Benign oesophageal disease. 10-30% of patients with suspected angina don't have coronary disease....

Benign Benign oesophageal oesophageal

diseasedisease

10-30% of patients with 10-30% of patients with suspected angina don't suspected angina don't have coronary disease.have coronary disease.

From these 50% will have From these 50% will have oesophageal disordersoesophageal disorders..

AnatomyAnatomy- Muscular tube - Conduit from - Muscular tube - Conduit from the pharynx to the stomachthe pharynx to the stomach

- C6 (Cricoid cartilage) to below - C6 (Cricoid cartilage) to below the diaphragmthe diaphragm

- From the incisor 40-45 cm - From the incisor 40-45 cm (actual 20-25cm)(actual 20-25cm)

- Passes behind aortic arch and - Passes behind aortic arch and left main bronchus.left main bronchus.

- Enters abdomen through - Enters abdomen through oesophageal hiatus → 2-4 cm oesophageal hiatus → 2-4 cm below the diaphragmbelow the diaphragm

AnatomyAnatomy

- Held in position by:- Held in position by:. . Reflection of the peritoneum Reflection of the peritoneum onto the stomachonto the stomach

. Phreno-oesophageal ligament . Phreno-oesophageal ligament to the oesophagus .to the oesophagus .

AnatomyAnatomyThree area of narrowingThree area of narrowing

- Cricopharangeus- Cricopharangeus- Behind the aortic arch- Behind the aortic arch- LOS (thickening of the - LOS (thickening of the

circular circular muscles ~ muscles ~ 4cm)4cm)

The muscles upper 1/3 of The muscles upper 1/3 of oesophagus is striated, oesophagus is striated, remainder is smooth muscle remainder is smooth muscle peristalsis wave 4-6cm/s (reflex peristalsis wave 4-6cm/s (reflex regulated in the medulla)regulated in the medulla)

Arterial supply:Arterial supply:Upper → inferior thyroid artery Upper → inferior thyroid artery Middle → Bronchial arteries and Middle → Bronchial arteries and oesophageal branches directly oesophageal branches directly from aortafrom aorta

Lower → L inferior phrenic and Lower → L inferior phrenic and gastricgastricVenous drainage:Venous drainage:

Upper → oesophageal venous Upper → oesophageal venous plexus to azygos veinplexus to azygos vein

Lower → oesophageal branches Lower → oesophageal branches of the coronary vein, a tributary of the coronary vein, a tributary of the portal veinof the portal vein

Histology:Histology:- Stratified columnar epithelium - Stratified columnar epithelium with scattered mucus glandswith scattered mucus glands

- No serosa hence does not heal - No serosa hence does not heal as well as the rest of GIT as well as the rest of GIT

- Lower Oesophageal Sphincter - Lower Oesophageal Sphincter (LOS)(LOS)

Contraction: α-adrenergic & Contraction: α-adrenergic & cholinergic cholinergic Gastrin Gastrin

Relax:Relax: β-adrenergic,VIP β-adrenergic,VIP and NO and NO

CCK & glucagonCCK & glucagon

Symptoms:Symptoms:- Dysphagia: difficulty - Dysphagia: difficulty swallowingswallowing

- Odynophagia: pain on or - Odynophagia: pain on or painful swallowingpainful swallowing

- Globus: lump in the throat- Globus: lump in the throat- Heart burn: - Heart burn: Stomach/Substernal burning Stomach/Substernal burning sensation radiating up to the sensation radiating up to the neck and relieved acutely (but neck and relieved acutely (but transiently) by antacidstransiently) by antacids

Oesophageal Motility Oesophageal Motility DisordersDisorders(1)(1)

(i) Achalasia(i) Achalasia

(ii) Others(ii) OthersDiffuse oesophageal Diffuse oesophageal

SpasmSpasmNutcracker Nutcracker

OesophagusOesophagusHypertensive LOSHypertensive LOSScleroderma & other Scleroderma & other

collagen-collagen- vascular vascular disorders (eg CREST)disorders (eg CREST)

Diffuse oesophageal Diffuse oesophageal SpasmSpasm- 3-5% of motility disorders- 3-5% of motility disorders- Normal peristalsis + - Normal peristalsis + Spontaneous contraction Spontaneous contraction ++ increase in LOS pressureincrease in LOS pressure

- Aetiology is unknown, ? defect - Aetiology is unknown, ? defect in neural inhibition normally in neural inhibition normally mediated by NOmediated by NO

- Hypersensitive oesophagus- Hypersensitive oesophagus- Dx on Manometry- Dx on Manometry- Endoscopy is unremarkable & - Endoscopy is unremarkable & Ba Swallow is N or disorganised Ba Swallow is N or disorganised (Corckscrew)(Corckscrew)

Diffuse oesophageal Diffuse oesophageal SpasmSpasm

Nutcracker Nutcracker OesophagusOesophagus- High amplitude peristaltic - High amplitude peristaltic waves (>180mmHg) prolonged waves (>180mmHg) prolonged (>6s) (>6s)

- Endoscopy unremarkable but - Endoscopy unremarkable but Endo US shows thickening of Endo US shows thickening of muscularis propriamuscularis propria

