Thoracic Diseases  Esophageal Diseases
The Esophageal Program at New York-Presbyterian/Columbia (NYPH/Columbia) draws together world-renowned experts in the diagnosis and treatment of benign and malignant esophageal diseases to provide state-of-the-art evaluation and treatment.
Esophageal Cancer
The two most common types of esophageal cancer are squamous cell carcinoma, most often occurring in the upper and middle portions of the esophagus, and adenocarcinoma, affecting the mucous-secreting cells in the lower portion near the stomach.
Risk factors for esophageal cancer include smoking, heavy alcohol use, and Barrett's esophagus, a condition in which the glandular cells of the lower portion of the esophagus are irritated by repeated exposure to stomach acid, often because of gastro-esophageal reflux disease (GERD).
To permit optimum therapeutic decision-making in treating patients with esophageal tumors, accurate staging is necessary. We use endoscopic transesophageal ultrasound (EUS) to visualize tumor depth, surrounding lymph nodes, and the tumor's relationship to adjacent structures.
In combination with PET (positron emission tomography) and CT scanning, EUS is highly effective in properly staging tumors of the esophagus
Esophageal Motor Disorders
The muscles of the esophagus may function abnormally in multiple conditions, including GERD, in which the lower esophageal sphincter does not close properly or achalasia in which that muscle does not relax with each swallow At NewYork-Presbyterian/Columbia, patients with esophageal motor disorders undergo careful radiographic, manometric (pressure), and motility (movement) studies.
Achalasia is the most common motor disorder of the esophagus. We offer a variety of treatments, including pneumatic dilatation, botox, and minimally invasive laparoscopic myotomy.
Gastroesophageal Reflux Disease (GERD)
Gastroesophageal reflux disease (GERD) is a common digestive disorder with symptoms of heartburn in which stomach contents regurgitate (reflux) into the esophagus often causing inflammation and damage to the esophagus and occasionally to the lungs and vocal cords.
Afflicting an estimated 25 million Americans, GERD has a variety of different causes.
Most patients respond well to conservative measures including dietary modification, weight loss and antacid therapy; however, lasting control of symptoms is sometimes difficult to attain.
Treatment of Esophageal Cancer
NYPH/Columbia, offers a multidisciplinary approach to treatment of esophageal cancer.
Our team of specialists from multiple disciplines, including gastroenterology, surgery, oncology, and radiation therapy, work together to create diagnostic and treatment plans for patients.
Patients with early stage tumors can be treated by a combination of minimally invasive techniques that can include endoscopic mucosal resection (EMR), photodynamic therapy (PDT) or minimally invasive surgery.
Patients with more advanced tumors are encouraged to undergo multimodality therapy with chemotherapy and radiation therapy followed by surgery. Preoperative therapy increases the likelihood of complete removal of the tumor, and increases cure rate.
We perform many of our esophageal resections for cancer using laparoscopy or thoracoscopy.
These minimally invasive approaches can significantly reduce the post operative convalescence, and speed recovery.
Not all patients are candidates for this, but our considerable experience with open surgery enables us to select appropriate patients for minimally invasive procedures.
Treatment for GERD
For those patients in whom a medical regimen has not been successful, anti-reflux surgery can offer gratifying, durable results with relief of GERD.
While GERD can have several causes, surgery is most effective for those patients whose GERD is caused by a defective lower esophageal sphincter (LES), the muscle connecting the esophagus with the stomach. In general, more than 90% of patients who undergo surgery have no reflux after surgery.
Fundoplication, done as either an open or a laparoscopic procedure, treats the reflux by making a new valve mechanism at the lower esophagus as a barrier to reflux. Several new minimally invasive procedures are available that enable the patient to return home the same day and return normal activity.
Surgery for GERD: Fundoplication
Fundoplication, involves constructing a new "valve" between the esophagus and the stomach by wrapping the upper portion of the stomach (the fundus) around the lowest port of the esophagus.
As the stomach becomes distended during a meal, the wrap compresses the lower esophagus, preventing reflux. Fundoplication also involves repair of a hiatal hernia (if present).
For patients who have other problems contributing to or accompanying their GERD, such as a swallowing disorder, a shortened esophagus, or gastric outlet obstruction, there are variations to this surgery so that there is a better overall control of symptoms.
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| Fundus(top of stomach) is wrapped around esophagus. |
Nissen Procedure:Full wrap around LES |
The two types of fundoplication are most commonly performed are the Nissen and the Toupet. Nissen fundoplication involves wrapping the fundus completely around the esophagus (360°), producing a short, loose wrap.
In Toupet fundoplication, the fundus is wrapped only part of the way around the esophagus (270°), producing a short, even looser wrap.
The type of operation is chosen based on the severity of reflux and complications involved, as well as the function of the esophagus. While the Toupet results in less difficulty with gas bloat syndrome and swallowing, the Nissen procedure is the most effective for controlling reflux. Therefore, the Toupet is generally best for patients whose reflux is less severe.
The Surgery
Fundoplication is done as either an open or a laparoscopic procedure.
The open procedure involves an incision of about 8 inches in the abdomen, while the laparoscopic approach is a minimally invasive technique producing 4 to 5 half inch incisions.
Although the laparoscopic approach offers many advantages over the open technique, such as a quicker recovery and less complications, it may not be appropriate for some patients, including those who have had previous abdominal surgery or who have some pre-existing medical conditions.
In addition, some patients may have to be converted from the laparoscopic procedure to the open technique during surgery.
However, this is uncommon and most patients (95%) can undergo the laparoscopic procedure without difficulty.
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