Esophagus—GERD
Concept
Incompetent lower esophageal sphincter related to inade- quate pressure (< 6 mmHg), inadequate length (< 2 cm), insufficient intraabdominal esophagus (< 1 cm). Hiatal hernia, delayed gastric emptying, and bile reflux may com- plicate the picture.
Way Question May be Asked?
“45 y/o man presents to your office with a history of heart- burn, choking at night, and recent onset of asthma.”
Symptoms may be many and can include chest pain, water brash, adult onset asthma, dysphagia, odynophagia, sinusitis, aspiration pneumonia, choking feeling at night, regurgitation, excessive salivation, and chronic hoarseness.
Also, patient may present with a complication of their reflux disease: Barrett’s, stricture, or ulcer.
How to Answer?
Must be methodical in your approach to not get caught by the pt with abnormal motility who you decide to perform a complete wrap on.
First, complete history including relationship to meals, solids versus liquids, maneuvers tried (loose clothing, caffeine cessation, trial of H2 blockers or PPIs) Second, complete physical exam including epigastric
masses and lymph node basins (will all be negative but if you leave out the PE, the pt will end up having a pronounced supraclavicular node and the scenario will have changed to esophageal cancer with obvious mets).
Appropriate preoperative studies including full labs, EKG, CXR.
Appropriate work-up of GERD which always starts with Barium UGI
Look for reflux, hernia, shortened esophagus, diver- ticula, other motility disorders
The next test should be an upper endoscopy to evaluate the severity of the reflux
Stage I erythema and edema II ulcerations
III stricture
The rest of the work-up must include:
Manometry to r/o ineffective motility that will affect your type of anti-reflux procedure, to document the low LES pressures, and determine location of LES
24 h pH monitoring to document the relationship between pt’s symptoms and reflux as well as pro- vide a baseline for post-op evaluation of success of surgery
(A gastric emptying study should be added in any pt with a history of significant belching or bloat- ing after meals and/or history of duodenal ulcer as a delay in gastric emptying contributes to 10 % of Nissen failures)
Remember, the indications for surgery are failure of medical therapy or complications of reflux disease (young age is a relative indication)
Procedure = Nissen Fundoplication (usually performed laparoscopically)
Lithotomy position 5–6 ports
Nissen performed over a bougie (54–56) Start dissection at gastrohepatic ligament Mobilize esophagus well into mediastinum Divide short gastrics down 1/3 along greater curve Crural repair
3 cm anterior wrap
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Take care not to injure the vagus nerve, perforate stomach, esophagus, injury spleen, or make wrap too tight/too long/ or twist the stomach when passing it around esophagus
Belsey, Dor, or Toupet can be performed in pts with ineffective esophageal motility
Post-op UGI with gastrografin prior to feeding
Common Curveballs
Pt has a malignancy/Barrett’s/stricture on endoscopy (non-dilatable stricture=OR)
Pt won’t have normal manometry (don’t Nissen) Perforation during procedure by you, by advancing
bougie, or seen post-op on UGI
Pt will present with a stricture where first you must r/o malignancy and dilate prior to any studies
Pt will have “shortened esophagus” (be prepared to describe Collis gastroplasty)
Pt will develop pneumothorax or bleeding from liver/spleen during procedure
Fundoplication herniates into chest post-op (poor hiatal closure, didn’t mobilize esophagus enough)
Fundoplication falls apart post-op (technical failure) Pt has “gas bloat” syndrome post-op (inadequate gas-
tric emptying)
Pt has difficulty swallowing post-op (made wrap too tight)
Strikeouts
You forget the UGI, EGD, or manometry
You can’t describe the fundoplication or forget to men- tion taking the short gastrics
You take pt to surgery right away without trying medical therapy (only 5 to 10% GERD pts need surgery)
You don’t take an adequate history or order manome- try and perform Nissen on pt with achalasia
Discussing endoscopic measures to treat Barrett’s (cryotherapy or phototherapy)
Discussing endoscopic measures to treat GERD (“Plicator,” “Stretta,” or newly approved injectable agents)
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