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Click on one of the conditions listed below for information about that condition:
Achalasia
Gallstones
Hernia
Hiatal Hernia
Minimally Invasive Oesophagectomy
Reflux Disease
Thoracic Disease
Achalasia
This is a relatively rare condition of the oesophagus (1 in 250 000). The function of the oesophagus highly abnormal. The valve between the stomach and oesophagus becomes very tight, and fails to open on swallowing, preventing ingested material entering the stomach. The peristaltic function in the oesophagus itself becomes weak and loses co-ordination, failing to propel material downwards as normal. Consequently, patients with achalasia have severe dysphagia, which can then lead to weight loss and malnutrition.
Achalasia can effectively be treated by an operation known as a Heller's procedure or cardiomyotomy.
Gallstones
Gallstones are solid crystal deposits which usually form in the gallbladder, a small bag-like organ situated beneath the liver in the upper right quadrant of the abdomen, normally designated for the storage of bile. Their presence causes irritation and inflammation to the lining of the gallbladder, and the stones can also migrate from the gallbladder and this can result in serious, life-threatening emergencies.
Common symptoms of gallstones include abdominal pain (sometimes very severe), often after meals or food containing fat, nausea, vomiting and loss of appetite. Serious complications of gallstones include cholecystitis, biliary colic, jaundice, cholangitis, pancreatitis, peritonitis, bowel obstruction and rarely cancer. It is therefore recommended that once diagnosed, the diseased gallbladder containing stones be removed by keyhole surgery.
Hernia
The term hernia commonly refers to a weakness in the muscular wall of the abdomen which allow the protrusion of abdominal viscera (bowels). This usually manifest as the presence of a lump, which causes discomfort and impairment in the ability to carry out normal activities.
Hernia can become stuck (incarcerated) and this may lead to an life-threatening emergency situation where trapped bowel loses its blood supply (strangulation)
Hernias are named in relation to the anatomical location of the defect.
Inguinal and femoral hernia occur in the groin, of either side.Umbilical and Paraumbilical hernia occur in and around the belly button. Epigastric (ventral) hernia front of the abdomen.
Incisional hernia occur after previous abdominal and recurrent hernia is the term used to describe the re-appearance of a hernia at the site of a previous repair. name given to any kind of hernia that has re-appeared, despite having been previously repaired surgically.
Keyhole surgery is now an increasingly popular alternative to traditional open hernia repair.
Hiatal hernia
The stomach normally resides in the abdomen, where is acts as an organ for the initial storage and digestion of ingested material. The oesophagus, which travels from the back of the mouth, through the neck and the entire length of the chest normally joins the stomach just within the abdomen, passing through a muscular sheet between these two body cavities called the diaphragm. Correct anatomy of this arrangement is crucial in maintaining the normal function of these complex organs
Two types of hiatal hernia are described: A sliding hiatal hernia means that the stomach slips up and down from the stomach into the chest and back; a paraoesophageal hernia describes the condition in which the upper part of the stomach, including the junction of the oesophagus and stomach (oesophago-gastric junction, OGJ) is all in the chest and stays there. In some cases, a hiatal hernia can get stuck in the chest (incarcerated) and this may then lead to a cut-off in its blood supply (strangulated), particularly if the stomach becomes twisted (gastric volvulus). This condition is seriously life threatening without emergency surgery.
The presence of a small hiatal hernia is very common, and symptoms are essentially that of reflux disease. As hiatal hernia get larger, they can start to cause more serious problems. Reflux symptoms, particularly regurgitation and dysphagia become more intolerable, and this can lead to aspiration of gastric contents into the chest causing infection and pneumonia. Breathing itself can become compromised because of the space that the stomach now occupies within the chest. The part of the stomach trapped in the chest can get inflamed, causing bleeding and anaemia, and if the blood supply gets cut off, then the stomach itself is at risk.
Minimally Invasive Oesophagectomy
The incidence of cancer of the oesophagus has dramatically risen over the last three decades for reasons that remain largely unclear. In the industrialised and Western nations this has been the biggest increase of any solid organ tumour.
The nature of the disease has also changed. Cancers now predominantly develop from glandular tissue at the junction of the lower (distal) oesophagus and upper stomach (gastroesophageal junction, GOJ), and are referred to as adenocarcinoma . The other type of oesophageal cancer, squamous cell carcinoma (SCC) is becoming much rarer, and when it occurs tends to form in the upper (proximal) oesophagus. This tumour is often linked to environmental toxins, smoking and high alcohol intake.
Adenocarcinoma of the oesophagus is not linked with smoking, drinking or environmental pollutants. The only established risk factor is gastroesophageal reflux disease (GORD), the presence of which significantly increases the chances of developing this malignancy. It appears to predominantly affect white or Caucasian males (six time more common in men), usually of middle or high income, and worryingly occurring in younger and younger individuals.
Early symptoms are similar to symptoms of reflux disease. Dysphagia (difficulty in swallowing) is often a sadly late feature. Diagnosis is confirmed by endoscopy and biopsy. The disease is staged (assessed for how advanced it is) by CT scan, PET scan and endoscopic ultrasound (EUS).
Curative surgical resection ( oesophagectomy ) is possible if the disease is localised to the oesophagus and local glands ( lymph nodes ) only.
If the disease has spread to organs or glands well away from the site of the primary tumour, then curative options are not available, and the disease symptoms have to be palliated and spread controlled using an variety of treatment modalities including chemotherapy, radiotherapy and stents.
