Edward Auyang MD MS FACS Assistant Professor of Surgery Director of Minimally Invasive Surgery Residency Program Director General Surgery Disclosures No financial disclosures I do perform antireflux operations ID: 460164
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Slide1
Medical and Surgical Management of Gastroesophageal Reflux Disease (GERD)
Edward
Auyang
, MD, MS, FACS
Assistant Professor of Surgery
Director of Minimally Invasive Surgery
Residency Program Director, General SurgerySlide2
DisclosuresNo financial disclosuresI do perform anti-reflux operations…Slide3
ObjectivesRecognize symptoms of GERDLearn the diagnostic tests to evaluate GERD
Learn the medical treatments for GERD
Learn the surgical treatments for GERDSlide4Slide5
Epidemiology
61 million Americans complain of heartburn and
indigestion
40%
monthly
20
%
weekly
7
% dailySlide6
Anatomy
Barriers to
GERD
Esophageal peristalsis
Intra-abdominal
segment of
esophagus
Lower esophageal sphincter (LES)
tone
Diaphragmatic
crura
Phrenoesophageal membraneAngle of His Normally – Transient relaxation of LESSlide7
PathophysiologySlide8
Pathophysiology
P
rimary mechanisms
S
pontaneously
, accompanying transient LES
relaxations
S
tress
reflux associated with a weakened LES
Increased intra-abdominal pressure
Dysfunctional LES/Hiatal hernia
Reflux -> mucosal injury -> weakened LES and/or esophageal dysmotilitySlide9
Clinical PresentationTypical vs. AtypicalSlide10
Clinical Presentation
Typical symptoms
Heartburn
Regurgitation
Water brash
Acid brash
Nocturnal Aspiration
Dysphagia
Atypical
symptoms
Chronic
nausea
AsthmaAspirationCoughHoarse throatDental erosionsChest painSlide11
Diagnostic StudiesSlide12
Diagnostic Studies
Anatomic
EGD (± biopsy)
RULE OUT CANCER/Barrett’s!
Contrast radiographs (UGI
Esophagram
)
Physiologic
24-hr pH testing (on/off medication)
Esophageal
manometry
Scintigraphy (gastric emptying)Slide13
EGDSlide14
Upper GISlide15
ManometrySlide16
24 Hr pH MonitoringSlide17
Treatment - MedicalSlide18
Treatment - Medical
L
ife style modifications
Weight loss
Alteration of diet
Avoid chocolate, peppermint, fat, onions, garlic, alcohol, caffeine, and nicotine
Nothing by mouth for 2-3
hr
before bedtime
Elevation of head of bed 6-10 in. Limit potentially precipitating activities, such as bending over or strenuous exercise
MedicationSlide19
Medication OptionsAntacids (Neutralize)Tums, Rolaids, Maalox
H2 Blockers
Ranitidine, famotidine
PPI
Omeprazole, pantoprazole, esomeprazole, etc.
Beware of osteoporosis/
penia
,
fundic
polypsMax Omeprazole 40mg BIDSlide20
Treatment – SurgicalSlide21
Treatment – Surgical
Complications of GERD unresponsive to medical therapy
Esophagitis
Stricture
Recurrent aspiration or pneumonia
Barrett esophagus
Continued symptoms despite maximal medical treatment
Symptomatic
paraesophageal
hernia
Patient desire to discontinue PPI therapy
Financial burden
Lifestyle choice Young age Intolerance to proton pump inhibitor therapy Slide22
Basic Tennets of Surgery
Restoration
of an effective LES
C
reation
of a
gastroesophageal
valve
Fundoplication requires wrapping the fundus itself, not the body of the stomach, around the esophagus, rather than around the proximal body of the stomachThe fundoplication should reside within the abdomen without tension, and the crura
should be closed adequately to prevent migration of the stomach or the
fundoplication
into the chestComplete Vs. Partial wrapSlide23
OperationSlide24
OperationSlide25
OperationSlide26
Post-op CareHospitalizationDiet
ActivitySlide27
OutcomesLap Nissen Fundoplication Success Rate:
90-95%
Gas Bloat
Dysphagia
Hernia/GERD RecurrenceSlide28
GERD and ObesitySlide29
Case Scenario56yoM presents to your office with HeartburnHPI – What do you want to know?
PMHx
– HTN, GERD, HL
PSHx
– Cholecystectomy
PE – HR:75 BP:122/85 O2: 97% RA BMI 30
Workup ?Slide30
Questions?Slide31Slide32
ResultsSlide33
GERD and Barrett’s Disease
60
% of patients with clinical GERD will have normal-appearing esophageal mucosa at
endoscopy
Barrett
esophagus is estimated
in 10
% of patients with
GERD
GERD + Barrett esophagus have
0.4
% per patient-year risk of
adenocarcinoma Vs. 0.07% per patient-year risk for patients with GERD but without Barrett esophagusSlide34
Esophagitis Grading System (Endoscopic)
Los Angeles Classification
System
G
rade
A (≤5 mm in length
)
G
rade
B (>5 mm in length
)
G
rade C (continuous between two mucosal folds)Grade D (≥75% of esophageal circumference)