- Higher incidence of psychiatric - Higher incidence of psychiatric disorders disorders

Hypertensive LOSHypertensive LOS- Elevated LOS pressure - Elevated LOS pressure (>45mmHg) with normal (>45mmHg) with normal peristalsisperistalsis

- LOS relaxation is normal- LOS relaxation is normal

TreatmentTreatment- Medical Rx effective in 80%- Medical Rx effective in 80%- Agents acting on Smooth - Agents acting on Smooth Muscle (eg Nitrates, Ca channel Muscle (eg Nitrates, Ca channel blockers),blockers),

- Psychoactive agents (eg - Psychoactive agents (eg Benzodiazepines, Tricyclics) (?Benzodiazepines, Tricyclics) (?more effective) more effective)

- Botox injection- Botox injection- Surgical Rx, reserved for Px with - Surgical Rx, reserved for Px with dysphagia and poor oesophageal dysphagia and poor oesophageal emptyingemptying

Myotomy (Lap / Myotomy (Lap / Thoracoscopic)Thoracoscopic)

Ineffective motilityIneffective motility

- Scleroderma (80% of Px), other - Scleroderma (80% of Px), other Collagen Vascular disorders Collagen Vascular disorders (SLE, RA, MCTD), Amyloidosis, (SLE, RA, MCTD), Amyloidosis, Alcoholism, MS, myxoedema etcAlcoholism, MS, myxoedema etc

- Affect the myenteric plexus + - Affect the myenteric plexus + fibrosis and vascular fibrosis and vascular obliteration (Predominantly obliteration (Predominantly distal SM)distal SM)

- ↓ or absent peristalsis and LOS - ↓ or absent peristalsis and LOS pressurepressure

AchalasiaAchalasia- Uncommon (0.5-1 in 100,000), - Uncommon (0.5-1 in 100,000), M=F, 20-50sM=F, 20-50s

- Ineffective relaxation of the LOS - Ineffective relaxation of the LOS combined with loss of combined with loss of oesophageal peristalsis → oesophageal peristalsis → impaired oesophageal emptying impaired oesophageal emptying and gradual dilatationand gradual dilatation

- ↓ or loss of inhibitory myenteric - ↓ or loss of inhibitory myenteric ganglion cells & progressive ganglion cells & progressive neural fibrosis neural fibrosis

- Also decreased production of - Also decreased production of NO & VIP NO & VIP

- Slight increase risk of SCC - Slight increase risk of SCC

Achalasia - Achalasia - PresentationPresentation

- Dysphagia - delayed and - Dysphagia - delayed and progressive presentation (mean progressive presentation (mean 2 years)2 years)

- Stress or cold fluid exacerbates - Stress or cold fluid exacerbates symptomssymptoms

- Spontaneous or forced - Spontaneous or forced regurgitation of undigested food regurgitation of undigested food

- 10% will have pulmonary - 10% will have pulmonary complicationcomplication

- Can have heartburn (not GORD)- Can have heartburn (not GORD)

- Chest pain (≠ heartburn) - 30-- Chest pain (≠ heartburn) - 30-50% resolves with Myotomy50% resolves with Myotomy

Achalasia - Achalasia - DiagnosisDiagnosis- Air fluid levels on plain Xray- Air fluid levels on plain Xray- Ba swallow: dilated oesophagus - Ba swallow: dilated oesophagus with Bird's beak taperingwith Bird's beak tapering

- Manometry is gold standard- Manometry is gold standard. Resting LOS pressure is . Resting LOS pressure is

usually usually normal (may be normal (may be elevated)elevated)

. Complete absence of . Complete absence of peristalsisperistalsis

- Endoscopy: dilated oesophagus - Endoscopy: dilated oesophagus with tightly closed LOS with tightly closed LOS gentle gentle pressure will admit the scope pressure will admit the scope with a "pop“.with a "pop“.

Achalasia - Achalasia - DiagnosisDiagnosis

Achalasia - Achalasia - TreatmentTreatment- Palliation of dysphagia - Palliation of dysphagia → → relieve functional obstruction relieve functional obstruction of distal oesophagus of distal oesophagus (neuromuscular defect is not (neuromuscular defect is not corrected)corrected)o Medical (Nitrates and Ca Medical (Nitrates and Ca channel blockers)channel blockers)

. Poorly absorbed, . Poorly absorbed, inconsistent and inconsistent and short lived short lived effect effect

. SE.. SE.

Achalasia - Achalasia - TreatmentTreatment- Botox injection: - Botox injection: bind to bind to cholinergic nerves and cholinergic nerves and irreversibly inhibit Acetyl irreversibly inhibit Acetyl Choline release Choline release

- 60-85% of patient get relief but - 60-85% of patient get relief but 50% get recurrent symptoms 50% get recurrent symptoms within 6 months.within 6 months.

- Efficacy decreased with - Efficacy decreased with repeated injectionrepeated injection

- Expensive- Expensive- Cause intense inflammatory - Cause intense inflammatory reaction which will make reaction which will make subsequent surgery more subsequent surgery more difficult and increase risk of difficult and increase risk of perforation.perforation.

