Gastroesophageal reflux ailment and antireflux surgery

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Brannon Hyde, MD Gastroesophageal reflux sickness and antireflux surgery

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Learning targets Understand the regular history of reflux infection Understand how to recognize contender for antireflux surgery Understand the confusions of antireflux surgery and patient's fulfillment with surgery

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Why do we think about reflux? Americans encounter reflux manifestations 44% month to month 20% week after week 4-7% day by day Most regular gastrointestinal conclusion on outpatient doctor visits Frequency and seriousness does not anticipate esophagitis, stricture, or malignancy improvement

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Definition of GERD Montreal accord board (44 specialists): "a condition which creates when the reflux of stomach substance causes troublesome side effects as well as complexities " Troublesome — tolerant gets the chance to choose when reflux meddles with way of life Vakil N, et al. Am J Gastroenterol 2006;101:1900

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Clinical presentation Heartburn 1-2 hours in the wake of eating, frequently around evening time, acid neutralizer alleviation Regurgitation Spontaneous return of gastric substance proximal to GE jxn; less very much soothed with stomach settling agents Dysphagia (40%)— trouble with gulping ought to provoke look for pathologic condition

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Clinical presentation Atypical side effects (20-25%) Cough Asthma Hoarseness Non-cardiovascular mid-section torment

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Diagnosis in view of manifestations alone is right in just 2/3 patients Differential (ALL CAN KILL YOU!) Achalasia Diffuse esophageal fit Other esophageal motility issue Cancer Ulcer malady Coronary course sickness

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So I have GERD, what's going to transpire? Range of sickness hypothesis: Nonerosive ailment  erosive malady  Barrett's  esophageal adenocarcinoma Am J Gastroenterol 2004;99:946.

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3,894 patients had gauge and rehash endoscopy at 2 years , paying little respect to side effects. Conclusion : movement and relapse happen regardless of PPI treatment ProGERD study Am J Gastroent 2006;101:2457-62 Severe esophagitis Mild esophagitis

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So I can analyze it, and I know how awful it can get, however why does indigestion and disgorging happen in any case? Reply: modification from ordinary physiology Normally, the lower esophageal sphincter exists as a zone of high weight amongst throat and stomach; when the HPZ is lost, reflux happens

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Proximal throat Swallow Transducer following recognizes the LES High weight drops simply after a swallow or when fundus is stretched with gas (to burp) Distal throat Distal throat Distal throat Distal throat Relaxation of LES Gastric standard

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Physiology of antireflux boundary Three parts of high weight zone Absolute weight Overall length Intra-stomach length

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Overall length abbreviates as stomach widens, expanding the weight important to keep up ability ( neck on an inflatable )

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Physiology of antireflux obstruction If intra-stomach length is short, LES weight can be overcome by little increments in intra-stomach weight Increased stomach weight needs even dissemination over high weight zone stomach length to counteract reflux

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Normal physiology If adequate intraabdominal length is available, crush ( expanded stomach weight ) will happen around "neck of inflatable," and reflux won't happen

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Physiology of antireflux hindrance

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Pathophysiology of GERD Fundic enlargement (indulging) & postponed gastric discharging (high fat) Lower esophageal sphincter is pulled distally by growing fundus Squamous epithelium presented to gastric juice Repeated introduction  columnarization

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What does my body do to adjust for reflux esophagitis? Remuneration: Increased gulping  salivation washes harmed mucosa, lightening inconvenience Results in aerophagia, bloating, and burping Distention prompts to encourage dull damage to the terminal squamous epithelium in distal throat

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Pathophysiology of GERD Extension of irritation into muscularis propria causes dynamic misfortune long and weight of the LES—"esophageal shortening" Loss of LES prompts to disgorging, acid reflux, and consequent serious esophagitis

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What part does a hiatal hernia play? More prominent gastric dilatation is important to open LES in patients with in place point of HIS contrasted with those with a hiatal hernia Reflux happens less demanding < 3 cm > 3 cm

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So I have a deficient sphincter, what complexities will I have? Esophagitis ( mucosal damage ) with or without indigestion Reflux mid-section torment disorder Respiratory intricacies Metaplastic and neoplastic inconveniences

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Why is esophagitis awful? Corrosive alone does insignificant harm, yet is exceedingly lethal in mix with pepsin Bile reflux alone does negligible harm, yet when combined with gastric corrosive , is damaging to esophageal mucosa Decrease corrosive (with PPI or surgery), and esophageal covering mends

