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Heartburn and reflux
- 2. GERD • Defined as the presence of troublesome symptoms and/or complications that develop due to retrograde reflux of gastric contents in the esophagus • Incidence: 20% • First line tx: PPI • Most patients never undergo work up
- 3. Diagnostic Evaluation • pH monitoring • EGD • Manometry • Esophagram
- 4. Classification of Hiatal Hernias • Type I - sliding hiatal hernias, where the gastroesophageal junction migrates above the diaphragm. • Type II - are pure paraesophageal hernias (PEH); the gastroesophageal junction remains in its normal anatomic position. • Type III - combination of Types I and II • Type IV - hiatal hernias are characterized by the presence of a structure other than stomach, such as the omentum, colon or small bowel within the hernia sac.
- 5. Laparoscopic Nissen fundoplication 1 2 3 4 Yates RB, 2015
- 6. Comparison of Different Wraps
- 7. For patients with GERD due to acid reflux the fundoplication is the most appropriate surgical option For patient with GERD due to bile reflux the most appropriate surgical option is the gastric bypass or gastrojejunostomy
- 8. Roux en Y Gastric Bypass
Editor's Notes
- Gastroesophageal reflux disease (GERD) is defined as the presence of troublesome symptoms and/or complications that develop due to retrograde reflux of gastric contents in the esophagus [1]. There is also Montrela definition from 2006 as “Reflux of stomach contents that causes troublesome symptoms and/ or mucosal injury in the esophagus” (Montreal definition 2006) In western countries, prevalence is extremely high – 20% US population reported reflux symptoms occurring at least weekly. Most patients presenting to GP with typical symptoms never undergo formal diagnostic evaluation and are effectively managed with proton pump inhibitors. Consequently, most guidelines recommend an empirical trial of PPI therapy could be viewed as both diagnostic and therapeutic for patients with typical symptoms. Upper endoscopy is NOT required unless in the presence of alarming symptoms (e.g. elderly, long-standing symptoms >5-10yr, male sex, constitutional symptoms) Although effective, PPIs provide incomplete control of reflux symptoms in up to 40% patients. A partial response can occur because these meds do NOT address an incomplete sphincter or prevent reflux
- ACG American College of Gastroenterology AGA American Gastroenterological Association EDAP Esophageal Diagnostic Advisory Panel SAGES
- Type I hernias are sliding hiatal hernias, where the gastroesophageal junction migrates above the diaphragm6. The stomach remains in its usual longitudinal alignment7 and the fundus remains below the gastroesophageal junction. Type II hernias are pure paraesophageal hernias (PEH); the gastroesophageal junction remains in its normal anatomic position but a portion of the fundus herniates through the diaphragmatic hiatus adjacent to the esophagus. Type III hernias are a combination of Types I and II, with both the gastroesophageal junction and the fundus herniating through the hiatus. The fundus lies above the gastroesophageal junction. Type IV hiatal hernias are characterized by the presence of a structure other than stomach, such as the omentum, colon or small bowel within the hernia sac.
- Starts with dissection of left crus +/- ligation of short gastric vessels mobilization of gastric fundus Then divide left phreno-eso membrane expose length of left crus. Right crural dissection and division of gastrohepatic ligament expose right crus + creation of retroesophageal window (Penrose drain placed around eso to facilitate) Posterior mediastinal dissection Posterior crural closure, a 52-F bougie should easily pass beyond the eso hiatus Creation of a 360 Fundoplication: posterior fundus is passed behind the esophagus from the patients’ left to right, anterior fundus on the left side of the esophagus is then grasped, both portions of the fundus are positioned on the anterior aspect of the esophagus Using 3 or 4 interrupted permanent sutures, the fundoplication is created to a length of 2.5 to 3.0 cm the wrap is anchored to the esophagus and crura (Fig. 8, inset) to help prevent herniation into the mediastinum and slipping of the fundoplication over the body of the stomach.