Gastroesophageal Reflux Disease

Question 1

What are the typical symptoms of GERD?

Answer 1

Heartburn and regurgitation, which are classic esophageal manifestations of gastroesophageal reflux.

Question 2

What are some atypical symptoms of GERD?

Answer 2

Cough
dysphonia
sore throat
globus sensation
and noncardiac chest pain
which are extraesophageal manifestations of reflux.

Question 3

Why is it important to differentiate between typical and atypical symptoms of GERD for surgeons?

Answer 3

It helps assess the likelihood that a patient’s symptoms are attributable to GERD and will respond to surgical intervention

Question 4

How do patients with typical GERD symptoms respond to treatment compared to those with atypical symptoms?

Answer 4

Patients with heartburn and regurgitation tend to respond better to acid suppression therapy and have higher symptom resolution rates after antireflux surgery (ARS).

Question 5

What are alarm symptoms in GERD, and why are they concerning?

Answer 5

weight loss
early satiety
dysphagia
odynophagia
and signs of gastrointestinal bleeding, raising suspicion for malignancy and other complications

Question 6

What intraesophageal complications can arise from chronic GERD?

Answer 6

Peptic stricture
Barrett’s metaplasia
and esophageal adenocarcinoma.

Question 7

What extraesophageal complications can GERD cause?

Answer 7

Laryngopharyngeal reflux and lung injury from aspiration. It can also exacerbate conditions like asthma or interstitial lung diseases

Question 8

What is the primary purpose of preoperative testing in the surgical evaluation of GERD?

Answer 8

(1) confirm the correct diagnosis
(2) evaluate the anatomy (e.g., presence of a hiatal hernia)
(3) rule out concurrent esophageal or gastric pathology.

Question 9

What is the gold standard for diagnosing GERD, and how is it performed?

Answer 9

Ambulatory pH monitoring off acid suppression therapy, either using a 24-hour dual-probe catheter or a 48-hour wireless capsule placed endoscopically.

Question 10

What is considered an abnormal DeMeester composite score in pH testing?

Answer 10

A score above 14.72 or total distal esophageal acid exposure time greater than 5% to 6%

Question 11

What findings on upper endoscopy confirm the diagnosis of GERD?

Answer 11

LA Grade C or D esophagitis
Barrett’s metaplasia
or a peptic stricture

Question 12

How is esophageal manometry used in GERD surgical planning?

Answer 12

To determine the type of fundoplication to perform (360-degree Nissen fundoplication for normal motility )

or 270-degree Toupet fundoplication for ineffective motility.

Question 13

What is the role of a barium esophagram in the evaluation of GERD?

Answer 13

-diagnosing a hiatal hernia or other anatomic abnormalities

-useful for understanding the anatomy after previous fundoplication surgery

Question 14

The Los Angeles Classification of Esophagitis

Answer 14

See Pic

Question 15

What should most patients be on before being considered for antireflux surgery (ARS)?

Answer 15

Acid suppression therapy with a proton pump inhibitor (PPI).
40 mg daily.

Question 16

What should be considered in patients who report preoperative bloating before ARS?

Answer 16

evaluated for delayed gastric emptying and counseled on the risk of worsening gas bloat with ARS.

Question 17

What is the primary reason for performing antireflux surgery (ARS)?

Answer 17

Symptomatic control
improve patients’ quality of life

presence of persistent symptoms affecting quality of life despite maximal medical therapy

Question 18

Has fundoplication been shown to reduce rates of esophageal adenocarcinoma or improve survival outcomes?

Answer 18

NO

Question 19

What should be carefully discussed with patients who have atypical symptoms and confirmed reflux before ARS?

Answer 19

counseled that approximately one-third may not see improvement in symptoms after ARS

Question 20

Which patients are most likely to experience significant improvement following ARS?

Answer 20

Patients with typical GERD symptoms that are partially mitigated with acid suppression or worsen when stopping acid suppression

Question 21

What should be considered in patients with interstitial lung disease and GERD?

Answer 21

ARS can slow the deterioration of pulmonary function, which is relevant for patients considered for or having undergone lung transplantation

Question 22

Should patients with a normal DeMeester score and normal distal acid exposure on ambulatory pH testing be considered for antireflux surgery (ARS)?

Answer 22

No

Question 23

What should be the approach for patients with abnormal pH monitoring but a preoperative workup that identifies another diagnosis, such as achalasia or esophageal cancer?

Answer 23

These patients should be treated for their primary diagnosis rather than GERD

Question 24

Why is obesity a relative contraindication for ARS?

Answer 24

Patients with a BMI > 40 should be referred for bariatric surgery, such as Roux-en-Y gastric bypass, which addresses both obesity-related health problems and GERD.

