Extinguish the “fire” of serious heartburn

Extinguish the Fire of Serious HeartburnEric M High MD – General Surgery Department

2www.SpringfieldClinic.comwww.SpringfieldClinic.com

Overview• Define reflux

• Symptoms of reflux

• How do we diagnose reflux

• Treatment options

• What can I offer?

What is reflux?• backup of stomach contents

into esophagus

• normal component-occurs after meals and is typically short lived and doesn’t occur at night and causes minimal if any symptoms

What is reflux?• abnormal component-occurs

outside meals, during sleep, affects everyday life

What Would “Reflux” feel like

• Burning sensation beneath sternum and/or upper abdomen– “heartburn”

• regurgitation-gastric contents may come up into mouth during burping or hiccups or spontaneously

Other lesser known symptoms

•chest pains

•“lump in their throat”

•nausea

•persistent cough

•hoarse voice/raspy voice

A+B=C• Differential

– cardiac• heart attack

– esophageal dysfunction– gallbladder

• stones, sludge, low EF– stomach

• gastritis, ulcer, gastroparesis, tumors, infections– pancreas

• pancreatitis, tumor

What should I tell my doctor?

• pay attention if some/all of the above symptoms present

• if symptoms are worsening• discuss with your primary doctor

Diagnosis

• UGI– chalky material that patient drinks, then multiple

images are taken to see if contents “reflux”– can see hernias with this method sometimes

• Esophagram– similar to above except only looks at esophagus– can see masses, narrowing

Diagnosis

• Endoscopy– allows biospy– hernia– ulcers

Diagnosis

• other tests– manometry

• probe in esophagus to see pressures

– pH monitoring• probe inserted in esophagus to measure how

often reflux occurring• more often during evening, laying down, etc.• not used very often

Treatment

• Medical – lifestyle modifications

• weight loss• smoking cessation• avoid late night eating

– eating smaller meals

• avoid caffeine, chocolates, alcohol• sleeping positions

Treatment

• Medical– medications

• H2 blockers vs PPI– prilosec, protonix, etc.

– review meds to see if they could be causing any of the symptoms

Treatment

• Medical– Infection

• H. Pylori– 10-14 day course of antibiotics and medications to

eliminate the bacteria– need check after treatment to ensure bacteria gone

» urease test

Complications

• untreated reflux can lead to severe complications – strictures

• inability to swallow that may need repetitive dilatations

– cancer• leading cause for converting normal mucosa to

cancer

Treatment

• Surgical– hiatal hernia can lead to increased

incidence of reflux and need repaired surgically

– inability to adhere or tolerate medical therapies

– symptoms are not improving on medicine or needing increasing dosage

Treatment

• Complete picture from endoscopy, UGI, length of symptoms, and medical treatments

• May need surgery to fix/help with symptoms

Hiatal Hernia

Type I

Surgery: Nissen Fundoplication

Type II

Surgery: Paraesophageal Hernia Repair w/Nissen

Type III

Surgery: Paraesophageal Hernia Repair w/Nissen

Type IV

Surgery: Paraesophageal Hernia Repair w/Nissen

• Sliding hernia (Type I)• GE junction above diaphragm• Causes Acid Reflux Disease (GERD)• No true hernia sac• Nissen Fundoplication is performed

Normal Anatomy

Paraesophageal hernia (Type II)•Stomach fundus into chest•Fixed GE Junction

Paraesophageal hernia (Type III)•Stomach fundus into chest•GE Junction above diaphragm

Paraesophageal hernia (Type IV)•Stomach, GE Junction, and other organs above diaphragm

Primary Closure Straight suturingSmall herniasMost common

Mesh Closure Synthetic or Biologic MeshFor Large hernias (>5cm)Costly (biologic even more)Sutures or Tacks (cost)

Surgical Options

• “Wrap”– upper portion of stomach is wrapped

completely around end of esophagus– “Nissen”

Surgical options

• Partial wraps– Dor

• anterior wrap

– Toupet• posterior

• CT Surgery options– Belsey– used if multiple upper abdominal surgeries

or if very large hiatal hernia

Surgical Options

• Open– large midline incision, longer recovery

• now mainly used as choice if recurrent or multiple previous surgeries

• Laparoscopic – 4-6 incisions– carbon dioxide for inflating and giving room

to work– most often done now

Surgical options

• Robotically– similar to laparascopic surgery– 3-4 incisions– carbon dioxide for inflating

•3-Dimensional Anatomy•Protect Vagus Nerve, Aorta

Advanced Sealing / Dissection*•Wristed Vessel Sealer•Avoid gastric or esophageal perforation

Advanced Suturing Capability•Fundoplication can come undone•Assessment of wrap tightness

Learning Curve•In preparation for complex paraesophageal hernia or redo Nissens

Visualization

Primary Closure Straight suturingSmall herniasMost common

Mesh Closure Synthetic or Biologic MeshFor Large hernias (>5cm)Costly (biologic even more)Sutures or Tacks (cost)

Final thoughts

• reflux is very common • most patients are managed very well

with medications and lifestyle changes– obesity– smoking

• if symptoms are not improving– may need EGD to check anatomy– may need surgery to address problem

What can I offer?

• Board certified General Surgeon– advanced laparoscopic training – robotic trained

• Endoscopy trained

More Resources

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www.SpringfieldClinic.com/DoctorIsIn