Information about Gerd surgical management by Dr Dhaval Mangukiya. Details of both sides of Gerd, Introduction, Surgical Anatomy, Hiatus Hernia, Esophageal dearance, Investigation etc. http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat https://gastrosurgerysurat.blogspot.com/ https://drdhavalmangukiya.com/

1. Dr.Dhaval O. MangukiyaSurgical Management of GERD

2. Introduction:
Goals of long term GERD management include:
Maintenance of symptom control
prevent lesion recurrence
Ultimately, allowing a return to a nearly normal quality of life
Points needs to understand:
Surgical anatomy
Role of hiatal hernia
Esophageal clearance

3. Surgical Anatomy - LES

4. Hiatus hernia and GERD

5. Esophageal clearance
• Esophageal pH
• Peristaltic pattern
• Water brash
• Overeating
• High fat western diet
• Sphincter taken up by expanding fundus

6. Investigation – Surgeon’s purspectives
• Endoscopic evaluation
• Detection of reflux
24 hour pH monitoring – esophageal/gastric
Combined multichannel intraluminal Impedence pH
• Esophageal manometry
Exclude motility disorders
LES assessment

7. Indications for antireflux surgery:
• Have failed medical management (inadequate symptom control, severe regurgitation not
controlled with acid suppression, or medication side effects)
OR
• Opt for surgery despite successful medical management (due to quality of life considerations,
lifelong need for medication intake, expense of medications, etc.)
OR
• Have complications of GERD (e.g., Barrett’s esophagus, peptic stricture)
OR
• Have extra-esophageal manifestations (asthma, hoarseness, cough, chest pain, aspiration)
7
Guidelines for Surgical Treatment of Gastroesophageal Reflux Disease (February 2010) Society of American Gastrointestinal and Endoscopic Surgeons

8. Traditional antireflux surgery vs. Laparoscopic surgery:
8http://my.clevelandclinic.org/services/laparoscopic_antireflux/ts_overview.aspx cited on 20 Dec 2013

9. 9
Guidelines for Surgical Treatment of Gastroesophageal Reflux Disease (February 2010) Society of American Gastrointestinal and Endoscopic Surgeons
The American Journal of Gastroenterology 2013; 108, 308-328
Surgical management if GERD:
• The highest surgical responses are seen in patients with typical symptoms of heartburn and/ or
regurgitation that demonstrate good response to PPI therapy or have abnormal ambulatory pH
studies with good symptom correlation
• The most common adverse events associated with fundoplication include the gas-bloat
syndrome (in 15 – 20 % of patients) postoperative dysphagia and inability to belch

10. Surgical management in refractory GERD:
• In refractory patients before considering laparoscopic fundoplication, it is very important that
patients are phenotyped appropriately to exclude functional heartburn or other, non-reflux
refractory symptoms
• In patients with abnormal acid exposure and refractory symptoms, high supine acid exposure
and very poor esophageal motility are found to be predictors of recurrent pathological acid
exposure post fundoplication
• Overall, there does appear to be a role for antireflux surgery in well defined refractory
patients with objectively determined GERD
10Curr Opin Gastroenterol 2013, 29:431–436Gut 2012; 61(9): 1340-1354

11. Elements of laparoscopic Nissen:
Crural closure
Fundic mobilization by division of short gastrics
Creation of short, loose fundoplication by enveloping anterior and posterior wall
around lower esophagus
Laparoscopic fundoplication:

12. Laparoscopic fundoplication:

13. 270 degree wrap
Toupet
Nissen
Anterior (Dor)
Fundoplication Types:

14. • Complete fundoplication offers superior protection to reflux
Increased incidence of dysphagia, inability to belch, and excessive flatus
• Partial wraps offer less protection against reflux, but also less symptoms
Up to 51% may have pathologic esophageal acid exposure on 24-hour pH monitoring
• Complete now considered superior to partial even in patients with weak esophageal
peristalsis
• Exceptions:
achalasia—anterior wrap utilized with myotomy
Aperistalis (i.e, scleroderma)
Surg Endos 1997;11:1080.
Differentials of fundoplication:

15. Esophageal lengthening procedure:

16. Patient satisfaction is high (86-97%)
Long-term symptom relief (heartburn and regurgitation) in 84-97%
Symptomatic failure rate 3-13%
heartburn and regurgitation
Does not correlate with acidic reflux exposure
Bloating and increased flatulence (9-53%): Most common side effect
Surgeon, August 2009:224.
Laparoscopic fundoplication:

