Baylor Scott & White Center for Advanced Surgery – Dallas 

Achalasia

Achalasia is an incurable disease that affects the lower esophageal sphincter. The normal lower esophageal sphincter functions to relax by opening to accommodate a food bolus when humans swallow. The nerves are activated during a swallow to signal the lower esophageal sphincter to relax and open as food, liquids, and/or air can pass. With achalasia, the nerves don't work properly and the sphincter cannot relax and open. This causes the inability to get food from the esophagus into the stomach to continue with digestion. Patients usually experience regurgitation of food and liquids and experience chest pain. Weight loss is a common symptom experienced by patients with achalasia.

Causes

There is no known cause, but there are some hypothesized theories that haven't been proven.

Diagnosis

Achalasia is often misdiagnosed as gastroesophageal reflux disease (GERD). Patients will proceed with the standard treatments for GERD without relief. This will typically prompt further investigation revealing a diagnosis of achalasia.

The definitive diagnosis is made with a test called an esophageal manometry. This test is done with a skinny probe with multiple sensors down its entire length that is passed through the patient's nose and into the esophagus. The patient is then asked to swallow small amounts of water, usually 10 swallows are performed, and the probe will be able to sense the function of the esophagus' ability to push the water down into the esophagus and measure the pressure of the lower esophageal sphincter at rest and whether it relaxes. This is the gold standard to make a definitive diagnosis.

Sometimes, findings on an upper GI swallow study with barium can help allude to the diagnosis based on the dilated appearance of the esophagus and the abrupt narrowing at the lower esophageal sphincter. During this workup, the patient should have an upper endoscopy to help rule out some other cause for the appearance of the narrowing such as a tumor or scar tissue.

Treatment

There are several treatments available for achalasia. Achalasia does not go away on its own, and there is no cure. The treatments available only make it possible for esophageal contents to pass through the lower esophageal sphincter and into the stomach.

Pneumatic dilation and Botox injections have been used by gastroenterologists for decades that have varied success. Both modalities require serial treatments and have a significant overall failure rate associated with them.

Esophagomyotomy, or commonly called Heller myotomy, is a procedure that has been performed for nearly a century. This procedure is most commonly done through the abdomen, but can also be done through the chest. The procedure is performed to cut the lower esophageal sphincter relieving the obstruction. Relief of symptoms is very high and recurrence rates are low. This has been regarded at the standard of care for patients with achalasia.

Per oral endoscopic myotomy (POEM) procedure

Recently, surgical endoscopists and some gastroenterologists have been able to perform an esophagomyotomy with a purely endoscopic approach. This is called the POEM procedure. The POEM procedure does not require any incisions, and there is very little to no pain. The POEM procedure is done in the operating room under general anesthesia. Post-operative care involves an average of one day in the hospital and patients are back to work in an average of 4 days. Resolutions of symptoms are equivalent to the Heller myotomy. The POEM procedure is available for any patient that can tolerate general anesthesia and have a diagnosis of achalasia.

The POEM procedure has been used to treat some other esophageal motility disorders, but those are still under investigation.

Esophageal cancer

There are several cancers that can arise in the esophagus, but the most common are squamous cell carcinoma and adenocarcinoma. Squamous cell carcinoma is typically related to smoking, where esophageal adenocarcinoma is related to gastroesophageal reflux disease, or GERD. There has been a significant rise in the incidence of esophageal adenocarcinoma in the last 35 years, especially in the United States. This rise has reached an approximate 700% increase over this time frame and correlates with the use of acid-suppressing medications such as Proton Pump Inhibitors, or PPIs (Protonix, Prevacid, Dexilant, etc.). There are several hypotheses for the correlation, but the most widely accepted hypothesis is that the lining of the esophagus is exposed to the intestinal secretions, such as acid and bile, causing the lining to attempt to accommodate this harsh environment. The esophagus lining begins to change to appear like the stomach lining. However, this change is disorganized and can result in premalignant (pre-cancer) changes.