Achalasia - Achalasia - TreatmentTreatment- - Graded pneumatic dilatation Graded pneumatic dilatation (under fluoroscopy)(under fluoroscopy)

Tears the muscle Tears the muscle (myotomy)(myotomy)

30mm for 1-3min (day 30mm for 1-3min (day procedure)procedure)

Can have repeated Can have repeated dilatation dilatation

60-90% success rate 60-90% success rate Efficacy is decreased Efficacy is decreased

after second after second dilatation dilatation perforation rate ~ 2%perforation rate ~ 2%

Achalasia – Surgical Achalasia – Surgical ttreatmentreatment- - Originally performed by Ernest Originally performed by Ernest Heller in 1914 for AchalasiaHeller in 1914 for Achalasia

Two myotomies: anterior Two myotomies: anterior and posterior and posterior

- Modified Heller: anterior only- Modified Heller: anterior only- Excellent results in 90-95%- Excellent results in 90-95%- Traditionally trans-thoracic or - Traditionally trans-thoracic or trans-abdominaltrans-abdominal

- Now minimally invasive - Now minimally invasive Laparoscopic / ThoracoscopicLaparoscopic / Thoracoscopic

Achalasia – Surgical Achalasia – Surgical ttreatmentreatment- Controversies- Controversies

Length of myotomyLength of myotomy

Proximal 5-7 cm above GOJ Proximal 5-7 cm above GOJ

? evidence? evidence(1)(1) longer gastric longer gastric myotomies myotomies (>3cm) better relief (>3cm) better relief from dysphagiafrom dysphagia

Need for antireflux Need for antireflux procedure as wellprocedure as well

Benign oesophageal Benign oesophageal tumourstumours- From any layer- From any layer

- Mucosal: - Mucosal: . Papillomas (sessile . Papillomas (sessile or or pedunculated) pedunculated)

- Intramural:- Intramural: . Leiomyoma, . Leiomyoma, Fibroma Fibroma LipomaLipoma

. Congenital cysts or . Congenital cysts or

reduplication (lower)reduplication (lower)

Benign oesophageal Benign oesophageal tumourstumours- Asymptomatic or may be large - Asymptomatic or may be large enough to encroach the lumenenough to encroach the lumen

- Peristalsis is normal with - Peristalsis is normal with Leiomyoma, but spasm with Leiomyoma, but spasm with cysts and reduplicationcysts and reduplication

- Intraluminal lesions Dx on - Intraluminal lesions Dx on Endoscopy (should Bx)Endoscopy (should Bx)

- Intramural lesions Dx - Intramural lesions Dx Radiologically (smoothly Radiologically (smoothly rounded) should not be Bx rounded) should not be Bx

Gastro-oesophageal reflux Gastro-oesophageal reflux diseasedisease- - Reflux of gastric content is Reflux of gastric content is normalnormal

- GORD is when affects patient’s - GORD is when affects patient’s well beingwell being

. Symptoms. Symptoms

. Physical complications. Physical complications- Common - (difficult to assess - - Common - (difficult to assess - Px self treat)Px self treat)

- 75% of oesophageal disease in - 75% of oesophageal disease in clinical practiceclinical practice

In the USIn the US(2)(2)40% monthly40% monthly14% weekly (15-20% 14% weekly (15-20%

Australia)Australia)7% daily7% daily

Gastro-oesophageal reflux Gastro-oesophageal reflux diseasediseasePathogenesis:Pathogenesis:- Excessive exposure and- Excessive exposure and reduced reduced clearanceclearance of gastric content of gastric content

- Competent LOS - Competent LOS Resting pressure >6mmHg Resting pressure >6mmHg Abdominal location of LOS Abdominal location of LOS

(>1cm) (>1cm) (diaphragmatic (diaphragmatic crura and intra crura and intra abdominal abdominal pressure)pressure)

Total length >2 cmTotal length >2 cm- Recurrent / prolonged - Recurrent / prolonged relaxationrelaxation

Gastro-oesophageal reflux Gastro-oesophageal reflux diseasedisease- Normal gastric emptying - Normal gastric emptying - Adequate oesophageal clearance- Adequate oesophageal clearance- Contributing Factors:- Contributing Factors:

Familial, Obesity, Diet (Fat, Familial, Obesity, Diet (Fat, Chocolate, Chocolate, Caffeine), Smoking, Caffeine), Smoking, Drugs Drugs

- Hiatus hernia 85% of Px with - Hiatus hernia 85% of Px with reflux have a sliding herniareflux have a sliding hernia

But most people with a sliding But most people with a sliding hernia don’t have disabling hernia don’t have disabling symptomssymptoms

Gastro-oesophageal reflux Gastro-oesophageal reflux diseasediseaseSymptomsSymptomsMild / SevereMild / Severe- Heartburn (also in PUD and 40% - Heartburn (also in PUD and 40% IBS Px)IBS Px)

- Regurgitation of previously - Regurgitation of previously ingested foodingested food

- Waterwash (saliva production)- Waterwash (saliva production)- Dysphagia (defective - Dysphagia (defective peristalsis / stricture)peristalsis / stricture)

