Prof John Windsor

Surgical Diseases of the Oesophagus

Gastro-oesophageal reflux

Acid reflux, also called gastro-oesophageal reflux disease (GORD), is a condition where the stomach contents (food or liquid) rise up from the stomach into the oesophagus, a tube that carries food from the mouth to the stomach.

Normally the stomach contents do not enter the oesophagus due to contraction of the lower oesophagus due to a number of factors. But in patients with acid reflux stomach content travels back into the oesophagus because of a weak or relaxed lower oesophageal sphincter (LES). The lower oesophageal sphincter acts like a valve between the oesophagus and stomach preventing food from moving backward into the oesophagus

Heartburn is usually the main symptom; a burning-type pain in the lower part of the mid-chest, behind the breast bone. Other symptoms such as a bitter or sour taste in the mouth, trouble in swallowing, nausea, dry cough or wheezing, regurgitation of food (bringing food back up into the mouth), hoarseness or change in voice, and chest pain may be experienced.

The exact cause of what weakens or relaxes the LES in GORD is not known, however certain factors including obesity, smoking, pregnancy, and possibly alcohol may contribute to GERD. Common foods that can worsen reflux symptoms include spicy foods, onions, chocolates, caffeine containing drinks, mint flavourings, tomato based foods and citrus fruits. Certain medications can also worsen the reflux.

General measures the patient can take to reduce reflux symptoms are:

  • Avoid eating before going to bed as this may decrease the acid production
  • Eat smaller and more frequent meals
  • Lose weight if you are over weight
  • Elevate the head of the bed
  • Eliminate the foods that increases the reflux
  • Avoid smoking and use of alcohol
  • Check with the physician regarding side effects of prescription medications

There are several tests that can be performed to diagnose acid reflux and they include:

  • Endoscopy: This test allows the doctor to examine the inside of the patient’s oesophagus, stomach, and portions of the intestine, with an instrument called an endoscope, a thin flexible lighted tube. The lining of the lower oesophagus usually becomes inflamed with GORD, and when this has occurred over a long period of time the lining can undergo a transformation (Barrett’s oesophagus) that is a pre-malignant state.
  • Barium Swallow: This investigation is still occasionally used to look at the swallowing efficiency and to examine a hiatus hernia.
  • pH monitoring: This is the best way to diagnose acid reflux. A fine tube is inserted through the nose into the oesophagus and positioned across the LES. The tube has multiple sensors that measure the extent of acid exposure at different levels of the oesophagus and over 24 hours. It also allows a correlation between the patient symptoms and the occurrence of reflux events.
  • Manometry: This measures the pressure of contractions of the oesophagus and the relaxation of the LES.
  • Impedance study: This test measures impedance (the resistance to current) during oesophageal transport. It is able to detect both acid and alkaline reflux. Combined impedance/pH recording is clinically useful in the evaluation of symptoms when acid suppression treatment is being given, as well as for hoarseness, unexplained cough, and applications of particular interest.
  • High Resolution Impedance Manometry: Using impedance and manometry together clarifies which patients with pressure abnormalities have disorders that will not be helped by surgery. This is because measuring the transit of a fluid or food bolus may be the single most important parameter for assessing swallowing difficulties and investigating patients prior to anti-reflux surgery.

The indication for surgical treatment of reflux disease is usually because patients do not have satisfactory control of symptoms with medical treatment. Other indications include intractable volume reflux, which is when reflux rises into the throat and may be associated with coughing, aspiration and a hoarse voice. Another indication for surgery is when the hiatus hernia is large enough to compromise breathing and the stomach is at risk of becoming trapped and losing its blood supply.

The surgical treatment of reflux (fundoplication) makes sense when the underlying problem is a failure of the valve mechanism. Antacid treatment takes the sting out of the fluid but does not stop reflux, and that is a concern when long-standing reflux can progress to oesophageal cancer. This is controversial in some settings, but it stands to reason when the purpose of treatment is to stop abnormal reflux is the goal, altering the acidity of the fluid to stop symptoms but not reflux lacks logic.


Achalasia is a rare condition where the lower oesophagus does not let food and sometimes fluid through to the oesophagus. The normal relaxation of this region that occurs with swallowing does not occur. The symptoms that are experienced by the patient include food sticking (dysphagia) and food regurgitation. They may also experience weight loss and a cough. In the late stages of achalasia the oesophagus stops contracting and can become much dilated.

A barium swallow or endoscopy may suggest the diagnosis, but the definitive test is oesophageal manometry or an impedance study.

A number of treatments have been tried for this condition, but it has now been shown that surgery provides the most durable and most effective treatment. The surgery involves accurately dividing the muscle layers responsible (laparoscopic cardiomyotomy). Balloon dilatation of the lower oesophageal region carries the risk of oesophageal perforation, has to be repeated in many patients and is often not durable. It also scars the tissue making surgery more dangerous. Botox injections are effective in many patients, but the effect is usually short lived. Medications are ineffective.

Oesophageal cancer

Oesophageal cancer develops from the lining of the oesophagus and is becoming more common in western societies. This reflects a number of factors including increasing obesity, reflux disease and smoking.

There are two common types of oesophageal cancer: adenocarcinoma which is often related to reflux disease and squamous cell carcinoma which is the more common variant in many non-western parts of the world.

In the early stages of oesophageal cancer, there may be no symptoms. But as the cancer grows it is usual to develop difficulty swallowing (dysphagia) and weight loss. Other later symptoms might include chest pain, fatigue, indigestion, coughing, and hoarseness.

The diagnosis of oesophageal cancer is made by endoscopy and biopsy.

It is important, as with any cancer, to determine whether the cancer is confined to the site of origin or whether it has spread. This process is called staging and CT scanning of the neck, chest and abdomen is most commonly used for staging oesophageal cancer. Additional staging investigations might be arranged. Endosonography is able to look at he the depth of cancer invasion through the wall of the oesophagus and to do biopsies of any enlarge nodes close to the oesophagus. PET scanning is a new method that adds extra information to the CT scan by determining sites of cancer based on metabolic activity.

Patients with very early cancer, confined to the inner layer of the oesophagus, might be treated with local endoscopic resection. This is rarely possible.

The majority of patients have advanced oesophageal cancer and are not offered surgery because the cancer has spread. Another reason is because that patients is not fit enough for the surgical treatment. These patients are usually managed with chemotherapy and are sometimes also offered radiotherapy and/or a stent.

Those patients who can be offered surgery are first treated with chemotherapy. If the repeat CT scan does not show evidence of distant spread and if the patient is considered fit enough then surgery will be offered. The operation (Ivor Lewis oesophagogastrectomy) involves not only removing a portion of the oesophagus along with local lymph nodes, but also fashioning a replacement tube out of the stomach to join to the oesophagus in the chest or neck. Most patients will be offered further chemotherapy after they have recovered from surgery.

Royal Australasian College of SurgeonsThe University of AucklankMercy Ascotacckuland sages isdeihbpaaasuniversity-society-of-surgeonsssatiap Royal Society Newzealand