# Upper Gastrointestinal & Foregut Surgery — GCMD Library living collection

Updated: n/a · 6 episodes · 55 cited statements

## Episodes
### Gastroesophageal Reflux Disease
- [Gastroesophageal Reflux Disease](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751) — podcast · 33:57 · [machine version](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751.md)
- [V119 Use of transoral incisionless fundoplication for recurrent reflux after foregut surgery](https://qa.library.globalcastmd.com/watch/v119-use-of-transoral-incisionless-fundoplication-for-recurrent-reflux-after-for-13729) — video · [machine version](https://qa.library.globalcastmd.com/watch/v119-use-of-transoral-incisionless-fundoplication-for-recurrent-reflux-after-for-13729.md)
- [V119 Use of transoral incisionless fundoplication for recurrent reflux after foregut surgery](https://qa.library.globalcastmd.com/watch/v119-use-of-transoral-incisionless-fundoplication-for-recurrent-reflux-after-for-13730) — video · [machine version](https://qa.library.globalcastmd.com/watch/v119-use-of-transoral-incisionless-fundoplication-for-recurrent-reflux-after-for-13730.md)

### Gastroparesis & Gastric Motility
- [Safety and Feasibility of Per-Oral Pyloromyotomy as Augmentative Therapy after Prior Gastric Electrical Stimulation for Gastroparesis](https://qa.library.globalcastmd.com/article/safety-and-feasibility-of-per-oral-pyloromyotomy-as-augmentative-therapy-after-p-13690) — article · [machine version](https://qa.library.globalcastmd.com/article/safety-and-feasibility-of-per-oral-pyloromyotomy-as-augmentative-therapy-after-p-13690.md)
- [Laparoscopic pyloroplasty versus endoscopic per-oral pyloromyotomy for the treatment of gastroparesis](https://qa.library.globalcastmd.com/article/laparoscopic-pyloroplasty-versus-endoscopic-per-oral-pyloromyotomy-for-the-treat-13691) — article · [machine version](https://qa.library.globalcastmd.com/article/laparoscopic-pyloroplasty-versus-endoscopic-per-oral-pyloromyotomy-for-the-treat-13691.md)

### Gastric Neoplasms
- [Combined endoscopic/laparoscopic intragastric resection of gastric stromal tumors](https://qa.library.globalcastmd.com/article/combined-endoscopic-laparoscopic-intragastric-resection-of-gastric-stromal-tumor-13718) — article · [machine version](https://qa.library.globalcastmd.com/article/combined-endoscopic-laparoscopic-intragastric-resection-of-gastric-stromal-tumor-13718.md)

## Chapters
- [0:00](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=0) Introduction and Case Presentation (Ep 1)
- [1:38](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=98) Initial Medical Management and PPI Trial (Ep 1)
- [3:55](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=235) Diagnostic Workup: Endoscopy and pH Studies (Ep 1)
- [7:12](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=432) Role of Manometry in Preoperative Assessment (Ep 1)
- [11:19](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=679) Nissen Fundoplication Technique (Ep 1)
- [18:16](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1096) Toupet Fundoplication for Weak Motility (Ep 1)
- [20:34](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1234) Postoperative Dysphagia Management (Ep 1)
- [25:21](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1521) Reoperative Surgery for Failed Fundoplication (Ep 1)
- [29:31](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1771) Technical Aspects of Reoperative Foregut Surgery (Ep 1)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- For initial GERD management in a patient never on PPIs, start with 20mg daily Prilosec for 6 weeks — Michael Rosen (clinical) [Ep 1 · 2:27](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=147)
- PPIs are preferred over H2 blockers because they don't need to be taken as often, last longer, and are more convenient as once-daily drugs — Michael Rosen (clinical) [Ep 1 · 2:59](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=179)
- There is mounting data that lifetime use of proton pump inhibitors has consequences associated with it — Michael Rosen (clinical) [Ep 1 · 3:34](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=214)
- At minimum, patients with GERD symptoms requiring continued PPI therapy need upper endoscopy to assess esophagitis and rule out Barrett's esophagus — Michael Rosen (clinical) [Ep 1 · 4:06](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=246)
- In 2016, for a patient without esophagitis, no hiatal hernia, and no Barrett's, more workup is needed before keeping them on PPIs indefinitely, especially in young active people due to concerns about osteoporosis and other issues — Michael Rosen (clinical) [Ep 1 · 5:02](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=302)
- A Bravo pH study is preferred over traditional pH monitoring because it's easier for the patient (no nasal tube) — Michael Rosen (clinical) [Ep 1 · 5:50](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=350)
