By FARID GHARAGOZLOO, MD
There has been much discussion around why esophageal cancer has increased by more than 600 percent in the U.S. since 1978. I strongly believe that the increase may be related to esophageal reflux and hiatal hernias. Medical therapy of acid reflux using proton pump inhibitors has not decreased the incidence of esophageal cancer, and in fact may play a role in increasing the numbers. There are hypotheses as to why this is, one being that esophageal cancer may not be caused by acid at all. Yes, we can shut off the acid with medicines, but what if the acid was making things harder on cancer cells all along? Other theories as to risk factors include bile salts and bacterial overgrowth due to backed up food that has liquefied in the esophagus, causing pain and burning. Many doctors, confronted with a patient who presents with "heartburn" pain, will give stronger and stronger medications for acid reflux, not realizing the patient is actually experiencing esophageal (as opposed to gastroesophageal, GERD) reflux caused by a hiatal hernia. In a normally functioning esophageal hiatus, the esophagus goes through the hiatus opening in the diaphragm where it joins the stomach in the abdomen, forming a gastroesophageal valve - not a sphincter, as it is often called. I explain to my patients that if their hiatus gets bigger, even by two centimeters, the valve will no longer work. The wider the opening, the more the stomach can move through the opening, like a napkin pulled through a ring.
Hiatal Hernias Should Be Taken Seriously Hiatal hernias are more than just uncomfortable bulges. A larger hiatal hernia becomes an obstruction of the esophagus, and in addition to concerns around esophageal cancer, a hiatal hernia of that size can cause a host of other preventable disorders. When a hiatal hernia patient lies down, digested liquid can flow into airways causing labored breathing. Believing they have chronic sinus problems, they make visits to the ENT, who can discover no real cause for the infection present. When this hernia gets bigger, as the stomach migrates into the chest, it can compresses the vena cava, preventing the heart from filling with blood. Patients begin complaining of low energy. They can't exercise because they can barely breathe, not due to the hernia compressing the lungs, but due to heart failure. They think it's all because they're getting older and gaining more weight, causing poor circulation. When I speak to my patients about this, suggesting that hernia repair can alleviate these symptoms, they often cry with relief. The truth is, our understanding of hiatal hernias has grown. Medicine is like a big ship - it's hard to turn it fast enough, especially when it comes to the super-specialized area
of upper GI. But as an estimated third of our local population has this problem, we must be vigilant in diagnosing and treating it correctly.
Advanced Robotic Surgery for Hiatal Hernia Advances in robotic surgery have completely transformed the treatment of hiatal hernia. In the not-so-distant past, patients avoided having the procedure because the methods available made the treatment riskier than the disease. Laparoscopy, though better than open surgery, didn't allow the visibility or flexibility needed. Things have changed. Robotics allows us to use wrist-like action, with 3D cameras giving the full view necessary to see in the space to reconstruct the hiatus. This technology has changed the game, allowing highly successful results with almost nonexistent hernia recurrence rates.
Robotic Surgery for Achalasia The many benefits of robotic surgery make it an excellent solution to treat many thoracic and esophageal disorders, including achalasia. Patients present with pain on eating and difficulty swallowing. Most achalasia patients we see have been coping with the disorder for many years. Their esophagus have become damaged, causing many problems to occur, including aspiration and choking. Patients who have trouble swallowing should see a specialist who focuses on esophageal medicine for a proper diagnosis. The sooner achalasia can be treated, the better - and not with dilation. Physicians have been searching for ways to treat achalasia since the 1700s, at one point using a whale bone to open the esophageal valve. But dilation, whether it's done with a whale bone or endoscopy, doesn't work as a long-term solution. In the past, as with hiatal hernia surgery, patients wanted to avoid open techniques.
Laparoscopy, while better, is still not sensitive enough to allow the muscle to be cut and avoid putting a hole in the esophagus. Laparoscopic myotomy, where the muscle of the lower esophagus is cut in a longitudinal fashion on the front of the esophagus, can be effective, but is associated with an increased incidence of reflux, which necessitates a partial fundoplication, also decreasing long-term benefit. Robotic Lateral Heller Myotomy eliminates the need for fundoplication. Using this technique, the muscle of the esophagus is cut longitudinally on the left side. Cutting the muscle on the left side of the esophagus preserves the normal gastroesophageal valve, which prevents reflux and removes the need for a fundoplication. Robotic Lateral Heller Myotomy procedure without fundoplication is associated with 98 percent benefit, without any reflux. These results have been superior to that of all previous procedures. The robot's 3D visualization allows the depth of visibility needed. It's an elegant surgical strike! The patient wakes up and can eat.
Leading the New Way Minimally invasive procedures using medical robotic tools help us operate with more precision and efficiency at the Center for Advanced Thoracic Surgery. Thanks to the assistance of the revolutionary robotic technology, positive patient outcomes are dramatically increased, while blood loss, pain, hospital stay and risk of infection or death are drastically decreased. In most cases the use of the robot allows us to access afflicted areas with minimal incisions and increased visibility for greater success.
Farid Gharagozloo, MD, FACS is board certified in general surgery and thoracic surgery, and specializes in providing the latest robotic surgery options to treat thoracic, esophageal, gastrointestinal, and lung diseases and cancers. He is an esteemed physician and is the founding surgeon of the Center for Advanced Thoracic Surgery at Florida Hospital Celebration. His role at Florida Hospital's acclaimed Global Robotics Institute establishes him as one of a handful of internationally recognized physicians at the leading edge of robotic surgery. To learn more about the Center for Advanced Thoracic Surgery or to refer a patient, contact the practice at (407) 303-4877.