1. 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

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

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

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

6. 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

7. Pathophysiology

8. 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

9. Clinical Presentation
Typical vs. Atypical

10. 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

11. Diagnostic Studies

12. 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)

13. EGD

14. Upper GI

15. Manometry

16. 24 Hr pH Monitoring

17. Treatment - Medical

18. 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

19. 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

20. Treatment – Surgical

21. 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 

22. 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

23. Operation

24. Operation

25. Operation

26. Post-op Care
Hospitalization
Diet
Activity

27. 90-95% Outcomes Lap Nissen Fundoplication Success Rate: Gas Bloat
Dysphagia
Hernia/GERD Recurrence

28. GERD and Obesity

29. 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 ?

30. Questions?

32. Results

33. 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

34. 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.