This document discusses the anatomy of the gastroesophageal junction, with a focus on hiatal hernia and the anatomical basis for therapeutic intervention. Key points include:
- The gastroesophageal junction is defined anatomically by the squamocolumnar junction, the transition from esophageal to gastric lining, and the junction of the esophageal and gastric musculature.
- Hiatal hernias are classified based on the location of the hernia, with type I being a sliding hernia and type II being a paraesophageal hernia where the gastric fundus herniates alongside a normal cardia.
- Indications for surgical repair of paraesophageal hernias include symptoms and the risk
KEYWORDS
Liver Pancreas Spleen CT angiography Dual-energy CT
KEY POINTS
MDCTA allows acquisition of data with enhanced spatial and temporal resolution that can be reconstructed
for robust preoperative road mapping.
MDCTA can detect normal and variant vascular anatomy as well as allow accurate lesion characterization
within the liver and pancreas.
Using dual-energy CT, virtual unenhanced images can be generated, thereby reducing overall radiation
dose. In addition, material composition allows for robust delineation of enhancement.
A triphasic, or triple-phase, CT scan is an enhanced CT technique mostly used to evaluate liver lesions. This technique acquires images at 3 different time points, or phases, following the administration of a contrast.
KEYWORDS
Liver Pancreas Spleen CT angiography Dual-energy CT
KEY POINTS
MDCTA allows acquisition of data with enhanced spatial and temporal resolution that can be reconstructed
for robust preoperative road mapping.
MDCTA can detect normal and variant vascular anatomy as well as allow accurate lesion characterization
within the liver and pancreas.
Using dual-energy CT, virtual unenhanced images can be generated, thereby reducing overall radiation
dose. In addition, material composition allows for robust delineation of enhancement.
A triphasic, or triple-phase, CT scan is an enhanced CT technique mostly used to evaluate liver lesions. This technique acquires images at 3 different time points, or phases, following the administration of a contrast.
Radiological anatomy of abdominal spaces ...pathway of tumor and infection s...Ahmed Bahnassy
The lecture combines gross anatomy with cross sectional imaging in evaluation of different abdominal and pelvic cavities and recesses.This will explain the routes of spread of infection or malignancies.
Radiological anatomy of abdominal spaces ...pathway of tumor and infection s...Ahmed Bahnassy
The lecture combines gross anatomy with cross sectional imaging in evaluation of different abdominal and pelvic cavities and recesses.This will explain the routes of spread of infection or malignancies.
Surgical therapy is usually prescribed to a patient for these underlying problems. The surgeon will attempt to pull the stomach back into the abdomen, correcting the hiatal hernia, but there is another, less invasive way to fix this problem.
If you are diagnosed with a hiatal hernia, via a doctor’s visit and subsequent endoscopic exploration, then you are likely going to be prescribed one of various pharmaceutical medications, or surgeries, most of which can have mild to severe side effects or complications.
For many, the prescribed treatment of a hiatal hernia is similar to the management of GERD. Though surgery is usually only considered for patients with recurring symptoms and those who develop complications, such as recurrent bleeding, ulcerations or strictures, it has become more common in the past several years.
Medication for Hiatus Hernia
Grocare has developed a way to treat hiatal hernia without resorting to these more common methods. It is also very effective.
In Grocare’s estimation, there are a number of underlying reasons that this specific type of hernia develops in the body.
Most often, hiatal hernias are caused by a combination of muscle weakness and strain. This means that hernias can develop based on your lifestyle. Depending on its cause, a hernia can develop quickly or over a long period of time.
An unbalanced lifestyle will contribute to developing hernia most commonly, over a prolonged period of time.
A sedentary lifestyle causes an imbalance of pH in the body which causes all of the organs to weaken (including the stomach and esophagus). When the unbalanced lifestyle is continued over a period of time, it leads to additional stress on the organs – primarily the intestines. Coupled with acidity and an imbalanced pH, a hiatal hernia can develop.
Though there are other reasons that a hiatal hernia can develop, such as coughing excessively, straining during bowel movements or from vomiting, a hiatal hernia that results from these actions also usually indicates weakened organs.
