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)