GERD ~Gastroesophageal reflux (GER) occurs when intragastric pressure is greater than the high-pressure zone of the distal esophagus. This can develop under two conditions 1.)the LES resting pressure is too low (i.e., hypotensive LES). 2.the LES with normal resting pressure inappropriately relaxes in the absence of peristaltic contraction of the esophagus (i.e., spontaneous LES relaxation) ~ Not all GER is pathologic—in fact, it is a normal physiologic process that occurs even in the setting of a normal LES. ~Heartburn, regurgitation, and water brash are the three typical esophageal symptoms of GERD. ~Heartburn and regurgitation are the most common presenting symptoms. Heartburn is specific to GERD and described as an epigastric or retrosternal caustic or stinging sensation. ~it does not radiate to the back and is not described as a pressure sensation ~ Regurgitation of gastric contents to the oropharynx and mouth can produce a sour taste that patients will describe as either acid or bile. This phenomenon is referred to as water brash. •Esophageal impedance monitoring identifies episodes of nonacid reflux •Impedance catheters use electrodes placed at 1-cm intervals to detect changes in the resistance to flow of an electrical current (i.e., impedance) •Impedance increases in the presence of air and decreases in the presence of a liquid bolus •pH-impedance catheters can determine the direction of movement of esophageal acid exposures ~frequent drinking of water ~posture of sitting lean forward with their lungs inflated to vital capacity ~ This maneuver flattens the diaphragm, narrows the anteroposterior diameter of the hiatus, and increases the LES pressure to counteract GER. ~yellowing of teeth ~injected oropharyngeal mucosa Both peptic strictures and LA class C and D esophagitis can be considered pathognomonic for GERD patients found to have LA class A and B esophagitis should undergo pH testing to confirm abnormal distal esophageal acid exposure. Endoscopic evaluation should also include an assessment of the GEJ flap valve In hiatus hernia craniocaudal and lateral dimensions are measured •immediate side effects of ppi are rare but long term usage causes side effects •long term side effects of ppi are 1)loss of bone density 2)risk of fracture, dementia, myocardial infarction 3)micronutrient (magnesium, iron, B-12) deficiencies 4)Clostridioides difficile infection 5)kidney disease • judicious prescription of PPIs for well-established indications is prudent. •operative technique (LARS) 1)short gastric vessel ligation and mobilisation of gastric fundus 2)left crus dissection by incision at phrenoesophageal ligament 3)right crura dissection 4) The esophagus is mobilized in the posterior mediastinum to obtain a minimum of 3 cm of intra abdominal esophagus 5)fundoplocation is done If an anterior fundoplication is to be performed (e.g., Thal or Dor), there is no need to disea

1. Gastroesophageal reflux
disease (GERD)
By Dr.B Jayaprakashnarayan
JR-1 in dept of general surgery
Guntur medical college

2. Pathophysiology of GERD
~It is most common benign conditions of stomach and
esophagus
~endogenous antireflux mechanism includes LESand
spontaneous esophageal clearance GERD results from failure of
these endogenous antireflex mechanisms
~The LES is made up of 4 anatomic structures
1.)intrinsic musculature of distal esophageous
2.)sling fibres of gastric cardia
3.)crura of diaphragm
4.)GEJ anchoring to abdominal cavity

3. ~Gastroesophageal reflux (GER) occurs when intragastric
pressure is greater than the high-pressure zone of the distal
esophagus. This can develop under two conditions
1.)the LES resting pressure is too low (i.e., hypotensive LES)
2.the LES with normal resting pressure inappropriately
relaxes in the absence of peristaltic contraction of the
esophagus (i.e., spontaneous LES relaxation)
~ Not all GER is pathologic—in fact, it is a normal physiologic
process that occurs even in the setting of a normal LES.

4. ~The distinction between physiologic reflux (i.e., GER) and
pathologic reflux (i.e., GERD) hinges on the total amount of
esophageal acid exposure, the patient’s symptoms, and the
presence of mucosal damage of the esophagus
~Hiatal hernias are often associated with GERD because their
abnormal anatomy compromises the efficacy of the LES
~. Hiatal hernias are classified into four types (I to IV)

5. Clinical presentation of GERD

6. ~Heartburn, regurgitation, and water brash are the three typical
esophageal symptoms of GERD.
~Heartburn and regurgitation are the most common presenting
symptoms. Heartburn is specific to GERD and described as an
epigastric or retrosternal caustic or stinging sensation.
~it does not radiate to the back and is not described as a
pressure sensation
~ Regurgitation of gastric contents to the oropharynx and mouth
can produce a sour taste that patients will describe as either acid
or bile. This phenomenon is referred to as water brash.

7. ~regurgitation can be digested or undigested
~ extraoesophageal sympytoms are due to
1.), proximal esophageal reflux and microaspiration of
gastroduodenal contents
2.) distal esophageal acid exposure triggers a vagal
nerve reflex that results in bronchospasm and cough.