Other people are simply born with a larger opening or valve (hiatus.)
Grocare has noticed that many medical practitioners prescribe chemicals such as omeprazole and esmeprazole for hiatus hernia. These chemical ‘cures’ do not really help in the treatment of your hernia.
Grocare India offers two medicines that address pH balance in the body and begin to decrease inflammation that is caused by improper pH levels.
Hernica and Acidim, have been especially effective in the treatment of hernia.
These natural medicines help the whole system to becomes healthy. They help to reduce the swelling of the intestines, and any obtrusion (lumps) from the stomach into the abdomen starts to heal.
www.grocare.com/diagnose/hiatal-hernia
http://www.grocare.com/blog/2016/12/07/medication-for-hiatus-hernia/
Carcinoma esophagus is a lethal disease and carries poor prognosis.The diagnosis is usually delayed and over all 5yrs survival is less than 15% In this presentation I have discussed carcinoma esophagus - its pathology, clinical features, investigations and treatment in nutshell
We understand the unique challenges pickleball players face and are committed to helping you stay healthy and active. In this presentation, we’ll explore the three most common pickleball injuries and provide strategies for prevention and treatment.
R3 Stem Cells and Kidney Repair A New Horizon in Nephrology.pptxR3 Stem Cell
R3 Stem Cells and Kidney Repair: A New Horizon in Nephrology" explores groundbreaking advancements in the use of R3 stem cells for kidney disease treatment. This insightful piece delves into the potential of these cells to regenerate damaged kidney tissue, offering new hope for patients and reshaping the future of nephrology.
Navigating Challenges: Mental Health, Legislation, and the Prison System in B...Guillermo Rivera
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According to TechSci Research report, "India Clinical Trials Market- By Region, Competition, Forecast & Opportunities, 2030F," the India Clinical Trials Market was valued at USD 2.05 billion in 2024 and is projected to grow at a compound annual growth rate (CAGR) of 8.64% through 2030. The market is driven by a variety of factors, making India an attractive destination for pharmaceutical companies and researchers. India's vast and diverse patient population, cost-effective operational environment, and a large pool of skilled medical professionals contribute significantly to the market's growth. Additionally, increasing government support in streamlining regulations and the growing prevalence of lifestyle diseases further propel the clinical trials market.
Growing Prevalence of Lifestyle Diseases
The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
Leading the Way in Nephrology: Dr. David Greene's Work with Stem Cells for Ki...Dr. David Greene Arizona
As we watch Dr. Greene's continued efforts and research in Arizona, it's clear that stem cell therapy holds a promising key to unlocking new doors in the treatment of kidney disease. With each study and trial, we step closer to a world where kidney disease is no longer a life sentence but a treatable condition, thanks to pioneers like Dr. David Greene.
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
Navigating the Health Insurance Market_ Understanding Trends and Options.pdfEnterprise Wired
From navigating policy options to staying informed about industry trends, this comprehensive guide explores everything you need to know about the health insurance market.
How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
Anatomy of gastroesophagial junction with specail reference to hiatus hernia & its basis of therapeutic intervention
1. Anatomy of Gastroesophageal
Junction with special reference
to hiatus hernia and anatomical
basis of therapeutic intervention
Dr. Rana Pratap Singh
JRII Surgery
M.L.B. Medical College, Jhansi
2. Introduction
• From mouth to stomach, the food conduit
consists of the oral cavity, pharynx, and
esophagus.
• The esophagus serves as a dynamic tube,
pushing food toward the stomach.
• Active peristaltic contractions propel residual
material from the esophagus into the
stomach.
3. Anatomical Division
The esophagus is a midline structure lying on
the anterior surface of the spine.
It descends through three compartments: the
neck, the chest, and the abdomen.
This progression has led to its classic anatomic
division into cervical, thoracic, and abdominal
segments.
4. Two new subdivisions
One is functional aspects and makes a distinction
between the esophageal body and the upper and
lower sphincters.
