Gastroesophageal reflux disease Principles of GERD treatment Treatment of reflux diseases GERD
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1 Esophagus Anatomy/Physiology Gastroesophageal reflux disease Principles of GERD treatment Treatment of reflux diseases GERD Manometry Question 50 years old female with chest pain and dysphagia. Manometry shows normal relaxation of LES and simultaneous moderately high amplitude contraction. DX A. Nutcraker esophagus B. Diffuse esophageal spasm C. Achalsia D. Scleroderma Nutcraker Very high Amplitude of persitalis >300 Scleroderma Lack of peristalis in distal esophagus Loss of High pressure Zone Rflux,ulceration
2 Barret esophagus Treatment of Barret Tumors of esophagus (leiomyoma) Esophageal neoplasms To use stomach for esophageal replacement, the blood supply to the stomach will be from right gastroepiploic. Leiomyoma of esophagus Dx smooth filling defect on esophagogram Tx DO NOT biopsy on EGD Thoracotomy and enucleation Mid- esophageal lesions Right thoracotomy Lower esophageal lesions Left thoracotomy Tumors of esophagus (adenocarcinoma) Transhiatal vs. Transthoracic esophagectomy Stages T1 = lamina propria or submucosa T2= invades musclaris propria T3= invades adventia T4= invades adjacent structures N1= regional lymph nodes Celiac lymph node is M1( a and b) Cervical lymph node is M1(a and b)
3 Stage I; T1 N0 Stage IIA; T2 NO - T3 N0 Stage II B ; T1 N1 - T2 N1 Stage III; T3 N1 and any T4 Stage IV; any M Esophageal carcinoma Esophageal Carcinoma: - Adenocarcinoma more common that squamous cell Ca. - Barrett s patients are at great risk of developing adenocarcinoma Contraindications for curative resection: 1. distant metastasis (liver, lung, bone, etc.) 2. + mediastinal/paratracheal/celiac nodes 3. esophagobronchial fistula (MUST DO BRONCHOSCOPY for w/u of ALL MID-ESOPHAGEAL LESIONS) Neoadjuvant Chemotherapy and radiation now has an effective role in stages II or more. It makes Transhiatal surgery more difficult Laparscopic resection is getting momentum Perforation of esophagus Perforated esophagus,treatment Perforated esophagus ttt (special situations) Diverticular disease Zenker diverticulum= pharngyesophageal is a Pulsion false diverticulum. Elderly males with dysphagia.
4 - Treatment is Myotomy of cricopharngeus muscle + excision of diverticulum if large - You may also do Diverticulopexy Epiphrenic diverticulum Lower esophagus,just above diaphragm Most cases are associated with motility disorders Mannometry study,before surgery to determine the exact length needed for myotomy Ttt is diverticulectomy with long myotomy Middle esophagus diverticulum Usually secondary to lymphadenitis with traction on the esophagus Not associated with motility disorder Hiatus hernia Type I ; Sliding associated with reflux Type II; Paraesophageal hiatus hernia with a normally placed gastroseophageal sphincter Type III ; mixed Paraesophageal hernia is liable to incarceration and therefore surgery is indicated,even if asymptomatic Hiatal hernia Treatment: Type I: sliding hernia, GEJ is in the chest. Tx is the same as that for GERD
5 Hiatal hernia Treatment: Type III: Type II with esophageal shortening, GEJ is in the chest. Tx: Nissen collies gastroplasty through the left thorax. Paraesophageal hernia operate, for the risk of incarceration and strangulation is high. This has been recently challenged Hiatal hernia Treatment: Type II: paraesophageal hernia, GEJ is in the abdomen. Tx operate as the risk of incarceration and strangulation is high. Operative objectives are: 1. Reduction of stomach from chest to abdomen 2. Excision of hernia sac 3. Closure of diaphragmatic defect (DO NOT use mesh/prosthetic if possible) 4. Anchoring the stomach to abdomen to prevent recurrence, usually by gastrostomy Achalasia pathology: decrease/absent Auerbach s plexus. CXR UGS swallow (cine) bird s beak appearance *UGI endoscopy check for reflux esophagitis, R/O Ca manometric studies show: Aperistalsis o incomplete LES relaxation o high LES resting pressure Tx: 1. pneumatic esophageal dilation in non fit patients 2. Heller myotomy (in patients with reflux, add fundoplications partial only pre-opmanometry
6 Motility disorders Achalasia Treatment Pneumatic dilatation for patients not fit for surgery Botox injection is short acting Myotomy,Laparoscopic Heller Myotomy with partial fundoplication left thoracotomy extends from the gastric cardia up to midway between the inferior pulmonary ligament and aortic arch Diffuse esophageal spasm DES Corkscrew/nutcracker appearance on barium swallow Treatment is medical NTG/isosorbide (SM relaxant) Nifedipine (Ca blacker) Rarely a dilated esophagus may end up with resection
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