The premalignant changes progress in a well-known pathway, and in this sequence:

• Normal squamous lined esophagus
• Intestinal metaplasia
• Low grade dysplasia
• High grade dysplasia
• Carcinoma in situ
• Invasive cancer

The correlation with the rise in the incidence of esophageal adenocarcinoma mirrors the rise in the use of PPIs. Use of PPIs for long periods of time masks symptoms by taking away heartburn while the esophagus still endures the harsh environment present in the stomach and with the presence of bile. Gastroesophageal reflux disease progresses over time, and will often wear out the effects of PPIs. Surgery should be considered when a patient reaches this point. It has been shown that surgical intervention can reverse the premalignant changes, or halt its progression.

Diagnosis

Diagnosis of esophageal adenocarcinoma is made with a biopsy. These biopsies are obtained with an upper endoscopy. This is why patients with long-standing GERD or symptoms should have an upper endoscopy performed.

Treatment

The treatment of esophageal adenocarcinoma varies based on its stage. When caught early, and the cancer is confined to the innermost layer of the esophagus exposed to stomach acid and intestinal bile, it can be treated with endoscopic methods only. Once cancer grows further into the esophageal wall, surgical intervention needs to be considered, and possibly chemotherapy with radiation.

• Endoscopic treatment – Treatment of choice for high-grade dysplasia, Carcinoma in situ, and T1a cancer
  • Endoscopic mucosal resection (EMR) – resecting portions of the lining of the esophagus, or mucosa, containing cancer.
  • Endoscopic mucosal dissection (ESD) – resecting the lining of the esophagus, or mucosa, in one single piece.
  • Endoscopic ablation (BARRX) – using radiofrequency ablation to burn the lining of the esophagus, or mucosa, containing cancer.

• Esophagectomy (removing the esophagus) - This procedure is performed when the cancer is performed in several cases and is at the discretion of the surgeon.
  • Possible indications include Carcinoma in situ and high-grade dysplasia, and T1a cancer but endoscopic treatments are preferred.
  • T1b and T2 cancer.
  • T3 and T4, positive lymph nodes will usually require chemotherapy and radiation, followed by esophagectomy.

Gastroesophageal reflux disease

This is a term to describe contents from the stomach splashing up into the esophagus. It is normal for humans to experience some reflux of gastric contents, but the frequency that exceeds a normal exposure diagnoses gastroesophageal reflux disease. Notice that the word "disease" is in the phrase and is the "D" in the acronym GERD. There is a pathological level of gastroesophageal reflux earning a patient the diagnosis of the disease.

GERD is a common disorder that affects millions of Americans. Many of these patients are not happy or insufficiently treated with medications alone. In addition, there has been a lot of press about the potential negative side effects related to anti-reflux medications. Surgery is an effective option that relieves GERD symptoms and prevents patients from needing these medications. As leaders in the treatment for GERD, our surgeons offer a comprehensive diagnostic evaluation to determine an appropriate treatment plan.

Causes

Gastroesophageal reflux disease comes from the failure of the natural reflux barrier. The failure can occur in several ways. Some of these common causes include a hiatal hernia, a weak or short lower esophageal sphincter, pregnancy, delayed gastric emptying, and certain diets.

Diagnosis

Just like other diseases, GERD progresses over time. Often times patients start early in their life with symptoms that cause their physician to diagnose them with GERD. The patients are then started on an acid-suppressing medication like a Proton Pump Inhibitor, or PPI. Usually, patients have already exhausted over the counter medications to help with the symptoms of GERD. Using the PPI will alleviate the heartburning symptom which will essentially make the diagnosis of gastroesophageal reflux disease. However, the true test for an absolute diagnosis is a pH study, such as a 24 hour pH catheter or a probe. These tests will demonstrate elevated levels of acid in the esophagus which definitively makes the diagnosis of GERD. These tests have become less common to diagnose GERD because the disease is extremely common and is easier done by a trial with a PPI.

In either situation, the diagnosis of gastroesophageal reflux disease is reliably made and can be treated. The progression of the disease will often exceed the ability of the PPI to control the symptoms of GERD. Patients will often return several times to their prescribing physicians for the persistent symptoms and complaints. Physicians will titrate to a higher dose and frequency of the medications and emphasize a strict regimen. But with continued use of PPIs, the symptoms will often return as the disease progresses. At this point, PPIs will no longer control the symptoms and surgery is indicated to stop the gastroesophageal reflux.

