Current status of surgery for benign disorders of the esophagus

Abstract

This thesis aimed at exploring new techniques for the surgical treatment of benign disorders of the esophagus. Specifically, studies were performed on surgery for gastroesophageal reflux disease and large (type II-IV) hiatal hernia. The chapters presented in this thesis involve studies that have been conducted to conclude on long-term durability and cost-effectiveness of laparoscopic Nissen fundoplication. Furthermore, the background and treatment of failed primary antireflux surgery for gastroesophageal reflux disease in a large cohort series was studied and, finally, new surgical options for the repair of large hiatal hernia were investigated with emphasis on the advantages of robot-assistance and the selective addition of an antireflux procedure. In short, this thesis provides new insights into the long-term outcome of laparoscopic Nissen fundoplication and the cost-effectiveness of this technique in perspective of its learning curve and potential social-economic advantages. In addition, the benefits robot-assistance were explored in laparoscopic Nissen fundoplication and large hiatal hernia repair. It is now apparant that laparoscopic Nissen fundoplication is a durable technique up to five years after surgery but that it is not cost-effective when compared to conventional surgery. Not until sick leave days and/or operation related costs will drop is this strategy viable from an economic point of view. Regarding antireflux surgery, a large cohort of patients undergoing redo antireflux surgery was investigated to elucidate both symptomatic and objective outcome. Seventy per cent of patients was either satisfied with reoperation or reached normal objective evaluation. These figures were unknown before the start of this study. Furthermore, it is demonstrated that robot-assistance offers no subjective and objective benefits for the patient in laparoscopic Nissen fundoplication, but that usage of these systems may result in less recurrences of hiatal hernia after repair of these technically demanding disorders. This thesis also provides a systematic review on hiatal hernia repair in anticipation of a pilot study (chapter 9) in which it was demonstrated that a selective approach to antireflux procedures after hiatal hernia repair is reasonable. A randomized trial regarding this topic is therefore not advised.