This chapter is written by experts in the surgical treatment of a wide variety of benign esophagogastric diseases, and presents a comprehensive picture of a how to manage these patients. In this commentary, we discuss indications for operation, the surgical skill required, and the techniques required to address these benign conditions.

There is a funny thing about digestive diseases, at least when it comes to their surgical treatment (perhaps their medical treatment as well—another subject….): that is that, in the universal scales of the gods of health, there seems to be an equal “disease burden” between benign and functional diseases and cancer. This balance extends from anal/rectal disease (rectal cancer vs sphincter dysfunction, condylomata, hemorrhoids, etc), colon (colon cancer vs inflammatory bowel disease [IBD], irritable bowel syndrome [IBS], constipation, volvulus etc), small bowel (cancer vs IBD, bleeding small bowel obstruction [SBO]), Hepato-pancreato-biliary (HPB) (bilio/duodenal/pancreatic cancer vs ulcer, pancreatitis, etc.), gastric (gastric cancer vs gastroparesis, peptic ulcer disease [PUD], dyspepsia, bleeding, etc.) and esophageal (cancer vs motility disorders, achalasia, gastroesophageal reflux disease [GERD], hiatal hernia, non-cardiac chest pain, dysphagia, etc.). Obviously gastrointestinal (GI) cancer is not a good thing, and rightfully deserves a lot of attention. However, GI cancers are relatively rare when compared to functional and benign diseases. Furthermore, benign functional digestive diseases have been shown to often have a quality of life impact comparable to the worst chronic medical conditions such as diabetes, but also to debilitating acute problems such as trauma and cancer.^1–4 With IBD as a possible exception, the medical world, industry, and the public spends more time, money, and human resources on GI cancers than it does on the far more prevalent, costly, and often equally debilitating chronic/functional benign conditions. Of course, digestive cancers kill the majority of patients, and other than from narcotic drug overdose, the benign diseases seldom lead to death.

All of the conditions addressed in this section have a surgical option. It may be a radical surgery, minimally invasive, or endoscopic, but at some point some of these benign and essentially medical problems will need some sort of surgery. This is a daunting decision point: “…at some point, some of these, and some sort of surgery…” should give any sensible surgeon pause. For the surgeon and the patient with a benign foregut issue, particularly for the more chronic or functional diagnoses, the proper answer to these questions is essential. In general, a conservative initial approach is a good idea for most conditions. For the more functional conditions—noncardiac chest pain, dysphagia, gastroparetic symptoms, etc.—extensive attempts to treat conservatively is mandatory before proceeding to surgery. This is because there is a substantial risk that surgery will not improve the patient’s symptoms—and can even make them worse. For benign disease with a more objective definition or anatomic state, such as GERD, achalasia, and paraesophageal hernia (PEH), medical attempts at symptom control are less important but still might be required by third-party payers and offer a reassurance to the patient that the discomforts, costs, and side effects of the surgery were worth it.

A major problem with many benign foregut procedures is that they are reconstructive, and optimal techniques are not well described. In addition, there is a wide variety of patient anatomy, physiology, and psychology to which to adapt the surgery. Mistakes in this realm can lead to severely unhappy patients even in the face of objectively good results.⁵ The other major problem with these surgeries is that “mastery” necessitates a holistic interest in the patient and therefore has a substantially long learning curve to achieve this highest degree of ability. Antireflux surgery provides a good example of this. In spite of being around since the 1950s, there remain a plethora of described surgical variations, both global (partial vs total fundoplication) and particular (construction with or without a bougie? etc.). Even in the face of level one evidence of the superiority or equivalency of technical approaches or details, practitioners will continue to argue and advocate their own “brand” of functional repair. In the end, it is probably more the experience of the practitioner that will determine the quality of the outcome more than particular technical details.⁶ This is one reason that education in benign foregut operations is of critical importance, and probably justifies postgraduate fellowship training. Training for true mastery, in our opinion, should cover all aspects of the disease; diagnostics, endoscopy, minimally invasive surgery, open surgery, complication management, etc. rather than just the technical aspects of the operations.