Managing Failed Anti-Reflux Therapy (eBook)

Preface 6
Contents 8
Contributors 10
1 The Epidemiology and Pathophysiology of Gastroesophageal Reflux Disease --- Peter J. Kahrilas and John E. Pandolfino 12
GERD Pathophysiology 13
Functional Constituents of the EGJ 13
Mechanisms of EGJ Incompetence in GERD 16
Transient LES Relaxations 16
LES (Intrinsic Sphincter) Hypotension 17
The Diaphragmatic Sphincter and Hiatus Hernia 18
Gastroesophageal Flap Valve 18
Mechanical Properties of the Relaxed EGJ 18
Esophageal Acid Clearance 20
Impairments of Esophageal Emptying 21
Salivary Function 21
Summary 22
References 22
2 History of Medical and Surgical Anti-Reflux Therapy --- Mark K. Ferguson 26
Early Nonsurgical Therapy 27
Esophageal Dilation 27
Esophageal Stents 28
Palliative Surgical Therapy 29
Early Surgical Therapy 30
Physiologic Surgical Therapy 31
Pharmacologic Therapy 34
Endoscopic Therapy 35
References 36
3 Medical Management of GERD: Algorithms and Outcomes --- David A. Johnson 42
Background 42
Lifestyle/Diet Modifications 43
Antacids 43
Promotility Agents 44
H2-Receptor Antagonists 45
Proton Pump Inhibitors 45
Nocturnal Acid Breakthrough (PPI Plus H2RA) 46
Maintenance of Remission 46
Barrett’s Esophagus 46
Extraesophageal GERD 47
Measuring Esophageal pH As an Outcome of Anti-Reflux Therapy 48
Measuring Esophageal Motility and LESP As an Outcome of Anti-Reflux Therapy 49
Endoscopic Assessment Endpoints As an Outcome of Anti-Reflux Therapy 49
Symptom Assessment As an Outcome of Anti-Reflux Therapy 50
Quality-of-Life Assessment As an Outcome of Anti-Reflux Therapy 51
Medication Use As an Outcome of Anti-Reflux Therapy 51
Conclusions 52
References 52
4 Complications of GERD: Esophagitis, Stricture, Barrett’s, and Cancer --- John A. Bonino and Prateek Sharma 56
Erosive Esophagitis 56
Prevalence 56
Pathogenesis and Risk Factors 57
Symptoms 58
Treatment 58
Esophageal (Peptic) Stricture 59
Pathogenesis and Prevalence 59
Risk Factors 59
Symptoms 59
Treatment 59
Barrett’s Esophagus 60
Prevalence 60
Pathogenesis and Risk Factors 60
Symptoms 61
Surveillance 61
Medical Therapy 62
Anti-reflux Surgery 62
Endoscopic Therapy 62
Esophageal Adenocarcinoma 63
Incidence 63
Pathogenesis 63
Risk Factors 63
Symptoms 64
Treatment 64
Summary 64
References 65
5 Principles of Successful Surgical Anti-Reflux Procedures --- Federico Cuenca-Abente, Brant K. Oelschlager, and Carlos A. Pellegrini 68
Indications 68
Averse to Lifestyle Changes 68
Poor Response to Proton Pump Inhibitors 68
Patients with Airway Manifestations of GERD 69
Patients with Barrett’s Esophagus 69
Contraindications 69
Morbid Obesity 69
Severe Comorbidities 69
Preoperative Evaluation 69
Flexible Endoscopy (EGD) 69
Manometry 70
Twenty-four-hour pH Esophageal Monitoring 70
Upper Gastrointestinal Series 70
Twenty-four-hour Esophageal and Pharyngeal pH Monitoring 70
Laryngoscopy 70
Impedance 70
Surgical Technique—Nissen Fundoplication 71
Basic Tenants of Anti-Reflux Procedures 71
Relative Advantages of Different Fundoplications 71
Perioperative Considerations 72
Creation of Pneumoperitoneum and Port Placement 72
Dissection of the Cardia (“Left Crus Approach”) 73
Division of the Short Gastric Vessels 73
Esophageal Mobilization 73
Hiatal Closure 74
Construction of the Wrap 74
Anchoring the Fundoplication 74
Conclusio 75
References 75
6 Acute Complications of Anti-Reflux Surgery --- Gianmattia del Genio and Jean-Marie Collard 78
Intraoperative Complications 79
Vascular Injury 79
Esophageal and Gastric Tear 80
Vagal Nerve Injury 81
Pneumomediastinum and Pneumothorax 81
Acute Postoperative Complications 82
Gastric and Esophageal Fistula 82
Bleeding 83
Herniation of the Wrap into the Chest 84
Acute Dysphagia 85
Summary 86
References 86
7 Persistent Symptoms after Anti-Reflux Surgery and their Management --- John G. Hunter and M. Brian Fennerty 90
Introduction 90
Evaluation of Patients with New or Recurrent Symptoms of GERD 90
Early Postoperative Symptoms 90
Recurrent GERD Symptoms 91
Persistent Postoperative Dysphagia 93
Anatomic Failure of Nissen Fundoplication 95
Fundoplication Herniation 95
Slipped Nissen Fundoplication 95
Disrupted Fundoplication, Twisted Fundoplication, and the Twocompartment Stomach 96
Bloating, Nausea, and Epigastric Pain 96
Reoperation for Fundoplication Failure 98
Exposure for Reoperative Laparoscopic Fundoplication 98
