QUESTIONS & ANSWERS
GERD, ACID REFLUX,
|Dr BALLANTYNE||CENTER (CALS)||GERD (REFLUX)||Rx OF GERD||ROBOTICS IN|
|LAPAROSCOPY||COLECTOMY||HERNIA REPAIR||GALLBLADDER||ALT MEDICINE|
QUESTIONS & ANSWERS
|GERD, ACID REFLUX,|
Anti-reflux surgery is a safe, effective and cheap alternative to long term medical treatment of Gastro-Esophageal Reflux Disease (GERD). Three factors have contributed to the recent increase in popularity of surgical treatment for patients afflicted with GERD:
1. Modifications in the technique of fundoplication have decreased side effects such as gas-bloat syndrome to a rate of less than 5 percent;
2. Improved diagnostic studies correctly identify the subgroup of GERD patients that will benefit from surgical treatment; and
3. Minimally invasive surgical techniques decrease pain, shortened hospitalization and decrease disability after fundoplication.
This review will focus on the means of proper selection of those patients that will most likely benefit from laparoscopic Nissen fundoplication as the treatment of their Gastro-Esophageal Reflux Disease.
A variety of mechanisms contribute to the emptying of the esophagus and the prevention of the reflux of gastric contents into the esophagus (Figure 1). These include:
1. the rapid propulsion of ingested food down the esophagus and into the stomach by the normal propagation of esophageal motility waves;
2. the contraction of the crura of the diaphragm around the Lower Esophageal Sphincter prior to each inspiration;
3. the relaxation of the Lower Esophageal Sphincter (LES) in conduction with the arrival of ingesta at the Gastro-Esophageal junction;
4. the contraction of the Lower Esophageal Sphincter prior to contractions of the gastric fundus;
5. the proper closure of the Gastro-Esophageal flap valve (as proposed by Lucius Hill);
6. appropriate gastric emptying; and
7. appropriate relaxation and contraction of the pylorus.
Compromise of any of these mechanisms can lead to the symptoms generally attributed to GERD.
Gastro-Esophageal Reflux Disease (GERD) is caused by a variety of mechanisms. Esophageal motility disorders can cause symptoms by two mechanisms. Incomplete emptying of the esophagus after ingestion of liquids or solids can allow esophago-esophageal reflux. Also, small amounts of gastric contents normally reflux into the distal esophagus. Rapid emptying of this material by the esophagus prevents injury of the esophageal mucosa. Delay in emptying of this material because of an esophageal motility disorder, however, leads to irritation of the esophagus and possibly to the sensation of heartburn or the development of esophagitis.
The crura of the diaphragm contract around the Lower Esophageal Sphincter before each inspiration. This action augments the pressure gradient generated by the LES between the stomach and the esophagus. The development of a hiatal hernia causes the LES to slide up into the mediastinum away from the hiatus. As a result, the negative pressure within the chest generated by each inspiration compromises the positive pressure generated by the LES. Moreover, the crura contracts around the fundus of the stomach rather than the LES which negates the contribution of this action to the pressure gradient of the LES.
Lucius Hill of Seattle believes that a flap valve at the GE junction plays an important role in the prevention of GE reflux. Loss of the angle of His compromises this valve leading to reflux.
Delay in gastric emptying contributes to GERD. Improper gastric emptying allows accumulation of liquids and solids within the stomach. This can cause an increase in gastric pressures above the pressure generated by the LES. In addition, retention of ingesta within the stomach increases the number of episodes of reflux following a meal. This can increase the percentage of time that the esophageal mucosa is exposed to a low pH.
Dysfunction of the pylorus can aggravate GERD. Inadequate relaxation or stricture of the pylorus can cause delays in gastric emptying and as discussed above contribute to reflux. In contrast, an incompetent pylorus allows reflux of alkaline fluid and bile. Reflux of either into the esophagus can cause esophagitis and the symptoms of GERD.
Fundoplication is the most effective treatment for GERD. Consequently, surgical treatment can be offered to many patients afflicted with GERD. These include:
1. any patient with moderate to severe symptoms of GERD who wishes to avoid a lifetime of pharmacological therapy;
2. patients who require Prilosec for more than a year;
3. patients who continue to suffer from symptoms of GERD despite maximum medical therapy; and
4. patients with paraesophageal hernias.
This list suggests the group of patients that might be considered for surgical therapy not the smaller group who is likely to benefit from fundoplication. These candidates require further evaluation prior to the recommendation of surgical therapy.
