ArcaMax

DEAR DR. ROACH: For years, my 80-year-old aunt has been suffering from profound reflux problems that result in vomiting. Her esophagus was surgically detached from her stomach for over a year. Now that it is reattached, she undergoes "stretching" of her esophagus to curb reflux and vomiting. She has some short-lived improvement so far.

I struggle to understand how such a severe condition occurs and what the prognosis can be. Would you explain? -- J.H.

ANSWER: If you're really saying what I think you're saying, I am very surprised. A diverting esophagostomy is a procedure where the esophagus is truly detached from the stomach. Of course, this would mean that all food and water would have to come through a tube, such as a gastric tube that is placed through the abdominal wall.

I have never seen this procedure done, but my reading says that it is done primarily in people with neurological problems where there is no other choice or those who have failed other treatments.

When lifestyle treatments alone fail, standard medical treatments for reflux disease include medications to reduce acid and promote food to go out of the stomach into the intestines. If people do not do well with these, standard surgical treatments include fundoplication, which tightens the lower esophageal sphincter (the muscular valve-like structure at the bottom of the esophagus).

There are several surgical approaches to do this, including both laparoscopic and endoscopic options. My experience with these has been generally favorable. A recent procedure, magnetic sphincter augmentation, has been shown to have similar effectiveness, and I have had a few patients (and several readers) write in to tell me that they have also been generally pleased with this treatment.

When all other surgical treatments have failed, esophagostomy has been attempted, but experts recommend a very careful consideration beforehand. Complications include a stricture (a partial blockage of the esophagus), which needs to be treated through stretching it, usually with a balloon procedure. This may be what is happening with her.

DEAR DR. ROACH: A recent letter from a patient who had a benign kidney tumor that was removed along with one of their kidneys got me thinking. What about someone like myself (and many others) who have a horseshoe kidney? Is this a situation where whatever affects one of the kidneys affects both? How is this handled? -- O.V.

ANSWER: A horseshoe kidney is, indeed, shaped like a horseshoe. Instead of two kidneys developing separately, one horseshoe kidney is formed by the kidneys fusing across the midline. It is surprisingly common (1 in 500 people) and often unrecognized.

Although people with horseshoe kidneys are at a higher risk for kidney stones and infection, no specific action beyond careful monitoring is needed. People with a horseshoe kidney should avoid excess anti-inflammatory drugs and should promptly seek attention for urinary symptoms.

Because it is a single kidney, the person obviously cannot have their single kidney removed without kidney replacement therapy, such as dialysis or a transplant. A tumor of a horseshoe kidney would ideally be treated through the removal of the tumor -- not the whole kidney -- if possible.

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Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu.

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