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...

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...

Short and Longterm Outcomes of Endoscopic Anti Reflux Procedures

All four of the FDA cleared and approved devices either have completed sham trials (Stretta, EndoCinch, Enteryx-European) or have them underway (Plicator, Enteryx-United States) and in general the success rates with these devices in these studies is 60-70 .57,58,60,65-69 Previous uncontrolled studies of endoscopic anti-reflux devices indicated clinical response rates of 90 or more, but these earlier studies' results are not nearly as reliable as the data we are deriving from the sham-controlled...

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...

Laparoscopic Gastric Bypass for Recurrent Reflux

Revision Ethicon

Several studies mention the use of gastric bypass as an alternative and superior technique for morbidly obese patients who present with primary GE reflux disease.44,45 Perez et al.46 identified a higher rate of recurrent reflux in obese patients undergoing laparoscopic Nissen fundoplication compared with their normal-weight cohorts. Applying this theory to patients with recurrent symptoms, Heniford et al.25 described using the Roux-en-Y gastric bypass in obese patients with recurrent reflux...

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 ,...

Procedure

Colon Arteries

Decision making regarding the optimal incision to use is complex and is discussed earlier in this section. Once the decision has been made to proceed with esophagectomy, the distal esophagus is mobilized and the esophagus and stomach are freed from the diaphragmatic crura. The order in which this is accomplished depends on the approach being used. The proximal stomach is mobilized but no major blood supply left gastric artery, right gastric artery is divided at this point. Any prior...

Erosive Esophagitis

Erosive esophagitis, or breaks in the esophageal mucosa, represents one of the common manifestations of chronic reflux disease. Histologi-cally, erosive esophagitis is defined as superficial necrotic defects that do not penetrate the muscularis mucosae, whereas esophageal ulcerations are described by a deeper invasion through the muscularis mucosae and into the submucosa.2 Several classifications have attempted to grade the severity of esophagitis as observed at the time of upper endoscopy. One...

Methods of Evaluation

Slipped Nissen And Endoscopy

Given the poor correlation between symptoms and anatomic failure, a careful and thorough evaluation is warranted. A complete history and physical should be performed with particular attention to the patient's current symptoms. Are the symptoms similar to those experienced before the original surgery Do symptoms of reflux or dysphagia predominate Was there a precipitating event Do antacid medications ameliorate the symptoms The patient's original operative report should be obtained to clarify...

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...

Barretts Esophagus

Columnar Metaplasia Esophagus

One of the most controversial and intriguing topics discussed with regard to the complications of chronic reflux is Barrett's esophagus. Barrett's esophagus is a metaplastic change in the esophagus that results in replacement of the normal squamous-lined epithelium with a columnar type. The definition of Barrett's esophagus has continued to evolve over time. During an American Gastroenterological Association workshop in February 2003 Barrett's Esophagus Chicago Workshop , the definition for...

Recurrent GERD Symptoms

Total Parenteral Nutrition

When recurrent or new symptoms of gastroe-sophageal reflux develop in the late postoperative period gt 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...

Considerations for Esophageal Lengthening Procedures

Collis Transthoracic

It is essential that the gastroesophageal junction lie tension free in the abdomen before creating a fundic wrap. The length of tension-free intraabdominal esophagus should be measured after closing the crural defect. When the crura are closed from the caudal condensation of the crural fibers toward the anterior margin of the hiatus, the hiatal orifice is effectively displaced cephalad. This transposition of the hiatal orifice lengthens the intraabdominal segment of esophagus because the...

Open Laparotomy for Reoperative Fundoplication

Pyloroplasty Complications

The most common approach for reoperative anti-reflux surgery is revision fundoplication via laparotomy, or the so-called open technique. Once in the operating room, the patient is placed in the supine position. The abdomen is prepped and draped in a sterile fashion. An upper midline incision is performed and extensive adhesiolysis may be necessary. Use of meticulous technique is important to minimize gastrotomies, enterotomies, or esophagotomies. If created, they are repaired primarily and, if...

Functional Constituents of the EGJ

Hill Grade Iii Esophagus

Conceptualized as an impediment to reflux, the EGJ is generally viewed as a high-pressure zone at the distal end of the esophagus that isolates the esophagus from the stomach. The anatomy of the EGJ is complex. The tubular esophagus traverses the diaphragmatic hiatus and joins the stomach in a nearly tangential fashion. Thus, there are several potential contributors to EGJ competence, each with unique considerations the intrinsic lower esophageal sphincter LES , the influence of the...

Potential Causes of Failure

Floppy Fundoplication

Regardless of the surgical nuances, failed antireflux operations can be analyzed and subdivided into three distinct anatomic regions. Failure can occur at the esophageal, wrap, or crural level, although there may be overlapping or concurrent issues. Before the wide adoption of laparoscopic techniques,wrap disruption was the most common mode of failure. In the laparoscopic era, the most common cause of failure is herniation of the wrap through the diaphragmatic hiatus. The construction of a...

Early Nonsurgical Therapy

How Insert Mousseau Barbin Tube

Early therapy for esophageal disorders included the usual compendium of useless and occasionally life-threatening techniques used for a host of different ailments, including emetics, venesection, leeches, cathartics, enemas, opiates, electrolysis, and immersion in a cold bath. Section of constricting diaphragm muscle was proposed by Bowditch8 for treatment of diaphragmatic hernia, but no surgeon was recorded as being sufficiently adventuresome to undertake such an operation for almost half a...

Herniation of the Wrap into the Chest

Slipped Nissen Fundoplication Symptoms

Herniation of the fundic wrap into the chest may occur in the early postoperative period, even as early as while the patient awakens from the anesthetic. Various conditions predispose to this unfortunate outcome The physiologic intraabdominal pressure is higher than the one existing in the thorax so that abdominal organs are naturally attracted to the chest through any defect in the diaphragm, the roof of the abdominal cavity. A sudden increase in abdominal pressure, as may occur when the...

Mechanisms of EGJ Incompetence in GERD

Gerd Surgery

Physiologically, the EGJ must perform seemingly contradictory functions. During swallowing it must facilitate the esophagogastric flow of swallowed material while at the same time preventing reflux of gastric content into esophagus that is otherwise favored by a positive abdomen-to-thoracic pressure gradient. During rest the EGJ must, again, contain caustic gastric juice but also be able to transiently relax and permit gas venting. These functions are accomplished by the delicate interplay of...

Lengthening Gastroplasties

Collis Nissen Fundoplication

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...

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...

Belsey Fundoplication Technique

Belsey Fundoplication 360

The total Nissen fundoplication is a 360-degree wrap of gastric fundus around the distal esophagus. After complete distal esophageal and proximal gastric mobilization including division of the proximal short gastric vessels left panel , the crura are approximated to close the hiatus to a normal caliber center panel . The proximal fundus is wrapped posteriorly around the esophagus and a portion of the fundus is brought anterior to the esophagus.The two edges are sutured together to...