- Bravo pH testing should be done off PPIs to allow for symptom correlation, which is important for setting patient expectations about what surgery will improve — Michael Rosen (clinical) [Ep 1 · 6:19](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=379)
- Manometry is not needed at initial workup but is essential before any surgical discussion — Michael Rosen (clinical) [Ep 1 · 6:51](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=411)
- The primary reason for manometry before fundoplication is to rule out achalasia, because wrapping someone with achalasia destroys their esophageal function — Michael Rosen (clinical) [Ep 1 · 11:19](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=679)
- Before doing routine manometry for reflux workup, achalasia cases requiring Heller myotomy were rare; now with routine manometry, achalasia is found more frequently because patients with achalasia can have heartburn from food stasis and fermentation in the esophagus — Jeff Ponsky (clinical) [Ep 1 · 11:47](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=707)
- On manometry, look for total relaxation of the lower esophageal sphincter with swallowing and a low resting LES pressure to support the diagnosis of reflux disease — Michael Rosen (clinical) [Ep 1 · 12:24](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=744)
- Distal esophageal amplitudes on manometry help tailor the fundoplication type, with detailed discussion needed about postoperative dysphagia expectations in patients with poor esophageal motility, and consideration of the difference between full wrap and Toupet — Michael Rosen (clinical) [Ep 1 · 12:38](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=758)
- For laparoscopic Nissen fundoplication, a full mediastinal dissection is important to create scar tissue and reduce recurrences, and also provides more esophageal length — Michael Rosen (clinical) [Ep 1 · 14:14](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=854)
- Taking down the short gastric vessels during Nissen makes it easier to avoid twisting the wrap and to see exactly what is being brought around — Michael Rosen (clinical) [Ep 1 · 14:38](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=878)
- It's important to bring the posterior aspect of the stomach to the anterior aspect so there's a ridge of short gastrics behind the GE junction — Michael Rosen (clinical) [Ep 1 · 14:45](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=885)
- The way a Nissen is created is highly variable, and one downside of this operation that makes it hard to reproduce data is that everybody does it just a little bit differently without great standardization — Michael Rosen (opinion) [Ep 1 · 14:55](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=895)
- The geometry of the wrap is critically important; if it doesn't look right after putting it together, take it down and reestablish it — Jeff Ponsky (clinical) [Ep 1 · 15:35](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=935)
- A common mistake is grabbing the posterior greater curve too low on the left when creating the wrap, which results in being too high on the right and too low on the left, trapping a portion of the fundus above — Jeff Ponsky (clinical) [Ep 1 · 15:50](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=950)
- A common mistake when younger was making the wrap too long because of having good intraabdominal esophageal length; this adds to dysphagia — Michael Rosen (clinical) [Ep 1 · 16:19](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=979)
- For Nissen fundoplication, use 3 sutures with silk, making the wrap about 2 centimeters long (nothing longer); first stitch is stomach to stomach to allow positioning adjustment, then stomach-esophagus-stomach just above GE junction, then another above that — Michael Rosen (clinical) [Ep 1 · 16:37](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=997)
- The last stitch is a posterior gastropexy taking the posterior aspect of the stomach to the crus; doing this beforehand is 'cheating' because the stomach should sit there without tension — Michael Rosen (clinical) [Ep 1 · 17:06](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1026)
- Earlier in career, a 56 French bougie was used for crural closure, but with more experience it's needed less and less; now close the crus without a bougie — Michael Rosen (clinical) [Ep 1 · 17:42](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1062)
- The crus should be closed enough so the esophagus has a little V-shaped triangle of air below it; as experience increases, the crural closure is made tighter — Michael Rosen (clinical) [Ep 1 · 18:00](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1080)
