Laparoscopic approach to benign esophageal disorders

Background: The technique of laparoscopic surgery (LS) has taken rapid strides over the past decade. Though the biliary tract has been the main focus of LS, the surgical treatment of benign esophageal disease is an area of growing interest. In this article we outline our experience using LS in the treatment of benign esophageal diseases.
Material and Methods: From March 1999 to February 2003, 60 patients have been operated upon using laparoscopic technique. Thirty-six patients had gastro esophageal reflux disease (GERD) with or without a sliding hiatus hernia, 8 patients had a paraesophageal hernia (PEH) and 16 patients had achalasia cardia. Patients were worked up by an upper gastrointestinal (UGI) endoscopy, a barium study and a routine preoperative evaluation. All patients with achalasia and 5 with GERD also under went an esophageal manometry. The patients were operated under general anesthesia. The placements of ports for all patients were the same. The pattern of dissection was similar for patients with GERD and PEH but was modified in patients with achalasia. Patients were started on a liquid diet on the first postoperative day and were then maintained on a soft diet for 3 weeks. The first follow up was 1 month after surgery and then every 3rd month for the 1st year and then 6 monthly thereafter.
Results: The operating time for the GERD and PEH group ranged from 90 to 240 minutes (mean 120) and for the achalasia group from 120 to 180 minutes (mean 140). Intraoperative complications included 2 pneumothoracis in the GERD patients, 2 mucosal tears in patients with achalasia. One patient with GERD had an esophageal perforation during passage of an esophageal bougie; this resulted in an empyema, which needed intercostal drainage. Postoperative stay ranged from 3 to 5 days. Delayed complications in the GERD patients included severe "gas bloat" in 1, recurrent stricture in 1 and 1 patient had undiagnosed gastric dysmotility, which worsened after surgery. Four patients with GERD have been lost to follow up. Twenty nine patients with GERD and all 8 patients of PEH are relieved of symptoms. Fifteen of sixteen patients with achalasia have normal swallowing.
Conclusions: On account of the good results obtained, LS is an ideal method for treating patients with benign esophageal disorders. Patients with GERD need careful preoperative evaluation for optimizing results. PEH, though more difficult to treat than GERD, gives good results as experience increases. Laparoscopic myotomy should be the treatment of choice for achalasia cardia, with dilatation and botox therapy being reserved for failures of myotomy.