GERD management

1. Approach, indications and
surgical management of GERD
Dr Shambhavi Sharma
1st year resident
MS general Surgery
PAHS

2. Anatomy of GE junction

3. Introduction
• Gastroesophageal reflux disease (GERD) is a condition that develops
when the reflux of stomach contents into stomach or beyond into oral
cavity or lungs causes troublesome symptoms and/or complications

4. Erosive esophagitis
characterized by endoscopically visible breaks
in the distal esophageal mucosa with or
without troublesome symptoms of GERD
Nonerosive reflux disease
characterized by the presence of
troublesome symptoms of GERD without
visible esophageal mucosal injury.

5. Troublesome symptoms
• Mild at least 2 times per week
• Moderate to Severe : at least once per week

8. Diagnostic criteria
Recommendation
• Based on the available evidence, the diagnosis of GERD can be
confirmed if at least one of the following conditions exists: a
mucosal break seen on endoscopy in a patient with typical
symptoms, Barrett’s esophagus on biopsy, a peptic stricture in
the absence of malignancy, or positive pH-metry (Grade A)
GUIDELINES FOR SURGICAL TREATMENT OF GASTROESOPHAGEAL REFLUX DISEASE (GERD)
SOCIETY OF AMERICAN GASTROINTESTINAL AND ENDOSCOPIC SURGEONS

9. PH metry
• In the absence of endoscopic
evidence of reflux, the current gold-
standard objective test
• Can be wireless 48 hours PH metry
• Or 24 hours ambulatory PH metry
• the total time with pH < 4 as
recorded by a probe placed 5 cm
above the LES, and a composite score
(comprised of the following six
variables):
1. total esophageal acid exposure time
2. upright acid exposure time,
3. supine acid exposure time
4. number of episodes of reflux
5. number of reflux episodes lasting more
than 5 minutes
6. the duration of the longest reflux
episode) [

10. Normal value
reflux episodes

12. Algorithm for management

13. Indications for surgery
Gastrointestinal indications
• Failed optimal medical management
• Noncompliance with medical therapy
• Large hiatal hernias >5cm
• Severe esophagitis by endoscopy
• Benign stricture
• Barrett’s esophagus
• Persistent regurgitation

14. No gastrointestinal indications
upper respiratory symptoms including
• hoarseness
• laryngitis
• Wheezing
• nocturnal asthma
• cough
• aspiration

15. Investigations prior to surgery
• Esophagoduodenoscopy
• pH-metry
Esophageal manometry:
• identify conditions that might contraindicate fundoplication (such as
achalasia)
• modify the type of fundoplication according to a tailored approach based on
esophageal motility
• no support in the literature for mandatory preoperative
Barium swallow:
valuable in patients with large hiatal hernias who have a shortened esophagus
Yang Het al. Esophageal manometry and clinical outcome after laparoscopic Nissen fundoplication.
J Gastrointestinal Surg 11:1126-1133

16. Choice of surgery
Factors determining choice of surgery :
1. degree of esophageal shortening
2. disturbances of esophageal motility
3. prior operations
4. local expertise with laparoscopic techniques
Open
techniques

17. Early uncomplicated disease
• ant reflux procedures :
Nissen fundoplication
Cure rate : 98% at 3 years
73% after 10 years
Complicated disease
Benign strictures: preoperative dilation with 48 fr dilator
Barret's esophagus : mucosal ablation
Ca esophagus : esophageal resection

18. Nissen fundoplication
Approach : transabdominal

19. Laparoscopy versus laparotomy
• Laparoscopic : lesser hospital stay
• Faster return to work
• Similar outcomes
• reduced rates of complications
• Significantly lower incidence of incisional hernias and defective fundic
wraps
• relatively high incidence of postoperative dysphagia (8 to 12 percent)
compared with an open approach
• may be attributable at least in part to difficulty determining the
looseness of the wrap at laparoscopy

