Best Home Remedies for Heartburn

Heartburn and Acid Reflux Cure Program

Acidity is of the most dangerous problem that not only middle aged or old aged people faces but also the young generation is also facing. Untreated and ill treatment of this disease can lead to even heart stroke. The synthetic anti acidic products available in the market causes more harm in the fast relief process and does cure it holistically so that you do not suffer from it now and then. Here comes the best book on step acid reflux treatment written by Jeff Martin, a well renowned researcher and nutrionist.While these easy process stated in this book allows you to get heal of all types of digestive disorders on a permanent solution basis but in addition to it you get a three months direct counseling from Jeff Martin himself while ordering this product direct from this website. The treatment is so easy to follow and a 100% results is well expected but even then in case on is not satisfied with the results can get even 100 % refund. Indeed one of the cheapest and best ways to get rid of the long lasting digestive disorders especially heart burn in a holistic way without drugs and chemicals. Continue reading...

Heartburn and Acid Reflux Cure Program Summary

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The Epidemiology and Pathophysiology of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is present in individuals with a symptomatic condition or histopathological alteration resultant from episodes of gastroesophageal reflux. Reflux esophagitis is present in a subset of GERD patients with lesions in the esophageal mucosa. However, reflux often causes symptoms in the absence of esophagitis. Although GERD is widely reported to be one of the most prevalent clinical conditions afflicting the gastrointestinal tract, incidence and prevalence figures must be tempered with the realization that there is no gold standard definition of GERD. Thus, epidemiological estimates regarding GERD make assumptions the most obvious being that heartburn is a symptom of GERD and that when heartburn achieves a certain threshold of frequency or severity, it defines GERD. A cross-sectional study surveying hospital employees in the United States in the 1970s found that 7 of individuals experienced heartburn daily, 14 weekly, and 15 monthly.1 Ten years later,...

Medical Management of GERD Algorithms and Outcomes

Therapeutic efficacy of treatments for gastroe-sophageal reflux disease (GERD) has been measured using a variety of different endpoints. Across the surgical, endoscopic, and pharmacological treatment interventions for GERD, an attempt has been made to measure the therapeutic effect of these interventions by both objective and subjective means. This has included objective measures such as the effect a treatment has on esophageal sphincter pressure, intraesophageal acid exposure, and endoscopic esophagitis. Subjective measures of effect have included symptom response as assessed by questionnaires, symptom severity scales, physician assessment, and quality-of-life impact. Despite the innumerable studies reporting various treatment interventions for GERD, overall there is a general lack of use of standardized methodology that would allow comparison of the relative success achieved between the various therapies. Furthermore, there is a striking lack of use of validated instruments to...

Complications of GERD Esophagitis Stricture Barretts and Cancer

Gastroesophageal reflux disease (GERD) has become a very prevalent disorder in the United States and the Western hemisphere. It has been estimated that as many as 44 of adults in the United States experience GERD symptoms described as heartburn at least once a month.1 In addition, as many as 10 of adults in the United States experience daily heartburn.2 The true prevalence of reflux disease may be largely underestimated when taking into account atypical manifestations of the disease as well as those patients who self-medicate.3,4 Unfortunately, many of these atypical manifestations often go unrecognized, and may take the form of ear-nose-throat, pulmonary, or laryngeal manifestations such as laryngitis, sinusitis, asthma, bronchitis, chronic cough, chest pain, and halitosis.4 A study by Harding and col-leagues5 showed that among those patients studied with a diagnosis of asthma and who denied reflux symptoms, > 29 had abnormal esophageal pH studies. Irwin and Richter,6 when...

Patients with Airway Manifestations of GERD

Patients with GERD and related airway symptoms represent a significant management challenge. When compared with patients with typical symptoms, medical therapy is more often ineffective, making surgery a more attractive alternative for these patients.3 The greater problem is that there is no current diagnostic test to conclusively link GERD and airway symptoms. The gold standard, 24-hour pH monitoring, is helpful, but reflux, although present, may not be the cause of the symptoms. Furthermore, abnormal reflux may be caused by pulmonary diseases such as asthma.4

How Do I Know If The Chest Pain Is Due To A Heart Attack And Not Indigestion Or Something Else

It can be difficult to distinguish between a heart attack and indigestion because both cause a similar type of chest discomfort. This is because the heart and the gullet develop from similar cells and have a similar a nerve supply. In the same way that we know if a finger has been burned (even without looking) because the sensation from the finger is represented in a certain area of the brain, so the heart and gullet are also represented in the same area of the brain. The brain finds it difficult to distinguish whether pain is from the heart or the gullet. They both feel the same That's why indigestion is often called heartburn. Therefore, people who have indigestion may think they have had a heart attack, and people who have had a heart attack may believe (and naturally would prefer to believe) that they have only indigestion.

Future Directions of Therapy for GERD

This book has been devoted to a critical appraisal of treatment options for gastroesophageal reflux disease (GERD) and failed anti-reflux therapy and has provided a physiologic basis for managing the postoperative syndromes associated with surgical anti-reflux therapy. In this final chapter, we would like to explore what we feel are future prospects for the various management options for patients with newly diagnosed, persistent, or recurrent GERD. Much of what we hypothesize is speculative but these thoughts are meant to encourage the reader to consider what we may be able to offer and how we might approach these patients in the near future.

Physiologic Evaluation of Suspected GERD

The accuracy of intraesophageal pH monitoring will improve as longer monitoring periods become the norm with increased battery capacity of these devices. Furthermore, the patient acceptance of this technique will become substantially better with the tubeless capsule systems that are becoming increasingly available. However, the real advance in physiologic testing of the GERD patient will likely come with improvements in and increased availability of esophageal impedance testing.1 Impedance testing not only detects acid reflux events but also detects nonacidic reflux events as well, and can evaluate air and liquid esophageal exposure during a reflux event. This technology should ensure that nonacidic reflux causing reflux-type symptoms is accurately diagnosed, and should also help identify the truly functional heartburn patient who will not respond to any of the usual treatment options for GERD (pharmacologic, endoscopic, and surgical antireflux therapies).

Mechanisms of EGJ Incompetence in GERD

Gerd Surgery

Investigations have focused on three dominant mechanisms of EGJ incompetence 1) transient LES relaxations (tLESRs), without anatomic abnormality, 2) LES hypotension, again without anatomic abnormality, or 3) anatomic distortion of the EGJ inclusive of (but not limited to) hiatus hernia. Which reflux mechanism dominates seems to depend on several factors including the anatomy of the EGJ. Whereas tLESRs typically account for up to 90 of reflux events in normal subjects or GERD patients without hiatus hernia, patients with hiatus hernia have a more heterogeneous mechanistic profile with reflux episodes frequently occurring in the context of low LES pressure, straining, and swallow-associated LES relaxation.30 These observations support the hypothesis that the functional integrity of the EGJ is dependent on both the intrinsic LES and extrinsic sphincteric function of the diaphragmatic hiatus. In essence,gastroesophageal reflux requires a two hit phenomenon to the EGJ. Patients with a...

Recurrent GERD Symptoms

Heller Myotomy Wrap

When recurrent or new symptoms of gastroe-sophageal reflux develop in the late postoperative period (> 3 months), the symptoms should be investigated. For individuals who develop symptoms identical to those in which they underwent surgery, a trial of PPIs is appropriate. In addition, a barium swallow will demonstrate any new anatomic abnormalities in 90 of patients with anatomic failure.6 If the barium swallow does not demonstrate any anatomic problems, it is unlikely that the PPIs will be of much benefit. In this case, it is likely that the recurrent symptom is the result of a problem distinct from GERD. Because so-called extrae-sophageal reflux symptoms (cough, asthma, hoarseness, chest pain, etc.) are so common, it may be difficult to determine which of these symptoms, if any, are related to reflux and which are related to other conditions such as extrinsic asthma, or postnasal drip. It may take the performance of a fundoplication to determine, once and for all, which...

Dyspepsia indigestion

Indigestion' is a common complaint, it is essential that the patient explains in detail what is meant by this vague term. Indigestion might describe nausea, heartburn, epigastric discomfort, abdominal pain, belching or a feeling of postprandial bloating. It may even be used to describe angina pectoris. Peptic ulcers usually produce characteristic symptoms, as shown in Table 5.7. Differentiation between oesophageal, gastric or duodenal ulcers on Ihe basis of symptoms alone is often unreliable. Functional dyspepsia, i.e. persistent dyspepsia for which no structural or biochemical cause can be found, is common it is commonly classified on the basis of subsets of symptoms though many patients with functional dyspepsia have more than one symptom subset (Table 5.y).

Gastroesophageal Reflux

Much has been written about gastroesophageal reflux in infants, but cinematographic or videorecording or full polygraphic registration of a reflux-associated episode that might be described as a seizure has not been reported, though a true reflux episode associated with an epileptic seizure has been described (60). Nonetheless, there is a persuasively recognizable condition, the awake apnea syndrome (61). Having been fed within the previous hour, often following an imposed change of posture, the infant gasps, is apneic, stiffens, changes color, and may then look startled. A personal case is described in Stephenson (1).

