Sabiston GERD and HH Flashcards
LES is made up of four anatomic structures
1-The intrinsic musculature of the distal esophagus
2- Sling fibers of the gastric cardia
3-The crura of the diaphragm
4- increased intra abdominal pressure is transmitted to the GEJ
Best time to measure LES
at mid-expiration or end-expiration.
Hypotensive LES is frequently associated with
hiatal hernia because of displacement of the GEJ into the posterior mediastinum
A type I hernia
when the GEJ migrates cephalad into the posterior mediastinum.
This occurs because of laxity of the phrenoesophageal membrane
water brash phenomenon
Regurgitation of gastric contents to the oropharynx and mouth > produce a sour taste that patients will describe as either acid or bile
Two mechanisms may lead to extraesophageal symptoms of GERD
-proximal esophageal reflux and microaspiration of gastroduodenal contents cause direct caustic injury to the larynx and lower respiratory tract
-distal esophageal acid exposure triggers a vagal nerve reflex that results in bronchospasm and cough
GERD with extraesophageal symptoms should be referred to
a laryngologist or a pulmonologist to determine if a nongastrointestinal condition is causing these symptoms
In patients with asthma and GERD
antireflux surgery appears to be more effective than medical therapy at managing pulmonary symptoms
Proximal esophageal reflux with microaspiration of acid and nonacid gastric contents can lead to
Idiopathic pulmonary fibrosis > severe, chronic, and progressive lung disease that generally results in death
Tx : Laparoscopic antireflux surgery
Signs of proximal esophageal reflux and regurgitation of gastric contents
-erosion of their dentition (revealing yellow teeth caused by the loss of dentin)
-injected oropharyngeal mucosa
-signs of chronic sinusitis
-constantly drinks water ( To clear Acid )
-sit leaning forward > To flattens diaphragm, narrows the anteroposterior diameter of the hiatus, and increases the LES pressure
pathognomonic for GERD ( By Endoscopy )
peptic strictures and LA class C and D esophagitis
LA class A and B esophagitis should undergo
pH testing
HH measurement in Endoscopy
hernia should be measured in both cranial-caudal and lateral dimensions
most common cause of dysphagia in GERD
is a reflux-associated inflammatory process of the esophageal wall
What can cause a false-negative pH study
presence of a tight stricture may prevent reflux of acid
The majority of peptic strictures are effectively treated with
-dilation and PPI therapy
Refractory peptic strictures are defined as strictures that recur despite dilation and PPI therapy > Tx with LARS / steroid injections
Another cause of dysphagia in patients with GERD
Schatzki ring >
submucosal fibrotic bands (as opposed to mucosal strictures).
Ineffective esophageal motility
at least 50% weak or failed peristaltic swallows on high-resolution manometry.
patients with GERD and ineffective esophageal motility > (Toupet or Dor) fundoplication should be performed
Nissen fundoplication > greater postoperative dysphagia
For barret Based on endoscopic measurements
long segment (≥3 cm) and short segment (<3 cm).
present with typical symptoms of GERD Tx
8-week course of PPI therapy is recommended
How long to stop PPI for ambulatory pH monitoring
patients must stop PPI therapy 1 week
PPI use has been associated with the following
-loss of bone density and risk of fracture
-dementia
-myocardial infarction
-micronutrient (magnesium, iron, B-12) deficiencies
-Clostridioides difficile infection
-kidney disease
-interactions with antiplatelet medication
Intraoperative Management of Short Esophagus
-unilateral vagotomy > additional 1 to 2 cm of esophageal length
-division of both vagus nerves > 3 to 4 cm of additional esophagus
Operative Complications of LARS
-Pneumothorax
When identified intraoperatively, the pleura should be closed with a suture
postoperative radiograph should be obtained.
If a pneumothorax is identified on this radiograph, the patient may be maintained on oxygen therapy to facilitate its resolution
Dysphagia post LARS
If the patient cannot tolerate liquids, a UGI series should be obtained to ensure that no anatomic abnormality, such as an early hiatal hernia, exists
If the patient cannot maintain hydration or dysphagia persists beyond 3 months
UGI series > check for anatomic abnormality
If the UGI series > appropriately positioned fundoplication below the diaphragm
esophagogastroduodenoscopy with empirical dilation of the GEJ should be performed.
most common symptoms of failed LARS
are typical symptoms of GERD
WorkUp:
-Anatomic problems >
persistent or recurrent hiatal hernia, slipped fundoplication, and incorrectly constructed fundoplication.
All patients who present with recurrent or persistent symptoms of GERD > esophageal manometry and ambulatory pH study.
If the pH study > elevated distal esophageal acid exposure > an esophagram and upper endoscopy
PPI therapy should be instituted
If the patient’s symptoms are not effectively managed by medical therapy
reoperation should be performed to create an effective antireflux valve.
The late development of dysphagia after LARS suggests
esophageal obstruction
results from a recurrent hiatal hernia or a slipped fundoplication
UGI series and EGD > initial studies
If a clear anatomic abnormality is visualized > reoperation
If concurrent GERD symptoms > ambulatory pH testing and manometry
To achieve resolution of symptoms, reoperation is almost always necessary in these patients.
incorrectly constructed fundoplication
-created out of the body of the stomach and not the fundus
-Failure to completely excise the sac of a hiatal hernia or PEH
Operative management strategies for GERD in patients following SG and RYGB
patients following RYGB:
-closure of gastrogastric fistula
-correction of hiatal hernia
-revision of large gastric pouch
following SG:
-conversion to RYGB
-correction of hiatal hernia
Alternative Operative Therapies for GERD
-Transoral Incisionless Fundoplication > endoluminal fundoplication can be created up to 4 cm in length and 270 degrees.
-Magnetic Sphincter Augmentation
PEH Vs HH
PEH is frequently associated with obstructive symptoms and, less frequently, typical symptoms of GERD
dysphagia, odynophagia, and postprandial chest pain, as well as early satiety
PEH did endoscopy
Check for
Cameron ulcers and Barrett’s esophagus
four key steps to PEH repair
(1) reduction of the hernia contents to the abdominal cavity
(2) complete excision of the hernia sac from the posterior mediastinum
(3) mobilization of the distal esophagus to achieve a minimum of 3 cm of intra abdominal esophageal length
(4) an antireflux operation.
The most challenging aspect of the sac dissection is encountered during the mobilization of the posterior sac
esophagus and posterior vagus nerve are intimately associated with the sac posteriorly and can be easily injured during this dissection. A lighted bougie helps identify the exact location of the esophagus.
If a tension-free closure of esophageal haitus is not possible, two options are available
(1) close the hiatus under tension and reinforce the closure with biologic mesh
(2) perform a diaphragmatic relaxing incision to allow primary tension-free closure of the hiatus and reinforce the relaxing incision and hiatal closure with biologic mesh.
Importantly, permanent synthetic mesh should never be used at the esophageal hiatus as it is associated with esophageal erosion and stenosis
The C configuration Mesh
has the advantage of reinforcing the anterior and posterior hiatus
biologic mesh reinforcement of the hiatal closure in PEH repair and recurrence
decreases early but not late recurrent hiatal hernias.
Initial management of acute gastric volvulus
-nasogastric tube
-esophagoscopy can facilitate gastric decompression and nasogastric tube placement
-endoscopic reduction of volvulus is possible, allows assessment of the gastric mucosa
-if gastric ischemia is present, emergent operation is indicated.