8. • In patients with GERD, the most common cause of dysphagia is a
refluxassociated inflammatory process of the esophageal wall.
• This inflammation can be manifested as a Schatzki ring, a diffuse distal
esophageal inflammation, or a peptic stricture
• In patients with peptic strictures, it can be challenging to document abnormal
GER on ambulatory pH monitoring. The presence of a tight stricture may
prevent reflux of acid, resulting in a false-negative pH study.

9. Physical examination
~Except in patients with severely advanced disease, the physical
examination rarely contributes to confirmation of the diagnosis
~frequent drinking of water
~posture of sitting lean forward with theirlungs inflated to vital
capacity
~ This maneuver f lattens the diaphragm, narrows the
anteroposterior diameter of the hiatus, and increases the LES
pressure to counteract GER.
~yellowing of teeth
~injected oropharyngeal mucosa

10. Preoperative diagnostic testing
~Frequently, the diagnosis of GERD is based on the presence of
typical symptoms and improvement in those symptoms with PPI
therapy
~four diagnostic tests are useful to establish the diagnosis of
GERD and to identify abnormalities in gastroesophageal anatomy
and function that may have an impact on the performance of
LARS.
1.)ambulatory ph and impedance monitoring
2.)esophageal manometry
3.)esophagogastroduodenoscopy
4.)barium eosophagogram

11. Ambulatory ph and impedance monitoring
• Ambulatory pH monitoring quantifies distal esophageal acid exposure and is the
“gold standard” test to diagnose GERD
• Abnormal distal esophageal acid exposure is defined by a DeMeester score of
14.7 or higher
• Stop ppi before 2wks
• Demeesters score is based on diiferent variables
• total number of reflux episodes (pH <4), longest episode of reflux, number of
episodes lasting longer than 5 minutes, and percentage of time spent in reflux in
the upright and supine positions.

13. •Esophageal impedance monitoring identifies episodes of nonacid
reflux
•Impedance catheters use electrodes placed at 1-cm intervals to
detect changes in the resistance to flow of an electrical current (i.e.,
impedance)
•Impedance increases in the presence of air and decreases in the
presence of a liquid bolus
•When pH-impedance catheters are used, it is possible to determine
the direction of movement of esophageal acid exposures and
therefore to differentiate between an antegrade event (as in a
swallow) and a retrograde event (as in GER)

14. • There also exists a specialized pH-
impedance catheter with a very proximal
pH sensor that detects pharyngeal acid
reflux.

15. Esophageal manometry
• Esophageal manometry is the most effective way to assess function of the
esophageal body and the LES.
• esophageal manometry can exclude achalasia and identify patients with
ineffective esophageal body peristalsis.

16. Esophagogastroduodenoscopy
• The esophagus should be examined for evidence of mucosal injury due to
GER, including ulcerations, peptic strictures, and Barrett esophagus.
• Esophagitis can be reported according to several scoring systems, including
the Savary-Miller and Los Angeles (LA) classifications.

17. • Both peptic strictures and LA class C and D esophagitis can be
considered pathognomonic for GERD.
• patients found to have LA class A and B esophagitis should
undergo pH testing to confirm abnormal distal esophageal acid
exposure.
• Endoscopic evaluation should also include an assessment of
the GEJ flap valve.

18. Barium Esophagram
• Barium esophagram provides a detailed anatomic evaluation of
the esophagus and stomach that is useful during preoperative
evaluation of patients with GERD.
•Additional gastroesophageal conditions that can be identified on
barium esophagram are esophageal diverticula, tumors, peptic
strictures, achalasia, dysmotility, and gastroparesis.

19. Treatment of GERD
Medical management
• For patients who present with typical symptoms of GERD, an 8-week course
of PPI therapy is recommended.
• before empirically prescribing a PPI, it is necessary to ensure that the patient
does not have symptoms of non-GERD diagnosis
• These drugs stop gastric acid production by irreversibly binding the proton
pump in the parietal cells of the stomach
• T he maximal pharmacologic effect occurs approximately 4 days after initiation
of therapy, and the effect lasts for the life of the parietal cell.

20. •immediate side effects of ppi are rare but long term usage
causes side effects
•long term side effects of ppi are
1)loss of bone density
2)risk of fracture, dementia, myocardial infarction
3)micronutrient (magnesium, iron, B-12) deficiencies
4)Clostridioides difficile infection
5)kidney disease
• judicious prescription of PPIs for well-established indications is
prudent.

21. Surgical management
• For patients who exhibit elevated distal esophageal acid exposure and
persistent typical GERD symptoms despite maximal medical therapy,
antireflux surgery should be strongly considered.

