From
Dr. Jeffrey Ponsky
Gastroesophageal Reflux Disease
With Dr. Michael Rosen · hosted by Dr. Jeffrey Ponsky
Chapter 1 of 9 · Case-Based Learning
Introduction
Introduction and Case Presentation
Expert statements on this page
No expert statements were drawn from this page.
Host summaries · secondary, not cited in answers
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
For initial GERD management in a patient never on PPIs, start with 20mg daily Prilosec for 6 weeks
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
There is mounting data that lifetime use of proton pump inhibitors has consequences associated with it
At minimum, patients with GERD symptoms requiring continued PPI therapy need upper endoscopy to assess esophagitis and rule out Barrett's esophagus
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
A Bravo pH study is preferred over traditional pH monitoring because it's easier for the patient (no nasal tube)
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
Manometry is not needed at initial workup but is essential before any surgical discussion
The primary reason for manometry before fundoplication is to rule out achalasia, because wrapping someone with achalasia destroys their esophageal function
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
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
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
For laparoscopic Nissen fundoplication, a full mediastinal dissection is important to create scar tissue and reduce recurrences, and also provides more esophageal length
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
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
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
The geometry of the wrap is critically important; if it doesn't look right after putting it together, take it down and reestablish it
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
A common mistake when younger was making the wrap too long because of having good intraabdominal esophageal length; this adds to dysphagia
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
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
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
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
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
For patients with weak motility, a Toupet fundoplication (posterior 270-degree wrap) is performed in the vast majority of cases
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
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
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
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
Fundoplication is tightest right after surgery and gets looser over time
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
Would not worry about early postoperative dysphagia whatsoever for the first 6 weeks, even if the patient had to maintain a liquid diet
Would not consider endoscopic intervention for dysphagia until 3 months postoperatively with no progression and no ability to tolerate anything besides liquids
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
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
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
For pseudoachalasia, before rushing to the operating room, ensure nutrition is optimized; if not, consider PEG tube for feeding beforehand
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
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
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
For morbidly obese patients with BMI over 35 and reflux, refer to bariatric surgery for gastric bypass rather than fundoplication
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
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
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
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
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
In reoperative surgery, where the liver and wrap are obliterating the right crus, drifting off the wrap can lead to injury of the cava
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
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
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
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
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
If the anterior vagus nerve is injured during reoperative fundoplication but the posterior vagus is OK, would do nothing acutely in the operating room
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
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
The Bravo capsule is placed 6 centimeters above the EG junction and can measure 48 hours of pH data
Nissen fundoplication doesn't work well in morbidly obese patients
There's some evidence that even taking both vagus nerves may not matter