Fisiopatologia del Reflusso e delle Plastiche Antireflusso XXIV Congr. Naz. ACOI, Montecatini 2005 Sez. Chirurgia Esofago- Gastrica U.Fumagalli I I I C Istituto Clinico HUMANITAS Rozzano - Italy UO Chirurgia Generale e Mininvasiva Resp: R.Rosati

GERD pathophysiology Impaired mucosal defense Poor esophageal clearance Poor esophageal clearance Hiatal hernia (promotes LES dysf.) LES pressure abn Hypotensive sphincter Delayed gastric emptying Acid Pepsin Bile Food TLESR

Transient LES Relaxations Vagally mediated, spontaneous, non-swallow- induced decreases in LESRP, triggered by postprandial gastric fundic distension Antireflux operations result in decreased duration and frequency of TLESR, possibly by preventing distension of the gastric fundus

Guidelines for diagnosis and treatment of GERD Am.Coll.Gastroent GERD Endoscopy Dysphagus, odynophagia, bleeding, weight loss, anemia Long standing symptoms Empirical therapy (incl. lifestyle) Pyrosis, regurgitation Aggravated by recumbency or bending Relieved by antacids History: uncomplicated GERD Symptoms of complicated disease Risk for BE Mucosal injury in less than 50% of patients Symptoms do not predict degree of esophagitis

GERD Diagnosis: pH metry Confirms diagnosis in patients with persistent symptoms (typical and atypical) without evidence of mucosal damage (especially if a trial of acid suppression has failed) Monitor the control of reflux in patients with symptoms in therapy Combined impedance and acid testing has been developed: allows measurement of acid and non acid (volume) reflux

Preoperative pH metry? Symptomatic GERD patients with normal preoperative 24-hour pH test results have significantly worse subjective outcomes after Nissen fundoplication compared with patients having abnormal preoperative pH test results. Preoperative abnormal DMS (n 208) Preoperative normal DMS (n 15) Khajanchee Am J Surg 2004

EXTRAESOHAGEAL MANIFESTATIONS OF GERD

PPI twice daily for 3-6 months Suspected GERD extraesophageal manifestations Increase PPI dose Taper down to lower PPI dose that controls symptoms 24 pH metry on therapy Consider non GERD related manifestations success failure + -

Outcomes of typical and atypical symptoms attributed to GERD treated by laparoscopic fundoplication So JB Surgery, 1998

GERD - Diagnosis: manometry Ensure accurate placement of monitoring probes Exclude motility disorders such as achalasia or aperistalsis associated with disorders such as scleroderma Helpful prior to antireflux surgery (?)

Oleynikov Pellegrini, Surg Endosc 2002 GERD – Defective peristalsis Partial and total fundopl.are effective in controlling symptoms of GERD in defective peristalsis. Total fundoplication does not cause dysphagia of new onset Total fundopl. (n 57) Partial fundopl. (n 39)

GERD – Taylored surgery May 1996 – April 2005: 228 op. for GERD Sez. Chirurgia Esofago- Gastrica U.Fumagalli I I I C UO Chirurgia Generale e Mininvasiva Resp: R.Rosati

How to evaluate the results of antireflux surgery? Symptoms after medical or surgical treatment of GERD do not correlate with physiologic response (low specificity/sensibility) Sarela AI, Arch Surg % of patients with Barrett esophagus, asymptomatic under PPI have pathologic acid reflux Jenkinson AD, Br J Surg 2004

Symptoms and pH metry after fundoplication 26 patients who underwent pH-metry a mean of 15 months after surgery (1-58 mos) (*) 2 patients had hernia recurrence Sez. Chirurgia Esofago- Gastrica U.Fumagalli UO Chirurgia Generale e Mininvasiva Resp: R.Rosati C I I I

pH-metry is an important tool in the diagnosis of GERD and of its atypical symptoms; pH-metry is an important tool in the diagnosis of GERD and of its atypical symptoms; It still has indication in the preoperative work up of patients candidate to fundoplication; It still has indication in the preoperative work up of patients candidate to fundoplication; It should be used to objectively evaluate the results of antireflux treatments It should be used to objectively evaluate the results of antireflux treatments Esophageal manometry is an important tool for the diagnosis of esophageal diseases: it may correct a wrong diagnosis or suggest an underlying diagnosis (achalasia – scleroderma); Esophageal manometry is an important tool for the diagnosis of esophageal diseases: it may correct a wrong diagnosis or suggest an underlying diagnosis (achalasia – scleroderma); Great expectations exist for the results of impedance monitoring in patients with gastroesophageal reflux disease Great expectations exist for the results of impedance monitoring in patients with gastroesophageal reflux disease Conclusions