GERD

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GERD

• Gastroesophageal Reflux Disease

Prof. Faisal Ghani Siddiqui FCPS
PGDip-bioethics MCPS-HPE faisal_at_lumhs.edu.pk www
.lumhs.edu.pk/faculties/surgery/gsurgery/faculty
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PREAMBLE

• What is GERD?
• LES?
• What causes GERD?
• How does GERD present?
• What are its complications?

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INTRODUCTION
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What is GERD?

• Condition characterized by
• heartburn and regurgitation
• due to the
• loss of the HPZ

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GERD

• Common Accounts for majority of esophageal
  pathologies
• Chronic disease needs life-long medical
  treatment
• Surgery is effective provides long-term relief

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PATHOPHY-SIOLOGY

• of
• gastroesophageal Reflux Disease

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LES

• HPZ located at the EG junction
• No distinct anatomical sphincter
• 3-4 cms long
• 10-25 mmHg
• Relaxes during swallowing / belching

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• Resting LES pressure
• Overall length of the sphincter
• Intra-abdominal length of the sphincter

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• Resting LES pressure
• Overall length of the sphincter
• Intra-abdominal length of the sphincter

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• Resting LES pressure
• Overall length of the sphincter
• Intra-abdominal length of the sphincter

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Permanently Defective LES

• Mean resting pressure lt 6mm
• Overall length lt 2cm
• Intra-abdominal length lt 1 cm

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SYMPTOMS
of Gastroesophageal Reflux Disease
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• Heartburn
• Regurgitation
• Dysphagia
• Chest pain

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COMPLICATIONS
of Gastroesophageal Reflux Disease
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Squamous epithelium replaced by columnar
epithelium Norman Barrett 1950
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Barretts Esophagus

• Endoscopically identified columnar mucosa, which
  on biopsy shows intestinal mucosa with goblet
  cells

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DYSPLASIA
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MANAGE-MENT

• of
• Gastroesophageal Reflux Disease

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Management of GERD
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Management of GERD
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CONSERVATIVE TREATMENT

• Antacids
• Alginic acid
• Metoclopromide / domperidone
• Proton pump inhibitors
• Change in life style

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Change in Life-style

• Elevate head of the bed
• Avoid tight fitting clothes
• Eat small, frequent meals
• Avoid eating before bedtime
• Dietary changes

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Control of refluxbetter than control of
symptoms!
PPIs suppress acidity relieve symptoms but do
not control reflux
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Antireflux surgeryeliminates reflux!
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Management of GERD
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INVESTIGATE IF SYMPTOMS

• Persist or progress
• Recur

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INVESTIGATIONS

• Endoscopy
• 24-hour pH monitoring
• Manometry

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Management of GERD
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WHEN TO OPERATE?

• Persistent or progressive disease
• Young patients with documented reflux
• Stricture
• Barretts esophagitis

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GOAL OF SURGERY

• to
• restore normal structure/pressure of the LES
• while preserving patients
• ability to swallow, and
• to belch

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PRINCIPLES

• Restore pressure
• (gt12 mmHg)
• Restore length
• (at least 3 cm)
• Place adequate length in abdomen
• (1.5 2 cm)

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ANTIREFLUX PROCEDURES

• Nissen fundoplication
• Toupet partial fundoplication
• Belsey Mark IV partial fundoplication

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COMPLICATIONS

• Temporary dysphagia
• Inability to vomit
• Increased flatulence