The other is oncosurgery aspects and
distinguishes between the proximal and the distal
esophagus, with the tracheal bifurcation used as
dividing part.
5.
6. Constrictions of esophagus
• It is the narrowest part of the alimentary tract (except for
the vermiform appendix).
• 1. at the beginning (15 cm from the incisor teeth),
• 2.crossed by the aortic arch (22.5 cm from the incisor
teeth)
• 3. crossed by the left bronchus (27.5 cm from the incisors)
• 4. as it passes through the diaphragm (40 cm from the
incisors).
7. • These are important clinically with regard to
the passage of instruments .
8.
9. Cervical esophagus
• approximately 5 cm long
• descends between the trachea and the vertebral
column.
• C6 to the level of the interspace between the T1 and
T2 vert posteriorly, and suprasternal notch
anteriorly.
10. Thoracic esophagus
• approximately 20 cm long.
• It starts at the thoracic inlet.
• In thorax, it is in close relationship
with the posterior wall of the
trachea and the prevertebral fascia.
11. • Just above the tracheal bifurcation, the
esophagus passes to the right of the
aorta. This anatomic positioning can
cause a notch indentation in its left
lateral wall on a barium swallow
radiogram.
12. abdominal esophagus
• 2 cm long and includes a portion of the lower
esophageal sphincter (LES) .
• It starts as the esophagus passes through the
diaphragmatic hiatus and is surrounded by the
phrenoesophageal membrane.
13. • The musculature divided into an outer
longitudinal and an inner circular layer.
• The upper 2 to 6 cm of the esophagus
contains only striated muscle fibers.
From there on, smooth muscle fibers
gradually become more abundant.
14. Arterial supply
• Cervical Oesophagus: Right & Left superior &
inferior thyroid arteries.
• Thoracic Oesophagus: Up to tracheal bifurcation
Right & Left inferior thyroid Artery
direct supply from aorta (tracheo-bronchial tree)
• Abdominal Oesophagus: ascending branch of the left
gastric artery and from inferior phrenic arteries
15.
16.
17. Gastroesophageal Junction
• 4 anatomical points that identify the
gastroesophageal junction (GEJ): two endoscopic
and two external.
• Endoscopically-
1. The squamocolumnar epithelial junction (Z-line)
may mark the GEJ provided the patient does not
have a distal esophagus replaced by columnar-
lined epithelium as seen with Barrett's
esophagus.
2. The transition from the smooth esophageal lining
to the rugal folds of the stomach.
18. • Externally-
1.the collar of Helvetius (or loop of Willis)-
where the circular muscular fibers of the
esophagus join the oblique fibers of the
stomach
2.the gastroesophageal fat pad
19.
20. • Two to three centimeters above the hiatus of
the diaphragm it is anchored at its lower end
by the insertion of a tough, skirt-like
prolongation of the endoabdominal fascia
from the undersurface of the diaphragm, the
ascending leaf of the phrenoesophageal
ligament.
21.
22. • 2 to 5cm below the insertion of the
phrenoesophageal ligament. squamous
changes to columnar epithelium.
• The point of transition is marked by ora
serrata or "z" line
• Two cm of the esophagus immediately above
the epithelial junction are contained within
the sling of the right diaphragmatic crus as it
forms the hiatus.
23. PHRENOESOPHAGEAL LIGAMENTS
• The phrenoesophageal ligament arises
primarily from the endoabdominal fascia.
• At the lower margin of the esophageal hiatus,
it decussates into an upper and a lower leaf.
• The upper leaf extends through the hiatus to
insert into the esophagus two to three
centimeters above it.
24. • The lower leaf, which exists as a loosely
defined collection of fibroelastic fibers,
descends to insert into the esophagus at or
below the epithelial junction.
• The upper leaf is strong, well-defined
membrane rather than a ligament
26. • Physiology
–It has been shown by manometric
techniques that a sphincteric mechanism
exists at the gastroesophageal junction.
–This barrier we refer to as the lower
esophageal sphincter.
27. • Two conditions under which the gastroesophageal
junction must maintain competence.