Medical Therapy for GERD

Pharmacologic therapy of GERD with antise-cretory agents originated in the mid-1970s when histamine-2-receptor antagonists first became available.2,3 However, healing of esophagitis was obtained in only 40-50 of patients and a similar number of patients continued to have symptoms of reflux. Omeprazole was released in 1989 as the first proton pump inhibitor (PPI) for clinical use. Three other firstgeneration PPIs subsequently became available but all were similar in efficacy, healing esophagi-tis in approximately 80 of GERD patients with a similar number achieving acceptable symptom relief.2-4 When a more potent PPI, esomeprazole, was introduced, its use was associated with healing of esophagitis and symptom relief in nearly 90 of patients with GERD.5 Physicians recently have come to realize that many patients require more frequent dosing (twice daily) or higher doses to achieve and maintain healing and symptomatic remission.6 Most importantly, we have learned that these potent...

Extraesophageal GERD

The majority of data regarding healing and symptom relief of GERD have been generated from clinical trials of patients with heartburn and erosive esophagitis. There are very few well-designed trials of medical therapy for patients with extraesophageal GERD-related disease (asthma, cough, noncardiac chest pain, laryngitis). A few uncontrolled trials have demonstrated superiority of PPIs for reducing respiratory symptoms thought related to GERD in patients with GERD-related symptoms but these data also indicate that there has been a need for higher doses and more prolonged therapy with PPIs to achieve adequate symptom relief.38 Medical therapies for reflux-related asthma have also shown improvement in asthma symptom scores, medication use, and quality-of-life measures, but not improvement in pulmonary function testing.39 Interestingly, a meta-analysis of the surgical anti-reflux trial data has demonstrated the same lack of improvement of this GERD therapy on pulmonary function...

Recurrent Heartburn

Univariate analysis of several factors suggested that previous abdominal surgery,female gender, lower socioeconomic status, and a normal pre-operative pH study were predictive of persistent, postoperative heartburn.9 Does the fact that the patient is back on PPI prove that their surgery has failed In a small study from our institution with 5-year follow-up, continuous PPI use was actually fairly rare (14 ) and perhaps more importantly, many of these patients did not have classic heartburn or regurgitation and appeared to be on PPI for more vague abdominal and chest symptoms.55 The actual prevalence of postoperative GERD symptoms in that study was regurgitation in 6.4 and heartburn in 5.8 . In a later preliminary report of a different cohort of patients, we found a greater percentage of patients back on medications at 2 years (39 ), although interestingly 84 of the patients were happy with their outcome and this satisfaction was not worse in those who were back on medications.56 Others...

GERD Pathophysiology

The fundamental abnormality in GERD is exposure of esophageal epithelium to gastric secretions resulting in either histopathological injury or in the elicitation of symptoms. However, some degree of gastroesophageal reflux and esophageal epithelial acid exposure is considered normal or physiological. GERD results when esophageal epithelial exposure to gastric juice exceeds what the epithelium can tolerate. overall anti-reflux integrity of the EGJ. By extension, the greater the degree of EGJ incompetence, the worse the severity of GERD.

Heartburn

Most healthy individuals have experienced heartburn the sensation of a hot. burning retrosternal discomfort often accompanied by the reflux of bitter-tasting gastric fluid into the mouth. It commonly occurs after meals or on bending or lying on the left side and is particularly frequent during pregnancy or following recent weight gain. Heartburn is caused by the reflux of acid, pepsin or bile into the oesophagus and is attributable to a combination of relaxation of the lower oesophageal sphincter and increased intra-abdominal pressure. Many patients with heartburn have no evidence of oesophagitis on oesophagoscopy. However, oesophagitis may develop resulting in pain on swallowing (odynophagia) or food sticking during swallowing (dysphagia). Heartburn is also commonly experienced by patients with duodenal ulceration. When accompanied by reflex salivation, known as waterbrash, the mouth fills with tasteless saliva, in contrast to the bitter lasle of acid reflux waterbrash is an uncommon...

History of Medical and Surgical Anti Reflux Therapy

Humans have no doubt suffered from the symptoms and complications of gastroesophageal reflux disease (GERD) for millennia. However, recognition of a relationship between acid-pepsin and foregut disorders is relatively recent. The powerful digestive and corrosive capability of gastric juices in humans was first extensively described in 1833 by Beaumont1 as a result of experiments performed on Alexis St. Martin. That reflux of these juices into the esophagus could cause symptoms and result in tissue injury was suspected as early as 1839 by Albers, who, as reported by Tileston,2 described a peptic ulcer of the esophagus that was similar to a peptic ulcer of the stomach. Periodic reports of peptic esophageal ulcer subsequently appeared, although the existence of this phenomenon was still in doubt in the second half of the 19th century. Quincke's3 report of three well-documented cases of peptic esophageal ulceration in 1879 put all doubt to rest. Tileston2 summarized reports of 40 cases of...

Physiologic Surgical Therapy

Success of this procedure initiated interest in physiologic control of acid reflux as a means to treat peptic stricture, but ultimately as a method for preventing complications of acid reflux. Other operations were devised for managing recalcitrant peptic stricture that included resection of the gastroesophageal junction with primary anastomosis, antrectomy, and Roux-en-Y reconstruction.57 Modifications of this with and without esophageal resection were subsequently used for recurrent stricture, failed anti-reflux surgery requiring reoperation, and management of alkaline reflux.58-63 From the late 1930s to the early 1950s, there was a growing impression that gastroesophageal reflux was related to a failure of the anti-reflux mechanism. Many physicians believed that failure of the anti-reflux mechanism was a result of a hiatus hernia. Allison15 stated that the symptoms are those of oesophagitis from the reflux of gastric contents into the oesophagus, due to incompetence of the...

Lifestyle Diet Modifications

Traditionally, the cornerstone of the medical management of GERD consisted largely of efforts to modify the patient's lifestyle and diet. Specific lifestyle modifications included elevation of the head of the bed,restriction of alcohol and smoking, dietary therapy, weight loss, and avoidance of lying down soon after a meal, especially at night.4 The primary reason for dietary modifications such as those noted above was related to the effect certain foods and meals in general had on the lower esophageal sphincter pressure (LESP) or the direct irritative effects of certain foods on the esophageal mucosa. Although it is clear that avoidance of offending foods may decrease sporadic GERD symptoms, there has been no controlled trial data to support that these specific lifestyle modifications are effective in patients with typical and more frequent GERD symptoms. Other lifestyle interventions such as sleeping with the left side down (compared with right side down, prone, or supine) have been...

Proton Pump Inhibitors

Proton pump inhibitors are currently the most effective medical treatment for GERD. These compounds profoundly suppress acid secretion through the inhibition of H+, K+ adenosine triphosphatase, the proton pump of the parietal cell, and the site responsible for acid production. All PPIs are substituted benzimidazoles and are prodrugs, which must be activated in the presence of acid in order to inhibit the proton pump. Unlike the H2RAs, PPIs block acid production regardless of the method of cell stimulation, thus providing a greater degree of acid suppression for a longer duration of time. This superior pharmacological effect translates into a higher efficacy rate in GERD symptom relief and healing of esophagitis. Conventional healing rates with the first four PPIs omepra-zole, lansoprazole, rabeprazole, and pantopra-zole have demonstrated that a once-daily morning dose of a PPI will provide relief of symptoms and healing of erosive esophagitis in approximately 80 of patients.8 Healing...

Maintenance of Remission

Because GERD is a chronic medical disorder, most patients will relapse once antisecretory medication is discontinued. Maintenance of remission frequently requires the same dose of medication necessary to effectively induce healing, although maintenance strategies typically try to go to the next lowest dose below that which controlled GERD symptoms or effected healing. Although H2RAs are only approved for the short-term use of GERD, there is also evidence that maintenance therapy with these agents will decrease the relapse of esophagitis somewhat, but they are nearly as effective as PPIs in this regard. Consistent with the superiority of PPIs over the H2RAs as acute GERD therapy, there is a similar superiority demonstrated in comparative maintenance trials.21 Relapse rates are higher for H2RAs dependent in part on the baseline grade of esophagitis before initial treatment. Additionally, PPIs have been shown to be superior versus H2RAs in the prevention of stricture recurrence and need...

Clinical Presentation Chest Discomfort

Of all the symptoms for which patients seek emergency medical care, chest pain or chest discomfort is one of the most common and complex. Published reports suggest that up to 7 of visits to the ED involve complaints relating to chest discomfort (30). The complaint of chest discomfort encompasses a wide specturm of conditions that range from insignificant to high risk in terms of threat to the patient's life, including but not limited to ACI (AMI and UAP), thromboembolic disease (pulmonary embolism), aortic dissection, pneumothorax, pneumonia, myocarditis, and pericarditis. Chest discomfort may be perceived as pain or as sensations such as tightness, pressure, or indigestion, or as discomfort most noticeable for its radiation to an adjacent area of the body. Elderly or diabetic patients may have altered ability to specifically localize discomfort. Individuals and cultural groups vary in their expression of pain and ability to communicate with health professionals, so that presentation...