20. Laparoscopic fundoplication

21. Mobilization of esophagus
A.posterior and right side dissection
B. anterior and left dissection

22. Esophagus brought to abdomen (3-4 cm)
Complete mobilization of the fundus

23. E.Wrap around the GE junction
Completed wrap

24. 360 degree wrap

25. Open fundoplication
• Upper midline incision
• Retraction of the liver
• Excision of gastrohepatic ligaments
• Exposure of the crus and exposure of retroesophageal space
• Esophageal dissection
• Fundus mobilization
• Repair and fundoplication

26. Complications
Double stomach or hourglass stomach
3-23%
4-16% 40-65%
Juhasz ASurg Endosc. Endoscopic assessment of failed fundoplication: a case for standardization.
2011 Dec;25(12):3761-6. doi: 10.1007/s00464-011-1785
1-10%

27. • esophagogastric perforations
• pneumothorax
• splenic injuries
• vagal nerve injuries
• incisions include wound infections, which are reported to range from
0.2% to 3.1%
• port-site hernias ranging from 0.17% to 9%

28. • Recommendation
minimize postoperative dysphagia by choosing a partial fundoplication
(Grade A) or a short total fundoplication (1 to 2 cm) over a large bougie
(56 French) (Grade C)

29. Recommendation
• Crural closure should be strongly considered during fundoplication
when the hiatal opening is large and mesh reinforcement may be
beneficial in decreasing the incidence of wrap herniation (Grade B)
• Anterior crural closure may be associated with less postoperative
dysphagia, but additional evidence is needed to provide a firm
recommendation (Grade C).

30. Predictors failure of operation

31. POSTOPERATIVE SYMPTOM MANAGEMENT
Dysphagia
• Most patients have some degree of postoperative dysphagia
• modified dietary intake primarily consisting of liquids from 2 to 12 weeks
• Dysphagia that persists for more than 12 weeks require
• barium swallow to assess the anatomic placement of the fundoplication
indication for dilatation :
• Patients with dysphagia in whom the 13 mm barium tablet passes slowly through the
esophagus
ho had normal motility preoperatively
Dominitz Jaet al. Clin Gastroenterol Hepatol Complications and antireflux medication use after antireflux
surgery.2006;4(3):299

32. • 6 to 12 percent of patients with fundoplication required dilation
• technique: bougie/ guidewire dilation/pneumatic dilations
If failed/if passage of barium tablets cannot be established
• may be converted to partial fundoplication by a reoperation

33. Gas bloat syndrome
• a sensation of intestinal gas with the inability to belch
• In patients with only mild symptoms, we suggest empiric trials of
simethicone chewable tablets or charcoal caplets
• an empiric trial with
• metoclopramide (10 to 15 mg four times daily)for 2-3 months
• Domperidone
• Erythromycin
• severe persistent symptoms despite the above treatment approaches and
who have documented gastroparesis, pyloroplasty, pyloric botox, and
pneumatic pyloric dilatations

34. Other techniques
Decreased motility ,pressure less than 30 mmHg
• For the patient with normal length but decreased motility, a complete
fundoplication is discouraged
• Laparoscopic or open Toupet or
• Hill gastropexy
• Transthoracic Belsey

35. Toupet
fundoplication Nissens complete vs partial wrap
Partial fundoplication preferred is suboptimal
peristalsis/decreased molility ( pressure < 30 mmHg )
Fewer obstructive symptoms (dysphagia )
Anterior wrap (180 DOR)vs posterior wrap(270 Toupet)
Posterior 270 degree wrap has lesser reflux,lesser post
operative PPI use and reoperations
Memon Ma et al Laparoscopic anterior versus posterior fundoplication for
gastro-esophageal reflux disease: a meta-analysis and systematic review World J
Surg. 2015 Apr; 39(4):981-96.