- Odynophagia (severe - Odynophagia (severe oesophagitis)oesophagitis)

- Haematemesis- Haematemesis

Gastro-oesophageal reflux Gastro-oesophageal reflux diseasediseaseComplicationComplication

Oesophageal: Oesophageal: OesophagitisOesophagitis

Barrett’s (10%)Barrett’s (10%)

StricturesStrictures

AdenocarcinomaAdenocarcinoma

50% of Px with GORD get 50% of Px with GORD get complications complications

Gastro-oesophageal reflux Gastro-oesophageal reflux diseasediseaseComplicationComplicationExtra-oesophageal:Extra-oesophageal: LaryngitisLaryngitis

PharyngitisPharyngitisSinusitisSinusitisPulmonaryPulmonaryAdult onset Adult onset

asthmaasthmaNB NB Poor correlation between Poor correlation between frequency and frequency and severity of severity of symptoms and prevalence of symptoms and prevalence of complicationcomplication

Gastro-oesophageal reflux Gastro-oesophageal reflux diseasediseaseGESA recommendation for Mx:GESA recommendation for Mx:Mild symptomsMild symptoms

- Antacids /over the counter H- Antacids /over the counter H22 antagonistsantagonists- Lifestyle changes:- Lifestyle changes:

Diet (Fatty, Spicy, Coffee, Diet (Fatty, Spicy, Coffee, Acidic)Acidic)

ETOH (moderation OK)ETOH (moderation OK)SmokingSmokingLate/large meals & early Late/large meals & early

recumbencyrecumbencyDrugsDrugsTight clothesTight clothes

Gastro-oesophageal reflux Gastro-oesophageal reflux diseasediseaseGESA recommendation for Mx:GESA recommendation for Mx:Moderate to severe symptoms Moderate to severe symptoms - First line Rx: 2-4/52 of - First line Rx: 2-4/52 of double dose PPI double dose PPI (Superior to (Superior to endoscopy for Dx)endoscopy for Dx) - Symptomatic control - Symptomatic control equates to equates to endoscopic healing endoscopic healing (even LA Grade (even LA Grade C&D)C&D)

Gastro-oesophageal reflux Gastro-oesophageal reflux diseasediseaseGESA recommendation for MxGESA recommendation for Mx- - Further Ix if:Further Ix if:

Unclear DxUnclear DxSymptoms persist/progress Symptoms persist/progress

on Rxon RxComplicated SymptomsComplicated SymptomsSuggestion of other Suggestion of other

pathology (Ca, pathology (Ca, PUD, PUD, infective/drug induced infective/drug induced oesphagitis)oesphagitis)

Gastro-oesophageal reflux Gastro-oesophageal reflux diseasediseaseGESA recommendation for MxGESA recommendation for Mx- - Further Ix:Further Ix:EndoscopyEndoscopy

Negative in >50% of Px with Negative in >50% of Px with GORD GORD

Ideal for: Ideal for: - Dx and grading of - Dx and grading of

oesophagitisoesophagitis- Other mucosal lesions- Other mucosal lesions- Dx and Rx strictures- Dx and Rx strictures- Dx of Barrett’s- Dx of Barrett’s

Gastro-oesophageal reflux Gastro-oesophageal reflux diseasediseaseGESA recommendation for MxGESA recommendation for Mx- - Further Ix:Further Ix: 24/24 ambulatory oesophageal 24/24 ambulatory oesophageal pH monitoringpH monitoring

pH <4 for >1 ½ hourspH <4 for >1 ½ hours

Gastro-oesophageal reflux Gastro-oesophageal reflux diseasediseaseGESA recommendation for MxGESA recommendation for MxTrial of withdrawal of therapyTrial of withdrawal of therapyMajority will have symptom Majority will have symptom relapserelapse

Repeat course of the Repeat course of the previous Rx previous Rx

Followed by on demand HFollowed by on demand H22 antagonistantagonist / PPI ± antacids/ PPI ± antacids→ → a small proportion will be a small proportion will be symptom freesymptom free→ → Majority continuous treatment Majority continuous treatment / Surgery/ Surgery

Gastro-oesophageal reflux Gastro-oesophageal reflux diseasedisease

Few topics of interestFew topics of interest- Barrett’s oesophagus- Barrett’s oesophagus

- Dysplasia- Dysplasia- H Pylori- H Pylori -Non-Acid-Non-Acid refluxreflux

Gastro-oesophageal reflux Gastro-oesophageal reflux diseasediseaseBarrett’sBarrett’s- - Transformation of Transformation of pseudostartified to columnar pseudostartified to columnar epitheliumepithelium

- If gastric or pancreatic (rarer) → If gastric or pancreatic (rarer) → no ↑ risk of AdenoCano ↑ risk of AdenoCa

- Specialised intestinal - Specialised intestinal metaplasia → ↑ risk of AdenoCa metaplasia → ↑ risk of AdenoCa (much less if length <3cm)(much less if length <3cm)

- Second yearly surveillance - Second yearly surveillance endoscopy with Bx (4 quadrant endoscopy with Bx (4 quadrant @ 2cm intervals) (GESA)@ 2cm intervals) (GESA)

Gastro-oesophageal reflux Gastro-oesophageal reflux diseasediseaseBarrett’sBarrett’s- - Once present → no evidence that Once present → no evidence that Acid suppression will reverse Acid suppression will reverse progression to dysplasiaprogression to dysplasia

- Recent study showed in Px with - Recent study showed in Px with Barrett’s there is ↓ progression Barrett’s there is ↓ progression after antireflux after antireflux surgerysurgery(3)(3)..