Measuring Esophageal Motility and LESP As an Outcome of Anti Reflux Therapy

Hypotension of the lower esophageal sphincter is recognized as a key factor in the pathogene-sis of GERD. The prevalence of low LESP increases with the severity of esophagitis.58 A large body of information indicates, however, that it is transient lower esophageal sphincter pressure relaxations of the LES (tLESRs) that is the major mechanism for reflux of acid into the both for normal individuals as well as those with GERD.59,60

Endoscopic Assessment Endpoints As an Outcome of Anti Reflux Therapy

Endoscopy allows for the identification of GERD-related mucosal damage. This is evident primarily by the demonstration of erosive changes or complications such as stricture or BE. Endoscopic assessment of esophagitis is a very objective parameter that can be followed sequentially to assess disease response to a specific therapeutic intervention. Although erosive esophagitis is easily recognized, there are many diagnostic instruments that have attempted to stratify the severity of erosive damage. Unfortunately, only 35-57 of patients with symptomatic GERD will have evidence of erosive esophagitis or BE.62-64 Several other issues are critical when evaluating endoscopic outcomes of a GERD therapy 1. Was a validated instrument used to assess the grade of esophagitis Despite the high prevalence of erosive esophagitis in clinical studies, there has only been a recent effort to use a validated instrument for the assessment of disease severity as it relates to the extent of erosions. To date,...

Qualityof Life Assessment As an Outcome of Anti Reflux Therapy

Utilized in recent trials assessing GERD outcomes.76-78 There are several generic as well as disease-specific instruments that have been utilized in these studies, including the SF-36, psychological general-well-being index (PGWBI), quality of life in reflux and dyspepsia (QOLRAD), and gastrointestinal quality-of-life index (GIQLI), among others. These HRQOL endpoints, however, are subject to the individual thresholds of the patient. If these assessments are used as primary outcomes to assess GERD therapy, they are subject to the variances in the patient expectations for disease management. This may be an issue especially if there is not a control arm in the scientific design of the study. It is clear that disease severity correlates with HRQOL and does contribute to a negative effect on both work productivity and absenteeism. There are, however, cultural and situational variances in patient willingness to go to work when they do not feel well. Absenteeism thereby may not be an...

Medication Use As an Outcome of Anti Reflux Therapy

A decrease in use of antisecretory or acid-buffering medication would seem to be an important endpoint for a therapeutic intervention for GERD. Recognizably, medication use is somewhat dependent on patient expectations and habit of use. This underscores the need for placebo-controlled studies when using this as an endpoint. The clinical trials of medical MEDICAL MANAGEMENT OF GERD ALGORITHMS AND OUTCOMES therapy for GERD have been relatively conscientious in the capture of data involving ancillary medication use. Most of the more recent trials have accounted for the use of antacids that are provided to the patient as rescue medication. This type of medication accounting does not, however, account for off-protocol medication use of other over-the-counter medications (H2RA, PPI). Study treatment bias, however, is for the most part precluded by the appropriate use of blinded studies involving a placebo control group. The potential problem of capturing an accurate assessment of ancillary...

Esophageal Adenocarcinoma

There is a strong and probable causal relationship between GERD symptoms and esophageal adenocarcinoma. A case control study from Sweden showed that among individuals with recurrent symptoms of reflux, the odds ratios were 7.7 for esophageal adenocarcinoma (95 CI 5.3-11.4).70 It was also shown that the more frequent, and more severe the symptoms of reflux, the more pronounced the risk of adeno-carcinoma.70 Although Barrett's esophagus is the most widely accepted risk factor for adeno-carcinoma, other risk factors exist as well such as tobacco use, increasing age, male gender, diets high in fats and low in fruits and vegetables, and obesity. A recent population-based study showed a strong correlation between increased body mass index (BMI) and esophageal adenocarcinoma individuals in the highest quarter of BMIs measure had an adjusted odds ratio 7.6 (95 CI 3.08-15.2) compared with those with the lowest BMIs.71 COMPLICATIONS OF GERD ESOPHAGITIS, STRICTURE, BARRETT'S, AND CANCER

Belsey Fundoplication Technique

Belsey Fundoplication 360

Beginning in 1949 Belsey began to investigate methods of repairing hiatal hernias and correcting gastroesophageal reflux symptoms. The fourth iteration of his operation, the Belsey Mark IV, consisted of a partial (270-degree) fundoplication performed with two rows of sutures, the latter of which was also brought through the diaphragm to anchor the stomach and the fundoplication within the abdomen (Figure 2.8). This operation was introduced in 1955, and results in > 600 patients were reported in 1967 after a median follow-up of almost 5 years.68 Anatomic correction and symptomatic success were noted in 85 of patients. This represented a milestone in the reporting of surgical treatments, in which long-term and complete follow-up as well as objective evaluation of symptoms were used to assess the outcomes of a new operation. Because of its complexity and the perceived need to perform the procedure exclusively through a thoracotomy incision, the Belsey Mark IV operation never gained...

Poor Response to Proton Pump Inhibitors

Failure of modern medical treatment to relieve at least some of the patient's symptomatology is one of the most common reasons for surgical referral. Yet, this is described as a poor predictive factor of favorable surgical outcomes.2 It is important to differentiate from this group those patients who, in fact, initially had a good response to proton pump inhibitors (PPIs) but for whom, over time, the effect of the medication decreased, leading the patient to increase the dose of medication and identifying the disease as being refractory to it. Patients that have never responded to medications, especially those with symptoms not classically associated with GERD such as abdominal pain, bloating, and nausea, are unlikely to benefit from an operation as much as those who initially responded well. Many of these patients may not even have GERD. Extensive testing, even sometimes repeat

Patients with Barretts Esophagus

Patients with Barrett's esophagus generally have more severe GERD, and thus often seek surgery to relieve symptoms. Surgical therapy is very effective, in our experience, at relieving reflux symptoms,5 although others have shown slightly less favorable results.6 We believe that if a technically good operation is performed, excellent results can be obtained in this population.

Preoperative Evaluation

For a practical description of the preoperative evaluation, we can divide patients into those with typical symptoms (heartburn and regurgitation) and those with atypical ones (airway symptoms, chest pain, etc.). For both groups, we believe an adequate work-up should include upper endoscopy (EGD), manometry, 24-hour esophageal pH monitoring, and upper gastrointestinal series. For those with atypical or airway symptoms, esophageal pharyngeal pH monitoring and laryngoscopy appear as useful adjunc-tive tools that help link these manifestations with GERD. Esophageal impedance is becoming recognized as a useful tool to evaluate these patients.

Adverse Reactions

Gastric upset, heartburn, nausea, vomiting, anorexia, and gastrointestinal bleeding may occur with salicylate use. Although these drugs are relatively safe when taken as recommended on the label or by the primary health care provider, their use can occasionally result in more serious reactions. Some individuals are allergic to aspirin and the other salicylates. Allergy to the salicy-lates may be manifested by hives, rash, angioedema, bronchospasm with asthma-like symptoms, and ana-phylactoid reactions.

Anchoring the Fundoplication

Coronal sutures. (Reprinted from Hiatal Hernia and Gastroesophageal Reflux Disease.In Townsend CM, Beauchamp DR, Evers MB, Mattox KL, eds. Sabiston Textbook of Surgery. 16th ed. 2004 755-768, Copyright 2004, with permission from Elsevier.) Figure 5.4. Coronal sutures. (Reprinted from Hiatal Hernia and Gastroesophageal Reflux Disease.In Townsend CM, Beauchamp DR, Evers MB, Mattox KL, eds. Sabiston Textbook of Surgery. 16th ed. 2004 755-768, Copyright 2004, with permission from Elsevier.)

Acute Complications of Anti Reflux Surgery

In the last three decades, surgical procedures for gastroesophageal reflux disease showed significant improvements in outcomes mainly because of standardization of the indications, widespread use of accepted fundoplication techniques, and improved perioperative management. Despite the good results of the currently adopted operations,1 acute complications of anti-reflux procedures occur and may be life-threatening. Large series with careful long-term follow-up are available and demonstrate recognizable patterns of failure.2-6 Complications are different in type and frequency in relation to both techniques (e.g., partial vs total fundoplication) and approach (e.g., thoracotomy vs laparotomy). Recently, the evolution toward the use of the laparoscopic approach7-9 changed the frequency of these untoward events. Some of the complications traditionally associated with open surgery decreased in incidence (e.g., inci-sional hernia, splenic injury), whereas other specific complications (e.g.,...

Adverse Effects of Steroids

Three broad groups can be identified, although 50 of patients report no adverse event. Early effects are mainly due to high doses and include cosmetic effects (acne, moon face, oedema), sleep and mood disturbance, dyspepsia, or glucose intolerance. Effects associated with prolonged use (usually 12 weeks) include posterior subcapsular cataracts, osteoporosis, osteonecrosis of the femoral head, myopathy, and susceptibility to infections. Effects during withdrawal include acute adrenal insufficiency (from sudden cessation), a syndrome of myalgia, malaise, and arthralgia (similar to recrudescence of UC), or raised intracranial pressure. Complete steroid withdrawal is facilitated by early introduction of azathioprine, adjuvant nutritional therapy, or timely surgery.

Technical Surgical Failures Presentation Etiology and Evaluation

Approximately 48,000 patients undergo antireflux procedures each year in the United States. Although surgery is the most effective treatment for gastroesophageal reflux disease (GERD),anti-reflux operations have reported failure rates between 3-30 . This wide variability reflects differences in operative technique,differences in the length of reported follow-up, and differences in the definitions used to describe failure. For the purposes of this chapter, failure is defined as the development of recurrent or new symptoms after anti-reflux surgery combined with documented pathologic gastroesophageal reflux or anatomic failure. Failures occurring within the first 3 months of surgery are termed early failures and are generally caused by technical errors. Diaphragmatic stressors such as weight lifting increase the risk of recurrence, especially in the early postoperative period. When failures occur after 3 months, they are termed late failures and a combination of factors may be...