- In patients with connective tissue disease and weak peristalsis (below 20 mmHg) with very weak LES, the key is to have a clear discussion that the goal is to improve reflux without creating dysphagia, because the esophageal pump doesn't work well enough to overcome a full wrap — Michael Rosen (clinical) [Ep 1 · 19:05](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1145)
- For patients with weak motility, a Toupet fundoplication (posterior 270-degree wrap) is performed in the vast majority of cases — Michael Rosen (clinical) [Ep 1 · 19:38](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1178)
- For Toupet fundoplication, perform formal esophageal dissection with Penrose drain, go up into chest, mobilize for intraabdominal esophagus length, take down short gastrics, create posterior 270-degree wrap about 2.5 to almost 3 cm long with 3 sutures on either side (esophagus to stomach), then do posterior gastropexy of stomach to posterior crus — Michael Rosen (clinical) [Ep 1 · 19:44](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1184)
- For Toupet, only one stitch is used for posterior gastropexy to the crus (not to each side) to avoid angulating things awkwardly and pulling the stomach — Michael Rosen (clinical) [Ep 1 · 20:33](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1233)
- The hardest transition of becoming an attending 12 years ago doing foregut surgery was managing patient satisfaction after fundoplication and realizing patients come back with complaints and issues, and learning when to intervene — Michael Rosen (opinion) [Ep 1 · 21:33](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1293)
- It's critical to tell patients preoperatively that fundoplication changes things: it will change how you swallow, how your stomach works, and how acid moves out of your body — Michael Rosen (clinical) [Ep 1 · 22:03](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1323)
- Fundoplication is tightest right after surgery and gets looser over time — Michael Rosen (clinical) [Ep 1 · 22:17](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1337)
- The expectation is that patients will have dysphagia postoperatively; the patient to worry about most is one who shows up two weeks after Nissen eating everything without dysphagia, because the wrap was made too loose and there will be trouble long-term — Michael Rosen (clinical) [Ep 1 · 22:28](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1348)
- Would not worry about early postoperative dysphagia whatsoever for the first 6 weeks, even if the patient had to maintain a liquid diet — Michael Rosen (clinical) [Ep 1 · 22:48](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1368)
- Would not consider endoscopic intervention for dysphagia until 3 months postoperatively with no progression and no ability to tolerate anything besides liquids — Michael Rosen (clinical) [Ep 1 · 22:55](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1375)
- For persistent dysphagia at 6-8 months, first get an upper GI to make sure the hernia hasn't recurred, ensure there's no anatomic reason, and look at where the hang-up is — Michael Rosen (clinical) [Ep 1 · 23:17](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1397)
- If there's no recurrence and persistent dysphagia, the assumption is the wrap was calibrated too tight, and the next move would be endoscopy with expectation for dilation — Michael Rosen (clinical) [Ep 1 · 23:37](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1417)
- If a patient one year post-fundoplication has dilated esophagus with bird's beak appearance on upper GI, tight GE junction on EGD with retained fluid pool, and manometry shows lack of peristalsis with non-relaxing LES, this represents pseudoachalasia where the esophagus has burned out from being too tight too long and can no longer pump food through — Michael Rosen (clinical) [Ep 1 · 24:06](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1446)
- For pseudoachalasia, before rushing to the operating room, ensure nutrition is optimized; if not, consider PEG tube for feeding beforehand — Michael Rosen (clinical) [Ep 1 · 24:57](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1497)
- For pseudoachalasia with optimized nutrition, the approach would most likely be to take down the Nissen, do a Heller myotomy, and probably add a Dor fundoplication — Michael Rosen (clinical) [Ep 1 · 25:17](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1517)
- An alternative approach for pseudoachalasia is to take down the Nissen, do a long Heller myotomy, and convert to a Toupet (opening the wrap and pinning at 180 degrees on both sides) to provide some antireflux protection — Jeff Ponsky (clinical) [Ep 1 · 25:33](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1533)
- For complex reoperative foregut surgery, the best approach is to plan to go in and start over again, though if unable to take the wrap down completely, can fall back on dividing it and leaving it as half a wrap — Michael Rosen (clinical) [Ep 1 · 26:40](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1600)
