Transcript
Page 1: Extinguish the “fire” of serious heartburn

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

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2www.SpringfieldClinic.comwww.SpringfieldClinic.com

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Overview• Define reflux

• Symptoms of reflux

• How do we diagnose reflux

• Treatment options

• What can I offer?

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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

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What is reflux?• abnormal component-occurs

outside meals, during sleep, affects everyday life

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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

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Other lesser known symptoms

•chest pains

•“lump in their throat”

•nausea

•persistent cough

•hoarse voice/raspy voice

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A+B=C• Differential

– cardiac• heart attack

– esophageal dysfunction– gallbladder

• stones, sludge, low EF– stomach

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

• pancreatitis, tumor

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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

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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

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Diagnosis

• Endoscopy– allows biospy– hernia– ulcers

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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

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Treatment

• Medical – lifestyle modifications

• weight loss• smoking cessation• avoid late night eating

– eating smaller meals

• avoid caffeine, chocolates, alcohol• sleeping positions

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Treatment

• Medical– medications

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

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

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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

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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

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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

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Treatment

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

• May need surgery to fix/help with symptoms

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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

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

Normal Anatomy

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

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

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

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Primary Closure Straight suturingSmall herniasMost common

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

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Surgical Options

• “Wrap”– upper portion of stomach is wrapped

completely around end of esophagus– “Nissen”

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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

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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

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Surgical options

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

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•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

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Primary Closure Straight suturingSmall herniasMost common

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

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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

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What can I offer?

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

• Endoscopy trained

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More Resources

Find videos, handouts and more resources at

www.SpringfieldClinic.com/DoctorIsIn


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