Gastro Marco 1

8/2/2019 Gastro Marco 1

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Antireflux Surgery

Parissa Tabrizian M.D.

Team IV 11/10/06


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Anatomy


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Esophageal Physiology


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Lower Esophageal Sphincter

Intrinsic distal esophageal musclestonically contracted Muscular Sling fibers of the gastric cardia Diaphragmatic crura Transmitted pressure of the abdominal cavity


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Introduction

Increased rate during the 90s.

4.4 to 12 procedures per 100 000 adults

Popularity of minimally invasive surgery 65%


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Historical Aspect

Rudolf Nissen ( 1896-1981)

Thoracic surgery- lobectomy and pneumonectomy

Professor of Surgery in Istanbul, Turkey 1933

Mid 1930s: began work that would lead to his 1st performed fundoplication in 1955

1956 Swiss journal, Schweizerische Medizinische Wochenschrift

Brooklyn Jewish Hospital and Maimonides Hospital 1941

Chairman of Surgery at the University of Basel, Switzerland 1951


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Gastroesophageal reflux disease

MC GI disorder of the western world.

44% adults in US have abnormal reflux of acidic gastric

juices into the esophagus on a montly basis.

10% of patients require daily acid suppression

medication

Over 1.0 million out patients visit per year


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GERD

Pathophysiology:

Defective lower esophageal sphincter (LES) function

transient LES relaxations ( TLESRs)

hypotonic LES ** ( e.g. sleroderma)

disruption of LES ** ( e.g. resection, balloon rupture)

Hiatal hernia ** ( mal alignment of LES and crural diaphragm)

Poor esophageal clearance **

Decreased salivary protection

decreased volume ( e.g. sicca syndrome)

deficient production of epidermal growth factor

Poor gastric emptying

Increased intra-abdominal pressure ( e.g. straining, obesity, pregnancy)

Duodenogastric reflux (bile)

** predisposes to severe GERD


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Hiatal Hernias


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Clinical presentation

Prevalence of Symptoms in 1000 Patients Evaluated for Gastroesophageal Reflux Disease *


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Extraesophageal Manifestations of GERD

Pulmonary

Asthma

Aspiration pneumonia

Chronic bronchitis

Pulmonary fibrosis

OtherChest pain

Dental erosion

ENT

Hoarseness

Laryngitis

PharyngitisChronic cough

Globus sensation

Sinusitis

Subglottic stenosis

Laryngeal cancer


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Diagnostic Tests for GERD

Barium swallow

Endoscopy

Ambulatory pH monitoring

Esophageal manometry


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Barium Swallow

Useful first diagnostic test for patients withdysphagia

Stricture (location, length)

Mass (location, length)

Birds beak Hiatal hernia (size, type)

Limitations

Detailed mucosal exam for erosiveesophagitis, Barretts esophagus


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Endoscopy

Indications

Alarm symptoms

Empiric therapy failure

Preoperative evaluation

Detection of Barretts

esophagus
http://www.gerd.com/maps/endoscop.map


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Ambulatory 24 hr. pH Monitoring

Physiologic study Quantify reflux in

proximal/distal esophagus

--% time pH < 4

Prox esophagus:


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Ambulatory 24 hr. pH Monitoring

Normal

GERD


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Wireless, Catheter-Free Esophageal pH Monitoring

Improved patient comfortand acceptance

Continued normal work,activities and diet study

Longer reporting periods

possible (48 hours)

Maintain constant probe

position relative to SCJ

Potential Advantages


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Esophageal Manometry

Assess LES pressure, location

and relaxation Assist placement of 24 hr.

pH catheter

Assess peristalsis

Prior to antireflux surgery

Limited role in GERD


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Treatment Goals for GERD

Eliminate symptoms

Heal esophagitis

Manage or prevent complications

Maintain remission


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Lifestyle Modifications

Elevate head of bed 4-6 inches

Avoid eating within 2-3 hours of bedtime

Lose weight if overweight

Stop smoking Modify diet

Eat more frequent but smaller meals

Avoid fatty/fried food, peppermint, chocolate,

alcohol, carbonated beverages, coffee and tea

OTC medications prn


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Acid Suppression Therapy for GERD

H2-Receptor Antagonists

(H2RAs)

Cimetidine (Tagamet)

Ranitidine (Zantac)

Famotidine (Pepcid)

Nizatidine (Axid)

Proton Pump Inhibitors

(PPIs)

Omeprazole (Prilosec)

Lansoprazole (Prevacid)

Rabeprazole (Aciphex)

Pantoprazole (Protonix)Esomeprazole (Nexium )


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Effectiveness of Medical Therapies for GERD

Treatment Response

Lifestyle modifications/antacids 20 %

H2-receptor antagonists 50 %

Single-dose PPI 80 %

Increased-dose PPI up to 100 %


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Complications of GERD

Erosive/ulcerative esophagitis

Esophageal (peptic) stricture

Barretts esophagus

Adenocarcinoma


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Indications for Surgery

Intractable GERDrare

Difficult to manage strictures

Severe bleeding from esophagitis ( grade III-IV)

Non-healing ulcers GERD requiring long-term PPI-BID in a healthy young patient

LES < 10

Large hiatal hernia

Persistent regurgitation/aspiration symptoms

Not Barretts esophagus alone

Noncompliance

Patients preference ( cost, life style)


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Mechanism of Antireflux Operations

Creation of a floppy valve by maintaining close apposition b/w theabdominal esophagus and the gastric fundus

Exaggeration of the flap valve at the angle of His

Increase in the basal pressure generated by the lower esophageal sphincter

Reduction in the triggering of TLES relaxations

Reduction in the capacity of the gastric fundus speeding prox. and a totalgastric emptying

Prevention of effacement of the lower esophagus


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* Restrospective analysis* Medical or surgical treatment for > 1 yr* 120 pts undergoing surgery* 51 pts nonoperative mgt* QOL: surgery > medical


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Nissen Fundoplication


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Postoperative Complications


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* 171 patients, mean f/u 6.4 yrs

* computerized log / questionnaire


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Overall: 96.5 % satisfied vs 3.5 %

* Persistent Sx: abd bloating ( 20%), diarrhea ( 12%), regurgitation ( 6.4%),

heartburn ( 5.8%)

27 % dysphagia 7% dilatation14% postop PPI ( 79% vague abd symptoms)

* Excellent long term treatment


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Complete vs. partial fundoplication

Ant. partial fundoplication Thal/Dor procedure

Post. partial fundoplication Toupet procedure


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Endoscopic Therapy

Endoscopic antireflux therapies

Radiofrequency energy delivered to the LES

Stretta procedure

Suture ligation of the cardia Endoscopic plication

Submucosal implantation of inert material in the regionof the lower esophageal sphincter

Enteryx

Gastro Marco 1

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