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FINAL GERD.pptx
- 1. Emerging trends in managementof GERD BY KRATIKA AGRAWAL MENTOR DRABHISHEKTIWARI
- 2. CONTENTS 1. INTRODUCTION 2. PATHOPHYSIOLOGY 3.SYMPTOMS 4. CLINICAL SPECTRUM OF DISEASE 5. INVESTIGATIONS 6. HOW TO APPROACH 7. LIFESTYLE MODIFICATIONS 8. MEDICAL MANAGEMENT 9. ENDOSCOPIC MANAGEMENT 10. SURGICAL MANAGEMENT
- 3. INTRODUCTI ON The AmericanCollege of Gastroenterology (ACG) guidelines define “symptoms or complications resulting from the reflux of gastric contents into the esophagus or beyond, into the oral cavity (including larynx) or lung.”
- 5. SYMPTOMS ESOPHAGEAL SYMPTOMS Heartburn Regurgitation Water brash Chest pain Discomfort Dysphagia Belching Epigastric pain Nausea Bloating EXTRAESOPHAGEAL SYMPTOMS Cough Hoarseness Throat clearing Throat pain Burning Wheezing Sleep disturbances • Dysphagia • Odynophagia • Anorexia • Weight loss • Upper gastrointestinal bleeding ALARM SYMPTOMS
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- 8. AMBULATORY PH MONITORING •Gold standard test. • Data : 1. total number of reflux episode (Ph<4) 2. Longest episode of reflux 3. No. of episode lasting longer than 5min 4. % of time spent in reflux in the upright and supine position DEMEESTER SCORE is calculated Abnormal when >= 14.7
- 9. PH IMPEDANCE CATHETAR •Monitor non acid reflux as well as acid reflux • performed with thin flexible catheter • Electrodes placed at 1 cm intervals • Impedance increase in air and decrease in liquid bolus • Differentiate retrograde (gastroesophageal reflux) and antegrade (swallow) event. • Drawback: automated analytic software is very sensitive and therefore overestimate non acid reflux episode (hence manually reviewed which is time consuming ) DUAL PH PROBE
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- 11. Esophageal manometry • Assess 1.function of esophageal body and LES (pressure wave) 2. Measures LES resting pressure 3. Esophageal motility (peristalsis) 4. measurements of gastric, pyloric and small bowel contractility
- 12. ESOPHAGOGASTRODUOD ENOSCOPY • Evaluate GERDconsidered for LARS • Examine mucosal injury d/t GER i.e ulcerations, peptic stricture, and barrett esophagus • Peptic stricture and LA C and D esophagitis – pathognomonic for GERD as ambulatory Ph is unnecessary in these patients • Assess GEJ flap valve (by retroflexing endoscope 180 degree in stomach) BARIUM ESOPHAGRAM Anatomy of esophagus and stomach (preop evaluation) Imp to diagnose hiatal hernia and PEH Episode of GER Identify additional condition : Esophageal diverticula, tumors, peptic strictures, achalasia, dysmotility
- 14. Heartburn and regurgitationwithout alarm symptoms Impairs quality of life Emperical t/t- PPIs for 8week OD before meal
- 19. Medical management Firstline treatment:PPIs (Adequate dose for 8 weeks) A policy of ‘step-down’ medical treatment is advocated after the initial 8 weeks of treatment 1. Decrease dose ( symptoms free) 2. Cessation of PPI Inadequate treatment 1. Another PPI 2. Increased Dosage 3. Twice-a-day 4. Addition Of An H2-receptor Antagonist
- 20. Antacid–alginate preparationstarget the acid pockets and form a polysaccharide barrier at the proximal stomach. Potassium-competitive acid blockers (P-CABs)- VONOPRAZAN rapid, competitive, reversible inhibition of proton pumps. Baclofen, a gamma-aminobutyricacid-B agonist refractory GERD by reducing the rate of TLESR
- 21. Minimal invasive therapyfor GERD
- 22. INDICATIONS Typical symptoms Low grade Erosive esophagitis A/B Endoscopy s/o normal acid reflux <3cm hiatal hernia Partial response to PPI Poor compliance and desire to discontinue medicine Not interested in medical and surgical therapy CONTRAINDICATIONS Sliding hernia >3cm Morbidly obese Scleroderma h/o esophageal and gastric surgery Esophageal motor disorders Stricture, Esophageal varices Barrett's esophagus Pregnant/lactating women ENDOSCOPIC TREATMENT
- 23. Endoluminal therapy Theoriginal endoluminal therapies have been broadly categorized to four different types; 1. Fixation 2. ablation 3. injection 4. mucosal excision and suturing.