Recurrent Atypical Symptoms

This is a particularly common and important problem. Whereas well-documented heartburn and regurgitation tend to respond to medicine or surgery in 85-95 of patients, pulmonary and atypical symptoms are less likely to respond to either type of therapy60 (Figure 9.5). It seems that a smaller amount of acid reflux is required to produce these symptoms than is needed to produce typical symptoms and routine esophagitis. This suggests that failure to control symptoms could be the result of incomplete control of small amounts of acid reflux. An alternative explanation is that many of these symptoms were never caused by reflux, even before the surgery. Asthma and GERD often coexist, although it is not always easy to determine if the two are truly related.61 However,medical and surgical therapy both have been demonstrated to improve or control both esophageal and pulmonary symptoms in many asthma patients.62,63 Objective evidence of improvement using pulmonary function testing has been more...

The Medical and Endoscopic Management of Failed Surgical Anti Reflux Procedures

Surgical anti-reflux procedures, both open and laparoscopic, when performed by an experienced surgeon have been shown to be extremely effective in eliminating the major symptoms (heartburn and regurgitation) associated with gastroesophageal reflux disease (GERD) as well as heal erosive esophagitis and prevent stricture. The results of surgical anti-reflux surgery have also demonstrated durability in maintaining symptomatic and endoscopic remission in most of the patients who have an initial response. However, not all patients exhibit an initial or permanent satisfactory outcome from surgery, and surgical failure is even more prevalent when surgery is performed outside community and academic anti-reflux surgery centers of excellence. Thus, both the anti-reflux surgeon and his her gastroenterology colleague likely will see an increasing number of their own or other physicians' patients that either failed to obtain initial symptom relief after anti-reflux surgery or whose symptoms have...

Ambulatory Esophageal pH Monitoring in Patients with Prior Anti Reflux Procedures

One of the great fallacies in managing patients with GERD is that pharmacological,endoscopic, or surgical anti-reflux therapy normalizes intraesophageal acid exposure in most patients. The reality is that many GERD patients, even those with complete resolution of heartburn and healing of esophagitis, often have improved but persistent pathological intraesophageal acid exposure, despite apparent adequate pharmacological, endoscopic, or surgical therapy. Thus, pathological intraesophageal acid exposure after anti-reflux surgery in of itself is not necessarily indicative of a failed surgical procedure. A postoperative esophageal pH assessment is difficult to reconcile with postoperative symptoms if the preoperative pH values are not known and unless a symptom correlation is performed between reflux events and symptoms with the follow-up study. Unfortunately, this later symptom assessment during interpretation of pH monitoring is not routinely performed by all that read these tests, but...

Control Of Digestive Functions By The Nervous System

Sensory nerves transmit information on the state of the gut to the brain for processing. Sensory transmission and central processing account for sensations that are localized to the digestive tract. These include sensations of discomfort (such as upper abdominal fullness), abdominal pain, and chest pain (heartburn). Neural interactions include the sensory inflow of information from the gut to the brain and outflow from the brain to the gut. Outflow may originate in higher processing centers of the brain (the frontal cortex) and account for the projection of an individual's emotional state (psychogenic stress) to the gut. This kind of brain-gut interaction underlies the symptoms of diarrhea and lower abdominal discomfort often reported by students anticipating an examination.

Pharmacological Therapy for Failed Anti Reflux Surgery

Pharmacological therapy of GERD with antise-cretory agents dates back to the mid-1970s when H2RAs first became available.28,74 These agents demonstrated healing and symptom relief in approximately 50 of patients treated. In the 1980s-1990s, use of prokinetic compounds (cisapride) was also being used primarily or adjunctively to treat GERD symptoms, with efficacy similar to that demonstrated with H2RAs.75 In 1989, the first PPI, omeprazole, was introduced and recently a second-generation PPI (esomeprazole) has become available. Substantial data from well-designed clinical trials with these drugs demonstrated healing and symptom response rates of 75-95 .76 We now have at our disposal substantial short- and long-term PPI efficacy data demonstrating that 80-95 of patients with GERD treated with these agents obtain symptom relief and can be maintained in clinical remission.77 Interestingly, in studies in which pharmacological therapy is directly compared with surgical therapy for GERD,...

Twentyfourhour pH Monitoring

Reflux is more complex than its use for acid reflux diagnosis because of the interaction between mucous and acid secretions, ingested food, saliva, and duodenal, pancreatic, and biliary secretions.42 The score proposed by Fuchs et al.43 allows the quantification of duo-denogastric reflux and gastric acid secretion and could be helpful in the assessment of DGER and gastric emptying disorders. The scoring had a sensitivity of 90 and a specificity of 100 . Alkaline reflux is confirmed by measurement of the time during which the esophageal pH is > 7, but several considerations must be taken into account. Electrodes made of glass instead of antimony should be used, and extreme caution is exerted with the calibration method. The patient's diet should be restricted to food at a pH < 7, the patient should be examined for dental caries that can raise the salivary pH, and strictures should be dilated to prevent second probe in the stomach may be helpful in differentiating acid reflux,...

Monitoring Acid and Bile Reflux

Ambulatory 24-hour pH monitoring has become the most objective documentation of acid exposure in the esophageal lumen. It provides valuable information in patients with pathological reflux disease by recording the frequency and duration of acid reflux episodes. The constant monitoring of acid exposure also suggests the severity of reflux-related mucosal damage, a severity that always has to be documented by endoscopy.

Multiple Failed Anti Reflux Operations

Another indication for esophagectomy for GERD is a history of multiple failed attempts at anti-reflux surgery. Compromise of esophageal blood supply occurs each time the esophagus and stomach are dissected to enable performance of a fundoplication. In addition, accumulated scar tissue as well as anatomic deformities caused by prior operations increase the risk of injury to the vagus nerves and the vagal plexus during dissection. The cumulative effect of these injuries results in loss of peristaltic function (pump function) leading to dysphagia and ineffective esophageal clearance of gastric refluxate. Several reports indicate that satisfactory results after fundoplication surgery occur in only 50-60 of patients who have had two or more prior fundoplications.22-24 The assessment of esophageal function is more important than merely counting the number of prior operations to determine optimal surgical therapy. Such assessment typically includes endoscopy, manometry, esophageal transit...

Endoscopic and Pharmacologic Therapy after a Failed Anti Reflux Surgery

Once it has been objectively determined through appropriate and increasingly accurate diagnostic testing that the symptoms a patient has in the postoperative state are related to continued or recurrent reflux, the next decision one needs to make is how best to manage the patient's GERD. Options include repeat anti-reflux surgery in a center with skill and experience in this type of surgery, endoscopic anti-reflux procedures, or pharmacologic anti-reflux therapy. The treatment choice in this situation, as noted in Chapter 10, is heavily dependent on the patient's preferences regarding further therapy for GERD as well as their unique physiology and anatomy determined by a careful evaluation. Furthermore, the availability of surgical or endoscopic skill in performing these types of repeat procedures may limit or expand the options offered the patient. It is likely that continued improvements and innovation in surgical, endoscopic, and pharmaco-logic anti-reflux therapy will further...

Presenting Symptoms of Failed Anti Reflux Operations

Upright Abdominal Radiograph

Patients with GERD often have associated gastrointestinal motility disorders. Because patients have high expectations of anti-reflux surgery, many perceive that residual symptoms represent an indication of fundoplication failure. It is well known, however, that symptoms correlate poorly with the presence of acid reflux after fundoplication. Soper and Dunnegan1 found that 26 of those undergoing laparo-scopic anti-reflux surgery reported postoperative foregut symptoms. After an extensive evaluation, 35 had no demonstrable abnormality and their symptoms resolved without intervention.1 Galvani et al.2 studied 124 patients with persistent or recurrent foregut symptoms after laparoscopic fundoplication. Only 39 were found to have acid reflux by 24hour pH monitoring. Viewed another way, two-thirds of the patients who were taking acid-reducing medications postoperatively were found to have normal 24-hour pH probes studies (the studies were performed off med-ication).2 Almost every patient...

Lengthening Gastroplasties

Collis Gastroplasty Hernia Repair

In 1957, Collis,8 dissatisfied with the problems generated by the short esophagus, including the frequent periesophagitis present in these patients, introduced the concept of esophageal lengthening using the proximal lesser gastric curvature to create a neoesophagus. The lengthening gastroplasty was seen as an alternative to esophagectomy and reconstruction, a solution which was used more liberally at that time. The repositioning of the esophagogastric junction with the recreation of the angle of His was initially thought to be sufficient to prevent gastroesophageal reflux.8 No anti-reflux mechanism was then added to the gastroplasty, leading to poor reflux control. Subsequently, the initial Collis gastroplasty was combined to a Belsey-type of fundoplication by Pearson whereas Orringer and Henderson advocated the use of a total fundoplication to wrap the neoesopha-gus.43 The indications for using a lengthening gastroplasty with either a partial or a total antireflux fundoplication...

Division of the Short Gastric Vessels

Dissection Short Gastric Vessels

Transecting the short gastric vessels. (Reprinted from Hiatal Hernia and Gastroesophageal Reflux Disease. In Townsend CM, Beauchamp DR, Evers MB, Mattox KL, eds. Sabiston Textbook of Surgery. 16th ed. 2004 755-768, Copyright 2004, with permission from Elsevier.) Figure 5.2. Transecting the short gastric vessels. (Reprinted from Hiatal Hernia and Gastroesophageal Reflux Disease. In Townsend CM, Beauchamp DR, Evers MB, Mattox KL, eds. Sabiston Textbook of Surgery. 16th ed. 2004 755-768, Copyright 2004, with permission from Elsevier.)