- Also increased evidence in the - Also increased evidence in the role if Bile salts in Barrett’srole if Bile salts in Barrett’s(4)(4)..

Gastro-oesophageal reflux Gastro-oesophageal reflux diseasediseaseNon-Acid refluxNon-Acid reflux(5)(5)

- Animal studies have shown: Acid - Animal studies have shown: Acid alone requires high alone requires high concentration to damage the concentration to damage the oesophageal mucosa oesophageal mucosa

- Oesophagitis has been observed - Oesophagitis has been observed in achlorhydric patientsin achlorhydric patients

- Duodenogastro-oesophageal - Duodenogastro-oesophageal reflux (DGOR) is the reflux of reflux (DGOR) is the reflux of duodenal content (bile acids and duodenal content (bile acids and pancreatic secretions) into the pancreatic secretions) into the stomach (normal – stomach (normal – postprandially and nocturnally) postprandially and nocturnally)


- Contains trypsin as well as bile - Contains trypsin as well as bile acids and can occurs at neutral acids and can occurs at neutral and acidic pH tooand acidic pH too

- Conjugated Bile salts @ low pH, - Conjugated Bile salts @ low pH, Unconjugated bile salts and Unconjugated bile salts and trypsin @ high pH → can damage trypsin @ high pH → can damage mucosa mucosa

- Clinical studies: There is - Clinical studies: There is evidence that mucosal damage evidence that mucosal damage increase with increased increase with increased exposure to the duodenogastro-exposure to the duodenogastro-oesophageal reflux.oesophageal reflux.


- Investigations- Investigations. . ScintigraphyScintigraphy (injection (injection

ofTc99m → @ ofTc99m → @ 5 min interval 5 min interval →→γγCamera for 60/60 → Camera for 60/60 → can can show duodenal refluxshow duodenal reflux

. . BilitecBilitec 2000 is 2000 is spectrophometry, spectrophometry, measure the measure the bilirubin concentration in bilirubin concentration in the the oesophagus. (can have oesophagus. (can have ambulatory ambulatory monitoring)monitoring)

Problem with very low Problem with very low pH, food & pH, food & mucosal folds mucosal folds


- Intraluminal impedance- Intraluminal impedance . It measures the opposition of . It measures the opposition of current current flow between 2 electrodes. flow between 2 electrodes. . Bolus movement in hollow . Bolus movement in hollow organs. organs. . Detects wall, air, saliva and . Detects wall, air, saliva and food all vary.food all vary. It is pH independent and can It is pH independent and can determinedetermine

the type and height of the the type and height of the refluxaterefluxate

Surgical Treatment of Surgical Treatment of GORDGORD- Surgery attempts to return the - Surgery attempts to return the gastroesophageal junction below gastroesophageal junction below the diaphragm and form a the diaphragm and form a barrier to reflux.barrier to reflux.

- NB acid suppression with PPI - NB acid suppression with PPI might not be enough to prevent might not be enough to prevent symptoms (impaired symptoms (impaired oesophageal clearance / non-oesophageal clearance / non-acid reflux). acid reflux).

- The cost of 10 year PPI - The cost of 10 year PPI treatment is ten times that of treatment is ten times that of laparoscopic Nissen, including laparoscopic Nissen, including preoperative evaluation and preoperative evaluation and postoperative carepostoperative care(7)(7)..

Surgical Treatment of Surgical Treatment of GORDGORDHill’s posterior gastropexyHill’s posterior gastropexy - Musculomucosal flap valve - Musculomucosal flap valve created by the angle of His created by the angle of His against the lesser curve - an against the lesser curve - an important barrier to reflux.important barrier to reflux.

- Anchoring the LOS within the - Anchoring the LOS within the abdomen and posteriorly fixing abdomen and posteriorly fixing it to the median arcuate it to the median arcuate ligament and accentuating the ligament and accentuating the angle of His.angle of His.

- Not popular → difficulty - Not popular → difficulty identifying the arcuate identifying the arcuate ligament.ligament.

Surgical Treatment of Surgical Treatment of GORDGORDHill’s posterior gastropexyHill’s posterior gastropexy

- Modified Hill’s uses the - Modified Hill’s uses the preaortic fascia and the preaortic fascia and the condensation of the crus as the condensation of the crus as the anchor for the repair.anchor for the repair.

- Good to excellent result, ? less - Good to excellent result, ? less side effect than fundoplication.side effect than fundoplication.