Undergoing Surgery (Oesophagectomy)
The aim of surgery is to cure patients with oesophageal cancer. This is done in the following way:
1. Remove the portion of the oesophagus containing the tumour
2. Remove all the lymph nodes associated with the oesophagus and tumour
3. Reconstruct a new oesophagus, usually from the unaffected part of the stomach
Unfortunately, the anatomical location of the oesophagus makes it very difficult to approach surgically. Not only is it located in the very middle of the body, but it also crosses three different body compartments; the neck, the chest and the abdomen. This makes any operation a very risky undertaking, and this is why the mortality rate is at least 5%, and morbidity (major complications) is 40-50%.
Oesophagectomy operations which are mainly in used today ( open oesophagectomy), were actually described in the 1930's and 40's and surprisingly very little has changed surgically in more than half a century. All these operations require very large incisions in the abdomen ( laparotomy ) and the most effective operations require an additional large chest incision ( thoracotomy ). These wounds cause huge problems in relation to the very significant trauma inflicted on patients, which is the major factor in the high risks associated with these operations. Improvements in survival after surgery has come mainly from our advances in critical care support, anaesthesia, antibiotics and so on rather than surgical technique.
Following open surgery, the return to a normal or near normal quality of life can take up to nine months. Many of the problems at this stage still come from wound pain, and difficulties associated with eating.
Minimally Invasive Oesophagectomy (MIO) provides a means of performing the same (or better) operation using keyhole-sized incisions. This significantly reduces the trauma of surgery and consequently many of the risks. Magnified views allow a very radical lymph node dissection, and return to a normal quality of life is in a matter of weeks rather than months.
Reflux Disease
Gastro-oesophageal reflux disease (GORD) is a condition where there is excessive backflow of noxious gastric juices (contains acid, bile and digestive enzymes) from the stomach into the oesophagus. The most common (typical symptoms) are heartburn, regurgitation and dysphagia; less common (atypical) symptoms include chest pain, chronic cough, sore throat or hoarse voice.
Damage to the cells lining the oesophagus (oesophageal epithelium) results in inflammation and erosions (oesophagitis) and over a prolonged period this can cause fibrosis and the formation of a stricture (narrowing). The epithelium can also transform to appear more like intestinal epithelium. This is referred to as specialised intestinal metaplasia (SIM) or Barrett's oesophagus. This tissue is regarded as pre-neoplastic, which means it has the potential to become cancerous. Approximately 1 in 100 patients per year who have SIM will develop oesophageal cancer. If patients with SIM develop high-grade dysplasia, then there is strong justification for them to undergo an oesophagectomy as up to 40% will already have developed a cancer at this time.
Symptoms of reflux disease can be significantly improved with medical therapy. However this does not remove the underlying anatomical defect, and while the acid component of the gastic juice is neutralised (causing less heartburn), some reflux persists. Furthermore, patients can become dependant on medication which they may be forced to take for many years. Surgery offers a means of correcting the anatomical defect, restoring normal physiology, provide long term symptom relief and remove the need for medication.
Thoracic Disease
Thoracic diseases treated by keyhole surgery include lung, pleural and mediastinal diseases in addition to chest wall deformities.
A pneumothorax (collapsed lung) is usually dealt with by Video-assisted Thoracic Surgery (VATS), as well as bullous lung disease , which is a common finding in patients with chronic airways obstruction. Lung biopsies are obtained by VATS in patients with interstitial lung disease . Pulmonary nodules can be excised with the help of just two to three skin incisions of about two centimetres each.
The diagnostic and therapeutic problems of a pleural effusion complicating an infection or a malignant disease are solved with a thoracoscopy and -if required- a pleurodesis (fusion of the pleural space).
Mediastinal diseases including tumours and lymph nodes are amenable for thoracoscopic or mediastinoscopic investigation, and -if appropriate and technically feasible- for resection.
The Minimally Invasive Pectus Excavatum Repair is a relatively new surgical technique to treat the funnel chest with smaller incisions, avoiding the resection of rib cartilage.
Thoracic Diseases Surgery
Video-assisted Thoracic Surgery (VATS) is performed through two to three skin incisions, whilst hands and eyes are coordinated via a video-screen.The treatment of pneumothorax and bullous lung disease implies firstly the identification and then excision of the diseased areas of lung with a so called endostapler. The same device, which is able to seal and cut the lung, helps to obtain biopsies for presumed interstitial lung disease , whenever a transbronchial attempt turns out to be inconclusive.
Pulmonary nodules of uncertain histology are excised to direct further treatment of these patients, which might then be medical (in case of diffuse metastic lung disease) or surgical (in case of solitary pulmonary metastases, lung primary).
Quality of Life is a major concern in patients with malignant pleural effusion , and a VATS procedure in conjunction with a pleurodesis (fusion of the pleural space) provides permanent palliation. The insertion of a so called Pleurx catheter enables these patients to be discharged usually on day one after their surgery.
The mediastinum is accessible to a Video-assisted mediastinoscopy if enlarged lymphnodes need further investigation, or if the local extent of a lung primary needs to be assessed.
Other indications for VATS are resection of mediastinal tumours of limited size and pericardial effusion (pericardial window, mostly due to an underlying malignancy).
The Minimally Invasive Pectus Excavatum Repair (or Nuss procedure) is a less invasive alternative to the "open" procedure, and involves the insertion of a retrosternal bar through three skin incisions of about three centimetres each.