Medical and Surgical Management of Gastroesophageal Reflux Disease (GERD) Edward Auyang, MD, MS,...

Medical and Surgical Management of

Gastroesophageal Reflux Disease (GERD)

Edward Auyang, MD, MS, FACSAssistant Professor of Surgery

Director of Minimally Invasive SurgeryResidency 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 – 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– 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– 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)– 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

Outcomes

• Lap Nissen Fundoplication Success Rate:

90-95%• 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)