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Antireflux Surgery
Parissa Tabrizian M.D.
Team IV 11/10/06
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Anatomy
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Esophageal Physiology
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Lower Esophageal Sphincter
Intrinsic distal esophageal musclestonically contracted Muscular Sling fibers of the gastric cardia Diaphragmatic crura Transmitted pressure of the abdominal cavity
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Introduction
Increased rate during the 90s.
4.4 to 12 procedures per 100 000 adults
Popularity of minimally invasive surgery 65%
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Historical Aspect
Rudolf Nissen ( 1896-1981)
Thoracic surgery- lobectomy and pneumonectomy
Professor of Surgery in Istanbul, Turkey 1933
Mid 1930s: began work that would lead to his 1st performed fundoplication in 1955
1956 Swiss journal, Schweizerische Medizinische Wochenschrift
Brooklyn Jewish Hospital and Maimonides Hospital 1941
Chairman of Surgery at the University of Basel, Switzerland 1951
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Gastroesophageal reflux disease
MC GI disorder of the western world.
44% adults in US have abnormal reflux of acidic gastric
juices into the esophagus on a montly basis.
10% of patients require daily acid suppression
medication
Over 1.0 million out patients visit per year
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GERD
Pathophysiology:
Defective lower esophageal sphincter (LES) function
transient LES relaxations ( TLESRs)
hypotonic LES ** ( e.g. sleroderma)
disruption of LES ** ( e.g. resection, balloon rupture)
Hiatal hernia ** ( mal alignment of LES and crural diaphragm)
Poor esophageal clearance **
Decreased salivary protection
decreased volume ( e.g. sicca syndrome)
deficient production of epidermal growth factor
Poor gastric emptying
Increased intra-abdominal pressure ( e.g. straining, obesity, pregnancy)
Duodenogastric reflux (bile)
** predisposes to severe GERD
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Hiatal Hernias
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Clinical presentation
Prevalence of Symptoms in 1000 Patients Evaluated for Gastroesophageal Reflux Disease *
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Extraesophageal Manifestations of GERD
Pulmonary
Asthma
Aspiration pneumonia
Chronic bronchitis
Pulmonary fibrosis
OtherChest pain
Dental erosion
ENT
Hoarseness
Laryngitis
PharyngitisChronic cough
Globus sensation
Sinusitis
Subglottic stenosis
Laryngeal cancer
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Diagnostic Tests for GERD
Barium swallow
Endoscopy
Ambulatory pH monitoring
Esophageal manometry
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Barium Swallow
Useful first diagnostic test for patients withdysphagia
Stricture (location, length)
Mass (location, length)
Birds beak Hiatal hernia (size, type)
Limitations
Detailed mucosal exam for erosiveesophagitis, Barretts esophagus
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Endoscopy
Indications
Alarm symptoms
Empiric therapy failure
Preoperative evaluation
Detection of Barretts
esophagus
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Ambulatory 24 hr. pH Monitoring
Physiologic study Quantify reflux in
proximal/distal esophagus
--% time pH < 4
Prox esophagus:
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Ambulatory 24 hr. pH Monitoring
Normal
GERD
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Wireless, Catheter-Free Esophageal pH Monitoring
Improved patient comfortand acceptance
Continued normal work,activities and diet study
Longer reporting periods
possible (48 hours)
Maintain constant probe
position relative to SCJ
Potential Advantages
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Esophageal Manometry
Assess LES pressure, location
and relaxation Assist placement of 24 hr.
pH catheter
Assess peristalsis
Prior to antireflux surgery
Limited role in GERD
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Treatment Goals for GERD
Eliminate symptoms
Heal esophagitis
Manage or prevent complications
Maintain remission
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Lifestyle Modifications
Elevate head of bed 4-6 inches
Avoid eating within 2-3 hours of bedtime
Lose weight if overweight
Stop smoking Modify diet
Eat more frequent but smaller meals
Avoid fatty/fried food, peppermint, chocolate,
alcohol, carbonated beverages, coffee and tea
OTC medications prn
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Acid Suppression Therapy for GERD
H2-Receptor Antagonists
(H2RAs)
Cimetidine (Tagamet)
Ranitidine (Zantac)
Famotidine (Pepcid)
Nizatidine (Axid)
Proton Pump Inhibitors
(PPIs)
Omeprazole (Prilosec)
Lansoprazole (Prevacid)
Rabeprazole (Aciphex)
Pantoprazole (Protonix)Esomeprazole (Nexium )
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Effectiveness of Medical Therapies for GERD
Treatment Response
Lifestyle modifications/antacids 20 %
H2-receptor antagonists 50 %
Single-dose PPI 80 %
Increased-dose PPI up to 100 %
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Complications of GERD
Erosive/ulcerative esophagitis
Esophageal (peptic) stricture
Barretts esophagus
Adenocarcinoma
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Indications for Surgery
Intractable GERDrare
Difficult to manage strictures
Severe bleeding from esophagitis ( grade III-IV)
Non-healing ulcers GERD requiring long-term PPI-BID in a healthy young patient
LES < 10
Large hiatal hernia
Persistent regurgitation/aspiration symptoms
Not Barretts esophagus alone
Noncompliance
Patients preference ( cost, life style)
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Mechanism of Antireflux Operations
Creation of a floppy valve by maintaining close apposition b/w theabdominal esophagus and the gastric fundus
Exaggeration of the flap valve at the angle of His
Increase in the basal pressure generated by the lower esophageal sphincter
Reduction in the triggering of TLES relaxations
Reduction in the capacity of the gastric fundus speeding prox. and a totalgastric emptying
Prevention of effacement of the lower esophagus
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* Restrospective analysis* Medical or surgical treatment for > 1 yr* 120 pts undergoing surgery* 51 pts nonoperative mgt* QOL: surgery > medical
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Nissen Fundoplication
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Postoperative Complications
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* 171 patients, mean f/u 6.4 yrs
* computerized log / questionnaire
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Overall: 96.5 % satisfied vs 3.5 %
* Persistent Sx: abd bloating ( 20%), diarrhea ( 12%), regurgitation ( 6.4%),
heartburn ( 5.8%)
27 % dysphagia 7% dilatation14% postop PPI ( 79% vague abd symptoms)
* Excellent long term treatment
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Complete vs. partial fundoplication
Ant. partial fundoplication Thal/Dor procedure
Post. partial fundoplication Toupet procedure
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Endoscopic Therapy
Endoscopic antireflux therapies
Radiofrequency energy delivered to the LES
Stretta procedure
Suture ligation of the cardia Endoscopic plication
Submucosal implantation of inert material in the regionof the lower esophageal sphincter
Enteryx