Medical and Surgical
Management of
Gastroesophageal Reflux
Disease (GERD)
Edward Auyang, MD, MS, FACS
Assistant Professor of Surgery
Director of Minimally Invasive Surgery
Residency Program Director, General Surgery
Disclosures
• No financial disclosures
• I do perform anti-reflux operations…
Objectives
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Recognize symptoms of GERD
Learn the diagnostic tests to evaluate GERD
Learn the medical treatments for GERD
Learn the surgical treatments for GERD
Epidemiology
• 61 million Americans complain of
heartburn and indigestion
– 40% monthly
– 20% weekly
– 7% daily
Anatomy
• Barriers to GERD
– Esophageal peristalsis
– Intra-abdominal segment
of esophagus
– Lower esophageal
sphincter (LES) tone
– Diaphragmatic crura
– Phrenoesophageal
membrane
– Angle of His
• Normally – Transient
relaxation of LES
Pathophysiology
Pathophysiology
• Primary mechanisms
– Spontaneously, accompanying transient LES
relaxations
– Stress reflux associated with a weakened LES
– Increased intra-abdominal pressure
– Dysfunctional LES/Hiatal hernia
• Reflux -> mucosal injury -> weakened LES
and/or esophageal dysmotility
Clinical Presentation
• Typical vs. Atypical
Clinical Presentation
• Typical symptoms
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Heartburn
Regurgitation
Water brash
Acid brash
Nocturnal Aspiration
Dysphagia
• Atypical symptoms
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Chronic nausea
Asthma
Aspiration
Cough
Hoarse throat
Dental erosions
Chest pain
Diagnostic Studies
Diagnostic Studies
• Anatomic
– EGD (± biopsy)
– RULE OUT
CANCER/Barrett’s!
– Contrast radiographs
(UGI Esophagram)
• Physiologic
– 24-hr pH testing
(on/off medication)
– Esophageal
manometry
– Scintigraphy (gastric
emptying)
EGD
Upper GI
Manometry
24 Hr pH Monitoring
Treatment - Medical
Treatment - Medical
• Life style modifications
– Weight loss
– Alteration of diet
• Avoid chocolate, peppermint, fat, onions, garlic,
alcohol, caffeine, and nicotine
• Nothing by mouth for 2-3 hr before bedtime
– Elevation of head of bed 6-10 in. Limit
potentially precipitating activities, such as
bending over or strenuous exercise
• Medication
Medication Options
• Antacids (Neutralize)
– Tums, Rolaids, Maalox
• H2 Blockers
– Ranitidine, famotidine
• PPI
– Omeprazole, pantoprazole, esomeprazole, etc.
– Beware of osteoporosis/penia, fundic polyps
• Max Omeprazole 40mg BID
Treatment – Surgical
Treatment – Surgical
• Complications of GERD unresponsive to medical therapy
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Esophagitis
Stricture
Recurrent aspiration or pneumonia
Barrett esophagus
• Continued symptoms despite maximal medical treatment
• Symptomatic paraesophageal hernia
• Patient desire to discontinue PPI therapy
– Financial burden
– Lifestyle choice
– Young age
• Intolerance to proton pump inhibitor therapy
Basic Tennets of Surgery
• Restoration of an effective LES
• Creation of a gastroesophageal valve
• Fundoplication requires wrapping
the fundus itself, not the body of the stomach,
around the esophagus, rather than around the
proximal body of the stomach
• The fundoplication should reside within the
abdomen without tension, and the crura should
be closed adequately to prevent migration of the
stomach or the fundoplication into the chest
• Complete Vs. Partial wrap
Operation
Operation
Operation
Post-op Care
• Hospitalization
• Diet
• Activity
Outcomes
• Lap Nissen Fundoplication Success Rate:
90-95%
• Gas Bloat
• Dysphagia
• Hernia/GERD Recurrence
GERD and Obesity
Case Scenario
• 56yoM presents to your office with Heartburn
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HPI – What do you want to know?
PMHx – HTN, GERD, HL
PSHx – Cholecystectomy
PE – HR:75 BP:122/85 O2: 97% RA BMI 30
Workup ?
Questions?
Results
GERD and Barrett’s Disease
• 60% of patients with clinical GERD will
have normal-appearing esophageal
mucosa at endoscopy
• Barrett esophagus is estimated in 10% of
patients with GERD
• GERD + Barrett esophagus have 0.4% per
patient-year risk of adenocarcinoma Vs.
0.07% per patient-year risk for patients
with GERD but without Barrett esophagus
Esophagitis Grading System
(Endoscopic)
• Los Angeles Classification System
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Grade A (≤5 mm in length)
Grade B (>5 mm in length)
Grade C (continuous between two mucosal folds)
Grade D (≥75% of esophageal circumference)