Surgical Treatment of Surgical Treatment of GORDGORDFundoplicationFundoplication

- Mobilise the lower oesophagus - Mobilise the lower oesophagus and wrap the fundus of the and wrap the fundus of the stomach around it either totally stomach around it either totally or partiallyor partially

Surgical Treatment of Surgical Treatment of GORDGORDTotalTotal FundoplicationFundoplication: : - Originally described by Nissen - Originally described by Nissen in 1956 in 1956

- 360° fundal wrap around the 360° fundal wrap around the distal oesophagus with division distal oesophagus with division of the short gastric vessels of the short gastric vessels (“floppy”). (“floppy”).

- Modified (Rosetti & others) → - Modified (Rosetti & others) → not dividing the short gastrics not dividing the short gastrics and using a lower part of the and using a lower part of the fundus/greater curve for the fundus/greater curve for the wrap (no evidence for wrap (no evidence for ↑dysphagia and some evidence ↑dysphagia and some evidence ↓ flatulence)↓ flatulence)(8)(8)

Surgical Treatment of Surgical Treatment of GORDGORDNissenNissen FundoplicationFundoplication: : - The fold should be - The fold should be approximately 2 cm – wider (too approximately 2 cm – wider (too generous) can cause dysphagia generous) can cause dysphagia

Surgical Treatment of Surgical Treatment of GORDGORDPartialPartial FundoplicationFundoplication(<360°)(<360°): : - Nissen cause an over competent - Nissen cause an over competent GOJ responsible for the post-op GOJ responsible for the post-op dysphagia and gas-bloat.dysphagia and gas-bloat.

- Belsey a 240° vertical - Belsey a 240° vertical fundoplication via a left fundoplication via a left thoracotomythoracotomy

- Toupet (posterior - Toupet (posterior fundoplication) fundoplication)

. Recent review. Recent review(8)(8) → no long- → no long-term term difference in reflux difference in reflux controlcontrol

. Less wind related S/E. Less wind related S/E

. ? Less short term . ? Less short term dysphagiadysphagia

Surgical Treatment of Surgical Treatment of GORDGORDAnterior fundoplication Anterior fundoplication . Flinders group – first . Flinders group – first prospective prospective randomised randomised study of Anterior vs Nissenstudy of Anterior vs Nissen

(180° anterior wrap (180° anterior wrap anchored to the right anchored to the right hiatal hiatal pillar and oesophagus)pillar and oesophagus)

Less dysphagia & FlatulenceLess dysphagia & FlatulenceTrade-off → less effective Trade-off → less effective

reflux controlreflux control

Surgical treatment Surgical treatment failure failure - Primary symptoms unchanged - Primary symptoms unchanged or worseor worse

- Minimal improvement in the - Minimal improvement in the Primary Primary

SymptomsSymptoms- New Symptoms (complication) - New Symptoms (complication) eg dysphagia, diarrhea, Gas-eg dysphagia, diarrhea, Gas-Bloat syndromeBloat syndrome

- Presence of oesophagitis or - Presence of oesophagitis or incorrect position of the incorrect position of the fundoplication on endoscopy → fundoplication on endoscopy → surgery not controlling GORDsurgery not controlling GORD

Surgical treatment Surgical treatment failure failure 1 - Dysphagia:1 - Dysphagia: ~50% of patients experience ~50% of patients experience dysphagia immed iately post-dysphagia immed iately post-op. (oedema & inflammation) → op. (oedema & inflammation) → resolves spontaneously in 2-resolves spontaneously in 2-3/123/12

3-25% persist beyond 3/12 and 3-25% persist beyond 3/12 and need Rxneed Rx

Surgical treatment Surgical treatment failure failure 1 - Dysphagia:1 - Dysphagia:

Causes: Causes: - Peptic Stricture (- Peptic Stricture (++

Recurrent Recurrent oesophagitis).oesophagitis).

- Wrap too tight of too long- Wrap too tight of too long- Achalasia (missed / new) - Achalasia (missed / new) - Slipped fundoplication- Slipped fundoplication- Paraoesophageal hernia - Paraoesophageal hernia

Surgical treatment Surgical treatment failure failure

1 - Dysphagia:1 - Dysphagia: - Slipped fundoplication- Slipped fundoplication

. Correctly fashioned but . Correctly fashioned but later a portion later a portion of the stomach of the stomach herniatesherniates

. Incorrectly mistaking the . Incorrectly mistaking the proximal proximal stomach for stomach for distal oesophagus → wrap distal oesophagus → wrap around the stomacharound the stomach


1 - Dysphagia:1 - Dysphagia: - - SlippedSlipped fundoplicationfundoplication


1 - Dysphagia:1 - Dysphagia: - - Using bodyUsing body instead ofinstead of fundusfundus

Surgical treatment Surgical treatment failure failure 1 - Dysphagia:1 - Dysphagia: - Paraoesophageal hernia is - Paraoesophageal hernia is usually from the fundoplication usually from the fundoplication itself, and may results from an itself, and may results from an attempt to construct a “floppy” attempt to construct a “floppy” wrap.wrap.

- Patient with ineffective - Patient with ineffective preoperative oesophageal preoperative oesophageal motility → Traditionally ? loose motility → Traditionally ? loose wrap / Toupet to avoid wrap / Toupet to avoid postoperative dysphagia postoperative dysphagia

- Recent study comparing the two - Recent study comparing the two found at 3/12 more dysphagia found at 3/12 more dysphagia and gas-bloat syndrome with and gas-bloat syndrome with Nissen but by 12 months these Nissen but by 12 months these differences disappeareddifferences disappeared(9)(9)..