Fundoplication Herniation

The second situation is the patient who has a similar event but more remote from the time of operation. Although these patients may develop severe acute pain after herniation of the fundo-plication, the return of symptoms is usually more insidious, and the time of herniation may be difficult to pinpoint. Under these circumstances, the herniation is more frequently heralded by the symptoms of heartburn, new onset dysphagia, or postprandial chest pain resulting from gas or food distending the mediastinal portion of the herniated fundoplication. These patients should be evaluated with a barium swallow and EGD. Depending on the length of time between the first operation and the development of the hernia, we will perform esophageal motility and or a gastric emptying study to better define foregut physiology in this postoperative state in planning for a second surgery. The third situation is even more insidious. In this situation, the patient develops a slow onset of recurrent or new...

Cerebral Palsy And Developmental Disabilities

Vomiting gastroesophageal reflux Oral-motor difficulties Discoordination of suck swallow Structural abnormalities (cleft lip palate dentition) Poor oral containment (food fluid loss) Tone abnormalities (hypo hypertonic) Altered oral sensory response (hypo hyper-responsive) Delayed oral motor skill development Aspiration

Early Surgical Therapy

Endoscopic Stricturoplasty

The first operations performed at least in part for possible gastroesophageal reflux problems were for correction of hiatal hernias, usually giant paraesophageal hernias. Hedblom11 stated that the first operation for a clinically diagnosed hiatal hernia was by Naumann in 1888, but the stomach could not be reduced into the abdomen and the patient died. By the time of Harrington's10 report in 1928, successful surgery for hiatal hernia had been accomplished in

Persistent Postoperative Dysphagia

Slipped Fundoplication

In contrast to the patient with recurrent GERD symptoms, the patient with persistent postoperative dysphagia represents a different problem. The management of the patient with early postoperative dysphagia was discussed above. In the patient with dysphagia persistent for > 3

Potential Causes of Failure

Floppy Fundoplication

The construction of a fundoplication (particularly a 360 fundoplication) may unmask previously unrecognized esophageal dysmotility or misdiagnosed achalasia leading to severe postoperative dysphagia. Chronic inflammation can also contribute to esophageal failure. Both Barrett's esophagus and severe esophageal reflux are associated with chronic esophageal inflammation. Chronic inflammation results in fibrosis, foreshortening, esophageal dysmotility, and poor acid clearance. Poor acid clearance in turn contributes to more esophageal irritation and the vicious cycle is propagated. Over time, the esophagus may become significantly foreshortened and fibrotic. Although there is controversy over the true incidence of the short esophagus, we believe that this entity exists. Figure 8.4. Types of surgical failure of Nissen fundoplication. (Reprinted from Hinder RA. Gastroesophageal reflux disease. In Bell RH Jr, Rikkers LF, Mulholland MW, eds. Digestive Tract Surgery A Text and Atlas....

NSAIDs and Desmoid Tumours

Although NSAIDs are widely used and are effective, their long-term use is limited by gastrointestinal effects such as dyspepsia and abdominal pain, gastric and duodenal perforation or bleeding, and small bowel and colonic ulcerations. The discovery of COX-1 and COX-2 has led to the suggestion that the therapeutic effect of NSAIDs is primarily the result of inhibition of COX-2, whereas the toxicity of NSAIDs may primarily result from inhibition of COX-1 65 In fact, NSAIDs toxicity in the gastrointestinal mucosa is the result of inhibition of COX-1 activity in platelets, which increases the tendency of bleeding, and in gastric mucosa, where prostanoids play an important role in protecting the stomach from erosion and ulceration 55 . While the conventional NSAIDs inhibit COX-1 and COX-2 to the same extent, the development of a new group of anti-inflammatory drugs, the coxibs, selective inhibitors of COX-2 (e.g. celecoxib, rofecoxib, valdecoxib, etori-coxib, lumiracoxib), represent a...

Dilated Pouch Gastric Bypass

Esophageal Dilation Gastric Banding

Esophageal dysmotility and dilation is a newly recognized complication of LASGB. Intuitively, one might expect an inverse correlation between stomal diameter and esophageal dilation, but none was found. The majority of patients in our study developed new or more severe esophageal symptoms after placement of the device. Other studies support an increase in reflux after gastric banding. Ovrebo found in a study of 17 patients with the so-called Swedish LASGB device that acid regurgitation and heartburn increased from approx 15 to 60 after gastric banding. Other authors report complications such as food intolerance unresponsive to band deflation being attributable to pouch dilatation and or stomal stenosis. Kuzmak, although using a previous version of the current band system, showed that early postoperative contrast study document a pouch dilation rate of 6.5 which increased to 50 over a four year follow-up. Doherty et al found that 38 of patients with an adjustable silicone gastric band...

Gastric Secretion Is Under Neural and Hormonal Control

Histamine Acid Secretion

Gastric acid secretion is mediated through neural and hormonal pathways. Vagus nerve stimulation is the neural effector,- histamine and gastrin are the hormonal effectors (Fig. 27.8). Parietal cells possess special histamine receptors, H2 receptors, whose stimulation results in increased acid secretion. Special endocrine cells of the stomach, known as enterochromaffin-like (ECL) cells are believed to be the source of this histamine, but the mechanisms that stimulate them to release histamine are poorly understood. The importance of histamine as an effector of gastric acid secretion has been indirectly demonstrated by the effectiveness of cimetidine, an H2 blocker, in reducing acid secretion. H2 blockers are commonly used for the treatment of peptic ulcer disease or gastroesophageal reflux disease.

Nocturnal Acid Breakthrough PPI Plus H2RA

Studies evaluating gastric pH using continuous intragastric pH monitoring have demonstrated a curious physiological and pharmacological phenomenon known as nocturnal acid breakthrough (NAB). In these studies, the majority of subjects who were taking a PPI BID still developed an intragastric acidity level of a pH < 4 for at least 1 continuous hour in the overnight period of monitoring.19 This decrease in pH began to be evident 6-7 hours after the second (PM) dosing of the PPI. This is not the result of PPI resistance. Additionally, NAB is a class effect that is seen with all of the PPIs and is evident in healthy subjects and GERD patients alike. Curiously, the addition of an H2RA at bedtime in addition to the BID dose of PPI has been shown to be effective for ameliorating this phenomenon, but not a third bedtime dose of a PPI. The clinical importance of this physiological and pharmacological observation has not been determined and has clearly been overestimated by some, as there have...

Vagotomy Antrectomy and RouxenY Diversion

Csendes and associates16 observed an extremely high failure rate when treating Barrett's esophagus patients using conventional anti-reflux repairs. With this observation, they opted for bilateral vagotomy, antrectomy and long-limb Roux-en-Y diversion as primary treatment for these patients. They tried biliary diversion without resection (duodenal switch) but observed a better acid reflux control if an antrectomy was selected. Using this operation, they observed a reduction of low-grade dyspla-sia in the esophageal columnar-lined mucosa in 50 of treated patients.

Evaluation of the Failed Anti Reflux Procedure

As has been noted throughout this book, surgical anti-reflux procedures, when performed by an experienced surgeon, are effective in eliminating the symptoms of GERD in the vast majority of patients treated in this manner. Furthermore, because most patients treated surgically derive a durable effect, anti-reflux surgery provides healing and maintenance of remission. Despite the high success rate achieved with antireflux surgery, many patients still will either fail to achieve an initial symptom response or experience a relapse of their GERD symptoms over time. The initial failure rate with antireflux surgery is likely much greater in less-experienced surgeons' hands, whereas later anti-reflux surgery relapses seem to occur even in patients treated by the most experienced surgeons. The mechanisms or reasons for persistent or recurrent reflux after anti-reflux surgery are not entirely understood. However, given the rapidly expanding use of this surgical procedure, it is clear that we...

Methods of Evaluation

Nissen Fundoplication Barium Swallow

A barium swallow should be the initial diagnostic study in the work-up of any symptomatic patient. This relatively noninvasive, inexpensive study will define the patient's anatomy and help clarify the relationship of the gastroesophageal junction to the hiatus. This study may also demonstrate gastroesophageal reflux and can detect evidence of delayed esophageal emptying. A barium swallow is particularly helpful when the patient presents with symptoms of dysphagia or pain and can help delineate a gross anatomic defect that might explain the patient's symptoms (Figure 8.2). However, the failure to visualize reflux on a barium study does not exclude the possibility that the patient is experiencing pathologic reflux. Because patients may have symptoms consistent with reflux without evidence of gastroesophageal reflux, a 24-hour pH study is important in patients whose anatomy seems to be intact. This functional study confirms the presence of pathologic gastroesophageal reflux. By...