Treatment options

Surgery is indicated for patients that have failed management with medications (such as PPIs), have a desire to no longer take medications, or have a hiatal hernia. The knowledge of the physiological changes with regard to GERD have been studied extensively and surgical treatments have improved. The steps to repair gastroesophageal reflux disease with surgery are at the discretion of the surgeon. With the expertise of our surgeons, the below procedures are recommended after careful consideration and the procedure is matched to each individual patient.

• Hiatal hernia – see the drop down section on Hiatal Hernias
• Fundoplication – Laparoscopic fundoplication is the most well studied surgical procedure for the treatment of GERD. A small portion of the stomach is used to reinforce the natural reflux barrier by wrapping it around the bottom of the esophagus and suturing it into place. This will prevent the backflow of bile and stomach contents into the esophagus. Potential side effects include bloating, trouble swallowing, and an inability to belch or vomit due to the newly reinforced valve. It is important that a surgeon who possesses significant training and experience does this procedure to minimize or prevent these side effects. Our surgeons typically recommend this operation for those patients with large hiatal hernias or advanced GERD. The ability of the surgeon to tailor the fundoplication to the patient's needs have improved greatly. There is a preoperative workup that needs to be undertaken for the surgeon to determine the best fundoplication for the patient.
• Magnetic lower esophageal sphincter augmentation – This procedure has been performed in Europe before 2012, but in March of that year, the FDA approved the device used for the procedure in the United States. This procedure is where an implant that also reinforces the natural reflux barrier at the bottom of the esophagus, but does it in a slightly different way. It consists of a string of magnetic beads that are placed around the lower esophageal sphincter that opens and closes using magnetic forces in response to food. In addition, the device will resist the natural forces from the stomach to prevent GERD, but can be overcome in instances were belching or vomiting need to occur. The procedure for implantation is much shorter than the fundoplication because the stomach anatomy is not disrupted. In cases of a hiatal hernia, the device can still be implanted after the hiatal hernia is repaired.
• Other options – There has been a significant effort to establish endoscopic techniques for treating GERD, but have fallen short when compared to the superior outcomes of Magnetic Lower Esophageal Sphincter Augmentation and fundoplications. These procedures are called TIF (transoral incisionless fundoplication) and Stretta. Although immediate improvements in symptoms have been shown in some studies, the durability of these procedures beyond one year is compromised and symptom recurrence is common. BSW Center for Advanced Surgery will consider using these procedures in special cases to avoid patient dissatisfaction.

Quality of life improvement

At BSW Center for Advanced Surgery the goal of GERD treatment is to improve quality of life and relieve life altering chronic symptoms. All patients are managed under a research registry to track the progress of patients and detect any aberrations in their quality of life. GERD is a disease that needs to be closely managed for optimal outcomes. Extensive research at our facility has shown symptom relief and patient satisfaction with LINX® and fundoplications. Patients can count on a three year 85 percent or better rate of GERD symptom remission allowing patients to be off all anti-reflux medications. In addition, they experience a drastic improvement in their quality of life, which allows patients to eat the food they enjoy, get a more restful night of sleep, and rid themselves of heartburn and regurgitation.

Gastroparesis

Gastroparesis (GP) is a chronic motility disorder of the stomach. GP often responds to multiple treatment options even though a 100% cure is unlikely. You have been referred to our specialty clinic for recommendations on guiding you to a personalized treatment regimen that best fits you.

In GP, the stomach has difficulty, or the inability, to empty its contents into the small intestine. The result is that ingested food, liquid, and swallowed air remains in the stomach instead of passing through. A range of symptoms are then experienced by the patient. Classically, patients experience nausea, vomiting, bloating, reflux and abdominal pain. These symptoms are directly related to the immobility of the stomach. Our goal is to you improve your symptoms.