22. •operative technique
1)short gastric vessel ligation and mobilisation of gastric
fundus
2)left crus dissection by incision at phrenoesophageal ligament
3)right crura dissection
4) The esophagus is mobilized in the posterior mediastinum to
obtain a minimum of 3 cm of intra abdominal esophagus
5)fundoplocation is done

24. Creation of 360degree fundoplocation
• To maintain appropriate orientation of the fundus during the creation of the
fundoplication, the posterior aspect of the fundus is marked with a suture 3 cm
distal to the GEJ and 2 cm off the greater
• The suture line of the fundoplication should lie parallel to the right anterior
aspect of the esophagus.

25. Creation of partial findoplication
• The suture line of the fundoplication should lie parallel to the right anterior
aspect of the esophagus.
• In this operation, the gastric and esophageal dissections as well as the repair
of the crura are the same as for a 360-degree fundoplication
• The key difference is that the stomach is wrapped 180 to 270 degrees
(compared with 360 degrees) around the posterior aspect of the esophagus

26. • If an anterior fundoplication is to
be performed (e.g., Thal or Dor),
there is no need to disrupt the
posterior attachments of the
esophagus, and the fundus is
folded over the anterior aspect of
the esophagus and anchored to
the hiatus and esophagus

27. Operative complications
• Pneumothorax most common intraoperative complication due to pleural
violation
• Gastric and esophageal injuries
• Splenic and liver injuries and bleeding

28. Side effects of LARS
• Bloating due to fewer transient LES relaxations and, therefore, decreased
belching postoperatively
• Dysphagia result of postoperative edema at the fundoplication and esophageal
hiatus. And due to result of hematoma at stomach or esophageal wall
• Failed antireflux surgery The most common symptoms of failed LARS are
typical symptoms of GERD (i.e., heartburn, regurgitation, and water brash
sensation) and dysphagia.

29. Alternative Operative Therapies for GERD
• The two most studied therapies that are currently available clinically are endoscopic transoral
incisionless fundoplication (TIF) and MSAD.
• Magnetic Sphincter Augmentation : The MSAD is a series of magnetic beads that is
positioned around the distal esophagus to increase LES resting pressure to counteract GER
• The most significant advantage of MSAD was preservation of the ability to belch and vomit
as well as reduction in gas-bloat.

30. Transoral incisionless
fundoplocation
• The endoluminal fundoplication
can be created up to 4 cm in
length and 270 degrees.

31. Paraeosophageal hernia
•Hiatal hernia types II to IV, also referred to as PEH, are frequently
associated with gastroesophageal obstructive symptoms (e.g.,
dysphagia, early satiety, and epigastric pain
•On occasion, a PEH is identified incidentally on imaging
performed for another purpose, and the patient’s PEH is
asymptomatic.
•the presence of a small asymptomatic hiatal hernia or PEH does
not constitute an indication for operative correction.

32. Pathophysiology of PEH
• the widening of the diaphragmatic crura at the esophageal hiatus and
stretching of the phrenoesophageal membrane
• After repeated episodes of the viscera entering the hernia sac, adhesions
develop between the wall of the sac and the surrounding thoracic structures,
thus preventing the herniated abdominal contents from returning to their
normal position in the peritoneal cavity.
• Gastric volvulus develops because of laxity in the stomach’s peritoneal
attachments and subsequent rotation of the gastric fundus on the organoaxial
or mesenteric axis of the stomach

33. Clinical features
• The symptoms of PEH are diverse and nonspecific.
• The most common symptoms attributed to PEH are gastroesophageal
obstructive symptoms, including dysphagia, odynophagia, and postprandial
chest pain, as well as early satiety.
• When intermittent visceral torsion and distention occur, epigastric and chest
pain can develop due to the resulting ischemia of the hernia contents.
• the diagnosis of PEH is often made only after performance of a barium
esophagram or UGI endoscopy
• Preoperative evaluation of PEH is same as GERD

34. Operative repair
• PEH can be repaired through the left side of the chest or the abdomen and
with open or minimally invasive techniques
• Regardless of the operative approach, there are four key steps to PEH repair:
(1) reduction of the hernia contents to the abdominal cavity.
2)complete excision of the hernia sac from the posterior mediastinum.
(3) mobilization of the distal esophagus to achieve a minimum of 3 cm of intra
abdominal esophageal length
(4) an antireflux operation.

35. • Patient positioning and trocar placement for laparoscopic PEH
repair are the same as for LARS.
• Contents of hernia are removed by gentle traction
• Divider short gastric vessel mobilize fundus to expose left
crura of diaphragm
• Plane created between left crura of diaphragm and herniated
sac
• Dissection of sac and reduction of contents into peritoneum

36. • Hernial sac is removed
• Once the sac is excised from the mediastinum, the esophagus
is further mobilized to obtain a minimum of 3 cm of intra
abdominal length. Then, the crura are reapproximated with
interrupted nonabsorbable suture.

37. Thank you