1. GASTROESOPHAGEAL REFLUX DISEASE

2. American College of Gastroenterology (ACG) guidelines
defines GASTROESOPHAGEAL REFLUX DISEASE (GERD) as
“TROUBLESOME symptoms or complications resulting from the reflux of gastric contents into
the esophagus or beyond, into the oral cavity (including larynx) or lung.”

3. PHENOTYPIC PRESENTATIONS OF GERD
Erosive esophagitis (EE),
Non erosive reflux disease (NERD) and
Barrett’s esophagus

5. GERD encompasses esophageal and extra-esophageal syndromes
otitis media
chronic coughing, asthma, laryngitis
reflux of gastric juice into the respiratory tract
syndromes with esophageal injury
reflux chest pain syndrome
typical reflux syndrome

6. Alarm features for GERD
Persistent vomiting
Odynophagia
Unexplained weight loss
New onset dyspepsia in patient ≥60 years
gastrointestinal bleeding
Iron deficiency anemia

7. DIAGNOSIS

8. UPPER GASTROINTESTINAL ENDOSCOPY
Principal test
Main use=====evaluation of treatment failures and risk management.
Typical esophagitis GERD
highly specific (90%–95%) for GERD, but low sensitivity

9. Manometry ---NOT TO CONFIRM GERD BUT RULE OUT FUNCTIONAL DYSPHAGIA
Persistent reflux symptoms despite PPI therapy and====== MANOMETRY
Normal findings on endoscopy ====================

11. 24-hour pH test Acid reflux episodes === pH fall <4.
Overall DeMeester score, should not exceed 14.7 in normal subjects.
Both catheter and wireless pH monitoring allow
quantification of esophageal acid exposure and
assessment of the temporal relationship between symptoms and acid reflux events

14. ESOPHAGEAL IMPEDANCE-PH MONITORING ---FAILED PPI TWICE DAILY
Multichannel intraluminal impedance monitoring with pH sensor
Several channels, detects the direction of bolus movement
ANTEROGRADE SWALLOWS RETROGRADE EVENTS

16. management

17. LIFE STYLE MODIFICATIONS
MEDICAL MANAGEMENT
SURGICAL MANAGEMENT

18. LIFE STYLE MODIFICATIONS

19. MEDICAL MANAGEMENT Antacids Histamine-2 (H2)-receptor antagonists,
approximately 75% effective
Proton pump inhibitors (PPIs)
PPIs have superior healing rates and decreased relapse rates

20. WHY SURGERY WHEN PPI SO GOOD???
Atrophic gastritis and/or hypergastrinemia induced carcinoid tumors due to hypochlorhydria.
Increased risk of Clostridium difficile colitis and bacterial gastroenteritis

21. Refractory Esophagitis
SURGICAL REFERRAL
Refractory Esophagitis
Non compliance
Desire to discontinue medical therapy
large hiatal hernia
Side effects of medical therapy

22. ANTIREFLUX SURGERY- NISSEN’S FUNDOPLICATION
The choice to consider anti-reflux surgery must be individualized.
Patients should have
documented acid reflux----- p H monitoring
a defective anti-reflux barrier in the absence of poor gastric emptying,
normal esophagus motility …NORMAL MANOMETRY
at least a partial response to acid reduction therapy
EFFECTIVE for heartburn and regurgitation (75-90%) and
less effective for extraesophageal symptoms (50-75%).

23. Tennets of Surgery reduction of the hiatal hernia,
repair of the diaphragmatic hiatus,
strengthening the attachment between the gastroesophageal junction and the posterior diaphragm,
strengthening the anti-reflux barrier by adding a gastric wrap around the gastroesophageal junction (fundoplication)

25. COMPLICATIONS:
After total fundic wrap several adverse consequences may occur;
persistent dysphagia,
inability to belch and vomit, epigastric fullness,
bloating and pain postprandially,
temporary swallowing discomfort, and sometimes
intense flatus

26. PARTIAL FUNDOPLICATION
Toupet fundoplication only encircles half of the esophageal circumference.
The preferred and most efficient modification of the Nissen fundoplication is the short “floppy” Nissen fundoplication, which has been shown to have success rates of up to 90% with minimal morbidity and mortality.

28. LINX Reflux system---NEWER SURGICAL OPTION
– Made of titanium beads with magnetic link
– Performance of Linx resulted in consistent symptom relief and pH control with markedly fewer side effects
– Not for patients with large hiatal hernia or abnormal peristalsis

30. Endoluminal Surgery
Endoluminal gastroplication (ELGP) -----first of the proposed endoscopic treatments for GERD.
EndoCinch
Plicator device
Enteryx Injection…polymerize into spongy material when injected submucosally

31. Submucosal Enteryx Injection

33. EsophyxXTM device A more practical technique,
the novel endoluminal fundoplication (ELF) technique
overcome some of the Plicator's disadvantages,
inability to reduce hiatal hernia and
create a robust gastroesophageal valve

36. Medical versus Surgical Treatment for GERD
MANY TRIALS favor laparoscopic antireflux surgery compared to long-term PPI therapy
RCT: from UK better physiological control of reflux in patients having undergone laparoscopic Nissen fundoplication than patients under PPI therapy ….follow up of 12 months
A prospective study on laparoscopic Nissen fundoplication from J. Hunter's group from Atlanta with an 11-year mean follow up,
significant symptom control,
increased patient satisfaction, and
complete withdrawal of antireflux medications by 70% of patients.

37. CONSIDER SURGERY IN LONG TERM CAREFULLY SELECTED PATIENTS

38. THE TWO SIDES OF THE SAME COIN
Conclusions
GERD results from TLESRs and hiatal hernia.
DIAGNOSIS , PPI test hour pH test alone or in combination with impedance.
PPIs the best therapeutic option
Choosing the right candidates for surgery still remains a problem and SHOULD BE INDIVIDUALIZED
Medical and surgical therapies for the GERD are not competing or they are not even complementary.
THE TWO SIDES OF THE SAME COIN

39. IMPROPER PATIENT SELECTION FOR SURGERY MAY END UP IN DISASTER
TAKE HOME MESSAGE
RIGHTLY AND TIMELY REFERRAL TO SURGERY CAN PREVENT MISERY OF THE PATIENT
IMPROPER PATIENT SELECTION FOR SURGERY MAY END UP IN DISASTER