GORD - Definition It is the abnormal exposure of the oesophagus to gastric contents : Results in symptoms complexes – mild symptoms 2X / week or moderate symptoms 1X/ week Affects quality of life OESOPHAGEAL REFLUX Mucosal injury to the oesophagus Sandie R Thomson PATHOPHYSIOLOGY ANTI – REFLUX BARRIER OFFENCE DEFENCE GASTRIC RESERVOIR LUMINAL CLEARANCE REFLUXATE ANTI- ANTI-REFLUX BARRIER HIATUS HERNIA CLINICAL PRESENTATION TYPICAL SYMPTOMS Traps gastric acid Abolishes valve Heartburn Acid regurgitation mechanism Widens oesophaeal hiatus GORD symptoms and severity of oesophagitis ENDOSCOPY > 45yrs < 45yrs that fail Rx Alarm symptoms Long standing symptoms (> 5 yrs) Suspicious Barium study LA GRADING SYSTEM Shift in management 1940 1970 1980 1990 2000+ Antacids H2 RA PPI’ PPI’s PPI’ “Better PPI’s” prokinetics OPEN SURGERY : LAPAROSCOPIC laparoscopic Refractory oesophagitis Alternative to PPI alternative to Complications PPI therapy MEDICAL MANAGEMENT MEDICAL MANAGEMENT > 45yrs or alarm symptoms = endoscopy Lifestyle modification Over the counter medication < 45yrs with typical Full dose PPI for 1 month with H Antacids and alginates symptoms pylori eradication if needed Prokinetics Relapse after Response Histamine 2 receptor antagonists stopping therapy Maintenance therapy On demand Proton pump inhibitors Daily maintenance Rx Intermittent Rx treatment Stop On-demand Rx On- treatment ANTI – REFLUX SURGERY PATIENT SELECTION 25000 POSITIVE PREDICTORS 20000 Good response to PPI 15000 Typical symptoms 10000 Volume refluxers 5000 0 1985 1997 JACKSON P – American journal of surgery 2001 USA RECOMMENDATIONS FOR PATIENT SELECTION SURGERY NEGATIVE PREDICTORS Young patients NERDS Females Respond well to PPI therapy Patients with psychiatric disorders Proven erosive disease Atypical symptoms Typical symptoms of heartburn Thibault, Alimentary pharmacology and therapeutics 2006 regurgitation Velanovich V, Surgical Endoscopy year GOALS OF ANTI – REFLUX PRE – OPERATIVE EVALUATION SURGERY Mandatory Endoscopy Restore sphincter structure Barium Swallow Selective investigation Preserve normal swallowing pH studies Motility studies Preserve ability to belch Impedance NERDS Extraoesophageal symptoms Poor responders to PPI CONTRAST RADIOLOGY 24 hr pH STUDIES Can show ulcers, erosions and strictures Indications Hiatus hernia No response to PPI Indications for contrast NERD study alarm symptoms eg Atypical symptoms dysphagia GORD before antireflux Recurrence after surgery surgery symptomatic reflux after antireflux surgery OESOPHAGEAL MANOMETRY LUMINAL IMPEDANCE Measures electrical conductivity of Placement of a pH intraluminal contents electrode Dysphagia after It measures volume exclusion of and nature of content structural lesion Confirmation of It is used to investigate patients effect of Rx eg with non – acid reflux achalasia PARTIAL WRAPS SHORT FLOPPY NISSEN’S Crural dissection Circumferential dissection of the oesophagus Reduce hernia Crural closure Division of short gastrics 1.5 – 2 cm wrap over bougie COMPLICATIONS Intraoperative and immediately post op Oesophageal perforation Bleeding Pneumothorax Vagal nerve injury COMPLICATIONS Local audit of anti – reflux surgery in private practice New symptoms Yes No Burping with Ease? 65.5% 30.9% Dysphagia Excess Flatulence? 72.7% 27.3% Gas Bloat Satisfied (Long Term) 60.0% 40.0% 334 patients Diarrheoa , nausea , vomiting Satisfied (Short Term) 535 79.4% 20.6% patients 30 – 47% of patients were taking medication post operation Losibekan, SAMJ 2005 SUMMARY COMPLICATIONS PPIs work very well – even long term Strictures Surgery is good BUT not perfect Patient selection is key Barretts oesophagus Informed consent for surgery Endoluminal therapy for specialised centres and clinical trials in NERDS BARRETT’S OESOPHAGUS Site of stricture Incidence 5–19% of pts with GORD Premalignant carcinoma risk 2– 5 % Barium high grade dysplasia assessment carcinoma risk 30 % 4. Maximum 3. Maximum BARRETT’S OESOPHAGUS height of circumferential Barrett`s Barrett`s Screening not 5. Measure C/M indicated grade 2. Locate the OG Junction Diagnosis established Endoscopically 1. Identify hiatus hernia Histologically PRAGUE CLASSIFICATION NARROW BAND IMAGING AUTOFLUORESCENCE CONFOCAL ENDOSCOPY BARRETT’S OESOPHAGUS Treat reflux first Surveillance Barrett’ Barrett’s no Low- Low-grade dysplasia High- High-grade dysplasia dysplasia Confirm diagnosis 6- Rpt endoscopy 6-12 monthly Surveillance endoscopy every Oesophagectomy 3 yrs Mucosal resection Intensive surveillance SURGERY FOR BARRETTS ENDOLUMINAL THERAPY Alternative to surgery? adjunct to accurate The problem diagnosis ? Traditional oesophagectomy Mucosal resection Mortality 5 – 10 % Knife resection Significant morbidity Suction cap snare resection Minimally invasive vagus sparing surgery Mucosal ablation Mortality 5% Morbidity decreased Radiofrequency GORD BARRETTS Screening out Surveillance in Medical management for everyone Prague standardised grading Imaging advances Patient selection for surgery is key HGD Endoluminal therapy Floppy Nissen’s is the surgery of choice Oesophagectomy Thank you for paying attention!
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