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- 25. Medigus ultrasonic surgical endostapler Mimicanterior fundoplication Procedure performed under GA with ET intubation
- 26. DEVICE(RADIOFREQUENCY ABLATION) Radiofrequency energy isdelivered to the muscularis propria INDICATED : Early reflux disease Mechanism of action: NEUROLYSIS OR TISSUE NECROSIS Causing • Local inflammation • Collagen deposition • Muscular thickening of LES RESULT : fewer TLOSRs SIDE EFFECT: chest pain and gastroparesis
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- 28. INJECTION/IMPLANTATION TECHNIQUE Enteryx Gatekeeper Durasphere GR Plexiglass All these therapies are not in use due to safety issues
- 29. Indications for Surgical management Patient’s choice and <18yrs Long term management in patient with objective evidence of GERD Severe reflux esophagitis (C and D) motility disorders Large hiatal hernia >2cm Troublesome and extraesophageal symptoms Persistent abnormal acid reflux and reflux hypersensitivity are likely to benefit Complications- barrett’s esophagus Morbid obesity
- 30. PREDICTORS OF SURGICALOUTCOME GOOD Typical symptoms PPI responders Hiatus hernia Complications present (reflux esophagitis, non dysplastic barrett’s esophagus POOR Normal pre operative pH functional heartburn EOO Connective tissue disease Extreme obesity SIDE EFFECTS • Dysphagia • Gas bloat • Abdominal discomfort • Failed antireflux surgery OPERATIVE COMPLICATIONS • Peumothorax • Gastric And Esophageal Injuries • Splenic And Liver Injuries And Bleeding
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- 32. Partial fundoplication POSTERIOR FUNDOPLICATIONANTERIOR FUNDOPLICATION TOUPET DOR/THAL BELSEY MARK IV FUNDOPLICATION INDICATED 1. MOTILITY DISORDERS, 2. EPIPHRENIC DIVERTICULA, 3. GIANT HIATAL HERNIA WITH PLEURAL ADHESIONS, 4. GASTRIC LENGTHENING NOT REQUIRED, 5. ESOPHAGEAL PERFORATION • Patient with esophageal dysmotility who have undergone LARS : partial fundoplication to dec postop dysphagia • Toupet – m/c Dor/thal –Used after esophageal (Heller) myotomy
- 33. Magnetic sphincter augmentation •Laparoscopically • LES resting pressure • Better control of regurgitation • Used in hiatal hernia >3cm • m/c s/e- dysphagia d/t extrinsic compression of device or fibrotic band formation around distal esophagus • Device erosion is feared complication – chest pain and dysphagia, endoscopy confirms it • If erode – removed by endoscopic approach f/b delayed lap removal of remainder
- 34. EndoStim Electrical StimulationTherapy Target weak lower esophageal sphincter (LES) to restore function via implantable pulse generator(IPG) and bipolar lead placed laparoscopically Showed significant and sustained improvement in GERD symptoms, esophageal pH and reduce in PPIs usage Currently not approved
- 35. COLLIS GASTROPLASTY Esophageallengthening procedure in patient undergoing fundoplication Involve stapling fundus of stomach(WEDGE FUNDECTOMY), create neoesophagus around which fundus can be wrapped Both transthoracic and transabdominal approach Cont on PPIs post op for short term d/t acid secreting gastric mucosa above the wrap.
- 36. Roux en yreconstruction Indications: 1. Bile Or Gastric Reflux 2. Morbid Obesity 3. Diabetes 4. Esophageal Dysmotility 5. Revisional Surgery (Scarring + And Questionable Vagus Condition Near Esophagojejunostomy Allow Passage Of All Gastric And Biliary Content Far Downstram Esophagus
- 37.
