أسئلة الثانية جراحة ثالثة الدلتا

• Gastro-Oesophageal Reflux Disease (GERD) involves chronic esophagitis resulting from the regurgitation of gastric acid into the esophagus
• In cases of gastrectomy followed by esophago-duodenostomy or oesophago-jejunostomy, the reflux may be alkaline (from the duodenum & jejunum)

Etiology of GERD:

• Primary cause is incompetence of the cardia (LES) due to sliding or mixed Hiatal Hernia (H.H.)
• Secondary cause is delayed emptying of the stomach

Delayed emptying of the stomach can be:

• Organic, such as pyloric stenosis
• Functional, such as pylorospasm due to duodenal ulcers, gallstones, or vagotomy.

Pathology of GERD:

• Loss of the anti-reflux mechanism
• Reflux esophagitis is characterized by superficial ulceration that heals and recurs repeatedly
• Ulceration causes longitudinal muscle spasm, drawing the cardia further into the thorax, increasing acid regurgitation
• A viscous cycle occurs, ending in esophageal fibrosis, which leads to progressive stricture and shortening of the esophagus
• Ulcers do not perforate

Symptoms & Signs of GERD:

• Burning pain (heartburn) is the presenting symptom
• Regurgitation of bitter acidic fluid (water brush)
• Dysphagia begins due to esophageal spasm and edema and becomes progressively worse as fibrosis and stricture develop

Complications of GERD:

• Peptic ulceration in the lower esophagus
• Bleeding, either chronic blood loss leading to secondary anemia, or hematemesis
• Inhalation Pneumonia from recurring reflux
• At night, regurgitation of fluid to the larynx can induce choking, hoarseness, and asthma attacks, especially in children, leading to repeated chest infections
• Infections of Monilia can occur with further mucosal damage
• Strictures and shortening of the esophagus
• Perioesophagitis
• Perforation is very rare
• Malignancy can lead to adenocarcinoma (10%)

Barrett's Esophagus:

• Occurs in 7-10% of GERD cases
• Columnar cell metaplasia (intestinal metaplasia) involves the presence of goblet cells in the lower esophagus of any length (3 cm or more) as an adaptive change in response to prolonged reflux
• Classified based on the association with dysplasia
• Types of dysplasia: No dysplasia, low-grade dysplasia, and high-grade dysplasia
• Predisposes to more stricture formation, massive hemorrhage, and esophageal cancer (adenocarcinoma).

Investigations for GERD:

• Barium Meal is conducted in Trendelenburg's position
• Looks for reflux of barium into the esophagus, associated sliding hernia, and stenosis if complications have developed
• Fibre-Optic Esophagoscopy with Biopsy
• Checks for patency of cardia on inspiration (normally closes on inspiration)
• Checks for reflux of gastric juice through cardia
• Checks for mucosal ulcers and leukoplakia

Esophageal Manometry:

• Transient lower esophageal sphincter relaxations are the most important manometric findings in GERD (TLOSRs)
• Used to detect underlying motility disorders
• Nearly normal peristalsis indicates complete fundoplication
• Absent or weak peristalsis indicates partial fundoplication

Physiological Tests (24-Hour pH Monitoring):

• Normal baseline pH of the lower esophagus is 5-6.5
• Confirms the presence of reflux and determines its degree, and is the Gold standard for GERD diagnosis
• Method Involves a belt around the chest with a recording disc sensitive to signals from a pH probe located 5 cm above the LES

Conservative (Medical) Treatment of GERD:

• Duration: 3-6 months continuously

Conservative Lines:

• Semi-sitting position during sleeping
• Six small, soft, spiceless, slowly masticated meals
• Maintaining an upright position after meals is beneficial
• Avoid smoking, alcohol, acid drinks, heavy work, and lifting weights
• Reduction of weight if the patient is obese is very important

Medication for GERD:

• Alkalies and antacids may control symptoms
• H2-receptor blockers like Ranitidine
• Proton pump inhibitors like omeprazole
• Prokinetic drugs like motilium may improve clearance

Surgical Treatment of GERD:

• Used when medical treatment fails, complications develop (stricture), to treat associated intra-abdominal conditions needing surgery (gall stones), associated esophageal motility disorders, and in young patients

Aims of Surgical Treatment:

• Replace the cardia to its normal position and narrow the hiatus, add an anti-reflux measure

Procedures in Surgical Treatment:

• Nissen's Fundoplication (Valvuloplasty)
• Belsey Mark IV (Cardioplasty)
• Ligmantum Teres (Round Ligament) Cardiopexy
• Hill posterior gastropexy
• Angelchik Prosthesis
• Collis Gastroplasty

Nissen's Fundoplication (Valvuloplasty):

• Crural repair may use optional interrupted non-absorbable sutures
• The fundus of the stomach is wrapped 360 degrees around the lower 5 cm of the esophagus with non-absorbable seromuscular sutures between the stomach and esophagus

Approaches to Nissen's Fundoplication:

• Transabdominal: Preferred to exclude other causes of heartburn like Saint's triad (H.H. Cholycystitis, Diverticulitis)
• Transthoracic: Used for previous unsuccessful transabdominal surgery
• Laparoscopic: Lower morbidity and shorter hospital stay

Advantages of Nissen's Fundoplication:

• Can be performed transabdominally or transthoracically
• Recurrence is rare
• Lesions of the stomach, duodenum, gallbladder, and colon can be addressed simultaneously

Disadvantage of Nissen's Fundoplication:

• Gas-bloat syndrome causes patients to complain of dysphagia and abdominal gaseous distension due to an inability to eructate or vomit (Super-competence)

Modifications of Nissen's fundoplication:

• Partial fundoplication (Incomplete Wraps)
• Toupet posterior partial fundoplication: Fundus of stomach is wrapped 270 posteriorly around lower 5 cm of esophagus

Treatment of Complications:

• Peptic Strictures: Dilatation with medical anti-reflux measures and surgical anti-reflux procedures for impassable strictures in young patients

Barrett's Esophagus with Dysplasia:

• No dysplasia: Aggressive antireflux therapy (60 mg PPI/day) and repeated biopsy every 3 months
• Low-grade dysplasia: Antireflux surgery
• High-grade dysplasia (confirmation by 2 pathologists): Confined areas can be treated with photodynamic therapy or endoscopic mucosal resection
• Widespread or multiple lesions can be treated with transhiatal oesophagectomy without thoracotomy

Malignant Transformation:

• Treated as cancer of the esophagus (lower 1/3 + cardia)

Summary of GERD:

• Due to loss of LES competence and is extremely common
• Associated with hiatal hernia (sliding or paraoesophageal)
• Common symptoms include heartburn, epigastric discomfort, and regurgitation, often worsened by stooping and lying
• Achalasia and GORD can be easily confused diagnostically
• Dysphagia may occur, but neoplasm must be excluded
• Diagnosis and treatment are based on clinical findings
• Endoscopy and a 24-hour pH test may be required (Gold Standard)
• Management is primarily medical (PPIs are the most effective)
• Surgery may be required
• Laparoscopic fundoplication is the most popular surgical technique
• Strictures may develop over time