Medical and Surgical Management of Gastroesophageal Reflux Disease (GERD) Edward Auyang, MD, MS, FACS Assistant Professor of Surgery Director of Minimally Invasive Surgery Residency Program Director, General Surgery

Disclosures No financial disclosures I do perform anti-reflux operations…

Objectives Recognize symptoms of GERD Learn the diagnostic tests to evaluate GERD Learn the medical treatments for GERD Learn the surgical treatments for GERD

Epidemiology 61 million Americans complain of heartburn and indigestion 40% monthly 20% weekly 7% daily

Anatomy Barriers to GERD Normally – Transient relaxation of LES Esophageal peristalsis Intra-abdominal segment of esophagus Lower esophageal sphincter (LES) tone Diaphragmatic crura Phrenoesophageal membrane Angle of His Normally – Transient relaxation of LES

Pathophysiology

Pathophysiology Primary mechanisms Spontaneously, accompanying transient LES relaxations Stress reflux associated with a weakened LES Increased intra-abdominal pressure Dysfunctional LES/Hiatal hernia Reflux -> mucosal injury -> weakened LES and/or esophageal dysmotility

Clinical Presentation Typical vs. Atypical

Clinical Presentation Typical symptoms Heartburn Regurgitation Water brash Acid brash Nocturnal Aspiration Dysphagia Atypical symptoms Chronic nausea Asthma Aspiration Cough Hoarse throat Dental erosions Chest pain

Diagnostic Studies

Diagnostic Studies Anatomic Physiologic EGD (± biopsy) RULE OUT CANCER/Barrett’s! Contrast radiographs (UGI Esophagram) Physiologic 24-hr pH testing (on/off medication) Esophageal manometry Scintigraphy (gastric emptying)

EGD

Upper GI

Manometry

24 Hr pH Monitoring

Treatment - Medical

Treatment - Medical Life style modifications Medication Weight loss Alteration of diet  Avoid chocolate, peppermint, fat, onions, garlic, alcohol, caffeine, and nicotine  Nothing by mouth for 2-3 hr before bedtime  Elevation of head of bed 6-10 in. Limit potentially precipitating activities, such as bending over or strenuous exercise Medication

Medication Options Antacids (Neutralize) H2 Blockers PPI Tums, Rolaids, Maalox H2 Blockers Ranitidine, famotidine PPI Omeprazole, pantoprazole, esomeprazole, etc. Beware of osteoporosis/penia, fundic polyps Max Omeprazole 40mg BID

Treatment – Surgical

Treatment – Surgical Complications of GERD unresponsive to medical therapy  Esophagitis  Stricture  Recurrent aspiration or pneumonia  Barrett esophagus  Continued symptoms despite maximal medical treatment  Symptomatic paraesophageal hernia  Patient desire to discontinue PPI therapy  Financial burden  Lifestyle choice  Young age  Intolerance to proton pump inhibitor therapy 

Basic Tennets of Surgery Restoration of an effective LES Creation of a gastroesophageal valve Fundoplication requires wrapping the fundus itself, not the body of the stomach, around the esophagus, rather than around the proximal body of the stomach The fundoplication should reside within the abdomen without tension, and the crura should be closed adequately to prevent migration of the stomach or the fundoplication into the chest Complete Vs. Partial wrap

Operation

Operation

Operation

Post-op Care Hospitalization Diet Activity

90-95% Outcomes Lap Nissen Fundoplication Success Rate: Gas Bloat Dysphagia Hernia/GERD Recurrence

GERD and Obesity

Case Scenario 56yoM presents to your office with Heartburn HPI – What do you want to know? PMHx – HTN, GERD, HL PSHx – Cholecystectomy PE – HR:75 BP:122/85 O2: 97% RA BMI 30 Workup ?

Questions?

Results

GERD and Barrett’s Disease 60% of patients with clinical GERD will have normal-appearing esophageal mucosa at endoscopy Barrett esophagus is estimated in 10% of patients with GERD GERD + Barrett esophagus have 0.4% per patient-year risk of adenocarcinoma Vs. 0.07% per patient-year risk for patients with GERD but without Barrett esophagus

Esophagitis Grading System (Endoscopic) Los Angeles Classification System Grade A (≤5 mm in length) Grade B (>5 mm in length) Grade C (continuous between two mucosal folds) Grade D (≥75% of esophageal circumference) Based on endoscopic appearance Los system most commonly used by GI and based on esophagitis However, up to 60% of patients with clinical GERD will have normal-appearing esophageal mucosa at endoscopy. Barrett esophagus is estimated to occur in approximately 10% of patients with GERD. Studies demonstrate that patients with GERD and Barrett esophagus have an estimated 0.4% per patient-year risk of developing adenocarcinoma, compared with a 0.07% per patient-year risk for patients with GERD but without Barrett esophagus.