Editor's Notes
- #9 Quatify distal esophageal acid exposure (24hr) with thin catheter passed into esophagus with nares To monitor 48 hrs – wireless ph monitor
- #10 intervals to detect changes in resistance to flow of an electrical current (impedance
- #12 Gather data from 32 channel flexible catheter Pressure sensing device at 1 cm intervals Conducted in 15 minutes During this time patient perform 10 swallows
- #13 Image showing sliding hiatus hernia
- #18 Refractory – symptoms even after double dose of PPI given for 8 weeks
- #24 Ablative- stretta Injections- Enteryx , gatekeeper, durasphere Fixation- endoluminal gastroplication, endoscopic full thickness gastroplication system (NDO plicator), esophyx (transoral incisionless fundoplication) Mucosal excison and suturing – safesticth medical gastroplasty system
- #25 esophyx Mimic classic fundoplication by Reconstruct GEFV in omega shaped Restore its function as a reflux barrier, For patient with LES incompetence( HILL GRADE 2) without HH MOA : Recreate dynamic of angle of his SIDE EFFECTS : AET and reflux episode are not improved and PPI usage increase with time Used during the (endoluminal fundoplication technique )TIF® procedure to create a 3 cm, 270° esophagogastric fundoplication. utilizes proprietary tissue manipulating technology to deploy 20+ SerosaFuse fasteners that evenly distribute force across the entire circumference of the wrap. A GERDx™ arms are opened. B Tissue retractor is advanced to serosa. C, D Gastric wall is retracted into the GERDx™ arms. E A pre-tied transmural pledgeted suture is deployed. F Full-thickness plication is restructuring the GE junction The distal end of the device was then retroflexed to the anterior gastric cardia approximately 1 cm below the gastroesophageal (GE) junction. Originally to create a full-thickness intussusception at the gastroesophageal junction by a transoral sewing technique. Later modified to create endoscopic plications below and at the “Z” line. conscious sedation,40 to 60 min procedure BENEFITS: improvement of the gastroesophageal flap valve grade. reduced the relaxation rate of the LES improving the reflux symptoms decreased esophageal acid sensitivity.
- #26 the transoral stapler was advanced into the stomach through an overtube (17 mm ID/19.5 mm OD) and retroflexed under direct video guidance. After identifying a stapling location, the stapler was gently pulled back to place the staple cartridge in the esophagus approximately 3 cm proximal to the gastroesophageal junction (Fig. 1C). The operator then used the articulation knob to bend the device tip to press the fundus against the esophagus. Next, the screws were deployed. As the tissues were compressed, and direct visualization was no longer possible, the ultrasonic range finder automatically engaged to display the tissue thickness . When the tissue thickness was 1.4–1.6 mm, the operator fired the stapler. Each firing delivers a quintuplet pattern of five standard 4.8 mm surgical staples simultaneously. The screws were retracted back into the tip of the device, and the stapler removed for reloading. The procedure was repeated to add additional quintuplets of staples
- #27 Tissue temp are measure using thermocouple incorporated INTO active electrodes for approximately 60 s to a target temperature of 65-85 degrees Fahrenheit Gastroscope inserted to measure distance till z line and withdrawn Cathetar inserted and placed 1cm proximal to z line
- #28 ARMS, scarring of the artificial ulcer created by endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) at the gastric cardia tightens the enlarged cardiac opening. Anti-reflux mucosectomy (ARMS) rebuild the flap valve at the gastric cardia and technically challenging due to scarring from the previous treatment Endoscopic Mucosal Resection, Or EMR, Uses A Specially Designed Endoscope Or Colonoscope To Remove Suspect Tissue Or Polyps From Your Esophagus. The Tissue Or Polyp Is First Injected With A Solution That Raises A Blister, To Remove The Tissue Without Damaging The Rest Of The esophagus. The Solution Also Helps Decrease Bleeding. Suction Is Then Used To Further Lift The Growth Up And Away From Surrounding Tissue. A Thin Wire Loop Is Slipped Over The Tissue, And An Electric Current Is Passed Through The Wire. This Cuts The Growth And Helps To Seal The Wound. Once The Growth Is Free, It's Scooped Up In A Small Wire Basket And Removed From The Digestive Tract For Analysis In The Lab. It involves resection of gastric mucosa at the GEJ, including approximately 2 cm of gastric mucosa and 1 cm of esophageal mucosa=> results in scarring with shrinking and remodeling of the GEJ and creation of a flap valve, which causes an improvement of the Hill grade Endoscopic follow-up of anti-reflux mucosal ablation (ARMA). a Pre-ARMA. Endoscopy in retroflexion demonstrated significant hernia (Flap valve grade III) but no sliding component. b Immediately post-ARMA. Endoscopy in retroflexion showed butterfly-shaped artificial ulcer. c Appearance at 1 month post-ARMA. Mucosal flap valve was re-shaped (Flap valve grade I). d Before ARMA. Los Angeles grade A esophagitis is seen. e After ARMA. Erosive esophagitis resolved. 6 hr pre ARMA fasting Under GA Supine or left lateral decubitus Stomach insufflated with CO2 Marking done using triangle-tip knife j connected to elctrocautery(spray,coagulation mode Mucosal ablation around cardia (butterfly shape) leaving c/l normal cardiac mucosa to avoid stenosis Saline with indigo carmine dye was injected into the submucosal layer (25g needle) Submucosal cushion reduces thermal injury and perforation during ablation Adequate depth- reaching submucal layer PPIs FOR 1 MONTH POST PROCEDURE