Surgical treatment Surgical treatment failure failure 1 - Dysphagia:1 - Dysphagia: - Achalasia has been reported to - Achalasia has been reported to develop after and presumably develop after and presumably as a consequence of antireflux as a consequence of antireflux surgerysurgery

- Early or later- Early or later- Mechanism not known- Mechanism not known- Functional LOS - Functional LOS

dysfunction.dysfunction.


1 - Dysphagia:1 - Dysphagia: TreatmentTreatment . Dilate Strictures and . Dilate Strictures and obstructions → successful in up obstructions → successful in up to 50% to 50% . Hernias → re-operation - more . Hernias → re-operation - more challenging - Success lower (70-challenging - Success lower (70-85%)85%)

Surgical treatment Surgical treatment failure failure 2 - Gas-Bloat Syndrome:2 - Gas-Bloat Syndrome: --Ill-defined and variable (early Ill-defined and variable (early satiety, abdominal distension, satiety, abdominal distension, nausea, pain, flatulence, inability nausea, pain, flatulence, inability to belch.to belch.

CausesCauses. Inability of the GOJ to relax in . Inability of the GOJ to relax in response to response to gastric dilatationgastric dilatation. Aerophagia (frequent habit of . Aerophagia (frequent habit of GORD Px)GORD Px). Inability of the stomach to relax . Inability of the stomach to relax and and accommodate food accommodate food . Surgical injury to the vagus nerve. Surgical injury to the vagus nerve

Surgical treatment Surgical treatment failure failure 2 - Gas-Bloat Syndrome:2 - Gas-Bloat Syndrome:

TreatmentTreatment. Most resolve in 6/12. Most resolve in 6/12

Avoid gas producing foodsAvoid gas producing foodsFrequent small volume mealsFrequent small volume mealsGas reducing drugs Gas reducing drugs

(simethicone)(simethicone)Pro-kinetic agents Pro-kinetic agents

(Metochlopromide, (Metochlopromide, Erythromycin)Erythromycin)

Advice to stop aerophagiaAdvice to stop aerophagia

Surgical treatment Surgical treatment failure failure 2 - Gas-Bloat Syndrome:2 - Gas-Bloat Syndrome:

TreatmentTreatment. If documented delayed gastric . If documented delayed gastric emptying → gastric drainage emptying → gastric drainage procedure (Pyloroplasty or Gastro-procedure (Pyloroplasty or Gastro-enterostomy) or Botox injection enterostomy) or Botox injection into pyloric sphincter.into pyloric sphincter.


3 – Diarrhoea3 – Diarrhoea

- Cause unknown – suggested - Cause unknown – suggested mechanism:mechanism: Accelerated gastric emptyingAccelerated gastric emptying Vagal injuryVagal injury Post-operative dietary Post-operative dietary modificationmodification

Surgery for Surgery for Para/oesophageal herniasPara/oesophageal hernias

Types I (sliding)Types I (sliding)


Types II (rolling or Types II (rolling or paraoesophageal)paraoesophageal)


Types III (mixed)Types III (mixed)


- Type III associated with Type III associated with significant morbidity and significant morbidity and mortality (incarceration of mortality (incarceration of stomach or other viscera)stomach or other viscera)

- Aims reduction of the hernia, - Aims reduction of the hernia, complete “excision of the sac”, complete “excision of the sac”, gastropexy, repair of the hiatus gastropexy, repair of the hiatus and “antireflux” procedure and “antireflux” procedure (fundoplication also help in (fundoplication also help in anchoring)anchoring)


- Recent study with a 13 year - Recent study with a 13 year follow-up showed high follow-up showed high recurrence rate with recurrence rate with laparoscopic (42%) compared to laparoscopic (42%) compared to open (15%)open (15%)(10)(10)

- NB most recurrence were - NB most recurrence were asymptomatic and Dx on video asymptomatic and Dx on video Ba swallowBa swallow

- Also did not excise the sac → - Also did not excise the sac → contribute to recurrence 20% vs contribute to recurrence 20% vs 0 % (6/12 follow up)0 % (6/12 follow up)(11)(11)

Promising Endoscopic Promising Endoscopic ProceduresProcedures

- Endoscopic suturing- Endoscopic suturing- Endoscopic polymer injection- Endoscopic polymer injection- Endoscopic partial - Endoscopic partial fundoplicationfundoplication

- Stretta Procedure (RF energy Stretta Procedure (RF energy delivered to the GOJ)delivered to the GOJ)

BibliographyBibliography1. Woltman T.A., Oelschlager B.K., and Pellegrini 1. Woltman T.A., Oelschlager B.K., and Pellegrini

C.A. Surgical Management of Esophageal C.A. Surgical Management of Esophageal Motility Disorders. Journal of Surgical Motility Disorders. Journal of Surgical Research 2004; 117: 34-43.Research 2004; 117: 34-43.