17. Risks of Antireflux Surgery
Vakil N. Aliment Pharmacol Ther 2007;25:1365-72.

18. Systematic Review of Surgical Vs. Medical Therapy of Barrett’s
Esophagus: Cancer Incidence
Ann Surg 2007;246:11-21

19. Review of 10,489 laparoscopic antireflux procedures
Complications:
Wrap herniation (early) 1.3%
Pneumothorax 1.0%
All others < 1% (perforation, hemorrhage, pneumonia, abscess, splenic injury, trocar
hernia, effusion, PE, ulcer, atelectasis, wound infection, MI, splenectomy)
Journal of the American College of Surgeons 2001: 193(4); 428-39
Complications with antireflux surgery:

20. Early dysphagia
usually transient (<6 weeks)
Persistent side effects (>1 month)
Bloating 9%
Reflux 4%
Dysphagia 3% (Often poorly defined)
Complications with antireflux surgery:
Journal of the American College of Surgeons 2001 Volume 193, Issue 4 , 428-439 The Surgeon 2009 Volume 7, Issue 4 , 224-227

21. Failure of fundoplication:

22. • Studies with shorter follow-ups (2-3 years) report 90 % symptom resolution rate than studies
with longer term follow-up (67% of patients at 7-year follow-up)
• Postoperative dysphagia remains a significant problem (26 -75 %) with reported re-operation
rates ranging from 1.8 to 10.8% and endoscopic dilatation rates ranging from 0 to 25% where as
long term dysphagia rates after surgery ranges 5-8 %
• Regurgitation rates have shown to be significantly improved following surgery with
improvement rates of 87% to 97% reported
22
Guidelines for Surgical Treatment of Gastroesophageal Reflux Disease (February 2010) Society of American Gastrointestinal and Endoscopic Surgeons
Laparoscopic fundoplication: Clinical Outcomes

23. 10-year follow-up of 250 patients:
83% highly satisfied with outcome
84% had good or excellent control of heartburn
3-7% revision operation
Recurrent hiatal hernia, dysphagia, reflux, bleeding (early take back protocol for
dysphagia)
21% used acid-suppressive medication
Use of acid-suppressive medication after antireflux surgery varies (21-62%)
Journal of the American College of Surgeons 2007; Volume 205, Issue 4 , 570-575
Laparoscopic fundoplication: Clinical Outcomes after 10 Years Follow-
up (RCT)

24. Randomized trial comparing treatment of GERD with omeprazole (n = 154) and
antireflux surgery (n = 144):
Treatment success—no symptoms or esophagitis (p < 0.002):
67% surgical
47% medical
Dysphagia, bloating, rectal flatulence common in surgical group
After 7 years, surgery was more effective in controlling overall disease symptoms, but
specific post-fundoplication complaints remained a problem.
Br J Surg. 2007 Feb;94(2):198-203
Seven-year follow-up of a randomized clinical trial comparing
proton-pump inhibition with surgical therapy:

25. Cancer risk in patient with reflux symptoms is < 1 in 10,000 per patient year
No benefit to avoidance of Barrett’s or adenocarcinoma with surgery compared to PPI
therapy
Low morbidity and mortality risks associated with laparoscopic antireflux surgery
dwarf potential benefit of avoiding cancer
Gastroent 2008;135:1392.

26. • Once reflux induced asthma is established, PPI therapy is instituted
25-50% have relief of respiratory symptoms
<15% have improvement in pulmonary function
• Antireflux surgery:
90% of children and 70% of adults have relief
~33% have improvement in pulmonary function
Am J Gastroenterol 2003;98:987

27. Recommendations from American College of Gastroenterology: 2013
1. Surgical therapy is a treatment option for long-term therapy in GERD patients. (Strong
recommendation, high level of evidence)
2. Surgical therapy is generally not recommended in patients who do not respond to PPI
therapy. (Strong recommendation, high level of evidence)
3. Preoperative ambulatory pH monitoring is mandatory in patients without evidence of
erosive esophagitis. All patients should undergo preoperative manometry to rule out
achalasia or scleroderma-like esophagus. (Strong recommendation, moderate level of
evidence)
4. Surgical therapy is as effective as medical therapy for carefully selected patients with
chronic GERD when performed by an experienced surgeon. (Strong recommendation, high
level of evidence)
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