Conclusion 99
References 99
8 Technical Surgical Failures: Presentation, Etiology, and Evaluation --- Carrie A. Sims and David W. Rattner 102
Presenting Symptoms of Failed Anti-Reflux Operations 102
Methods of Evaluation 103
Potential Causes of Failure 105
Treatment Options 107
What Is the Best Surgical Approach to a Reoperation? 108
Choosing a Partial or a Total Fundoplication 109
Considerations for Esophageal Lengthening Procedures 109
Management of the Difficult Hiatus 110
Technical Tips for Laparoscopic Reoperations 111
Conclusion 112
References 112
9 Symptoms after Anti-Reflux Surgery: Everything is not always caused by Surgery --- Kenneth R. DeVault 114
Dysphagia 114
Gas Bloat and Upper Abdominal Discomfort 115
Flatulence, Diarrhea, and Irritable Bowel Syndrome 117
Recurrent Heartburn 118
Recurrent “Atypical” Symptoms 119
Summary 120
References 120
10 The Medical and Endoscopic Management of Failed Surgical Anti-Reflux Procedures --- M. Brian Fennerty and John G. Hunter 124
Magnitude of the Problem 124
Documentation of Recurrent Reflux after Surgical Anti-Reflux Therapy 124
Endoscopic Assessment of a Prior Surgical Anti-Reflux Procedure 126
Ambulatory Esophageal pH Monitoring in Patients with Prior Anti-Reflux Procedures 128
Other Tests of Gastrointestinal Physiology and Function 129
Endoscopic and Pharmacological Therapy after Failed Anti-Reflux Surgery 129
Endoscopic Anti-Reflux Procedures in General 129
Food and Drug Administration Status of Endoscopic Anti-Reflux Procedures 130
Reimbursement Status of Endoscopic Anti-Reflux Procedures 130
Short- and Long-term Outcomes of Endoscopic Anti-Reflux Procedures 130
Use of Endoscopic Anti-Reflux Procedures in This Clinical Situation 131
Pharmacological Therapy for Failed Anti-Reflux Surgery 132
Use in This Clinical Situation 133
Conclusions 134
References 134
11 Reoperation for Failed Anti-Reflux Surgery --- Jennefer A. Kieran and Myriam J. Curet 138
Preoperative Evaluation 138
Operative Techniques 139
Open Laparotomy for Reoperative Fundoplication 139
Laparoscopic Revision of Fundoplication 141
Comparison of Open Versus Laparoscopic Refundoplication 144
Laparoscopic Gastric Bypass for Recurrent Reflux 145
Thoracotomy 146
Postoperative Management 147
Summary 147
References 147
12 Management of Alkaline Reflux --- Jose M. Clavero, Philippe Topart, and Claude Deschamps 150
Pathogenesis 150
Diagnosis 151
Endoscopy 151
Scintigraphy 151
Aspiration Studies 151
Twenty-four-hour pH Monitoring 152
Bilirubin Monitoring 153
Treatment 153
Bile Diversion Operations 153
Total Duodenal Diversion 153
Duodenal Switch 155
Biliary Diversion 156
Technical Aspects 156
Long-limb Roux-Y Jejunal Reconstruction after Total or Proximal Gastrectomy 156
Conclusion 158
References 158
13 Management of the Short Esophagus --- Éric Fréchette and André Duranceau 162
Evolution of Hiatal Hernia and Anti-Reflux Surgery 162
Definition 163
Etiology 163
nvestigation 164
Radiology 164
Endoscopy and Esophageal Biopsies 165
Motility Studies 165
Monitoring Acid and Bile Reflux 166
Medical Management 166
Surgical Treatment 166
Standard Anti-Reflux Repairs 166
Lengthening Gastroplasties 167
Stricturoplasty and Intrathoracic Fundoplication 170
Vagotomy, Antrectomy, and Roux-en-Y Diversion 171
Treatment of the Short Esophagus by Minimally Invasive Surgery 171
Conclusion 171
References 172
14 Esophagectomy: Indications, Techniques, and Outcomes --- Mark K. Ferguson 174
History 174
Indications 175
Peptic Stricture 175
Gastrointestinal Bleeding 175
Multiple Failed Anti-Reflux Operations 176
Complications of Barrett’s Esophagus 176
Techniques 176
Patient Preparation 176
Approach 177
Extent of Resection 178
Procedure 179
Outcomes 182
Conclusions 183
References 183
15 Vagal Sparing Esophagectomy --- Steven R. DeMeester 186
Evaluation 187
Indications for Vagal-sparing Esophagectomy 187
Surgical Approach 188
Results 189
Summary 191
References 191
16 Future Directions of Therapy for GERD --- M. Brian Fennerty and Mark K. Ferguson 192
Physiologic Evaluation of Suspected GERD 192
Medical Therapy for GERD 192
Endoscopic Anti-Reflux Procedures 193
Newer Indications for Surgical Therapy 193
Centers of Surgical Excellence 194
Evaluation of the Failed Anti-Reflux Procedure 194
Endoscopic and Pharmacologic Therapy after a Failed Anti-Reflux Surgery 195
References 196
Index 198