- For morbidly obese patients with BMI over 35 and reflux, refer to bariatric surgery for gastric bypass rather than fundoplication — Michael Rosen (clinical) [Ep 1 · 27:36](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1656)
- For symptomatic herniated wrap, reevaluate from the start with 48-hour Bravo study to understand symptom correlation and have honest discussion about what can be improved — Michael Rosen (clinical) [Ep 1 · 28:18](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1698)
- For reoperative patients, especially if the first surgery wasn't done by you, want to know gastric emptying function because delayed gastric emptying symptoms overlap with reflux and might have led to some problems — Michael Rosen (clinical) [Ep 1 · 28:45](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1725)
- Nausea and vomiting are red flags to be careful, even in primary fundoplication; if these are large components of complaints, put the brakes on rushing to surgery and really understand what's going on — Michael Rosen (clinical) [Ep 1 · 29:02](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1742)
- For reoperative slipped Nissen, the first step is looking at where prior surgeon put incisions: if there's an incision in the belly button, they never went up in the chest; if all 5 incisions with lowest 5cm from umbilicus, they did a real operation — Michael Rosen (clinical) [Ep 1 · 29:51](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1791)
- The first goal of reoperative fundoplication is to get to the right crus, which is the most important part because then you know where the cava is and where you can get in big trouble — Michael Rosen (clinical) [Ep 1 · 30:18](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1818)
- In reoperative surgery, where the liver and wrap are obliterating the right crus, drifting off the wrap can lead to injury of the cava — Michael Rosen (clinical) [Ep 1 · 30:32](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1832)
- First get the liver off the wrap using hook or scissors and accept bleeding, because the plan is to put the paddle (12mm retractor) there to compress any bleeding; using harmonic can injure the wrap which may be needed later — Michael Rosen (clinical) [Ep 1 · 30:44](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1844)
- Want to go specifically for the right crus at the base; most people haven't taken dissection low enough to the base of the crus — Michael Rosen (clinical) [Ep 1 · 31:11](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1871)
- A lot of fundoplications come back because there's just not scar tissue in the chest; if struggling down low, the second move is to get up in the chest wherever possible and work back down — Michael Rosen (clinical) [Ep 1 · 31:33](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1893)
- A trick for taking down the wrap is to get between the wrap and esophagus on the left side by wiggling an instrument between them — Jeff Ponsky (clinical) [Ep 1 · 31:46](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1906)
- The key in reoperative surgery is identifying named structures and digging them out in a systematic fashion, not trying to make a space without doing a dissection, or you get lost quickly — Michael Rosen (clinical) [Ep 1 · 32:01](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1921)
- If the anterior vagus nerve is injured during reoperative fundoplication but the posterior vagus is OK, would do nothing acutely in the operating room — Michael Rosen (clinical) [Ep 1 · 32:36](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1956)
- For reoperative surgery, get upper GI on first or second postoperative day to look at gastric emptying as a poor man's gastric emptying study — Michael Rosen (clinical) [Ep 1 · 32:59](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1979)
- If concerned about vagal injuries postoperatively with poor gastric emptying, would go early to Botox of the pylorus rather than doing pyloroplasty at the time of operation unless convinced both vagus nerves were taken — Michael Rosen (clinical) [Ep 1 · 33:05](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1985)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- The Bravo capsule is placed 6 centimeters above the EG junction and can measure 48 hours of pH data — Jeff Ponsky summarizes what Dr. Michael Rosen said [Ep 1 · 5:57](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=357)
- Nissen fundoplication doesn't work well in morbidly obese patients — Jeff Ponsky summarizes what Dr. Michael Rosen said [Ep 1 · 28:09](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1689)
- There's some evidence that even taking both vagus nerves may not matter — Jeff Ponsky summarizes what Dr. Michael Rosen said [Ep 1 · 33:19](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1999)

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