1. First is at rest
2. Second raised intra abdominal pressure.
28. At rest the sphincter normally maintains a
pressure barrier between positive intra gastric
and negative intrathoracic pressure.
This pressure differential is approximately 10
cm. H2O .
It is present in all phases of respiration and
may be maintained even when the GE
junction is displaced into the thorax, as in
sliding hernia.
29. • Raised intra abdominal pressure.
The phrenoesophageal ligament maintains the
esophagogastric junction within the abdomen,
and the increased intraabdominal pressure is
brought equally to bear on the abdominal
esophagus containing a portion of the
sphincter as well as on the stomach.
• The sphincter, reinforced by this pressure, is
able to maintain a pressure differential
between the stomach and thoracic esophagus.
30. • Pathophysiology
– In hiatal hernia of the sliding type, the clinical
manifestations are due to gastroesophageal reflux.
– hiatal hernia may exist and even attain mammoth
proportions without reflux.
– The mechanism which can prevent reflux under
these conditions is the sphincter .
31. • What then leads to the development of
gastroesophageal reflux?
– The answer is that the gastroesophageal sphincter
has become incompetent.
32. • The normal tension on the
A. Normally, the ascending limb
of the phrenoesophageal
ligament inserts into the
esophageal wall above the
lower esophageal sphincter
mechanism. Forces applied
to the ligament by the
contracting diaphragmatic
musculature serve only to
dilate the esophagus above
the sphincter. This may be
the origin of the
radiologically familiar
"Phrenic Ampulla."
33. B. If the ligamentous
insertion were to be
displaced inferiorly,
then tension
transmitted through the
ligament would serve to
dilate the sphincter
itself, allowing
gastroesophageal reflux
to to occur.
34. C. The same situation would
pertain in the patient with a
sliding hiatal hernia.
Normally, in the hiatal hernia
patient without reflux, the
ligament would insert above
the sphincter area, producing
the classic three radiologic
criteria of hiatal hernia: The
phrenic ampulla, the
esophageal vestibule
(corresponding to the
sphincter area which has
been displaced above the
diaphragm), and the supra-
diaphragmatic gastric
loculus.
35. D. If the ligamentous
insertion were to be
displaced inferiorly,
reflux would ensue. If
the patient still
possessed a
competent sphincter,
any operation which
would reduce
tension on the
ligaments would cure
the reflux.
36. Esophageal tissues
Wall structure at the esophagogastric junction. The tunica muscularis is composed of both a longitudinal (2a)
and a circular layer (2b). a, muscularis mucosae; b, lamina propria; c, epithelium; G1, esophageal glands; G2,
gastric glands; Ly,lymph vessels; N1, myenteric plexus; N2, submucous nerve plexus.
38. B. The rolling or PEH, type
II, characterized by an
upward dislocation of
the gastric fundus
alongside a normally
positioned cardia.
39. C. The combined
sliding-rolling or
mixed hernia, type
III, characterized by
an upward
dislocation of
boththe cardia and
the gastric fundus
40. D. In some taxonomies,
a type IV hiatal
hernia is declared
when an additional
organ, usually the
colon, herniates as
well
41. • incidence of a sliding hiatal hernia is seven
times higher than that of a PEH. The PEH is
also known as the giant hiatal hernia.
• The median age of the PEHs is 61 years old; of
the sliding hiatal, 48 years old. PEHs are more
likely to occur in women by a ratio of 4:1.
42. Clinical Manifestations
• The clinical presentation of a giant hiatal
(paraesophageal) hernia differs from that of a
sliding hernia.
• symptoms of dysphagia and postprandial
fullness with PEHs, but the typical symptoms
of heartburn and regurgitation present in
sliding hiatal hernias can also occur.
43. Diagnosis
1. A radiogram of the chest with the
patient in the upright position can
diagnose a hiatal hernia if it shows
an air-fluid level behind the cardiac
shadow.
44. 2. Fiber-optic esophagoscopy is useful in
the diagnosis and classification of a hiatal
hernia because the scope can be
retroflexed.