Causes

In our clinic, most GP patients acquired the disease for an unknown reason (idiopathic). Other causes include from diabetic neuropathy, and as a result of a surgical procedure intended for another diagnosis. Some possible idiopathic sources thought to cause GP are viruses, neurological disorders, autoimmune diseases, hypo and hyperthyroidism, mitochondrial diseases and eating disorders.

Diagnosis

Once symptoms of GP are identified, objective testing should be done to confirm the diagnosis. A gastric emptying study (GES) is the gold standard. It involves the patient eating a meal, usually scrambled eggs, labeled with trace amount of radioactive material. Scans are then taken of the patient at different time intervals, up to 4 hours, to watch the progression of the meal through the stomach. Based on the remaining amount of stomach contents at the end of each interval will diagnose GP.

Treatment

Narcotics do not successfully treat the symptoms.

Regardless of the cause, the treatments are the same. There is no cure for gastroparesis, but there are treatments available for symptomatic relief that vary in their effectiveness.

Most people with GP require a combination of treatments.

Diet

MAIN GOALS – low fat, low fiber, small frequent meals

• General diet guidelines
• Eat frequently – five small meals a day, and avoid large meals.
• Decrease high fatty meals
• However, fats in liquids, such as milkshakes, can be a great source of needed daily calories that are well tolerated because they are in liquid form and pass easily through the stomach.
• Start with the solid part of the meal, and follow with the liquids. This can aid to flush food through the stomach.
• Chew foods to a puree. Especially with meats.
• Using digestive enzymes can help break down proteins, fats, and carbohydrates. Enzymes such as sorbitol, lactose, sucrose, and fructose.
• Remain upright after eating for at least an hour. Incorporate walks after eating.
• Continually check your weight. This can be the first sign that you are not taking adequate nutrition.
• Keep hydrated, even when symptoms (i.e. vomiting) are at the worst. Take small sips of liquids. Avoid using straws. Dehydration can make the symptoms worse.

Diet modification

• Avoiding certain foods such as fatty foods. It is known that fats slow stomach emptying, even in the general population.
• Avoiding spices.
• Avoiding certain meats – especially red meat.
• Avoid high fiber content foods.
• Avoid certain fruits and vegetables.

Recommended food

• Soups
• Crackers
• Hard candy
• Starches such as pasta, rice, and potatoes. These tend to provoke stomach emptying.
• Meats such as baked chicken and fish.

You may want to seek out a nutritionist to tailor a diet to you.

REMEMBER – the goal is to help your stomach empty.

• Fats and fiber empty the slowest, while large meals will take longer to empty.
• Therefore, low fat, low fiber and small frequent meals are the mainstay.

Medication

• Prokinetics (increase motility) - Unfortunately, prokinetic options have been dramatically reduced over recent years due to safety concerns making alternative therapies even more important. However, domperidone is still in a reasonable option.
  • In the setting of GP, it is used as a prokinetic (increases stomach motility). In fact, trade names for the drug stem from its action, i.e. Motilium.
  • It has also been shown to have some antiemetic (anti-vomiting/nausea) effects.
  • Unfortunately, domperidone is not approved by the FDA for use in this country because of its unknown side effect panel. The main controversy is because it is secreted in breast milk, and the effects are unknown.
  • The medication does prove to improve symptoms in some GP patients, and it may be advisable for the patient to take on the responsibility of obtaining the medication on their own and using it at their own risk if the benefit outweighs the poorly tolerated symptoms of GP.
  • Anti-emetics (help to prevent nausea and/or vomiting)- such as Zofran or Phenergan.
  • Domperidone

Natural remedies

• Daikenchuto
  • This is an herbal medicine containing Daikenchuto extract powder and malt sugar produced in Japan.
  • It has been shown to increase intestinal motility in patients that have had a cessation of intestinal motility following surgery.
  • This can be prepared by an acupuncturist familiar with Chinese herbal formulas.

Surgery

Your surgeon will discuss which procedure is right for you. Surgery may become an option as these prior methods don't help improve symptoms.

