of stomach contents into the mouth (when bending or lying down), in case of severe motility disorders of the esophagus or in case of accompanying respiratory diseases. The operation is called "laparoscopic fundoplication"(fundoplication). It is performed minimally invasive (buttonhole surgery) through 5 punctures (5-10mm) in the abdominal cavity. In this procedure, the part of the stomach that is displaced into the chest cavity is brought back into the abdominal cavity, the diaphragmatic gap around the esophagus is narrowed and the gastric roof (gastric fundus) is wrapped around the esophagus from behind. This allows the closing mechanism of the esophagus to be completely restored. The hospital stay lasts about 4-5 days, patients must follow a liquid diet for 2 weeks after the operation (Postoperative diet information sheet for patients: Liquid nutrition, Light full diet, Postoperative Oral Feeding) and must take physical care for 2 months (do not lift heavy loads). A control with pressure measurement and gastroscopy is only planned after 6 months. After the operation, swallowing difficulties, stomach pressure, flatulence, diarrhoea, as well as inability to burp and vomit are normal side effects that usually disappear after weeks or months. The success of the operation lies in our long-term (>10 years!) over 85%. We deliberately do not perform gastroscopic therapy procedures (suturing via the gastroscope) for reflux treatment at present, since the ineffectiveness of these procedures in their current form has been clearly proven, they have a non-negligible complication rate and are as expensive as surgery. A special topic is reflux in cases of severe overweight. For this purpose, we maintain close cooperation with the in-house working group on obesity surgery.

Achalasia

Achalasia occurs much less frequently than reflux disease. There are 5 new cases per 100 000 inhabitants every year. It is characterized by an incomplete opening of the lower esophageal closing mechanism during swallowing. This results in swallowing disorders with a feeling of tightness in the throat and a feeling of pressure behind the breastbone until a food bite gets stuck completely just before the entrance to the stomach. The cause of the disease is usually unclear. The main symptom of achalasia is difficulty in swallowing, often accompanied by foul belching. Rarely, there is also strong, cramp-like pain behind the breastbone. Sometimes it is difficult to distinguish it from reflux disease because of the symptoms, since achalasia can also cause heartburn. The gold standard in diagnostics is exclusively esophageal manometry.

Therapy of achalasia
Therapeutically, a dilatation of the lower esophageal closing apparatus with a balloon (diameter 3 - 4 cm) is applied first. The procedure is performed under sedation (sleep injection). In case of failure of this therapy or in young patients (< 40 years) surgical therapy is indicated. Similar to fundoplication, the surgical therapy of achalasia is minimally invasive. The oesophageal sphincter muscle is severed (myotomy). In addition, the gastric roof is partially wrapped around the esophagus from behind (partial fundoplication) to minimize heartburn after surgery. The hospital stay is about 4 days. Diet as after antireflux surgery (Liquid nutrition, Light full diet, Postoperative Oral Feeding). As a side effect, mild heartburn occurs occasionally. The follow-up is after 6 months with gastroscopy and pressure measurement. The long-term success of the surgical therapy is over 90%. Rare functional disorders, such as diff. esophageal spasm, eosinophilic esophagitis, nutcracker esophagus, hypertensive LES, leiomyomatosis, diverticula, etc. are also (depending on their frequency of occurrence) our "daily bread".

Esophageal carcinoma (cancer of the esophagus)

The incidence of cancer of the esophagus is increasing. The success of treatment has improved dramatically in recent decades. Patients are examined in great detail not only with regard to the extent of the tumor and its concomitant diseases, but also with regard to their ability to cope with stress (surgery?). 

The therapy plan is determined in the interdisciplinary gastrointestinal tumor board (IGIT) and is adapted not only to the tumor stage but also to the patient's capacity. If surgery is required, we prefer minimally invasive procedures (e.g. completely minimally invasive esophageal resection with intrathoracic anastomosis).