2. Evaluating the GERD Patient – Minimum to Maximum Blair A. Jobe, MD Professor of Surgery Department of Surgery University of Pittsburgh Pittsburgh, Pennsylvania

3. Failure of Antireflux Surgery “It is well recognized that inadequate or inaccurate preoperative evaluation can be a major contributor to a poor outcome following antireflux surgery” Gastrointest Endoscopy Clin N Am 2005;15:347

4. Symptoms are not a Reliable Indicator of Reflux Status Prior to ARS DeMeester et al. J Thorac Cardiovasc Surg. 1980;79:656 Patti MG et al. Dig Dis Sci. 2001;46:597 73% 27% Typical GERD Symptoms (N=179) Normal pH Test Abnormal pH Test

5. Symptoms are not a Reliable Indicator of Reflux Status After Antireflux Surgery Symptoms (N=58) Asymptomatic (N=151) 29.3% 70.6% 11.9% 88.1% Abnormal DeMeester Normal DeMeester Khajanchee et al. Arch Surg. 2002;137:1008 PPV=29% NPV=88%

6. The majority of patients taking acid suppression medications after ARS do not have GERD PPI (N=37) Lord et al. J Gastrointest Surg. 2002;6:3 76% 24%

7. Antireflux Surgery Eliminates Symptoms of GERD AuthorResolution of Symptoms Postoperative Complications of GERD Follow-up period Hinder (1994)97%2 strictures12 mos Hunter (1999)94%None2.5 years Hunter (1996)93%None17 mos Peters (1998)96%no20 mos Cuschieri (1993) 95%None Watson (1995)98%no10 Years Campos (1999) 92%no15 mos Lundell (2001) 95%Minimal esophagitis5 Years

8. Antireflux Surgery is Effective and Durable Surg Endosc 2006;20:159

9. Antireflux Surgery Improves Quality of Life AuthorYearToolFollow- up Result Trus1999SF-361 yearSignificant Improvement Rattner2000PGWB,GSRS1 yearNormalized Capelluto2001GIQLI1 yearNear Normal Fernando2002SF-36Significant Improvement Blomqvist1996PGWB,GSRS, RVAS 1 yearNormalization Granderath2002GIQLI3-5 yearsSignificant Improvement

10. Success in Antireflux Surgery: What is Essential? 1.Patient Selection 2.Patient Selection 3.Patient Selection 4.Surgeon Training 5.Procedure Tailoring –Wrap type, length, tightness

11. Technique for Nissen Fundoplication Hernia reduction Esophageal mobilization Hiatal Closure Short gastric division Short and Floppy Fundoplication

12. Goals in Workup Query GERD-related symptoms Assess co-morbid conditions as they relate to surgery Objectify GERD Identify anatomic abnormalities Identify functional abnormalities Set expectations with patient Pick procedure (complete fundoplication) Gastrointest Endoscopy Clin N Am 2005;15:347

13. The History and Expectation Setting Typical vs. atypical symptoms R/O non-GERD causes of atypical symptoms Primary and secondary symptoms Response to medical therapy Associated symptoms –Bloating, emesis, nausea Eating disorder Counsel patient as to the probability of success

14. The Quiver Esophagram Upper Endoscopy Manometry –High resolution pH testing –Catheter-based –“Wireless” Impedance –pH or Manometry Gastric Emptying Esophageal Emptying

15. Video Esophagram (Required) Dynamic imaging of entire organ –Contour –Obstructive lesions –Some functional information

16. Upper Endoscopy (Required) Mucosal Inspection –Complications of reflux –Barrett’s esophagus and cancer Structural Inspection Therapy prior to surgery

17. Native Flap-Valve Anatomy Lesser curvature Anterior Valve Body Lip Posterior Valve Tightness around scope Relationship to diaphragm Fundus

18. Fundoplication as an Anatomic Remedy Pre-fundoplicationPost-fundoplication

19. EUS: Normal Nissen Gopal et al. J Gastrointest Endosc 2005

20. Manometry (Required) Identify etiology and severity of GERD (LES) Assess ability to tolerate fundoplication Exclude primary motility disorder (Body) Guide pH probe placement

