Extinguish the “fire” of serious heartburn


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Most adults have suffered from heartburn at one time or another, but some cases of heartburn can lead to more serious problems, including acid reflux. Conservative measures like oral medication can help, but when symptoms persist or worsen, there is a surgical solution. Robotic surgery can correct the problem, typically with fewer complications and faster recovery time than ever before. Dr. Eric High discusses this revolutionary treatment to treat severe acid reflux symptoms. www.SpringfieldClinic.com/GeneralSurgery

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  • Extinguish the “fire” of serious heartburn

    1. 1. Extinguish the Fire of Serious Heartburn Eric M High MD – General Surgery Department
    2. 2. www.SpringfieldClinic.com 2
    3. 3. Overview • • • • • Define reflux Symptoms of reflux How do we diagnose reflux Treatment options What can I offer?
    4. 4. • • What is reflux? backup of stomach contents into esophagus normal component-occurs after meals and is typically short lived and doesn’t occur at night and causes minimal if any symptoms
    5. 5. What is reflux? • abnormal component-occurs outside meals, during sleep, affects everyday life
    6. 6. What Would “Reflux” feel like • Burning sensation beneath sternum and/or upper abdomen – “heartburn” • regurgitation-gastric contents may come up into mouth during burping or hiccups or spontaneously
    7. 7. Other lesser known symptoms • chest pains • “lump in their throat” • nausea • persistent cough • hoarse voice/raspy voice
    8. 8. A+B=C • Differential – cardiac • heart attack – esophageal dysfunction – gallbladder • stones, sludge, low EF – stomach • gastritis, ulcer, gastroparesis, tumors, infections – pancreas • pancreatitis, tumor
    9. 9. What should I tell my doctor? • pay attention if some/all of the above symptoms present • if symptoms are worsening • discuss with your primary doctor
    10. 10. Diagnosis • UGI – chalky material that patient drinks, then multiple images are taken to see if contents “reflux” – can see hernias with this method sometimes • Esophagram – similar to above except only looks at esophagus – can see masses, narrowing
    11. 11. Diagnosis • Endoscopy – allows biospy – hernia – ulcers
    12. 12. Diagnosis • other tests – manometry • probe in esophagus to see pressures – pH monitoring • probe inserted in esophagus to measure how often reflux occurring • more often during evening, laying down, etc. • not used very often
    13. 13. Treatment • Medical – lifestyle modifications • weight loss • smoking cessation • avoid late night eating – eating smaller meals • avoid caffeine, chocolates, alcohol • sleeping positions
    14. 14. Treatment • Medical – medications • H2 blockers vs PPI – prilosec, protonix, etc. – review meds to see if they could be causing any of the symptoms
    15. 15. Treatment • Medical – Infection • H. Pylori – 10-14 day course of antibiotics and medications to eliminate the bacteria – need check after treatment to ensure bacteria gone » urease test
    16. 16. Complications • untreated reflux can lead to severe complications – strictures • inability to swallow that may need repetitive dilatations – cancer • leading cause for converting normal mucosa to cancer
    17. 17. Treatment • Surgical – hiatal hernia can lead to increased incidence of reflux and need repaired surgically – inability to adhere or tolerate medical therapies – symptoms are not improving on medicine or needing increasing dosage
    18. 18. Treatment • Complete picture from endoscopy, UGI, length of symptoms, and medical treatments • May need surgery to fix/help with symptoms
    19. 19. Hiatal Hernia Type I Type II Type III Type IV Surgery: Nissen Fundoplication Surgery: Paraesophageal Hernia Repair w/Nissen Surgery: Paraesophageal Hernia Repair w/Nissen Surgery: Paraesophageal Hernia Repair w/Nissen
    20. 20. Normal Anatomy • • • • • Sliding hernia (Type I) GE junction above diaphragm Causes Acid Reflux Disease (GERD) No true hernia sac Nissen Fundoplication is performed
    21. 21. Paraesophageal hernia (Type II) •Stomach fundus into chest •Fixed GE Junction Paraesophageal hernia (Type III) •Stomach fundus into chest •GE Junction above diaphragm
    22. 22. Paraesophageal hernia (Type IV) •Stomach, GE Junction, and other organs above diaphragm
    23. 23. Primary Closure Straight suturing Small hernias Most common Mesh Closure Synthetic or Biologic Mesh For Large hernias (>5cm) Costly (biologic even more) Sutures or Tacks (cost)
    24. 24. Surgical Options • “Wrap” – upper portion of stomach is wrapped completely around end of esophagus – “Nissen”
    25. 25. Surgical options • Partial wraps – Dor • anterior wrap – Toupet • posterior • CT Surgery options – Belsey – used if multiple upper abdominal surgeries or if very large hiatal hernia
    26. 26. Surgical Options • Open – large midline incision, longer recovery • now mainly used as choice if recurrent or multiple previous surgeries • Laparoscopic – 4-6 incisions – carbon dioxide for inflating and giving room to work – most often done now
    27. 27. Surgical options • Robotically – similar to laparascopic surgery – 3-4 incisions – carbon dioxide for inflating
    28. 28. •3-Dimensional Anatomy •Protect Vagus Nerve, Aorta Learning Curve Visualization •In preparation for complex paraesophageal hernia or redo Nissens Advanced Sealing / Dissection* •Wristed Vessel Sealer •Avoid gastric or esophageal perforation Advanced Suturing Capability •Fundoplication can come undone •Assessment of wrap tightness
    29. 29. Primary Closure Straight suturing Small hernias Most common Mesh Closure Synthetic or Biologic Mesh For Large hernias (>5cm) Costly (biologic even more) Sutures or Tacks (cost)
    30. 30. Final thoughts • reflux is very common • most patients are managed very well with medications and lifestyle changes – obesity – smoking • if symptoms are not improving – may need EGD to check anatomy – may need surgery to address problem
    31. 31. What can I offer? • Board certified General Surgeon – advanced laparoscopic training – robotic trained • Endoscopy trained
    32. 32. More Resources Find videos, handouts and more resources at www.SpringfieldClinic.com/DoctorIsIn