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Antireflux Surgery - PTabrizian

Antireflux Surgery - PTabrizian - Antireflux Surgery...

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Unformatted text preview: Antireflux Surgery Antireflux Surgery Parissa Tabrizian M.D. Team IV 11/10/06 Anatomy Anatomy Esophageal Physiology Esophageal Physiology Lower Esophageal Sphincter Lower Esophageal Sphincter Intrinsic distal esophageal muscles – tonically contracted Muscular Sling fibers of the gastric cardia Diaphragmatic crura Transmitted pressure of the abdominal cavity Introduction Introduction Increased rate during the 90’s. 4.4 to 12 procedures per 100 000 adults Popularity of minimally invasive surgery 65% Historical Aspect Historical Aspect Rudolf Nissen ( 1896­1981) 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 Gastroesophageal reflux disease 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 GERD 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 intra­abdominal pressure ( e.g. straining, obesity, pregnancy) Duodenogastric reflux (bile) ** predisposes to severe GERD Hiatal Hernias Hiatal Hernias Clinical presentation Clinical presentation Prevalence of Symptoms in 1000 Patients Evaluated for Gastroesophageal Reflux Disease * Extraesophageal Manifestations of GERD Extraesophageal Manifestations of GERD Pulmonary Asthma Aspiration pneumonia Chronic bronchitis Pulmonary fibrosis Other Chest pain Dental erosion ENT Hoarseness Laryngitis Pharyngitis Chronic cough Globus sensation Sinusitis Subglottic stenosis Laryngeal cancer Diagnostic Tests for GERD Diagnostic Tests for GERD Barium swallow Endoscopy Ambulatory pH monitoring Esophageal manometry Barium Swallow Barium Swallow Useful first diagnostic test for patients with dysphagia Stricture (location, length) Mass (location, length) Bird’s beak Hiatal hernia (size, type) Limitations Detailed mucosal exam for erosive esophagitis, Barrett’s esophagus Endoscopy Endoscopy Indications Alarm symptoms Empiric therapy failure Preoperative evaluation Detection of Barrett’s esophagus Ambulatory 24 hr. pH Ambulatory 24 hr. pH Monitoring Physiologic study Quantify reflux in proximal/distal esophagus ­­% time pH < 4 Prox esophagus: <1% Distal esophagus <4% ­­DeMeester score ( < 14.7 nl) Symptom correlation Ambulatory 24 hr. pH Monitoring Ambulatory Normal GERD Wireless, Catheter­Free Esophageal pH Monitoring Wireless, Catheter­Free Esophageal pH Monitoring Potential Advantages • Improved patient comfort and acceptance and • Continued normal work, activities and diet study activities • Longer reporting periods possible (48 hours) possible • Maintain constant probe position relative to SCJ position Esophageal Manometry Esophageal Manometry Limited role in GERD Assess LES pressure, location and relaxation Assist placement of 24 hr. pH catheter Assess peristalsis Prior to antireflux surgery Treatment Goals for GERD Treatment Goals for GERD Eliminate symptoms Heal esophagitis Manage or prevent complications Maintain remission Lifestyle Modifications Lifestyle Modifications Elevate head of bed 4­6 inches Avoid eating within 2­3 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 Acid Suppression Therapy for GERD Acid Suppression Therapy for GERD H2­Receptor Antagonists (H2RAs) Cimetidine (Tagamet®) Ranitidine (Zantac®) Famotidine (Pepcid®) Nizatidine (Axid®) Proton Pump Inhibitors (PPIs) Omeprazole (Prilosec®) Lansoprazole (Prevacid®) Rabeprazole (Aciphex®) Pantoprazole (Protonix®) Esomeprazole (Nexium ®) Effectiveness of Medical Therapies for GERD Effectiveness of Medical Therapies for GERD Treatment Response Lifestyle modifications/antacids 20 % H2-receptor antagonists 50 % Single-dose PPI Single-dose 80 % 80 Increased-dose PPI up to 100 % Complications of GERD Complications of GERD Erosive/ulcerative esophagitis Esophageal (peptic) stricture Barrett’s esophagus Adenocarcinoma Indications for Surgery Indications for Surgery Intractable GERD – rare Difficult to manage strictures Severe bleeding from esophagitis ( grade III­IV) Non­healing ulcers GERD requiring long­term PPI­BID in a healthy young patient LES < 10 Large hiatal hernia Persistent regurgitation/aspiration symptoms Not Barrett’s esophagus alone Noncompliance Patient’s preference ( cost, life style…) Mechanism of Antireflux Operations Mechanism of Antireflux Operations Creation of a floppy valve by maintaining close apposition b/w the abdominal 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 total gastric emptying Prevention of effacement of the lower esophagus * Restrospective analysis * Restrospective analysis * Medical or surgical treatment for > 1 yr * 120 pts undergoing surgery * 51 pts nonoperative mgt * QOL: surgery > medical Nissen Fundoplication Nissen Fundoplication Postoperative Complications Postoperative Complications * 171 patients, mean f/u 6.4 yrs * 171 patients, mean f/u 6.4 yrs * computerized log / questionnaire •Overall: 96.5 % satisfied vs 3.5 % * Persistent Sx: abd bloating ( 20%), diarrhea ( 12%), regurgitation ( 6.4%), heartburn ( 5.8%) 27 % dysphagia 7% dilatation 14% postop PPI ( 79% vague abd symptoms) * Excellent long term treatment Complete vs. partial fundoplication Complete vs. partial fundoplication Ant. partial fundoplication Thal/Dor procedure Post. partial fundoplication Toupet procedure Endoscopic Therapy 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 region of the lower esophageal sphincter Enteryx ...
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