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General Surgery
Gastroesophageal Reflux Disease and Hiatal Hernia (Including Paraesophageal)
Built from Maingot's Abdominal Operations
What’s inside
7 sections · 191 slides
Overview
- What this deck covers
Reflux disease and how it presents
Definition, typical symptoms, atypical symptoms
- Definition of gastroesophageal reflux disease
- Heartburn and regurgitation
- Nighttime reflux and its burden
- Nighttime reflux symptoms in a national survey
- Atypical symptoms of reflux
- Dysphagia in reflux disease
- Chest pain of esophageal origin
- Typical and atypical presentations
The antireflux barrier
Four parts keep gastric contents where they belong
- Four components of the antireflux mechanism
- Parts of the antireflux mechanism
- Normal relaxation of the lower esophageal sphincter
- Three requirements of an effective sphincter
- Normal manometric values of the lower esophageal sphincter
- The defective sphincter
- Gastric distension takes up the sphincter
- Sphincter shortening as the stomach fills
- Complete take-up of the sphincter by the cardia
- From a large meal to a reflux episode
- Belching, bloating and swallowed air
- Cardia geometry and yield pressure
- Yield pressure falls as hiatal hernia size grows
- What a hiatal hernia does to the barrier
- Esophageal peristalsis and its failure
- The cycle of reflux and failing peristalsis
- The crural diaphragm
- The stomach as a reservoir
Complications of reflux
Mucosal, respiratory, and metaplastic damage
- Three groups of complications
- How reflux complications are grouped
- Sphincter status and the complication seen
- Complications by sphincter status in 150 patients
- What it takes to injure the mucosa
- Acid and alkaline exposure across reflux complications
- Duodenogastroesophageal reflux
- Gastric versus mixed reflux in 53 patients
- Esophageal pH during bilirubin exposure
- Bilirubin exposure across degrees of mucosal injury
- Why symptoms and endoscopy disagree
- 100%
- Limits of acid suppression
- Stricture and esophageal shortening
- 50%
- Reflux and the airway
- Finding silent reflux behind lung symptoms
- Interpreting dual-probe pH monitoring
- Treating reflux-related respiratory disease
- Surgery for asthma with reflux: the randomised trial
- Barrett's esophagus: what it is
- Endoscopic appearance of Barrett's esophagus
- Microscopic appearance of Barrett's esophagus
- From metaplasia to cancer
- Four categories of Barrett's esophagus
- Cardia intestinal metaplasia
- Risk factors for developing Barrett's esophagus
- How Barrett's metaplasia develops
- Sequence of Barrett's metaplasia
- Screening for Barrett's esophagus
- Surveillance endoscopy
- Surveillance intervals in practice
- High-grade dysplasia as the threshold to treat
- Esophagectomy or endoscopic treatment for high-grade dysplasia
- Risk factors when choosing endoscopic treatment of esophageal neoplasia
- Histology and invasion as risk factors
- Radiofrequency ablation: the sham-controlled trial
- Balloon-based radiofrequency ablation catheter
- Scope-mounted radiofrequency ablation device
Assessment before surgery
What each test answers, and its limits
- Purpose of objective esophageal testing
- Barium esophagram
- Upper endoscopy
- Los Angeles classification of esophagitis
- Recognising Barrett's at endoscopy
- Prague C and M classification
- Prague C and M measurement of Barrett's extent
- Hill classification of the gastroesophageal flap valve
- Flap valve grades I and II
- Flap valve grades III and IV
- Endoscopic diagnosis of hiatal hernia
- Ambulatory pH monitoring
- Limitations of catheter pH studies
- The wireless pH capsule
- The DeMeester score
- What the six components measure
- Normal values for esophageal acid exposure
- Impedance-pH monitoring: the principle
- Impedance catheter and the shape of a swallowed bolus
- Impedance tracing of a reflux episode
- What impedance adds, and where it stops
- Esophageal manometry: three reasons to do it
- High-resolution manometry
- Manometric patterns: normal, achalasia and a nonrelaxing wrap
- Manometric patterns: hiatal hernia and nutcracker esophagus
- Manometric definitions
- Gastric emptying study
- When delayed emptying changes the operation
Antireflux surgery
Selection, principles, technique and results
- Evolution of antireflux surgery
- How the operation evolved
- Medical therapy comes first
- Who should be offered antireflux surgery
- Patients with esophageal stricture
- Patients with Barrett's esophagus
- Patients with airway symptoms
- Goal of the operation
- Principles that protect swallowing
- Checking the new valve from inside
- Endoscopic appearance of Nissen and Dor valves
- Endoscopic appearance of the Toupet valve
- Choosing between a complete and a partial wrap
- Key points of laparoscopic Nissen fundoplication
- Patient position and port placement
- Positioning and ports
- Opening the hiatus
- Sequence of the hiatal dissection
- Dividing the attachments at the angle of His
- Dissection of the phrenoesophageal ligament
- Identifying the anterior vagus nerve
- Opening the posterior esophageal window
- Division of the short gastric vessels
- Division of the posterior gastric vessels
- Creating a large retroesophageal space
- Why the fundus must be fully mobilised
- Mediastinal dissection
- Tension-free intraabdominal esophagus achieved
- Protecting the vagal trunks and the pleura
- Approximation of the diaphragmatic crura
- Closing the crura
- Building the wrap
- Shoeshine manoeuvre
- Completed fundoplication
- Finishing the operation and the partial wraps
- Dor fundoplication
- Toupet fundoplication
- Side effects after antireflux surgery
- Long-term results of laparoscopic fundoplication
- Open versus laparoscopic at eleven years
- Quality of life after surgery
- How often antireflux repairs fail
- Working up the failed repair
- Four patterns of failure after primary repair
- Transhiatal herniation of a repair
- Options at reoperation
Hiatal hernia and paraesophageal hernia
Four types, short esophagus, repair and results
- Milestones in hiatal hernia surgery
- How hiatal hernia surgery developed
- Type I: the sliding hiatal hernia
- Type II and type III
- Type IV
- The four types of hiatal hernia
- Symptoms of a paraesophageal hernia
- Who develops these hernias
- Short esophagus
- Preoperative assessment of a paraesophageal hernia
- Contrast study in paraesophageal hernia
- Endoscopy, manometry and emptying studies
- Goals of paraesophageal hernia repair
- The four tenets of the repair
- Transthoracic repair
- Laparoscopic repair: reducing the sac
- Laparoscopic repair: finishing
- Beginning the hernia sac dissection
- Medialising the gastroesophageal fat pad
- Assessing intraabdominal esophageal length
- Wedge gastroplasty
- Neoesophagus with fundoplication
- Mesh at the hiatus
- Results of transthoracic repair
- Laparoscopic repair: the early experience
- Laparoscopic repair today
- Conclusions on paraesophageal hernia repair
- Key points: the disease and its barrier
- Key points: assessment and treatment
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- Maingot's Abdominal Operations, 12th Edition