• Pyloroplasty - This procedure is done in the operating room under general anesthesia. It is done with a minimally invasive surgery technique. The surgery permanently opens the valve at the end of the stomach that allows contents to pass easier into the small intestine. In GP, this valve functions poorly and remains closed impending stomach emptying resulting in the symptoms.
• Gastric nerve stimulator (GNS) - Product name is Enterra - This procedure is done in the operating room under general anesthesia. Electrodes are implanted at certain locations in the stomach wall that carry an impulse from a transducer placed in the abdominal wall. The impulses act to increase the stomach's motility. The transducer is accessed transcutaneously (across the skin without the use of needles) to monitor its strength of contractions and for maintenance.
• Gastrostomy tube (G-tube) - This is a procedure that can be done in the operating room or in the endoscopy suite. A tube is placed into your stomach, and comes out of your abdomen, to act as a vent for air to escape that would normally cause bloating, distention, and nausea. 
• Jejunostomy tube (J-tube) - This is a tube that placed in the operating room while you are under general anesthesia. The tube enters your intestine through your abdominal wall. It aids to provide nutritional supplements to meet recommended goals. 
• Gastrectomy - This procedure is used as a last resort. This is done in the operating room under general anesthesia, and the stomach is removed. The small intestine takes the place of the stomach, bypassing the problem organ.

General surgery

• Ventral and inguinal hernias
  • Laparoscopic and robotic repair
• Cholecystectomy
  • Single-site robotic removal
• Intestinal surgery
• Appendectomy and splenectomy

Hiatal hernia

Hiatal hernias are similar to all other hernias in that they contain intra-abdominal organs, such as the stomach, colon, intra-abdominal fat, and small bowel, but their location is hidden from the outside of the body. This hernia occurs at the hiatus which is a normal defect in the diaphragm. Nature has provided this defect in the diaphragm to allow the esophagus to pass into the abdomen. In the case of a hiatal hernia, the intra-abdominal organs herniate through the hiatus. The most common hiatal hernia organs to herniate are the esophagus and stomach.

Causes

There are several causes of a hiatal hernia. Probably the most common cause in the United States of a hiatal hernia is obesity. A hiatal hernia appears to be directly related to intra-abdominal pressure. Obesity causes increased intra-abdominal pressure which pushes the stomach against the diaphragm, up into the hiatus, and into the chest. The result is a hiatal hernia. Other causes can be from the trauma that is a sudden increased pressure in the abdomen, a weak phrenoesophageal ligament which is the ligament that attaches the esophagus to the hiatus, and pregnancy.

Diagnosis

A diagnosis of a hiatal hernia can be made several ways. The most common way is by upper endoscopy. This means that a surgeon or gastroenterologist uses an endoscope to look inside your esophagus, stomach and the first part of your small bowel called the duodenum. As the endoscope passes down the esophagus and into the stomach, it will be noted that the stomach is above the hiatus and in the chest. This makes the diagnosis of a hiatal hernia. Additional ways to diagnose a hiatal hernia are with an upper GI swallow study in which barium is commonly used, and through a CT scan. There are other ways to diagnose a hiatal hernia, but these are the most common. Most importantly, one of these exams needs to be done to make the diagnosis of a hiatal hernia because it can not be made from a physical exam or by symptoms. Often times symptoms can raise suspicion for a hiatal hernia, but does not definitively make the diagnosis without one of these tests.

Treatment

A hiatal hernia can only be treated with surgery. This is the same case for all other hernias. They do not get better on their own, and they only get worse over time. Often times, patients can help with some of the symptoms of weight loss in the situation of obesity, but that still does not improve the actual hiatal hernia. This is a common misconception by patients.

Since symptoms often indicate that there is a hiatal hernia, patients are often prescribed Proton Pump Inhibitors, or PPIs, such as Protonix, Pepcid, Dexilant, etc. These medications only suppress the acid production in the stomach which will alleviate the heartburn symptom by changing the pH of stomach secretions. They do not fix the hiatal hernia! There is no medication to fix a hiatal hernia.

A hiatal hernia obliterates the natural reflux barrier, so stomach secretions can freely splash up into the esophagus regardless of the use of PPIs. Overtime, the irritation in the esophagus from a hiatal hernia and stomach secretions causes changes to the lining. The terms used to describe these changes are words like metaplasia, dysplasia, Barrett's Esophagus, and esophageal cancer. Repairing the hiatal hernia will stop this progression, and is thought to reverse it.