36. Hill gastropexy
• used in a patient with a small stomach
because of prior gastric resection
• involves imbrication of the anterior and
posterior lesser gastric curve around the
esophagus with tethering of the
complex to the median arcuate ligament
and closure of the diaphragm
• Intraoperative manometry is used to
achieve a desired LES pressure
• reconstruction of the angle of His

37. Gastric bypass
• For morbidly obese patients
• Roux-en-Y gastric bypass
• Several small series have reported a decrease in reflux symptoms as
well as complete or partial regression of Barrett's esophagus in
morbidly obese patients with RYGB

38. Shortened esophagus
• a shortened esophagus from chronic inflammation or altered anatomy
• Can be present in patients with
• esophageal stricture
• Barrets esophagus
• Paraoesophageal hernia
• A Collis (esophageal lengthening) gastroplasty combined with an intra-
abdominal or intrathoracic fundoplication
• Transthoracic approaches:
• concurrent pulmonary disease requiring evaluation
• extensive prior abdominal surgery

39. LINX prosthesis
works by augmenting the LES with a ring
made up of a series of rare earth magnets
The magnets have sufficient attraction to
increase the LES closure pressure but permit
food passage with swallowing
• Eligible patients
• Typical GERD symptoms.
• Abnormal pH study.
• Partial response to daily PPI therapy.
• Absence of a large hiatal hernia (>3 cm) or
severe esophagitis.
• C/I who have allergies to titanium, stainless
steel, nickel, or iron
Laparoscopic magnetic sphincter augmentation

40. Single-group trial of 100 patients with long-standing GERD
At five years after LINX implantation
• moderate or severe heartburn (12/89)
• moderate or severe regurgitation (1 /57)
• bothersome gas-bloat (8/52 )
• daily PPI use (15/100 )
• GERD-related quality of life was also better
• No device erosions, migrations, or malfunctions
• The ability to belch or vomit, when needed, was preserved in all patient
• Early dysphagia is prominent with LINX implantation but generally resolves
within a few weeks
• The rate of long-term dysphagia was not significantly increased from the
baseline (6 versus 5 percent).
Warren HF et al.Ann Surg. Manometric Changes to the Lower Esophageal Sphincter After Magnetic Sphincter Augmentation in Patients
With Chronic Gastroesophageal Reflux Disease.
2017;266(1):99

41. Endoscopic methods
Stretta
• effective therapy in patients with an LES
pressure of at least 8 mmHg and hiatal
hernia less than 3 cm
• The specialized catheter is placed with
endoscopic assistance over a guidewire
• Using monopolar energy, a series of 56
treatments is delivered across five levels
Mikami DJ,et al. Surg Clin Nort
Physiology and pathogenesis of gastroesophageal reflux disease
h Am. 2015 Jun;95(3):515-25. Epub 2015 Mar 24.

42. Transoral incisionless fundoplication
• endoscopic procedure
• performed under general anesthesia to create a
full-thickness serosa-to-serosa plication that is 3
to 5 cm in length and 200 to 300 degrees in
circumference (partial fundoplication)
Indications:
• typical GERD symptoms
• no or only low-grade erosive esophagitis
(grades A and B),
• no or only small hiatal hernia (≤2 cm)

43. C/I:
Barrett esophagus
Atypical
extraesophageal symptoms of GERD
Scleroderma
other esophageal pathology or surgery
• less invasive and safer than surgical fundoplication with the aim of
achieving similar efficacy rates
• decreased reliance on PPIs or other oral medications used for GERD
Dalbir S. Sandhu et al.Gut liver.Current Trends in the Management of Gastroesophageal Reflux Disease 2018 Jan; 12(1): 7–16.

44. Revisional Surgery for Failed Antireflux Procedures
Laparoscopic reoperative antireflux surgery is feasible, safe, and effective but has higher
complication rates compared with primary repair and should be undertaken only by experienced
surgeons using a similar approach to primary fundoplication (Grade B).

45. Summary
• GERD diagnosed by clinical features and endoscopic changes
• Non erosive esophagitis diagnosed with PH metry
• Indications for surgery
• Laparoscopic Nissens fundoplication is the gold standard
• Dysphagia is the common complication after 360 degree
fundoplication which can be reduced using a 56 fr bougie
• Other newer techniques are: LINX prosthesis and endoscopic
techniques

46. References
GUIDELINES FOR SURGICAL TREATMENT OF GASTROESOPHAGEAL REFLUX DISEASE (GERD), SAGES
2010
Shackelford's Surgery of the Alimentary Tract,7th edition
BAILEY AND LOVE SHORT PRACTICE OF SURGERY, 27TH EDITION