Oesophagus disorders
Hiatus Hernia
Acquired form of diaphragmatic hernia
Types:
- Sliding: GOJ slides through the oesophageal opening of the diaphragm
- Rolling / paraoesophageal: GOJ remains in position but area of stomachad peritoneum rolls up alongside oesophagus into thorax
Gastro-Oesophageal Reflux Disease
Management
- History
- Burning pain
- Examination
- Investigations
- Upper GI endoscopy + biopsy to detect oesophagitis and Barrett's oesophagus
- 24h pH manometry
- Treatment
- Lifestyle changes: weight loss, avoid alcohol and smoking, avoid large meals at night
- Medical: antacids, H2 antagonists, PPIs
- Surgery in: severe persistent regurgitation, severe reflux symptoms, patient choice
Nissen Fundoplication
Other options - Belsey Mark IV: fundoplication through thoracotomy - Hill gastropexy (securing cardia to pre-aortic fascia
- Laparscopic / Midline incision
- GA + elevate head end of table
- Create pneumoperitoneum / access oesophagus
- Divide lesser omentum
- Retract right lobe of liver
- Dissect oesophageal hiatus
- Repair crural defect
- Identify crura
- Dissect 3-4cm of abdominal oesophagus and mobilise
- Retract oesophagus to right
- Repair crural defect with interrupted non-absorbable sutures
- Free fundus and greater curvature
- Divide short gastric vessels
- Freed fundus passed behind and then to the left of the oesophagus
- Fundoplicate
- Fundal wrap held with 3 interrupted non-absorbable sutures, taking bites of both fundal folds and the oesophagus
- Finish
- Irrigate operative field + ensure haemostasis
- Close fascial defects