- #29 Ethylene vinyl alcohol copolymer with tantalum dissolved in dimethyl sulfide The procedure is considered satisfactory if 6 to 8 mL of Enteryx is delivered to the muscularis propria circumferentially without a submucosal or transmural injection. After the injection is complete at one site, the needle remains in place for 20 s allowing the material to stabilize and solidify. This maneuver prevents leakage of the prosthesis into the esophageal lumen. Patients are usually discharged 2 to 4 h after recovery Gatekeeper reflux repair system was a dehydrated hydrogel prosthesis Implanted into submucosa of cardia/LES . Within24 h, the hydrogel implants were fully expanded, creatingpillow-like mounds in the esophageal wall or cardia sub-mucosa, which bulged into the lumen, thus creating apotential mechanical antireflux barrier. Composed of pyrolite carbon coated graphite beads containing Zirconium oxide susoended in water based absorbable polysaccharide carrier gel Size of beads : 90microm to 212microm to prevent migration Injected in submucosa within 1 cm of Z line The procedure is considered complete when the esophageal walls are approximated at the GEJ. Patients can be discharged within 60 minutes. POLYMETHYLMETHACRYLATE,PMMA Implanted submucosally (1-2 cm proximally to SCJ ) Volume – 32ml S/E: transient and gas bloat syndrome if excessive treatment with 39ml volume Not antigenic and donot cause any systemic complications Highly viscous Sigmoidoscope with large biopsy channel (large capacity catheter ) used for implantation.
- #32 Surgeon- between patient’s legs and operate through two cephalad port Assistant- patient’s left and operate through two caudad port Access – veress needle at palmer point at left upper quadrant of abdomen Nathanson liver retractor- small epigastric incision not require trocar Low lithotomy position with steep reverse tredelenburg- to improve esophageal hiatus view
- #33 Belsey : Transthoracic approach Via left posterolateral thoracotomy Return high pressure zone of cardia(4-5cm distal esophagus) to its normal anatomical position below diaphragm. Incomplete 240 degree anterior fundal wrap Associated crural plication to narrow the esophageal hiatus and provide extra support of the LES Post :On both side of esophagus – most cephalad suture incorporate fundus, crus and esophagus Remaining suture anchor – fundus to either crura or esophagus Ant :donot disrupt posterior attachment of esophagus and fundus folded over anterior aspect of esophagus anchored to hiatus and esophagus Postop, antiemetics are given to avoid retching or emesis. If tension on closure, reduce CO2 insufflation will reduce the cephalad displacement of the diaphragm to allows tension-free closure. 360-degree wraps when reflux causes respiratory compromise, e.g lung transplant population Dysphagia is a major cause of reoperation in Nissen Dor fundoplication m/c used in- esophageal myotomy As postoperative patients, partial wraps are preferred in patients with a history of preoperative dysphagia or poor peristalsis on manometry Complete. Even in complete wraps, there should be space for the passage of an instrument between the stomach and esophagus to reduce postoperative dysphagia and gas bloat. The wrap can be individualized to the patient’s symptoms. Variations on this classic procedure exist that allow an operation to be individualized to the patient’s needs These findings highlight the critical importance of appropriate patient selection and medical therapy prior to entertaining antireflux surgery
- #34 series of biocompatible titanium beads with magnetic cores hermetically sealed inside placed around distal esophagus Linx create mechanical barrier Propogated bolus > separate beads> open GEJ > allow bolus to pass into stomach > beads return to original position > augment LES resting pressure Regurgiattion – d/t ineffective mechanical barrier to reflux Hb d/t acidic gastric contents contacting esophageal mucosa Ppi improves heartburn as it neautralise acidic exposure in esophageal mucosa
- #35 Don’t alter anatomy or mechanical constraint Tiny electrical impulses delivered to LES without causing any sensation IPG similar to pacdmaker implanted under the skin of abdomen Lead connect IPG to esophagus Through minimally invasive procedure 40min