Fundoplication repairs two simple mechanical defects. It reduces a hiatal hernia (if present) and augments the pressure generated by the Lower Esophageal Sphincter. As a result, it benefits only those patients who have symptoms caused by the reflux of acid into the esophagus because of a hiatal hernia and/or a defective lower esophageal sphincter. It does not correct the other causes of GERD. Indeed, a fundoplication can severely worsen the symptoms produced by esophageal motility disorders. Moreover, fundoplication provides no relief for the many patients who suffer from other conditions that mimic the symptoms of GERD. Consequently, fundoplication should be recommended only to patients in whom symptoms are caused by the reflux of acid through a defective LES. Unfortunately, a careful history and physical examination is ineffective in the identification of this subgroup of patients. It proves necessary, therefore, to subject candidates for surgery to a battery of five tests. All patients should undergo the following four tests before fundoplication is recommended:
1. Video esophagram for evaluation of esophageal motility;
2. Esophageal manometry for the assessment of the Lower Esophageal Sphincter;
3. 24 hour pH monitoring to demonstrate a correlation between the reflux of acid and the onset of symptoms; and
4. An upper gastrointestinal endoscopy to identify the presence of complications of GERD such as esophageal carcinoma.
Some patients in whom gastric motility disorders are suspected should also undergo an evaluation of gastric emptying. SURGERY IS ONLY RECOMMENDED TO PATIENTS WITH BOTH A DEFECTIVE LOWER ESOPHAGEAL SPHINCTER AND A CORRELATION BETWEEN ACID REFLUX AND THE ONSET OF SYMPTOMS.
Please note that patients with paraesophageal hernias require repair of the hernia because of the high rate of strangulation of the stomach. They might not need, however, a fundoplication.
Several factors tend to compromise the results obtained with fundoplication for the treatment of GERD (FIGURE 4). In patients with esophageal motility disorders in addition to both a defective lower esophageal and a correlation between the reflux of acid and the onset of symptoms, a full 360 degree Nissen fundoplication may severely worsen their swallowing disorder. In these patients, a partial wrap such as a Toupet fundoplication may achieve a better overall control of symptoms. In some patients, the esophagus is so shortened that the gastroesophageal junction can not be returned to the abdomen. These patients suffer a high rate of failed fundoplications and may require a Collis type procedure that lengthens the esophagus. Patients with gastric outlet obstruction should be treated with a gastric emptying procedure. Diabetics with gastroparesis often suffer poor results with fundoplications. Patient's with carcinomas require resection or other forms of palliation. Patients with alkaline or bile reflux may require an operation that diverts the duodenal contents away from the stomach.
Picking a surgeon for you patient is just as important as the careful selection of patients for surgery in the determination of end results. The performance of a laparoscopic Nissen fundoplication requires the application of a variety of new skills. Unfortunately, few surgeons are trained in these techniques. As a result, the learning curve for laparoscopic anti-reflux operations is even steeper than was observed for laparoscopic cholecystectomy. You should check that the surgeon to which you refer your patient meets the New York State Department of Health guidelines for credentialing in laparoscopic surgery. New York State suggests that surgeons should undergo the following process before they are granted privileges to perform a new laparoscopic operation such as a laparoscopic Nissen fundoplication:
1. Completion of a CME accredited course focused on that operation;
2. Practice with the surgical technique of that operation using first inanimate and then live animal models;
3. Observation of an expert performing the operation;
4. A preceptorship in which an expert scrubs with the novice surgeon during his first 10 to 20 operations of that type. The Preceptor takes an active role in the performance in the operation, instructs the novice in the technique of the procedure, ensures the safety of the patient and guarantees the quality of the operation; and
5. A proctorship in which a surgeon appointed by the hospital's credentialing committee observes the novice surgeon's next 10 to 20 independent operations (i.e. without the assistance of a preceptor) and reports confidentially to the credentialing committee on the ability of the surgeon to perform the operation safely.
The treatment of Gastro-Esophageal Reflux Disease with a laparoscopic Nissen fundoplication is a safe, effective and reliable therapeutic option when performed by a qualified surgeon. Unfortunately, poor outcomes are common during a surgeon's early experience.
Fundoplication achieves excellent results in 95 percent of carefully selected patients. Only patients with a defective Lower Esophageal Sphincter and a correlation between reflux of acid into the esophagus and the onset of symptoms should undergo surgical treatment. Identification of this small group of patients requires extensive preoperative evaluation that should include a video esophagram, esophageal manometry, 24 hour pH monitoring and an upper esophageal endoscopy. Some patients may also require an evaluation of gastric emptying. Recommendation of surgery based on history and physical examination alone may lead to a high rate of poor outcomes following fundoplication.
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