Gastrointestinal Diseases

Gastroesophageal Reflux Gastroesophageal reflux (GER) is the effortless movement of gastrie contents into the esophagus. While GER is considered a normal physiologic process rather than a disease. it can produce clinical symptoms ranging from mild heartburn to esophagitis. respiratory disease, and even apnea. Gastroesophageal retlux disease (GERDl refers to these symptoms. Pediatric patients with GERD may present with chest pain, dyspepsia, vomiting, burping, dysphagia. postprandial fullness, chronic hoarseness and cough, wheezing, and respiratory symptoms of unknown etiology. Gastroesophageal rellux disease is also a major cause of anorexia, resulting in malnutrition among pediatric patients with a variety of chronic illnesses. Multiple physiologic factors are generally thought to be responsible for GERD. including decreased lower esophageal sphincter (LES) tone, esophageal mucosal irritation from hydrochloric acid and pepsin, delayed esophageal peristalsis. and delayed gastric...

Symptom Assessment As an Outcome of Anti Reflux Therapy

Reflux disease is associated with a number of symptoms, but in GERD treatment studies, the major focus has been on the effect of an intervention on heartburn and regurgitation. Although heartburn is probably the best characterized symptom of GERD, there is no universally accepted definition of heartburn. This becomes of particular importance, because heartburn has been the major enrollment criterion for most of the GERD therapy trials. A definition of heartburn as a burning feeling rising from the stomach or lower chest towards the neck has led to an improved recognition of this symptom indicating GERD.67 Many patients, however, do not construe heartburn and retrosternal burning to be synonymous.67 The majority of trials have graded clinical heartburn using a severity scale such as a Likert scale or a visual analog scale. The reproducibil-ity and responsiveness of these scales have been fairly good in the assessment of upper gastrointestinal disease.68 It has been shown, however, that...

Dystonic Drug Reaction

Dystonia is a sustained abnormal posture that occurs from the contraction of both the agonist and antagonist muscle groups of an extremity. Dystonic postures may be generalized or focal. Spells of paroxysmal dystonias are difficult to differentiate from tonic seizures. In infants, a common etiology of sudden dystonia is an acute drug reaction. These reactions may manifest themselves as opisthotonic posturing, torticollis, and an ocu-logyric crisis. Metoclopramide, a parasympathomimetic drug often used for the treatment of gastroesophageal reflux, is a common medication used in infants that can cause this drug reaction. Other medications associated with dystonic drug reactions, such as phenothiazines and haloperidol, are used less often in toddlers.

Endoscopic Anti Reflux Procedures

We soon will have results of sham-controlled clinical trials evaluating all of the currently Food and Drug Administration cleared or approved endoscopic anti-reflux devices, and this will set the standard for the entire field as it relates to accurately measuring efficacy.14 There will be continued refinements in the techniques of use for all of these devices, and newer iterations of the devices will optimize the efficacy as well as safety of these procedures.15-17 It will be interesting to see results of the current endo-scopic anti-reflux procedures in patients with more severe reflux anatomy and physiology (those with larger hiatus hernias, more severe esophagitis, presence of Barrett's esophagus) as well as those with atypical GERD symptoms (i.e., cough, hoarseness, asthma).

Gas Bloat and Upper Abdominal Discomfort

Documented delayed gastric emptying is another potential cause of bloating that has been reported in several patients after antireflux surgery,24 although there have been no systematic studies of the incidence of this problem. Gastric emptying disturbances have been reported in up to 40 of patients with GERD,25 although the exact prevalence of clini It has been suggested that many GERD patients swallow air as a response to esophageal reflux.32 If this is true, then the surgery may be bound to produce symptoms. Also, some GERD patients tend to both overeat and eat very quickly, two factors that increase air swallowing. In fact, whereas inability to belch increased in patients after surgery, the symptom of bloating was less common and fullness or early satiety were equally common after surgery.12 Using means and medians to report changes in symptoms can be misleading a better approach is to look at symptoms in individual patients before and after surgery. For example, Anvari and Allen33...

Endoscopy and Esophageal Biopsies

The unequivocal documentation of visual and histological damage on the esophageal mucosa is the mainstay of decision-making when treating GERD. Endoscopic evaluation is of primary importance if a patient is suspected of having a shortened esophagus, and even more so in patients with a failed repair. Preferably the surgeon who will provide the treatment should perform or observe the endoscopic assessment. The identification of severe esophagitis or stricture usually presents no problem. Barrett's esophagus can only be documented with multiple biopsies and the histological identification of intestinal metaplasia in the columnar-lined esophagus. Multiple biopsies and brush cytologies are always needed to rule out malignancy if the esophagus is strictured. Esophageal dilatations, using bougies or balloon dilators, may be necessary to provide an esophageal lumen that will allow a proper examination while at the same time permitting easier food intake.

Sphincters Prevent the Reflux of Luminal Contents

The lower esophageal sphincter prevents the reflux of gastric acid into the esophagus. Incompetence results in chronic exposure of the esophageal mucosa to acid, which can lead to heartburn and dysplastic changes that may become cancerous. The gastroduodenal sphincter or pyloric sphincter prevents the excessive reflux of duodenal contents into the stomach. Incompetence of this sphincter can result in the reflux of bile acids from the duodenum. Bile acids are damaging to the protective barrier in the gastric mucosa,- prolonged exposure can lead to gastric ulcers.

Documentation of Recurrent Reflux after Surgical Anti Reflux Therapy

The first step in deciding how best to manage a patient with persistent or recurrent GERD symptoms after anti-reflux surgery is to ensure that the symptoms are actually reflux related. Patients are notoriously unreliable in understanding or describing what the term heartburn refers to and a word description such as a sub-sternal burning sensation rising towards the neck is a much more objective and reliable term to define reflux-related heartburn than the word heartburn itself.28 Thus, the first step one should take when a patient says they have heartburn after anti-reflux surgery is to ask them to carefully describe their symptom(s). Furthermore, the ability of physicians to adequately predict recurrent GERD in the postoperative state based on symptoms alone is also ques-tionable.22 In patients who underwent antireflux surgery for the symptoms of heartburn and regurgitation and where preoperatively objective evidence had linked these specific symptoms to pathological reflux...

Systemic Sclerosis and Related Syndromes

Cine-esophagography or manometric evaluations can help distinguish the pattern of esophageal involvement. Stomach involvement is less commonly symptomatic, but gastroparesis can contribute to dyspepsia and a sense of bloating. Gastric telangiectases occur but are uncommonly a cause of bleeding. Intestinal hypermotility can lead to bloating and cramps in addition to bacterial overgrowth, malabsorption, and diarrhea. Colonic manifestations often include constipation or pseudo-obstruction. Wide-mouthed colonic diverticula are common but are often not of clinical significance.

Flatulence Diarrhea and Irritable Bowel Syndrome

Anti Reflux Surgery

Problems related to flatulence, diarrhea, and irritable bowel syndrome (IBS) are very common among adult patients with or without GERD.38 It is therefore to be expected that many patients will have these symptoms both before and after anti-reflux surgery. In a study from our institution, diarrhea was present in 14 of patients before surgery and 29 after. Other symptoms included bloating (3 preoperative, 19 postoperative), constipation (15 and 18 , respectively), and abdominal pain (2 and 8 , respectively) (Figure 9.1).39 Flatulence has been reported in 12-88 of patients after anti-reflux surgery.40,41 It has been suggested that this flatulence is attributable to the patient's inability to belch and subsequent passage of more gas into and then through the gastrointestinal tract.42 Most of these studies are retrospective and at risk for recall bias, because many only surveyed patients after surgery and asked them to recall how they were before the surgery. In general, the suggested...

Choosing a Partial or a Total Fundoplication

The surgical literature is replete with articles debating the pros and cons of the Nissen fundoplication. Advocates of partial fundo-plications such as the Toupet and Belsey fundoplication point out advantages of less dys-phagia and preservation of the ability to vomit. Proponents of the Nissen fundoplication claim superior control of acid reflux as well as ease of performance of the procedure. In fact, there is little level 1 evidence to support the superiority of one procedure over another when performing a redo fundoplication. The choice of fundo-plication should be tailored to the symptom or anatomic defect needing correction. Patients who had a good short-term result from a Nissen fundoplication should probably have a full wrap reconstructed. Those patients who had a partial fundoplication with poor control of acid reflux should be considered for conversion to a Nissen. If a clear technical error can be identified that caused a full fundoplication to fail, one should not hesitate...

Esophagectomy Indications Techniques and Outcomes

The need for esophagectomy for managing gastroesophageal reflux disease (GERD) arises in a small minority of patients who experience severe complications of reflux or from antireflux surgery. When surgery other than routine fundoplication is necessary for correction of reflux complications, a variety of esophageal-preserving operations is available that minimizes operative risks compared with those associated with esophagectomy. Preservation of esophageal function is an important indication for use of such procedures, because no reconstructive organ can replicate esophageal peristaltic function. In addition, avoidance of esophagectomy helps preserve gastric reservoir and digestive capacities, and eliminates the risk of intrathoracic alimentary tract redundancy that frequently accompanies esophageal reconstructive procedures. Such redundancy can lead to food stasis, early satiety, and weight loss, and contributes to the risk of postprandial aspiration. Because many reconstructive...

Evolution of Hiatal Hernia and Anti Reflux Surgery

The concept of a shortened esophagus is not accepted by everyone, resulting in controversy over the years.1,2 Although an occasional patient may be seen with an esophagogastric junction clearly irreducible to its proper position under the diaphragm, there are discrepant opinions among surgeons on what constitutes a shortened esophagus and what is the real incidence of the condition in patients with gastroe-sophageal reflux disease (GERD) and hiatal hernia. There is no exact and reproducible method of measuring the length of the esophagus before and during surgery. The extent to which the esophageal surgeon has to address the During the last 50 years, the natural evolution of the various anatomic hiatal hernia repairs and, subsequently, of the numerous anti-reflux operations has resulted in identifying failure patterns which were then related to the severity of the disease. How often a failed anatomic repair was the consequence of not recognizing a short esophagus remains unknown. The...

