New Developments in Esophageal Surgery

This article covers some new areas of development in esophageal surgery. Specific topics include reviews of long-term outcomes after laparoscopic antireflux surgery, the use of surgically placed implantable device for LES augmentation (Linx), the use of mesh for hiatal hernioplasty, and prone and nonthoracic approaches to minimally invasive esophagectomy.

The past decade has seen a convergence of therapeutic endoscopy and gastrointestinal (GI) surgery starting with the joint interest and development of endoscopic antireflux procedures, and most recently with the combined development of Natural Orifice Transluminal Endoscopic Surgery (NOTES). In fact, the development of NOTES has been through a tangible collaboration through NOSCAR (Natural Orifice Surgery Consortium for Assessment and Research), a collaborative venture between the American Society for Gastrointestinal Endoscopy (ASGE) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). NOSCAR typifies the direction that we are headed with regard to interventional management of GI diseases, and especially the esophagus. Rather than simply add a surgeon’s perspective to the topics already covered in this publication, this article will cover some new areas of development in esophageal surgery. Specific topics include reviews of long-term outcomes after laparoscopic antireflux surgery, the use of surgically placed implantable device for lower esophageal sphincter (LES) augmentation (Linx), the use of mesh for hiatal hernioplasty, and prone and nonthoracic approaches to minimally invasive esophagectomy (MIE).

Long-term outcomes of laparoscopic antireflux surgery

Through most of the 1990s, laparoscopic antireflux surgery promised to cure gastroesophageal reflux disease (GERD) and replace proton pump inhibitors (PPIs). Some who felt that the increasing use of PPIs was actually inducing Barrett’s esophagus and the more recent increased prevalence of esophageal adenocarcinoma claimed victory over both GERD and the indiscriminant use of PPIs. In 2001, Spechler and colleagues published a 10-year follow-up to their 1992 prospective randomized comparison of surgery versus medical management of GERD. This 1992 study concluded that surgery was more effective than H2 receptor antagonists at controlling GERD. However, this long-term follow-up study declared surgery a failure and even implied that surgery was dangerous. This was based on a statistically nonsignificant finding that more patients in the surgery group had died during the follow-up period.

This study induced a significant decline in confidence in antireflux surgery and therefore a decline in the number of patients offered antireflux surgery by their health care providers. Concurrent with this was the realization that laparoscopic antireflux surgery was quite different from open antireflux procedures, if for no other reason than that the skills needed to perform a well-done fundoplication were special and not easily translated by those surgeons comfortable doing other laparoscopic procedures such as cholecystectomy. With this, anecdotal outcomes with laparoscopic fundoplication included mixed results such as high numbers of patients needing to resume antisecretory medications for symptom control, and high rates of redo fundoplication. This further indicted antireflux surgery as ineffective, at times requiring more surgery to manage poor outcomes and complications. The result of this has been most patients with GERD not being offered surgery unless they have more advanced and complicated problems like large hiatal hernia, Barrett’s esophagus, or refractory esophagitis.

Over the past 2 to 3 years there have been multiple publications detailing long-term (>10-year) outcomes with laparoscopic antireflux surgery. Several of these are summarized in Table 1 . In summary, it is clear that in centers with extensive experience with the surgical management of GERD, outcomes are excellent with 85% to 90% of patients being highly satisfied with their outcome with good to excellent control of their GERD symptoms. Around 20% to 30% of patients continue to use their antisecretory medication although often for unknown reasons that may not be directly attributable to GERD. In very few patients was surgery a failure as defined by a poor outcome or the need for more surgery. From these studies and our own experience with thousands of patients undergoing antireflux surgery, expertise in not only surgical skill, but also patient selection and a thorough understanding of GERD is necessary to achieve these outcomes. Antireflux surgery is very effective and best provided through centers of excellence where such expertise exists. Patients should not be denied the option of antireflux surgery, but instead, should be guided to those centers where good outcomes have been achieved. This will be increasingly important as patients find themselves with health insurance that will not cover prescription PPIs and will be seeking alternatives to medication, including antireflux surgery.

Table 1

Long-term outcomes of antireflux surgery

Author	No. pts	Follow-up, y	Results
Teixeira 2009 (qol)	143	5.4 (2–11)	92.3% very good or good result 13% using antisecretory meds
Kornmo 2008 (sc)	33	9.75	93% very good or good 52% with gas bloat 3% using antisecretories
Zaninotto 2007 (sc)	145	8.1	86% success 21% using PPIs 9% required redo
Morgenthal 2007 (sc)	166	11.1 (6–13)	93.3% success 30% using PPIs (unknown reasons)
Kelly 2007 (sc)	226	10–14	84% good to excellent 21% using PPIs 17% required redo

Abbreviations: PPI, proton pump inhibitor; pts, patients; qol, quality of life study; sc, symptom control.

Lower esophageal sphincter augmentation (Linx)

Over the years there have been several attempts to develop new techniques for augmenting the LES that would avoid the variable outcomes seen with esophagogastric fundoplication (see preceding section). Most have involved endoscopic approaches ranging from suturing to plicate the LES internally (Endocinch) to polymer injection to change the compliance of the LES (Enteryx). Of these recent new techniques, an endoscopic esophagogastric plication (Esophyx) remains the only new technique currently approved by the Food and Drug Administration (FDA). All others (Endocinch, Stretta, Enteryx, Gatekeeper, NDO) either failed to provide a safe or effective treatment, or were unable to establish a sustainable business model. Again, nearly all of these techniques sought to either reproduce a fundoplication or anatomically alter the LES.

The newest venture into developing an effective antireflux barrier between the stomach and esophagus seeks to mechanically reproduce the function of the LES. This implantable device (Linx) is a string of magnetic beads ( Fig. 1 ) that is affixed around the distal esophagus at the gastroesophageal junction ( Fig. 2 ). Each of the beads in this bracelet carries a weak magnetic force holding the beads opposed, similar to the constricted LES. The force typical of the esophageal body pressure generated with a swallow is enough to disrupt the magnetic force holding these beads together, thereby opening the ring of magnets allowing a swallowed bolus to pass, similar to the relaxation of the LES. Immediately following this bolus passage, the beads reoppose and the distal esophagus is again closed. This device is placed laparoscopically in a manner similar to how a laparoscopic fundoplication is performed. In contrast to a fundoplication, there is very little dissection and manipulation of the gastric fundus necessary, and the result is very reproducible and predictable. This device is currently only available through an FDA trial.