Surgery

Repairing a hiatal hernia is done with an abdominal or thoracic approach. Most commonly, Hiatal hernias are repaired through an abdominal approach and are done in a minimally invasive fashion. Surgeons will utilize a laparoscopic or robotic approach for repair of a hiatal hernia. In both situations, small incisions are used to repair a hiatal hernia with a camera and small instruments. A minimally invasive approach has been shown to minimize recovery time, post operative complications, and use of pain medications.

There are different types of Hiatal hernias and are classified into 4 categories:

• Type 1 – Sliding hernia
• Type 2 – Paraesophageal hernia (appropriate location of esophagus)
• Type 3 – Paraesophageal hernia (esophagus retracted into the chest)
• Type 4 – Other organs (such as colon) in the hiatal hernia

The repair of these hiatal hernias differs in their repairs from the surgeon's aspect. It is at the surgeon's discretion to use a mesh to help repair the hiatal hernia.

Watch our video on hiatal hernia

Surgical services

Dr. Steven G. Leeds and Dr. Marc A. Ward are skilled surgeons with many years of experience in minimally invasive surgery procedures. They use this innovative surgical technique to treat several conditions and perform general procedures as well.

Therapeutic and diagnostic endoscopy

• Endoscopic Mucosal Resection (EMR)
• Endoscopic Submucosal Dissection (ESD)
• Radiofrequency ablation of Barrett’s esophagus (BarrX)

Ventral and inguinal hernias

Abdominal hernias are a very common diagnosis, especially following previous surgery. A hernia is defined as contents moving from one cavity into another cavity. In the case of abdominal hernias, abdominal contents such as bowel, colon, and fat are pushed out of the abdominal cavity. Weaknesses in the strength layer of the abdominal wall, called fascia, are the locations of the herniation. This can happen at the esophageal hiatus called a hiatal hernia. See section on Hiatal hernias. Ventral abdominal hernias are when the abdominal contents are pushed out through the ventral abdominal wall. This happens through the weakest spot on the abdominal wall. Examples of these spots include a prior abdominal incision from a surgery or a weak spot in the fascia.

Hernias only progress over time and do not get better on their own. The feared complication from a ventral abdominal hernia is that parts of the gastrointestinal tract, such as bowel, get trapped in a hernia and lose blood supply. This portion of the bowel dies and can cause infection, sepsis, and possibly death. This situation requires an emergent operation, and possibly several subsequent surgeries.

Causes

Ventral hernias are common especially following prior open abdominal surgeries such as laparotomy for a bowel resection, hysterectomy, or cesarean section. Most commonly found without prior surgery is an umbilical hernia from the failure of the umbilicus (aka belly button) to close early in life. There are also hypotheses that patients can have weak fascia from their genetic makeup predisposing them to develop hernias. These hernias are exacerbated by obesity causing the progression to larger hernias faster and are more difficult to repair.

Hernias do not get better on their own.

Surgical repair is the only method to fix a hernia.

Treatment

Repair of ventral abdominal hernias can be accomplished several ways and largely depends on the type of a hernia and its size. Your surgeon will decide the best method for your hernia.

Studies show that use of mesh provides a more sturdy repair creating dense scar tissue that decreases recurrence. This practice uses mesh as a standard method to repair in most hernias.

• Open ventral hernia repair – another incision is made at the site of a hernia, and the fascia is repaired along with placement of a piece of mesh.
  • Typically used in larger hernias. This involves dissecting layers of the abdominal wall in order to properly repair its function, and to place the mesh in the proper layer.
• Laparoscopic or robotic ventral hernia repair.
  • Both methods provide a minimally invasive approach with small incisions. This is associated with a quicker recovery, but must be used in only certain types of ventral hernias.

Postoperative recovery may involve admission to the hospital. This depends on the size and repair of an abdominal hernia. Six weeks following the repair should refrain from lifting anything greater than 15 pounds and avoiding strenuous activity. This allows the mesh to integrate, proper scar tissue to be created, and the maximal strength achieved following repair.