Laparoscopic Gastric Bypass for Recurrent Reflux

Revision Ethicon

Port placement for Roux-en-Y gastric bypass for patients with morbid obesity and recurrent gastroesophageal reflux disease.Courtesy of Ethicon Endo-Surgery, Inc., a Johnson & Johnson company. All rights reserved. Figure 11.8. Port placement for Roux-en-Y gastric bypass for patients with morbid obesity and recurrent gastroesophageal reflux disease.Courtesy of Ethicon Endo-Surgery, Inc., a Johnson & Johnson company. All rights reserved.

Measuring Esophageal pH As an Outcome of Anti Reflux Therapy

The technology to monitor the presence of acid in the esophagus has made this endpoint a logical outcome for assessment of a therapy of GERD. Esophageal pH monitoring measures the frequency and duration of acid reflux as well as allows one to correlate the temporal events with a specific symptom related to GERD. Although esophageal pH testing is not considered a necessary test in the evaluation of patients with classic GERD, it does provide an objective measure of the degree of acid reflux. There are several types of pH electrodes suitable for intraesophageal use. The traditional approach has involved the use of a tube passed transnasally into the esophagus. Data are then accumulated via a direct-contact communication to a data logger worn by the patient. Differences exist between the monopolar electrodes that require an external reference electrode versus the combination electrodes with a built-in reference, because the former is more susceptible to artifact. Recently, a new wireless...

Centers of Surgical Excellence

A very large number of fundoplication procedures currently are being performed in Western societies,with an appreciable rate of subsequent surgical failure, and a strong association between failure rates and degrees of surgical experience. In many regions of Europe, surgical therapy is performed primarily in centers of excellence in which a high degree of surgical experience is concentrated. No such centers have been mandated in the United States, and most surgical procedures for GERD are performed in community hospitals by surgeons with moderate levels of experience. Given the high cost of GERD therapy, particularly among patients with failed therapy for GERD, important cost savings will be realized when centers of excellence are established for initial endo-scopic and surgical anti-reflux therapy.

Esophageal Mobilization

Diaphragmatic closure. (Reprinted from Hiatal Hernia and Gastroesophageal Reflux Disease. In Townsend CM, Beauchamp DR, Evers MB, Mattox KL, eds. Sabiston Textbook of Surgery. 16th ed. 2004 755-768, Copyright 2004, with permission from Elsevier.) Figure 5.3. Diaphragmatic closure. (Reprinted from Hiatal Hernia and Gastroesophageal Reflux Disease. In Townsend CM, Beauchamp DR, Evers MB, Mattox KL, eds. Sabiston Textbook of Surgery. 16th ed. 2004 755-768, Copyright 2004, with permission from Elsevier.)

Glycogen Storage Disease

Treatment is mainly supportive and is based on individual symptoms. Muscle fatigue, developmental delay, gastroesophageal reflux, and poor oropharyngeal coordination all predispose to poor intake. Undernourished states may produce symptoms that suggest an accelerated deterioration in the status of the patient. Attention to adequate nutrition is essential to maintain optimal growth, development, and level of functioning in these patients.

Effects of Increased Intra Abdominal Pressure on Laparoscopic Surgery in Severe Obesity

Abdominal Pressure

Laparoscopic surgery has become very popular for the treatment of severe obesity. Obesity can be distributed in either an android fashion, primarily within the abdominal area or centrally as seen primarily in male patients, or in a gynoid manner, in the hips and buttocks, peripherally as seen primarily in female patients. Many of our severely obese female patients have both peripheral and central obesity. We have found that central obesity is associated with a significant increase in intra-abdominal pressure and this pressure is as high or higher than the pressure seen in patients with an acute abdominal compartment syndrome (Fig. 5.1). Data support the finding that this increase in intra-abdominal pressure is associated with a number of obesity related co-morbidity problems leading to the development of a chronic abdominal compartment syndrome. These co-morbidities include obesity hypoventilation syndrome with its high cardiac filling pressures, gastroesophageal reflux disease,...

Esophageal Acid Clearance

After an acid reflux event, the duration of time that the esophageal mucosa remains acidified to a pH of < 4 is termed the esophageal acid clearance time. Acid clearance begins with peristal Prolongation of esophageal acid clearance among patients with esophagitis was demonstrated along with the initial description of an acid clearance test.61 Subsequent investigations have demonstrated heterogeneity within the patient population such that about half of the GERD patients had normal clearance values, Impaired esophageal emptying in reflux disease was inferred by the observation that symptoms of gastroesophageal reflux improve with an upright posture, a maneuver that allows gravity to augment fluid emptying. Subsequently, two mechanisms of impaired esophageal emptying have been identified peristaltic dysfunction and superimposed reflux associated with nonreduc-ing hiatus hernias. Peristaltic dysfunction in esophagitis has been described by a number of investigators. Of particular...

Patterns of presentation

A sudden onset of severe abdominal pain which progresses rapidly, becomes generalised in site and constant in nature, in a' previously asymptomatic patient, suggests either perforation of a hollow viscus, a ruptured aortic aneurysm or a mesenteric arterial occlusion. Prior symptoms may help the differential diagnosis preceding constipation suggests colonic carcinoma or diverticular disease as the catisc of the perforation, and preceding dyspepsia suggests a perforated peptic ulcer. Coexisting peripheral vascular disease, hypertension, cardiac failure or atrial fibrillation suggest a vascular disorder, e.g. aortic aneurysm, mesenteric ischaemia. The development of peripheral circulatory failure (shock) following the onset of the pain, strongly suggests intra-abdominal bleeding, e.g. ruptured aortic aneurysm or ectopic pregnancy. The rapid onset of abdominal pain may also occur if an organ twists -

Risk factors for NSAIDassociated upper gastrointestinal ulcers

In many patients who experience serious gastrointestinal complications, there may not be a history of prior dyspepsia. In the absence of warning signs there is no way to ascertain whether the complications are imminent. When NSAID use is unavoidable, a protective strategy is needed, particularly in those at greatest risk. This could comprise

Early Postoperative Symptoms

The management of patients with new or recurrent GERD symptoms after surgery is dependent on the time of presentation. Early postoperatively (< 3 months) the presence of several symptoms is extremely common and no treatment or evaluation is necessary. Another early postoperative symptom of no great consequence is the development of chest pain or recurrent reflux symptoms. The mecha-nism(s) related to these symptoms remains unclear. However, during the first 3 months after surgery, the patient should be reassured that it is extremely unlikely that the symptoms reflect recurring gastroesophageal reflux, especially if no postoperative events such as retching have occurred. A simple screening study such as a barium swallow may provide the opportunity to provide a worried patient great reassurance that their fundoplication has not come undone. A trial of proton pump inhibitors (PPIs) is often initiated if the patient returns to their primary

Control Measures

Indications for eradication of H. pylori at the specialist level should be broadened to include H. pylori-positive patients with (a) functional dyspepsia in whom no other possible causes of symptoms can be identified (after full investigation including endoscopy, ultrasound, and other necessary investigations), (b) patients with low-grade MALT lymphoma (managed in specialized centers), and (c) patients with gastritis showing severe macro- or microscopic abnormalities.

Short and Longterm Outcomes of Endoscopic Anti Reflux Procedures

As the data we are deriving from the sham-controlled studies because uncontrolled trials tend to overestimate treatment effect. Furthermore, the endpoint of many of these early trials was less than optimal because the primary endpoint for success was often a decrease, not elimination of proton pump inhibitor (PPI) use. It must also be appreciated that both the preliminary studies and the newer sham-controlled trials only enrolled patients with GERD that were responsive to PPIs and having no more than mild to moderate reflux disease determined endoscopi-cally (generally hiatus hernias < 2-3 cm and nonerosive reflux disease or at most Los Angeles grade A or B erosive esophagitis). Response rates in those with more severe disease (larger hiatal hernias, or those with more severe esophagitis) or atypical symptoms (dyspepsia, cough, asthma, etc.) have not been adequately studied but likely will be less than observed in the pivotal trials that only included patients with more mild or...

Newer Indications for Surgical Therapy

Newer methods for evaluating patients with GERD and Barrett's esophagus may help physicians better select which patients should be treated more aggressively. In patients diagnosed with Barrett's esophagus, biological characterization of their risk of developing dysplasia or adenocarcinoma may be achieved through use of proteomics, gene analysis, or other advanced techniques. Patients who are stratified into a FUTURE DIRECTIONS OF THERAPY FOR GERD

Esophageal Peptic Stricture

Another well recognized complication of GERD is esophageal strictures (Figure 4.1). Unlike erosive esophagitis, which may present as a sole complication, strictures frequently are diagnosed along with other complications such as erosive esophagitis. The most common location of the strictures are in the distal esophagus,near the gastroesophageal junction.23,30 Strictures are complications of deep esophageal ulceration in which fibrous tissue and collagen formation laid down during repair of the ulcer site result in stricture formation.23,30 Stricture formation, in the case of peptic strictures, is initiated by an insult to the esophageal epithelium (i.e., acid reflux). During the healing process, collagen and scar tissue production cause esophageal narrowing.12 Unfortunately, as many as 10 of patients who seek medical attention for gastroesophageal reflux disease can have esophageal strictures.31 Although gastroesophageal reflux is thought to contribute to a significant percentage of...