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What is reflux mid-section torment disorder? Indigestion without esophagitis bile salts repress pepsin corrosive pH inactivates trypsin torment originates from acidic gastric juice breaking mucosal hindrance and aggravating nerve endings

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Respiratory confusions Reflux and yearning of gastric substance incites asthma Correlation between hiatal hernia and aspiratory fibrosis Pathologic corrosive introduction frequently observed in proximal throat in patients with asthma Simultaneous tracheal and esophageal pH checking demonstrates fermentation of trachea working together with throat

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What metaplastic difficulties can emerge? Norman Barrett (1950) initially portrayed the procedure whereby the esophageal squamous epithelium changes to columnar epithelium Occurs in 7-10% of patients with GERD Factors inclining to Barrett's Early-onset GERD Abnormal LES or motility issue Mixed reflux of gastric and duodenal substance

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What are the neoplastic intricacies? Flagon cells Barrett's metaplasia harbors dysplasia in 15-25% 5-10% is high-review dysplasia High review dysplasia; structure of organs getting to be confused

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So I comprehend somewhat about reflux; who needs an operation? Requirement for ceaseless medication treatment or raising dosage of PPI Relatively youthful Financial weight or resistance with PPI Patient decision

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How would you know I'm a contender for surgery? Build up GERD as hidden reason for side effects Estimate danger of dynamic malady Determine nearness or nonappearance of esophageal shortening Evaluate esophageal body work

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How would you know I'm a contender for surgery? Variables prescient of effective result taking after antireflux surgery (n = 199) Abnormal score on 24-hour esophageal pH observing (p < 0.001) Presence of normal manifestations of GERD ( indigestion and disgorging ) (p< 0.001) Symptomatic change in light of corrosive suppressive treatment (p = 0.02) J Gastrointest Surg 1999;3:292-300

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What particular studies do I require preoperatively? Endoscopy 24-hour mobile pH checking Radiograph Esophageal body and gastric capacity

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Preoperative assessment: endoscopy Amounts to the physical examination Strictures or vast hiatal hernia may demonstrate abbreviated throat High-review dysplasia or a mass in the esophageal, gastric, or duodenal lumen will change administration

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Preoperative assessment: 24-hour pH observing Rationale: best quality level for finding of GERD Quantifies genuine time the esophageal mucosa is presented to gastric juice Measures the capacity of the throat to clear refluxed corrosive

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Preoperative assessment: 24-hour pH observing Correlates esophageal corrosive presentation with patients side effects Without irregular pH concentrate on, surgery is probably not going to profit Gives a composite score ( Johnson-DeMeester score) exceptionally delicate and particular (>96%) for diagnosing GERD

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Johnson-DeMeester ordinary qualities for esophageal pH < 4 (n = 50) J Clin Gastroenterol 8(suppl. 1):52-58, 1986.

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Preop assessment: swallow study Only 40% of patients with great side effects of GERD will have reflux seen on radiography Assess for: Esophageal shortening Hiatal hernia (80%) Paraesophageal hernia Stricture or deterring sore Beading or corkscrewing (motility issue)

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Manometry Rules out esophageal motility issue Esophageal body brokenness (achalasia or aperistalsis) ought to change administration.

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So I have reflux, and I think I need surgery; what surgery do I have? The most widely recognized antireflux operation is the laparoscopic fundoplication Crural analyzation, ID and conservation of both vagi 25% have left hepatic vein originating from left gastric conduit in the gastrohepatic tendon Circumferential dismemberment of throat

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So I have reflux, and I need surgery; what surgery do I have? Components of laparoscopic Nissen Crural conclusion Fundic activation by division of short gastrics Creation of short, free fundoplication by encompassing front and back divider around lower throat

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That operation looks pleasant, are individuals happy with it? Persistent fulfillment is high ( 86-97% ) Long-term indication alleviation (indigestion and spewing forth) in 84-97% Symptomatic disappointment rate 3-13% indigestion and disgorging Does not relate with acidic reflux introduction OPERATION DID NOTHING for 3-13%! Specialist, August 2009:224.

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How will I feel after that operation? Bloating and expanded fart (9-53%) Most regular reaction Different scoring frameworks represent run Pre-agent side effect scores are generally obscure Surgeon, August 2009:224.

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What are the genuine terrible things that can transpire? Survey of 10,489 laparoscopic antireflux techniques Complications Wrap herniation (mid) 1.3% Pneumothorax 1.0% All others < 1% (aperture, h