2. Kahrilas P.J. Gastroesophageal Reflux Disease. 2. Kahrilas P.J. Gastroesophageal Reflux Disease. JAMA 25-9-1996; 276: 983-988.JAMA 25-9-1996; 276: 983-988.

3. Gurski R.R., Peters J.H., Hagen J.A., DeMeester 3. Gurski R.R., Peters J.H., Hagen J.A., DeMeester S.R., Bremner C.G., Chandrasoma P.T., and S.R., Bremner C.G., Chandrasoma P.T., and DeMeester T.R. Barrett's esophagus can and DeMeester T.R. Barrett's esophagus can and does regress after antireflux surgery: a study of does regress after antireflux surgery: a study of prevalence and predictive features. prevalence and predictive features. J.Am.Coll.Surg. 2003; 196: 706-712.J.Am.Coll.Surg. 2003; 196: 706-712.

4. Liron R., Parrilla P., Martinez de Haro L.F., 4. Liron R., Parrilla P., Martinez de Haro L.F., Ortiz A., Robles R., Lujan J.A., Fuente T., and Ortiz A., Robles R., Lujan J.A., Fuente T., and Andres B. Quantification of duodenogastric Andres B. Quantification of duodenogastric reflux in Barrett's esophagus. reflux in Barrett's esophagus. Am.J.Gastroenterol. 1997; 92: 32-36.Am.J.Gastroenterol. 1997; 92: 32-36.

BibliographyBibliography

5. Katz P.O. The role of non-acid reflux in gastro-5. Katz P.O. The role of non-acid reflux in gastro-oesophageal reflux disease. Aliment Pharmacol oesophageal reflux disease. Aliment Pharmacol Ther 2000; 14: 1539-1551.Ther 2000; 14: 1539-1551.

6. Perkidis G., Lund R.J., Hinder R.A., McGinn 6. Perkidis G., Lund R.J., Hinder R.A., McGinn T.R., Filipi C.J., Katada N., Cina R., Hinder P.R., T.R., Filipi C.J., Katada N., Cina R., Hinder P.R., and Lanspa S.J. Esophageal Manometry and 24-and Lanspa S.J. Esophageal Manometry and 24-hour pH Testing in the Management of hour pH Testing in the Management of Gastroesophageal Reflux Patients. American Gastroesophageal Reflux Patients. American Journal of Surgery 1997; 174: 634-638.Journal of Surgery 1997; 174: 634-638.

7. Isolauri J., Luostarinen M., Viljakka M., 7. Isolauri J., Luostarinen M., Viljakka M., Isolauri E., Keyrilainen O., and Karvonen A.L. Isolauri E., Keyrilainen O., and Karvonen A.L. Long-term comparison of antireflux surgery Long-term comparison of antireflux surgery versus conservative therapy for reflux versus conservative therapy for reflux esophagitis. Ann.Surg. 1997; 225: 295-299.esophagitis. Ann.Surg. 1997; 225: 295-299.

8. Watson D.I. Laparoscopic treatment of gastro-8. Watson D.I. Laparoscopic treatment of gastro-oesophageal reflux disease. oesophageal reflux disease. Best.Pract.Res.Clin.Gastroenterol. 2004; 18: Best.Pract.Res.Clin.Gastroenterol. 2004; 18: 19-35.19-35.

BibliographyBibliography

9. Chrysos E., Tsiaoussis J., Zoras O.J., 9. Chrysos E., Tsiaoussis J., Zoras O.J., Athanasakis E., Mantides A., Katsamouris A., Athanasakis E., Mantides A., Katsamouris A., and Xynos E. Laparoscopic surgery for and Xynos E. Laparoscopic surgery for gastroesophageal reflux disease patients with gastroesophageal reflux disease patients with impaired esophageal peristalsis: total or partial impaired esophageal peristalsis: total or partial fundoplication? J.Am.Coll.Surg. 2003; 197: 8-fundoplication? J.Am.Coll.Surg. 2003; 197: 8-15.15.

10. Hashemi M., Peters J.H., DeMeester T.R., 10. Hashemi M., Peters J.H., DeMeester T.R., Huprich J.E., Quek M., Hagen J.A., Crookes P.F., Huprich J.E., Quek M., Hagen J.A., Crookes P.F., Theisen J., DeMeester S.R., Sillin L.F., and Theisen J., DeMeester S.R., Sillin L.F., and Bremner C.G. Laparoscopic repair of large type Bremner C.G. Laparoscopic repair of large type III hiatal hernia: objective followup reveals III hiatal hernia: objective followup reveals high recurrence rate. J.Am.Coll.Surg. 2000; high recurrence rate. J.Am.Coll.Surg. 2000; 190: 553-560.190: 553-560.

11. Edye M.B., Canin-Endres J., Gattorno F., and 11. Edye M.B., Canin-Endres J., Gattorno F., and Salky B.A. Durability of laparoscopic repair of Salky B.A. Durability of laparoscopic repair of paraesophageal hernia. Ann.Surg. 1998; 228: paraesophageal hernia. Ann.Surg. 1998; 228: 528-535.528-535.

Benign oesophageal disease. 10-30% of patients with suspected angina don't have coronary disease....

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