GIT

Forth stage

surgery
Lec-7
د.سمير الصفار

8/11/2015

Gastro-oesophageal reflux disease

Pathophysiology

Competence of the gastro-oesophageal junction is dependent into:
Physiology of LOS;
Basal tone, length, intra-abdominal length
Anatomy of the cardia
Diaphragmatic hiatus-Sliding hiatus hernia

Gastro-oesophageal reflux

Physiological reflux After meals
Physiological reflux occurs during transient lower oesophageal sphincter relaxations (TLOSRs)
Pathological reflux


Gastro-oesophageal reflux disease
Is by far the commonest condition affecting the upper GI tract.
Its incidence increased during the last years;
*Improvement of socioeconomic conditions ↓ H.pylori ↓ DU
Obesity

GORD

Reflux oesophagitis
is a complication of GORD that occur in a minority of sufferers

Clinical features

Retrosternal burning pain( heartburn)
Epigastric pain
These are usually provoked by food, particularly fatty food.
Unpleasant acidic taste
In advanced cases there is a history of pain and reflux when lying flat or on stooping.
Odynophagia
Less typical symptoms;
Angina-like chest pain
Pulmonary or laryngeal symptoms
Dysphagia


Diagnosis of GORD
In the majority of cases the dx is assumed rather than proven and treatment is empirical
Endoscopy;
To exclude: serious pathology
Reflux oesophagitis
Peptic stricture
Barrett’s oesophagus
Oesophageal manometery
24-hours oesophageal pH recording
Is the gold standard for the dx of GORD
Barium swallow and meal;
Gives the best appreciation of G-O anatomy but it is not important for the dx of GORD

Differential Dx

Achalasia and GORD are easily confused

Management of uncomplicated GORD

Non-operative management
Medical management
Simple medications; like
Antacids, H2 receptor antagonists
Simple measures; like
Advice about wt. loss, smoking, excessive consumption of alcohol, tea or coffee, and a modest degree of head up tilt of the bed
Proton pump inhibitors;
Omeprozole, Lansoprazole and pantoprazole are by far the most effective drug treatment for GORD


Operative management
Surgery
Indications:
In uncomplicated GORD-
Failure of medical therapy..PPI
Patient choice

Disadvantages of surgery:

Mortality (0.1-0.5%)
Failed operation (5-10%)
3-Side effects; dysphagia, gas bloat(5-10%)

What operation

There are many antireflux operations for GORD;
Total fundoplication …Nissen 360
Disadvantage of Nissen:
Over competent cardia….Dysphagia, gas bloat syndrome
Partial fundoplication …Belsy 240
Disadvantage; high recurrence rate….Hill operation

Other antireflux procedures

Angelchik prosthesis
Silastic prosthetic collar
Partial gastrectomy with Roux-en Y reconstruction


What operative approach
Abdominal
Thoracic
Minimal access surgery…Laparoscopic approach

Laparoscopic Fundoplication