45. • Sliding hiatal hernia can be identified by
1. Rugal folds extending above the
impression caused by the crura of the
diaphragm.
2. Measuring at least 2 cm between the
crura and the squamocolumnar
junction.
46. • PEH is identified on retroversion
of the scope by noting a separate
orifice adjacent to the GEJ into
which gastric rugal folds ascend.
48. INDICATIONS & SURGICAL APPROACH
• This recommendation is based upon two
clinical observations.
• First, retrospective studies have shown a
significant incidence of life-threatening
complications of bleeding, infarction, and
perforation in patients being followed with
known paraesophageal herniation.
49. • Second, emergency repair carries a high
mortality.
• If surgery is delayed and repair is done on an
emergency basis, operative mortality is high,
compared to <1% for an elective repair
50. SURGICAL APPROACH
• A transthoracic approach facilitates complete
esophageal mobilization but is rarely used
because the access trauma and postoperative
pain are significantly greater than a
laparoscopic approach.
51. The transabdominal approach facilitates reduction of
the volvulus that is often associated with PEHs.
Although some degree of esophageal mobilization
can be accomplished transhiatally, complete
mobilization to the aortic arch is difficult or
impossible without risk of injury to the vagal nerves.
52. ROLE OF FUNDOPLICATION IN HIATAL
HERNIA REPAIR
• Most advocate the routine addition of an
antireflux procedure following repair of the
hernia defect.
• The main reasons for this.
1. Physiologic testing with 24-hour esophageal pH
monitoring has shown increased esophageal
exposure to gastric juice in 60 to 70% of patients
with a PEHs,
2.71% incidence in patients with a sliding hiatal
hernia
53. PREOPERATIVE EVALUATION
1. First, the propulsive force of the body of the
esophagus should be evaluated by esophageal
manometry to determine if it has sufficient
power to propel a bolus of food through a
newly reconstructed valve.
54. • Patients with normal peristaltic contractions
do well with a 360° Nissen fundoplication.
• When peristalsis is absent a
partialfundoplication may be the procedure of
choice, but only if achalasia has been ruled
out.
55. 2. Second, shortening of the esophagus can
compromise the ability to do an adequate repair
without tension, and lead to an increased
incidence of breakdown or thoracic displacement
of the repair.
• Esophageal shortening is identified on a barium
swallow roentgenogram by a sliding hiatal hernia
that will not reduce in the upright position, or that
measures larger than 5 cm between the
diaphragmatic crura and GEJ on endoscopy.
56. PRINCIPLES OF SURGICAL THERAPY
• Operation should restore the LES
pressure twice the resting gastric
pressure.
• The length of the intraabdominal
oesophagus should be maintained 2 or
more cm.
• Apposition of diaphragmatic crurae,
reduction of hiatus hernia done when
present.
57. • Repaired OG junction should relax during
swallowing adequately. To ensure this
only fundus of the stomach should be
used to buttress the sphincter and avoid
damage to vagal nerve.
• Tension free short and flopy
fundoplication should be done.
58. Fundoplications
• Nissen’s – total 3600 posterior fundoplication.
• Toupet’s – partial 1800 posterior fundal.
• Dor – anterior partial.
• Rosetti Hell – total anterior fundal
• Watson’s – anterolateral 1200 partial.
• Lind – posterior and anterior
60. b. The liver retractor is affixed to a
mechanical arm to hold it in place
throughout the operation.
61. c. After division of the gastrohepatic
omentum above the hepatic branch of
the vagus (pars flaccida), the surgeon
places a blunt atraumatic grasper
beneath the phrenoesophageal ligament.
62. d. After completion of the crural
closure, an atraumatic grasper is
placed right to left behind the
gastroesophageal junction. The
grasper is withdrawn, pulling the
posterior aspect of the gastric fundus
behind the esophagus
63. e. Once the suture positions are chosen,
the first stitch (2-0 silk, 20 cm long) is
introduced through the 10-mm trocar,
and the needle is passed first through the
left limb of the fundus, then the
esophagus (2.5 cm above the
gastroesophageal junction), then through
the right limb of the fundus.