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General Thoracic Surgery > Esophageal Reflux > Flashcards

Esophageal Reflux Flashcards

1
Q

Prevelance of GERD in Western world

A

14-20% of population

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2
Q

2 primary pathophysiolic MOA of GERD

A
  1. Inability of esophagus to clear refluxate due to altered esophageal motility
  2. Loss of reflux barriers due to anatomic changes:
    1. hiatal hernia
    2. intrinsic LES hypotension
    3. increased intragastric pressure (obesity or delayed gastric emptying or outlet obstruction)
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3
Q

Results of pathologic reflux

A
  • esophagitis
  • ulceration
  • peptic strictures
  • Barrett’s esophagus
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4
Q

Risk associated with Barrett’s esophagus

A

Histologic changes (metaplasia) represent premalignant lesion with development of dysplasia and esophageal adenocarcinoma

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5
Q

Risk of esophageal adenocarcinoma associated with Barrett’s esophagus

A

40-fold increased risk

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6
Q

Sx associated with GERD

A
  • Heartburn
  • Dysphagia
  • Odynophagia
  • Hypersalivation
  • Astham
  • Laryngitis
  • Persistent cough
  • Globus sensation
  • Non-cardiac chest pain
  • Nausea
  • Assymptomatic
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7
Q

Diagnostic eval of GERD

A
  • Initial diagnosis based history
    • Typical sx of heartburn or regurgitation responsive to PPI
      • Further testsing if PPI therapy fails
  • Endoscopy with biopsy
  • UGI swallow
  • Manometry
  • pH testing
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8
Q

Biopsy and survillence approach for Barrett’s Esophagus

A
  • Biopsies: four quadrants of esophagus
    • every 2 cm for no dysplasia or low-grade dysplasia
    • every 1 cm for high-grade dysplasia
  • Surveillance: depends on grade of dysplasia
    • No dysplasia on 2 separate occassions: 3-5 years
    • Low-grade dysplasia: annual
    • High-grade dysplasia:
      • esophagectomy
      • local endoscopic therapy (EMR, PDT) with q3 month EGD
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9
Q

Mainstay of GERD treatment

A

Medical managment

  • H2 blocker or PPI
    • PPI better efficacy in resolution of heartburn/healing esophagitis
  • Diet counseling:
    • avoid fatty food and EtOH
    • avoid acidit/irritating foods (citrus and carbonated beverages)
  • Lifesyle modification
    • smoking cessation
    • weight reduction (BMI 20-25)
    • avoidance of meals witin 3 hrs of bedtime
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10
Q

2 conditions that must be satisfied before surgical treatmet of GERD

A
  1. Failure of medical managment
    1. persistence of sx
    2. documented presence of mucosal injury
  2. Preop studies demonstrate loss of barrier function that may improve with surgery
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11
Q

Goals of surgery for GERD

A
  • Ensure intra-abdomina location of GE junction
  • Reconstruct extrinsic sphincter (reduce esophageal hiatus to more physiologic size
  • Reinforce intrinsic LES with fundoplication
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12
Q

T/F

Barrett’s esophagus alone is an indication for surgery

A

False

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13
Q

Potential complication of long-standing GERD

A

Esophagel shortening due to chronic scarring

  • GE junction often in thorax
  • Requires esophageal lengthing procedure
    • Collis gastroplasty
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14
Q

Description of Collis gastroplasty

A
  • 3-6 cm, selectively vagotimized, proximal stomach is tubularized to create a neo-esophagus
  • Re-approximation of crura
  • Fundoplication
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15
Q

MC perfomed fundoplications for GERD

A
  • Nissen (360 degree): no esophageal dysmotility
  • Toupet (270 degreee: presence of quesion of esophageal dysmotility
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16
Q

Desired length of tension free intra-abdominal esophagus prior to fundoplication

A

2.5 - 3.0 cm

17
Q

Surgical principles of fundoplication

A
  • Fundus completely mobilized with division of short gastric vessels
  • Vagus nerves preserved
  • Diphragmatic crural defects closed (deep, non-absorbable suture)
  • Floppy, tension free fundoplication
18
Q

Overall success of surgical therapy for GERD

A

80-90% success in symptom relief (heartburn and regurgitation)

  • Rate of success for healing esophagis equivalent between surgery and medical therapy
    • Thus, surgery best for patients who have failed medical therapy
19
Q

Potential complications of surgery for GERD

A
  • Persistent bloating
  • Inabiltity to belch
  • Severe dysphagia (fundoplication too narrow)
  • Need for reoperation
20
Q

T/F

Definitive evidence exists demonstrating that surgical correction for GERD reduces or reverses Barrett’s esophagus

A

False

  • Managment of GERD should primarily involve medical managment with selective use of surgical therapy

General Thoracic Surgery (36 decks)

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