Benign esophageal disease
Sha-Ron Jackson-Johnson,MD
Clinical Instructor of Surgery
University of Cincinnati
GERD - pathophysiology
• Failure of LES to prevent reflux
• 3 Components to the LES
– Resting LES pressure (normal >
6mmHg)
– Resting LES length (normal >2
cm)
– Intra-abdominal LES length
(normal >1cm)
1 or 2 components = 75%
chance of GERD
3 components = 93%
GERD
60 yo man, complains of heartburn
• Typical/Atypical symptoms of GERD
• Lifestyle changes/Medical Management
• Indication for further workup
– Failure of medical management
– Immediate recurrence after withdrawal of
therapy
• Diagnostic workup
– EGD
Manifestations of GERD
• Esophageal
– Normal
– Esophagitis
– Ulceration
– Stricture
– Barrett’s Normal GE junction
• Extra-esophageal
– Asthma
– Cough
– Aspiration
– Hoarseness Stricture, hiatal hernia
Esophagitis
GERD
• Treatment
– Medical
• 90% esophagitis heals with medical management
• 80% recur within 1 year of withdrawal
– Surgical
• Indications for surgery
– Failure of medical management
– Primary treatment for reflux disease
– Complications of GERD
» Stricture, Barrett’s, ulceration, aspiration, vocal cord edema
• Contraindications for surgery
– Morbid obesity - controversial
GERD
• Preoperative workup
– EGD (mandatory)
– Esophagram (mandatory) helps identify
strictures/esophageal shortening
– Manometry (mandatory) detects esophageal
motility disorders; examines lower esophageal
sphincter
– 24h pH probe (mandatory if no other objective
signs), remains Gold Standard for diagnosis of
GERD.
Laparoscopic Anti-reflux Surgery
• Restore normal
anatomy
– GE junction to
abdominal cavity
• Lengthen esophagus
• Repair diaphragm
• Perform wrap
Hiatal hernia Hiatal hernia (posterior crura)
Repair of posterior crura 360° Nissen fundoplication
Laparoscopic Nissen Fundoplication
Outcomes
• Low morbidity and mortality
– Perforation 1%, failure of wrap 1%
– Dysphagia 2-10% with most improving with a
single surgical dilation
• 85-90% symptom free at 10 years
Other complications
• Dysphagia post-op -usually traumatic edema (2 weeks)
– Hematoma (4-6 weeks)
– Wrap too tight
– Poor peristalsis/pre-operative dysphagia
– Stricture
• Vomiting post-Nissen
– Usually disruption
• Complications of Nissen
– Perforation (1%)
– Recurrence mandating redo (3-5%)
– Paraesophageal hernia (failure to close the crura)
– Vagal nerve injury (less common)
Medicine vs Surgery in GERD
2010 Cochrane Review
• 4 randomized trials, 1232 participants
• Statistically significant improvements in
health-related quality of life at three months
and at one year in the surgical group
• All studies reported significant improvements
in GERD-specific QOL after surgery
• Cost 3-6 x higher in surgical group at 1 year
Barrett’s Esophagus
• Endoscopically visible
segment of columnar
mucosa with goblet cells
• Results from reflux-
induced mucosal injury
• Considered premalignant
• Progression to cancer
0.5% per patient-year
(range from 0.2-2.9%)
Barrett’s Esophagus
Role of Antireflux therapy
Marco Patti, MD. World Journal Gastroenterology. 2010
GERD and Obesity
• Direct correlation between BMI and GERD
• Surgery for both in severe, refractory cases
• Durability of fundoplication in obese patients
is significantly lower than in non-obese
– 31.3% vs 4.5% recurrence rates
• Remains controversial.
• Higher rate of fundoplication failures
– Hiatal hernia recurrence also more common
Case 2
• 34 yo woman
• Dyspnea and postprandial fullness x 9 months
• Sudden onset of severe epigastric pain
• Hgb 11.5
Types of Paraesophageal hernia
Paraesophageal hernia
• Symptoms
– Up to 50% asymptomatic
– Epigastric pain, postprandial fullness, chest
discomfort, heart burn, regurgitation, dysphagia,
vomiting
– Anemia from GI bleed
– Pulmonary dysfunction
– Acute symptoms (can mimic MI): Classic triad - Chest
pain, retching but unable to vomit, unable to pass
NGT
Paraesophageal hernia
• Diagnosis/Workup:
– CXR – retrocardiac
bubble or intrathoracic
stomach
– Barium Swallow – large,
intrathoracic upside
down stomach
– Endoscopy – ulcers,
erosions, Barrett’s,
neoplasm
– Manometry – LES status,
function of esophagus
(optional)
Case 2
• Treatment
– Repair if symptomatic, or on a selective basis in truly
asymptomatic patients (previously all Type II and III
were repaired)
• Surgery
– Reduction sac
– Excision sac
– Repair defect
– Antireflux procedure (usually partial)
Case 3
• 47 yo man
• Dysphagia, worsening over 2 years
– Solids vs liquids
• Workup
– Barium swallow
Case 3
• Absent peristalsis
• Dilated esophagus
• Birds beak
• 90% of achalasia patients
Case 3
• Further workup
– EGD to r/o tumor (pseudoachalasia)
• Retained food/liquid, esophageal dilation, or normal
– Manometry (GOLD STANDARD)
• Aperistalsis and incomplete relaxation of LES
• Increased LES pressures of >25 mmHg also seen
Achalasia
• Nonsurgical treatment
– Largely ineffective
• Smooth muscle relaxants (CCB, nitrates)
– short-lived
• Esophageal dilation
– response rates 60-80%, high recurrence, scarring
• Botulinum toxin
– Relief in 80%, recurrence 50% within 6 months
– Significant scarring 30% perforation rate in surgery
Achalasia
• Treatment – Surgical -
Heller myotomy
– Intraoperative EGD
– Restore normal
anatomy if necessary
– Myotomy at 11 o’clock
position
• 2-2.5 cm onto gastric
wall
• 6 cm above GE
junction
– Partial fundoplication
• Dor
• Toupet
Spastic motility disorders
• Diffuse esophageal spasm
– Dysphagia liquids and solids
– High amplitude contractions
with intervening periods of
normal peristalsis
– Medical management
• Reassurance, CCB, Nitrates
– Surgery less helpful
• Myotomy
• Botulinum toxin
Questions before we move on?