Question 25

Describe Surgical Approach (Initial)

Answer 25

-Positioned supine in the split leg position
-Clean and Drape, Place Trocars, Steep Reverse Trendelenburg
-Retract the Fundus
-Divide the Phrenogastric Ligament
-Expose the Left Crus
-Divide the Gastrosplenic Ligament and Short gastric
-Enter the Lesser Sac, Mobilize the Stomach
-Divide the Phrenoesophageal ligament left side
-attention to the anterior Vagus
-gastrohepatic ligament is divided starting at the pars flaccida
-expose the right crus
-Attention to accessory or replaced left hepatic artery
-Divide the right phrenoesophageal membrane.
-Attention to posterior Vagus
-Cont with Distal Esophageal dissection
-mobilized to achieve 3 to 5 cm of intraabdominal length without tension.
-Nonabsorbable suture to reapproximate the crura posterior to the esophagus. interrupted 2-0 silk

Question 26

Creating a 360-Degree Nissen Fundoplication

Answer 26

-Fundus and greater curve of the stomach is retracted medially
-marking stitch is placed on the posterior fundus approximately 3 cm below the angle of His and 2 cm inside the greater curve.
-the point on the stomach where the marking stitch was placed is lifted anteriorly against the right side of the esophagus.
-A point on the anterior fundus is identified that mirrors the location where the marking stitch was placed posteriorly
-This point on the stomach is pulled up along the left side of the esophagus.
-first stitch is placed, bringing the anterior and posterior fundus together
-52F bougie is then passed down the esophagus and into the stomach.
-remaining two or three sutures are placed with the bougie in place
-coronal suture on each side (the top of the fundus/ wrap, a partial thickness bite of the esophagus, and the ipsilateral crus)
-perform routine upper endoscopy upon completion of the fundoplication to evaluate and document the appropriate appearance of the newly augmented flap valve.

Question 27

Creating a 270-Degree Posterior Toupet Fundoplication

Answer 27

-fundus and greater curve of the stomach is retracted medially
-marking stitch is placed on the posterior fundus approximately 3 cm below the angle of His and 2 cm inside the greater curve.
-posterior fundus is passed behind the esophagus, and the point on the stomach where the marking stitch was placed is lifted anteriorly against the right side of the esophagus.
-Then Completing left side of the fundoplication
-Upper Scope

Question 28

What happens to acid suppression therapy postoperatively after ARS?

Answer 28

Acid suppression therapy is routinely discontinued, and all medications are given in crushed or liquid form for 4 weeks.

Question 29

What is the typical hospital admission process post-ARS?

Answer 29

Patients are admitted on a liquid diet
monitored for pain control and PO intake
and typically discharged the following day.

Question 30

Do all surgeons obtain a barium esophagram on the first postoperative day after ARS?

Answer 30

No, some surgeons do, but others, like the authors, do not.

Patients tolerating liquids are discharged on a soft esophageal diet.

Question 31

How long is the soft esophageal diet maintained post-ARS?

Answer 31

The soft diet is maintained for 4 weeks

Question 32

What common symptoms should patients expect after ARS?

Answer 32

Mild dysphagia
inability to belch or vomit
mild bloating
abdominal distention
or epigastric pain

Question 33

How long do symptoms like dysphagia and gas bloat typically last after ARS?

Answer 33

Most symptoms improve after 6 to 8 weeks.

Question 34

What can be considered if dysphagia and gas bloat persist beyond 8 weeks post-ARS?

Answer 34

Endoscopic dilation of the wrap may be considered

Question 35

What is the recurrence rate of GERD at 10 years following laparoscopic ARS?

Answer 35

The recurrence rate is 15% to 30%

Question 36

How are most patients with recurrent GERD after ARS managed?

Answer 36

They are managed medically with acid suppression therapy, and less than 5%-10% undergo reoperation

Question 37

Is esophageal lengthening usually necessary during laparoscopic ARS for GERD?

Answer 37

No, except in cases of paraesophageal hernia.

Question 38

When is Collis gastroplasty or esophageal lengthening typically considered?

Answer 38

usually reserved for paraesophageal hernia repairs, not for standard GERD surgeries.

Question 39

Is there an indication for mesh use in laparoscopic ARS for GERD?

Answer 39

NO

Question 40

What is the most common cause of anatomic failure in patients with a previous fundoplication?

Answer 40

-Herniation of the wrap cephalad into the mediastinum.
-Incorporation of the body of the stomach into the wrap
-loosening of the wrap over time

Question 41

When might surgical revision be considered after ARS?

Answer 41

persistent dysphagia
epigastric pain
or poorly controlled reflux symptoms despite medical therapy.

Question 42

What should a surgeon plan to do during a revisional operation for ARS?

Answer 42

The surgeon should plan to take down the prior fundoplication to evaluate and reconstruct the wrap correctly.

Question 43

What is the approach to patients who have failed two prior antireflux procedures?

Answer 43

A third attempt to redo the wrap is generally not considered

and if revision is considered, a partial gastrectomy and Roux-en-Y reconstruction may be necessary