Gastroesophageal Reflux Disease, Paraesophageal Hernias &

Transcription

1 & , , MD Assistant Clinical Professor of Surgery, UH JABSOM Associate General Surgery Program Director Director of Minimally Invasive & Bariatric Surgery Programs Director of The Queen s Comprehensive Weight Management Program Director of Surgical Skills Curriculum Gastroesophageal Reflux Disease, Paraesophageal Hernias & Achalasia Laparoscopic Operations of the Foregut C d i S F L MD Cedric S.F. Lorenzo, MD Assistant Clinical Professor of Surgery, UH JABSOM Associate General Surgery Program Director Director of Minimally Invasive & Bariatric Surgery Programs Director of The Queen s Comprehensive Weight Management Program Director of Surgical Skills Curriculum 1

2 Disclosures I have no relevant conflicts of interest to disclose Objectives Understand the presentation and evaluation of benign disorders of the foregut Gastroesophageal Reflux Disease (GERD) Paraesophageal Hernia Achalasia Describe minimally invasive surgical treatments for these ailments 2

3 Foregut Anatomy upper digestive tract esophagus 2 muscle layers LES cm stomach muscular organ football sized Hiatal Anatomy 3

4 The Antireflux Barrier Diaphragm Phrenoesophageal ligaments Cura LES Stomach sling & clasp Fibers Intra-abdominal esophageal position Gastroesophageal Reflux Disease (GERD)

5 Definition Physiologic reflux is normal Pathologic reflux is associated with: symptoms mucosal injury Montreal Classification & American College of Gastroenterology: Symptoms or mucosal damage produced by abnormal reflux of gastric contents into the esophagus The Epidemiology of GERD Western World: 10-20% USA 10 million report frequent heartburn 40% affected once per month 20% affected once per week 7% affected daily Asia: 5% 5

6 GERD Symptoms Typical Symptoms Heartburn Regurgitation & aspiration Water brash Chest pain Dysphagia Atypical Symptoms Chronic nausea Asthma Cough Hoarse voice Dental erosions Figure 1 A simple overview of the pathogenesis of gastroesophageal reflux disease. GI Motility online (May 2006) doi: /gimo21 6

7 Figure 2 Gastroesophageal reflux disease initiates a vicious cycle of increasing esophageal acid exposure. GI Motility online (May 2006) doi: /gimo21 Worse Case Scenario for GERD Barrett s Esophagus Esophageal Cancer (<1%) Esophagitis 10-15% of GERD patients undergoing endoscopic exam 10% of patients with erosive esophagitis 7

8 Medical Management Lifestyle modification Head of bed elevation Avoid tight fitting garments Weight loss Promotion of salivation Smoking cessation Dietary modification Avoidance of dietary triggers Decreased alcohol consumption No eating 4-6 hours before bedtime Antacid therapies H2 receptor antagonists (H2B) Proton pump inhibitors (PPI) Acid-suppressive Medications Increase intragastric ph > 4 Does not prevent reflux but reduces the acidity of the refluxate Therapeutic gain relative to placebo H2B: 10-24% PPI: 57-74% More rapid healing vs H2B Dose response curve unlike H2B 8

9 Figure 1 Approach to antisecretory therapy. GI Motility online (May 2006) doi: /gimo54 When is Surgery Indicated? Complications not responding to maximal medical therapy esophagitis stricture recurrent aspiration or pneumonia Barrett s esophagus Symptoms interfering with lifestyle despite medical therapy Paraesophageal hernia with GERD Patient desires to discontinue medications Financial burden Noncompliance Lifestyle choice Young age Side effects 9

10 GERD is a disease of dysfunctional anatomy and therefore is best treated with an operation! The Antireflux Barrier 10

11 How are and related? Antireflux Surgery Codes laparoscopic esophagogastric fundoplasty open esophagogastric fundoplasty Toupet Fundoplicaton Nissen Fundoplicaton 11

12 Laparoscopic Nissen Fundoplication Laparoscopic Nissen Fundoplication 12

13 Laparoscopic Nissen Fundoplication Not All Are the Same Type I: sliding hernia Type II: fundus herniates into the mediastinum GEJ is in normal position Type III: herniation of both the fundus and GEJ into the mediastinum Type IV: any of the above including another organ 13

14 Symptoms of Paraesophageal Hernia Asymptomatic Incidentally found on imaging studies Vague symptoms epigastric discomfort or pain postprandial fullness regurgitation nausea dysphagia GI bleed (Cameron s ulcer anemia) dyspnea Clinical Presentation Acute Surgical Emergencies: 2-17% profuse bleeding bowel incarceration volvulus strangulation perforation Mortality rate: ~50% 14

15 Diagnosis Contrast radiograph Upper endoscopy 15

16 Surgical Codes Laparoscopic p repair of paraesopahgeal p hernia (includes fundoplasty) when performed without implantation of mesh With implantation of mesh Thoracic approach Abdominal approach 16

17 Laparoscopic Paraesophageal Hernia Repair Laparoscopic Paraesophageal Hernia Repair 17

18 Laparoscopic Paraesophageal Hernia Repair Achalasia (530.0) An esophageal motility disorder: incomplete LES relaxation increased LES tone aperistalsis of the esophagus Incidence: /100, ,000 Prevalanece: 8/100,000 18

19 Pathophysiology of Achalasia Progressive loss of myenteric ganglion cells within the esophageal wall Loss of coordinated motor function Loss of LES function Exact cause still unknown Figure 10 Pathophysiology of idiopathic achalasia. GI Motility online (May 2006) doi: /gimo22 19

20 Symptoms of Achalasia Slow development of symptoms Gradual worsening dysphagia Weight loss Regurgitation of food Halitosis Diagnosis of Achalasia Esophagram Upper endoscopy Rule out pseudoachalasia Manometry (gold standard) Esophageal aperistalsis Incomplete LES relaxation Elevated intraluminal esophageal pressures 20

21 The Classic Bird Beak of Achalasia Non-surgical Treatments Pneumatic dilation Relief in 90% 2-5% perforation rate Botox injections 100 units 89% remission 21

22 Surgical Codes Laparoscopic p esophagomyotomy y with fundoplasty Abdominal approach Thoracic approach Laparoscopic Heller Myotomy 22

23 Laparoscopic Heller Myotomy Take Home Message Many diseases of the foregut: common rare similar presentation thorough evaluation needed MIS provides an effective and safe method of treatment 23

24 Thank You! Questions? 24