Minimally invasive fundoplication for GERD: the transoral esophagogastric approach

the transoral esophagastric fundoplication procedure and Dr. Darren Rohan, a thoracic surgeon performing this minimally invasive technique.

A cardiothoracic surgeon in New York, Dr. Darren Rohan has started a new minimally invasive program for reflux surgery (called fundoplication.)  With the transoral esophagogastric fundoplication  procedure, he can tighten the sphincter (valve) between the stomach and the esophagus by endoscopy (instead of laparoscopic surgery) to prevent acid from refluxing into the esophagus.  This is an important development in the treatment of gerd (gastroesophageal reflux disease) since the incidence of gerd is on the rise – due to obesity and this has led to an increase in esophageal cancer (as discussed in a previous post).

(Now, Dr. Rohan isn’t the first person to perform this procedure but I thought he’s be a great person to tell us more about it here at Cirugia de Torax, so I’ve written to him to request more information and to invite him to contribute a guest post.)

We also know that in addition to esophageal cancer (and Barrett’s esophagus) that reflux does more than destroy tooth enamel.  Work by researchers at Duke has linked reflux with problems with lung transplant recipients, and then to reactive airway disease itself.  While the degree of this relationship is not fully understood and is still debated – it is clear that there is a correlation to reflux disease and airway disease.  It has also been associated with aspiration pneumonia, particularly in patients on reflux suppressing medications.

I’ll be updating this story soon with more information.

Additional references and resources:

World J Gastrointest Endosc. 2010 Dec 16;2(12):388-96.  Gastroesophageal reflux disease: Important considerations for the older patients.  Chait MM.  (free full text).  This article talks about the range of complications and how elderly patients may present with more severe symptoms.
Saudi J Gastroenterol. 2010 Apr-Jun;16(2):84-9.  Study of respiratory disorders in endoscopically negative and positive gastroesophageal reflux disease.  Maher MM, Darwish AA.  9free full text).  An Egyptian study looking at the relationship between relux and lung disease.
This 2009 review of the literature, by Kumar and Gupta  out of India claims no association between reflux and asthma (but uses the effectiveness of acid suppressing medications in treating asthma as their proof of this theory – which is a faulty premise, in my opinion since these medications often don’t effectively treat reflux.)
More about the transoral esophagogastric fundaplication:
Surg Endosc. 2011 Jun;25(6):1975-84. Epub  2010 Dec 8.  Clinical and pH-metric outcomes of transoral esophagogastric fundoplication for the treatment of gastroesophageal reflux disease.  Bell RC, Freeman KD.  (Bell and Freeman also authored the article cited in the text above.)  Free full-text.

Only TIME will tell: Esophagectomy

There is a new trial on the horizon that sounds promising; the Traditional Invasive versus Minimally Invasive Esophagectomy (TIME). It’s a timely study indeed as the rates of esophageal cancer in western countries continues to increase, due to GERD and obesity.

I really don’t like the ‘cutesy’ way research trials have been named for the last ten years or so – but in this case – I will just have to look past it.  There is a new trial on the horizon that sounds promising; the Traditional Invasive versus Minimally Invasive Esophagectomy (TIME) trial based in the Netherlands.  It is a multi-center trial taking place at six hospitals in Europe.  This trial will compare both morbidity and mortality in patients undergoing traditional esophagectomy (Ivor Lewis) and patients undergoing minimally – invasive (thoracoscopy combined with laparoscopy) after both sets of patients receive adjuvant chemotherapy.  (This approach differs from the transhiatal esophagectomy developed at the University of Michigan in the 1970’s).

The researchers are planning for a five-year follow-up to compare both immediate post-operative complications / mortality with long-term effects (QoL) and cancer recurrence.

The full article is detailed on Medscape. (Also published in BMC Surgery. 2011;11 ).   This couldn’t come at a more appropriate time, with recent data showing an abrupt rise in the incidence of esophageal cancer.

In an article (Chustecka) dated from September 2010, British researchers at Cancer Research UK reported a 50% increase in diagnoses of esophageal cancer in the last 25 years, particularly in men in their 50’s. (with an incidence of 14.4 men per 100,000, to put it into perspective, up from 9.9 in 1983.)

More concerning, is the fact that the prevalence of the types of cancer are changing.  Previously, the majority of esophageal cancers were caused by squamous cell carcinoma which is linked to smoking and alcohol use.  This study, along with an American study, shows an increasing incidence of adenocarcinoma, which is more commonly attributable to gastroesophageal reflux (Barrett’s esophagus). Researchers  (Dr. Mark Orringer) estimate that the incidence of adenocarcinoma of the esophagus has increased by 350% in the last thirty years – and is directly related to huge increases in obesity.  It now accounts for over 85% of esophageal cancers in the USA.

We’ll bring you more as the trial continues, and preliminary results are reported.

(Dr. Mark Orringer, who was quoted in the original medscape article from 2007 is one of several pioneering surgeons in thoracic surgery.  He invented two of the surgical techniques in use today; the aforementioned transhiatal esophagectomy and the Collis -Nissen hiatal hernia repair.)