ESOPHAGEAL DISEASES
The esophagus is the tube located between the mouth and stomach and functions to pass food. Esophageal mucosa (inner lining) is always slippery due to mucus released by special glands. Passage of food is one way from mouth to stomach; however, reverse passage (vomiting, reflux) of food residue may occur in pathological conditions. Reflux - the passage of food residue, gastric acid, and content in the reverse direction, from the stomach to the esophagus. The main mechanism that prevents reflux is the esophageal sphincter. If this mechanism is not working for any reason, acidic gastric content may damage esophageal mucosa, which is not accustomed to such events. If it happens continuously and becomes chronic, gastroesophageal reflux disease (GERD) and its complications, esophagitis, Barrett's esophagus, ulceration, asthma that occurs due to passage of gastric content into the respiratory tract while sleeping, and chronic lung infections may develop. For GERD and its complications, surgical treatment may be considered as a result of investigations. Laparoscopic Nissen fundoplication is one of the surgical methods used to treat this condition. In recent years, some methods replacing lower esophageal sphincter are discovered instead of laparoscopic fundoplication.
The normal esophagus has a certain movement pattern. It starts with swallowing and terminates with the entrance of food into the stomach. If esophageal motility is ineffective, pathological conditions that require surgical treatment may develop. Achalasia is an irreversible narrowing of the lower part of the esophagus and may develop as the inability to swallow (dysphagia), frequent vomiting, loosening of the entire esophagus, and weight loss.
Pouches on the esophageal wall are called diverticula. There are many types of diverticula; the appropriate surgical procedure may be planned depending on its location and the findings. For some diverticula, endoscopic treatment is considered and for others, thoracoscopic surgery is possible.
Esophageal cancer is an aggressive tumor that originates from esophageal mucosa. It usually manifests itself as dysphagia (inability to swallow), weight loss, and anemia. Unfortunately, most of the patients are stage 3-4 at admission. In this stage, medical and radiotherapy are considered rather than surgical treatment. However, for patients who are in the risk group and are in close follow-up, if esophageal cancer is detected in the early stage, surgical treatment may be considered. The patients at risk include those who smoke (especially with heavy drinking), have untreatable reflux disease and its complications, are obese, have chronic damage of esophageal mucosa and burn, had previous esophageal burn due to drinking caustic substances, have HPV infection and achalasia.
The treatment of esophageal cancer involves the removal of the whole esophagus. The operation may be open or closed (combined laparo- and thoracoscopic). Instead of the removed organ, reconstruction is made with a segment (part) of the stomach, small intestine, or colon. After the operation, recommendations of Oncology are taken.
STOMACH
Hiatal Hernias
Hiatal hernia is when the stomach bulges up into the chest due to the expansion of the opening around the esophagus, which passes through the back half of the diaphragm and enters the stomach. This pathology is known as “stomach hernia” in colloquial language. Depending on the severity of the findings and complications, hiatal hernias may require planned or emergency surgery. Following hiatal hernia repair surgically, the aforementioned laparoscopic Nissen fundoplication is performed.
Gastric Cancer, Diagnostic and Treatment
Gastric cancer is a malignant disease originating from the inner lining of the stomach (mucosa). It is, unfortunately, diagnosed at a late stage, and therefore, surgical treatment may be warranted only in case of complications such as hemorrhage, perforation, or obstruction. Early-grade stomach cancer may be diagnosed during endoscopy. Routine gastroscopy performed for patients in the risk group helps with surgical treatment. The risk group patients include those who have Helicobacter pylori, consume an excessive amount of salty and smoked food, smoke tobacco products, are obese, underwent gastric surgery, have a chronic vitamin B12 deficiency, have Menetrier disease, have certain genetic syndromes, adenomatous gastric polyps and who work in coal/metal/latex manufacturing factories. Gastric cancer is diagnosed by pathological analysis of the biopsy material collected during gastroscopy. After confirmation of the disease, stage (prevalence) may be detected with investigations such as computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET). Surgery is the primary treatment option for early-stage gastric cancer. Following surgical treatment, medical treatment and radiotherapy may be considered and determined by Medical Oncology and Radiation Oncology depending on the final pathology report.
Regardless of its stage, surgical treatment of gastric cancer involves the removal of the stomach and all lymph nodes around the stomach. This procedure is known as total gastrectomy and lymph node dissection. The surgery may be laparoscopic in the early stage. Late-stage disease increases the risk of open surgery and the spread of disease over the intraabdominal membrane. After the operation, the patient is discharged following recovery and is provided with recommendations by the doctor.
Surgery is also considered for rare malignant or benign diseases of the stomach (gastrointestinal stromal tumor - GIST, gastric lymphoma, etc.). The scope of operation and part of the organ to be removed may vary depending on the diagnosis.
DISEASES OF THE SMALL INTESTINE
The diseases of the small intestine may be inflammatory, tumoral, structural, and functional, as in other organs.
Functional diseases
Intestinal motility disorders may cause some problems such as intestinal obstruction. Unfortunately, it is quite difficult to diagnose these problems. A diagnosis is achieved either in a very late stage or during the retrospective evaluation of previous pathology slides of the patients who underwent surgery repeatedly. Treatment should involve postponing surgery as much as possible. However, for really suspicious cases, diagnostic laparoscopy with biopsy collection and afterward, a specific pathological investigation may be performed.
Structural diseases
Diverticular disease of the small intestine is a rare pathology that may develop in all segments of the small intestine. Oftentimes, it does not cause symptoms and it is diagnosed during radiological investigation for another reason. There is no single center with serious experience in the world; therefore, a certain strategy cannot be developed. General surgical procedures are valid for the diverticular disease of the small intestine. Case-specific emergency treatment may be regulated if needed.
Inflammatory diseases
The most common inflammatory disease of the small intestine is Crohn’s disease. Crohn’s disease is a disease, which may involve any part of the digestive system starting from mouth to anus and affects all layers of the organ involved. The primary treatment of Crohn’s disease is regulated by Gastroenterology and surgical treatment may be considered if complications occur. The main principle for Crohn’s disease surgery is to preserve any part of the small intestine that may be spared. If there is no favorable response to treatment, the intestine may be shortened to a critical length as a result of every episode, and this is known as short bowel syndrome. Short bowel syndrome is a hardly treated pathology and requires small intestine transplantation in some cases.
Tumoral diseases
Small intestinal tumors are quite rare pathologies. According to prevalence, the most common tumors are endocrine-active tumors known as carcinoid and then adenocarcinoma. Stromal tumors and lymphoma are quite rare in the small intestine. Of gastrointestinal system tumors, tumors of the small intestine count for only 2%. The flow velocity of the fluid in small intestines is quite high; therefore, the prevalence of tumors in the small intestine is considered
as low. The above-mentioned four tumors constitute 98% of tumors of the small intestine and unfortunately, most of the patients are diagnosed in the late stages of the disease. Most of the time, symptoms include abdominal pain, nausea-vomiting, intestinal obstruction, hemorrhage, and weight loss. Therefore, oftentimes, surgical intervention is required even in late stages either for relieving the symptoms or at least to achieve a final diagnosis. Surgery mostly includes only segmentary (partial) resection (removal) of the small intestine. After the operation, the patient will be in follow-up by Medical Oncology.