Principles of Successful Surgical Anti Reflux Procedures

Gastroesophageal reflux disease (GERD) is the most common gastrointestinal disorder in the United States. Although lifestyle changes and medical therapy are the most common forms of therapy, with the advent of laparoscopy, more patients are choosing surgical therapy not only to treat the failures of medical therapy, but as an alternative to it. Surgeons must, therefore, be familiar with the principles of patient selection and with the techniques used to treat this disease. This chapter discusses the indications (and contraindications) and the work-up of patients suspected of having GERD and consulting for it, and the technique of anti-reflux procedures.

Twentyfourhour pH Esophageal Monitoring

This is the gold standard for the detection and quantification of GERD. At the University of Washington, we, as a matter of routine, simultaneously evaluate both the proximal and distal esophageal acid exposure. Normal pH monitoring should prompt a thorough work-up to rule out other etiologies, because these patients have an inferior result with surgical therapy. This test can also be used to correlate reflux episodes with symptom events, often serving as a confirmation of the clinical association. Finally,

Does Everyone with Narrowed or Blocked Heart Arteries Get Angina

Some people with blocked arteries do not get angina. The first sign may be a heart attack or sudden death. It is not understood why some people do not get warnings. Some might, but dismiss it as indigestion. Symptoms depend on a person's lifestyle. For example, an elderly person may have narrowed heart

Magnitude of the Problem

When a well-trained, competent surgeon performs anti-reflux surgery in a patient presenting with heartburn and regurgitation, 80-95 of patients obtain satisfactory relief of their reflux symptoms once recovered from the operation and eating normally again.1-14 Unfortunately, this degree of success cannot be matched outside of surgical centers of excellence and some data indicate that failure rates at 1 year as high as 50-60 may occur in less-experienced surgical centers.15,16 Furthermore, even in the best of hands, some patients will symptomatically relapse over time,with approximately 15-25 or more of patients reexperiencing symptoms of GERD five or more years after surgery despite initial success being achieved.17,18 Given the hundreds of thousands of anti-reflux procedures performed in the last few years and the continued rapid increase in the number of these procedures being performed,14,19,20 and with most of these being performed outside of highly skilled surgical centers, the...

Use in This Clinical Situation

Why choose medical therapy over a repeat operation or an endoscopic therapy for recurrent GERD symptoms after surgery The most obvious reason would be that the patient chose to be placed back on pharmacological therapy rather than undergo a second operation or have an invasive endoscopic anti-reflux procedure. This is not an evidence-based decision but one based solely on patient preference (perhaps with some understanding of the outcomes of the other various treatment options). Another reason for this choice would be that pharmacological therapy was superior in outcomes versus a repeat anti-reflux surgical or endoscopic procedure. However, there have been no comparative studies of these differing management approaches nor are we aware of any trials comparing these therapeutic approaches being planned. However, there are limited data suggesting that pharmacological therapy remains effective (as it would be expected to be) after anti-reflux surgical failure. In a study of children who...

Pharmacologic Therapy

Because neither the anatomic nor the chemical source of dyspepsia was determined until the late 19th century, therapy before that time was empiric and often quite imaginative. Recommendations included sedum (stonecrop), chewing green tea, and magnesia. For centuries, relief from dyspepsia was provided by chalk, charcoal, and slop diets.94 At the turn of the 20th century, proprietary medicines were popular, and were offered not only as cures for heartburn but also for impotence and alopecia.94 Therapy at that time centered on avoidance of acidic foods, otherwise bland diets free of cap-saicin, milk, antacids, and elevation of the head of the bed. In addition to their acid-neutralizing effects, antacids were subsequently demonstrated to increase lower esophageal sphincter pressure and decrease gastroe-sophageal reflux.95,96 Alginic acid, which reacts with saliva to form a viscous coating that protects the esophagus (and stomach) was shown to have effects on reflux symptoms similar to...

Symptoms after Anti Reflux Surgery Everything is not always caused by Surgery

Anti-reflux surgery controls reflux symptoms in a majority of patients. Unfortunately, that control comes with a price in some patients with the development of new, postoperative symptoms. These symptoms vary widely and can include dysphagia, increased abdominal gas (gas bloat syndrome), and several other symptoms. All of these are very common if inquired for by questionnaire. For example, in a study of 60 patients with 1-year follow-up, some gastrointestinal symptom was present in 93 of patients, but only 19 said that they had symptom that disturbed their lifestyle.1 There are many symptoms that may accompany both typical (heartburn and regurgitation) and atypical (pulmonary or ears, nose, and throat) presentations of reflux. These include dysphagia, epigastric pain, nausea, and vomiting.2 If the primary symptoms are relieved by surgery, there is a chance that a preexisting less-appreciated symptom may now become primary and appear to be attributable to surgery when, in fact, it was...

Mucosaassociated Lymphoid Tissue Lymphoma

Gastric MALT lymphomas affect males and females equally. The age range at which these lymphomas occur is wide, but the majority of patients are over the age of 50 yr. The majority of patients present with rather nonspecific symptoms including dyspepsia, nausea, and vomiting, while weight loss or the presence of an epigastric mass is rare. The symptoms may have been present for many years, and in some patients multiple endoscopies may have been performed before the diagnosis of lymphoma is reached. In these cases retrospective review of the gastric biopsy material may reveal changes consistent with low-grade MALT lymphoma from the start. The endoscopic picture is variable. In some patients the gastric mucosa may appear normal or show very minor changes such as hyperaemia, while others may show enlarged gastric folds, gastritis, superficial erosions, or ulceration. Mass lesions are relatively rare. Although any region of the stomach may be involved, the majority of gastric MALT...

Management of Alkaline Reflux

Gastroesophageal reflux disease (GERD) is the most common disorder of the upper gastrointestinal tract and can lead to complications such as esophagitis, stricture, ulcerations, and Barrett's esophagus. About one-quarter of patients develop complications despite adequate medical treatment. A mechanically defective lower esophageal sphincter (LES), inefficient esophageal clearance, and abnormalities that decrease gastric emptying or increase intragastric pressure have been described as the main causes for increased exposure of the esophageal mucosa to refluxed gastric juices.1 Duodenogastroesophageal reflux (DGER) is the regurgitation of duodenal contents into the stomach and esophagus.2 It is a condition intimately associated with GERD, but can also occur after previous surgical procedures such as pyloroplasty and partial or total gastrectomy.

Endoscopic Anti Reflux Procedures in General

Decreases reflux events or duration of acid exposure. The theoretical basis for all of these endo-scopic approaches is similar to those of surgery (improve valve function through anatomic and or physiological remodeling of the LES), but none of the current endoscopic anti-reflux techniques impact anatomically or physiologically the LES valve mechanism to the degree that can be achieved with surgery.57-64 Additionally, the exact mechanism of effect leading to improved GERD symptoms with any of these techniques is incompletely understood. However, all of these endoscopic anti-reflux techniques appear to decrease tLESRs and thus are presumed to work in part by decreasing cardia distension. However, none of the devices normalizes tLESRs, thus another mechanism(s) must also be effected in order to explain their efficacy in managing GERD symptoms. Neurolysis in the case of radio frequency ablation (RFA), increased yield pressure with plication, etc., are but some of the many additional...

Use of Endoscopic Anti Reflux Procedures in This Clinical Situation

Endoscopic Antireflux Procedures

One other consideration regarding endoscopic anti-reflux therapy versus other management approaches after failed surgery includes the issue of cost of therapy. In this era of health care, the issue of cost-effectiveness of a therapy will always remain a critical question. Payers not only are demanding efficacy be proven before paying for new therapies, they often require proof that new therapies are as, or more, cost-effective than currently used therapies. All of the endoscopic anti-reflux devices have high initial cost, related in part to the need for endoscopy to apply or direct therapy, but also related to the device itself and or its associated equipment costs (radiofrequency generators, etc.) as well. If repeat applications of these techniques are required to maintain remission or co-therapy with drugs are still needed once these devices have been applied (e.g., they downgrade the severity of GERD but do not eliminate symptoms), these costs will have to be taken into...

Basic Tenants of Anti Reflux Procedures

The anti-reflux mechanism is a complex combination of anatomic factors that, if disrupted, may lead to abnormal gastroesophageal reflux. They include 1) the intrinsic muscle function of the LES 2) the intraabdominal position of the LES and 3) the integrity of the collar sling fibers that maintain the angle of His. An effective antireflux procedure should address this anatomy, so that the anti-reflux valve is restored to competency.

Background

Gastroesophageal reflux disease is a multifac-eted disease defined by consensus as chronic symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus.1 Heartburn and regurgitation are the primary associated symptoms of GERD that prompt most patients to seek some form of therapy. There is, however, at present an expanded compendium of associated extrae-sophageal manifestations of GERD including cough, wheezing, atypical chest pain, and hoarseness among the growing list of associated pulmonary, otolaryngological presentations. Sleep disturbance attributed to GERD is another prevalent association that has also recently become apparent.2,3 There have been numerous clinical studies focusing on the patient response to various therapeutic interventions for GERD. Recently, reports on the results of interventions for GERD have also focused on which of the many available therapies might be preferable. Clearly, there are several factors that would weigh...

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