GERD: Management and Surgery

00:01 What are some of the initial management? Well, we want to do anything we can to reduce the acid.

00:07 Acid reduction maneuvers include proton pump inhibitors, histamine 2 receptor antagonist.

00:14 Recall that proton pump inhibitors and histamine 2 receptor antagonist work in two different mechanisms but the common pathway is to decrease hydrochloric acid secretion. What are some other methods of acid reduction on reflux: weight loss, elevation of the head during sleep, and avoiding smoking and alcohol. Weight loss and smoking and alcohol are tied to a decrease in your lower esophageal sphincter tone.

00:46 The lower esophageal sphincter, although not technically a sphincter itself does gate control of the amount of reflux into the esophagus. What’s the association of H. pylori with reflux disease? Here’s the sequence and a schematic of how I think about H. pylori. If H. pylori is classically associated with peptic ulcer disease and that there is a link between H. pylori and GERD then there is some suggestion that H. pylori is detected along with GERD, better symptomatic relief if the H. pylori is treated. What does that mean? There’s an association between H. pylori and gastritis and GERD. Therefore, oftentimes by treating the H. pylori, patients with GERD also have a resolution or at least an improvement in their symptoms. Barrett's esophagus, pay particular attention. Barrett's esophagus is a complication of chronic reflux disease.

01:44 It is defined by metaplastic columnar epithelium replacement of the normal squamous epithelium.

01:53 Most importantly, Barrett's esophagus predisposes to esophageal cancer.

02:04 Most importantly, Barrett's esophagus predisposes to esophageal adenocarcinoma.

02:06 When is surgery offered? Surgery is offered for complications of reflux disease. Again, like many of the diseases we have discussed in these lecture modules of surgery, non-surgical management or medical management is usually the first line. When the patients have failed medical management and require surgery for GERD, it’s usually because of a complication. Here are some complications and indications for surgery: failed medical management, Barrett's metaplasia or Barrett's esophagus, and importantly, severe esophagitis.

02:47 Severe esophagitis can lead to strictures and dysphagia. When you deem the patient necessary of surgery, a classic description of a Nissen fundoplication is something that we would offer the patient.

02:59 This is usually performed laparoscopically as a 360 degree wrap around the GE junction.

03:06 This is performed by mobilizing the greater curvature of the stomach. It has been demonstrated to offer the greatest long term durability in terms of symptomatic relief. Note that there are several goals of a Nissen fundoplication. Number 1, it keeps the GE junction in its anatomic space. Number 2, it also maintains the lower esophageal sphincter tone preventing chronic reflux. Here are some important clinical pearls. Patient may experience dysphagia if the fundoplication is too tight.

03:40 How do you know if the fundoplication is too tight? Well, immediately after surgery, the patient may have difficulty belching or tolerating their own saliva. This may also be coupled with abdominal pain.

03:54 Further down the line, the patient may experience dysphagia. Once the fundoplication scarring has formed, this can be diagnosed using endoscopy. For your examination, recognize that Barrett's esophagus predisposes to esophageal cancer due to chronic exposure to gastric acid. Thank you very much for joining me on this discussion of gastroesophageal reflux disease.