Gastroesopheal Reflux Disease

General Surgery
An interactive discussion about gastroesophageal reflux disease between Jeffrey Ponsky, MD and Michael Rosen, MD.

Dr. Rosen is a professor of surgery at the Cleveland Clinic Lerner College of Medicine, and general surgery staff in department of surgery at Cleveland Clinic in Cleveland, OH. Dr. Ponsky, is a professor of surgery at the Cleveland Clinic Lerner College of Medicine and Department of Surgery at Cleveland Clinic.


Sections

  • Play From Beginning / Intro (00:00)
  • Case presentation 40 year old woman with heartburn (01:16)
  • H2 Blockers (02:56)
  • Refractory symptoms after PPI (03:19)
  • Role of EGD- assess esophagitis, and rule out Barrett’s (04:23)
  • Frequency of EGD (04:57)
  • Bravo-study performed with patient off PPI (06:17)
  • Use of manometry done prior to operative intervention (07:13)
  • Management after Bravo results (07:41)
  • Workup for patient not responding to PPI management (09:30)
  • What is manometry? (11:04)
  • Surgical interventions to consider for GERD (13:18)
  • Nissen Fundoplication (13:54)
  • Nissen Technique (17:05)
  • Crural closure (17:36)
  • Manometry to tailor operation (18:32)
  • Description of Toupet (19:38)
  • Complications of anti-reflux surgery (21:09)
  • Loose wrap (22:31)
  • Management of rare case of long-term dysphagia-postoperative symptomatic dysphagia to solids (23:07)
  • Management of rare case of long-term dysphagia- patient 1-year postoperative symptomatic dysphagia to solids (23:52)
  • Management of patient with recurrent symptoms (27:12)
  • How to manage a Slipped Nissen surgically? (29:37)
  • Injury to the anterior vagus nerve what do you do? (32:30)

Additional Content

Dr. Ponsky, professor of surgery at the Cleveland Clinic Lerner College of Medicine and Department of Surgery and Dr. Michael Rosen, professor of surgery at Cleveland Clinic Lerner College of Medicine

 

Discussion Topic: Gastroesophageal reflux disease (GERD)

 

GERD (00:01:06)

Case presentation 40 year old woman with heartburn (00:01:16:30)

1)   Evaluation of the patient with GERD (00:01:56:00)

a)   Symptoms

b)  Lifestyle and/or lifestyle modification

c)   Duration

d)  Medication compliance

e)   Work up

2)   Medical management (00:02:39:00)

a)   Trial of proton pump inhibitors (PPI) for 6 weeks

i)    Starting dose Prilosec 20 mg QD

ii)   PPI achieves greater reduction of gastric acid secretion vs. H2 blockers

iii)  Data supporting downsides of PPI use

iv)  Potential consequences of PPI ex: osteoporosis

b)  H2-blockers (00:02:56:00)

i)    Shorter duration

ii)   Higher frequency dosing

3)   Workup

a)   After 6 weeks of PPI trial-and cessation of therapy patient develops symptoms again, perform EGD (00:03:19:52)

b)  Role of EGD- assess esophagitis, and rule out Barrett’s (00:04:23:26)

c)   Frequency of EGD (00:04:57:34)

d)  Bravo study-if no evidence of GERD, or esophagitis confirm diagnosis with pH Study-Bravo used for symptom correlation

e)   Bravo-study performed with patient off PPI (00:06:17:05)

f)    Use of manometry done prior to operative intervention (00:07:13:00)

g)   Management after Bravo results (00:07:41:19)

4)   Workup for patient not responding to PPI management (00:09:30:01)

a)   History, BMI, Medication compliance

b)  How to take medication- 30 minutes prior to meal

c)   If not responding to 20mg QD, switch to BID

d)  If still not responding, consider patient to have symptomatic reflux

i)    Workup patient with EGD & bravo pH, also perform manometry since we might consider surgical intervention

e)   What is manometry? (00:11:04:26)

i)    Why obtain manometry- Number one reason is to rule out achalasia, we want to make sure patient does not have achalasia prior to surgical intervention. If considering a Nissen Fundoplication and patient has achalasia you don’t want to destroy esophageal function of the patient.

ii)   When performing manometry for reflux we can also diagnose achalasia due to stasis thus fermenting food in esophagus.

iii)  Manometry will display relaxation of lower esophageal sphincter (LES) in reflux; low resting pressure of lower esophageal sphincter

5)   Surgical interventions to consider for GERD (00:13:18:56)

6)   What type of operation to perform in patient with normal peristalsis, amplitude 30mmhg, total relaxation of LES, normal endoscopy with no Barrett’s, with 2cm hiatus hernia? Nissen Fundoplication (00:13:54:51)

a)   Description of Nissen Fundoplication- 360-degree wrap, laparoscopic approach

b)  Common mistakes surgeons make is wrapping too long adding to dysphagia

 

8)   Fix posterior-wrap to crura as last stich "post gastropexy” posterior aspect of the stomach to crura (00:17:05:17)

 

9)   Crural closure- How tight to close? (00:17:36:00)

i)    No longer use bougie to guide

ii)   Close enough where esophagus comfortably has a v like shape ("triangle of error-which is a space that would be filled by using a bougie” previously described by Ron Hinder

10)        Use of manometry to tailor operation (00:18:32:50)

a)   If patient has connective tissue disease manometry shows peristalsis is below 20, LES is weak, how to proceed? Explain to patient the best operation to prevent reflux is Nissen Fundoplication, but in this specific case Toupet would be a better option

11)        Description of Toupet- formal esophageal dissection with Penrose, mobilize to obtain enough intra-abdominal esophagus, take down short gastrics for easy orientation then posterior 270 degree wrap approx. 2.5-3cm long. Three sutures esophagus to stomach, posterior gastropexy of stomach to post. Crus (with one stitch) (00:19:38:08)

12)        Complications of anti-reflux surgery (00:21:09:52)

a)   Dysphagia- when to worry about dysphagia in the postoperative period. Wrap is tightest immediately after surgery, and will loosen over time. Don’t worry about dysphagia for the first 6 weeks postoperatively. Consider intervening endoscopically at three months with no progression and no ability to tolerate anything but liquids.

b)  Worry about the patient the shows up 2weeks postoperatively stating they eat anything and deny symptoms of dysphagia, at which point you should become suspicious of a loose wrap. (00:22:31:52)

c)   Management of rare case of long-term dysphagia- patient 8 months’ postoperative symptomatic dysphagia to solids. (00:23:07:04)

i)    Perform Upper GI- rule out hernia recurrence, or other anatomical causes.

ii)   EGD- for dilation

d)  Management of rare case of long-term dysphagia- patient 1-year postoperative symptomatic dysphagia to solids. (00:23:52:20)

i)    Performed upper GI displayed "bird’s beak” appearance, next step is to make sure patient received a manometry. If manometry shows good relaxation, perform EGD.

ii)   EGD showing tight GE junction, dilated esophagus, retained pool of fluid, now become suspicious of pseudo-achalasia.

iii)  Suspicious of pseudo achalasia perform manometry- which may show lack of peristalsis, and non-relaxing LES. This maybe likely due to the wrap being too tight.

iv)  Prior to surgery optimize patient nutrition

v)   Surgical options include take down Nissen, and perform Heller Myotomy with the option of adding a Dor Fundoplication. Other surgical options previously described by David Ratner take down Nissen perform a long Heller, and convert to a Toupet.

e)   Management of patient with recurrent symptoms of severe pain, dysphagia, Upper GI revealing slipped Nissen with portion of fundus 2-3 inches above the wrap. (00:27:12:32)

i)    If morbidly obese BMI >35kg/m2 refer to bariatric surgery for Roux-en-Y-gastric bypass

ii)   If not morbidly obese re-evaluate again- 48 bravo study and repeat manometry for symptom correlation. Also evaluate gastric emptying due to overlapping symptoms. Look for nausea and vomiting (red flags). Redo-Nissen. If upon re-evaluation final conclusion remains as slipped Nissen take back to OR for Redo-Nissen.

f)    How to approach a re-operative slipped Nissen surgically? (00:29:37:30)

i)    1st of procedure look at where previous surgeon made incisions to help tailor re-do operation

ii)   Identify right crus to identify vena cava

iii)  Elevate liver off the wrap

iv)  Dissection of right crus

v)   Start taking wrap down

vi)  If struggling start from the chest and work your way back

vii)  Identify name structure systematically and dissect them to prevent making a space ultimately surgeons should aim to dissect

viii)       While taking down the wrap you identified iatrogenic injury to the anterior vagus nerve what do you do? (00:32:30:31)

(1) In re-operative situation if posterior vagus nerves is uninjured do nothing. Postoperatively Upper GI 1st, or 2nd day look to see if stomach was emptying. If not emptying start early Botox injections of the pylorus. Consider pyloroplasty if injured both anterior and posterior vagus nerves.

 

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