21. 24-Hour pH Testing (Required) Detects esophageal acid exposure Correlate symptoms with reflux episodes ? Tailor fundoplication Considered the “gold standard” for making diagnosis

22. Potential Pitfalls with pH Testing Wrong position “Good day” Acidic foods Atrophic gastritis Sensitive esophagus Achalasia Poor sensitivity in LPR

23. Refluxate pH Changes During Migration Weusten, Bas L. et al, American. Journal GI. 266:G357-G362, 1994

24. How Do You Select the Correct Patient with GERD? The Three Most Important Factors which Predict the Likelihood of Success Abnormal 24-hour pH score Typical primary symptom Clinical response to PPI J Gastrointest Surg 1999;3:292

25. Situations in which ARS may be Applied Typical GERD NERD PEH Achalasia Primary, Secondary, Tertiary Failure Asthma and other Extraesophageal Sxs Atypical

26. Pitfall #1 Missed Achalasia Perform manometry on everyone Think of this with re-dos Read your own tracings Be suspicious –Positive pH –Esophagitis

27. Pitfall #2 Eating Disorder History Physical –Finger nails –Dentition –Body habitus may be normal Esophagitis with normal manometry or pH Index of suspicion

28. Pitfall #3 Functional Dyspepsia History and physical Don’t mistake for GERD Listen to your objective evidence Order more tests If uncertain, refer for second opinion

29. Pitfall #4 Structural Gastric Outlet Obstruction Be suspicious with normal LES physiology and abnormal pH Bloating, nausea NSAID use or prior treatment for H. pylori EGD

30. Pitfall #5: Occult GERD- Proving Association with Extraesophageal Symptoms 1) Gastric juice, of either acid or alkaline pH, can cause damage to the laryngeal or airway mucosa 2) Airway desquamation is followed by mucosal regeneration over 3-7 days 3) Microaspiration can be asymptomatic and occur with a normal 24 hour pH score 4) Symptoms can occur with only distal esophageal acid exposure

31. Gastroesophageal Reflux of Fluid Over an Impedance Electrode Pair No bolus=few ions= high impedance Bolus present=many ions= low impedance Air liquid Refluxate Proximal

32. pH Proximal Distal

33. Hypopharyngeal Sensor Positions 0.25 cm 1.75 cm 3.25 cm 1.0 cm UES 2.5 cm

34. Mr. E 75 year old male75 year old male non-smokernon-smoker 17 months of non-productive cough and dysphonia17 months of non-productive cough and dysphonia –Worse when supine and after meals –Mild HB symptoms and no regurgitation History of post-nasal dripHistory of post-nasal drip Two episodes of pneumonia in last yearTwo episodes of pneumonia in last year No history of AsthmaNo history of Asthma Does not take ACE inhibitorsDoes not take ACE inhibitors

35. Mr. E Physical ExamPhysical Exam –Fit appearing –VSS –normal

36. CXR

37. “PPI Test” Omeprazole 40mg bid for 4mos –Mild subjective improvement in hoarseness but cough is same –Chronic throat clearing –GERD symptoms resolved

38. ENT: Granulation tissue on vocal cords with gastric matter in pyriform recess; no other identifiable ENT-related etiology for symptoms

39. Esophagram NL Manometry -Esophageal Body-NL -LES-NL DeMeester Score=22 -off meds -all upright reflux -no symptom correlation with cough -some symptom correlation with GERD -cough more pronounced off meds -3 proximal reflux events

40. Upper Endoscopy No esophagitis No hiatal hernia Slightly varigated squamocolumnar junction -less than 2 cm Biopsy obtained  Barrett’s esophagus without dysplasia

41. LPR Impedance

43. “Wisdom and understanding can only become the possession of individual men (and women) by traveling the old road of observation, attention, perseverance, and industry” -Samuel Smiles

45. LETS VOTE Nissen Fundoplication after lengthy informed consent?Nissen Fundoplication after lengthy informed consent? Increase PPI therapy?Increase PPI therapy? Promotility Agent?Promotility Agent? Antihistamines, beta-2 agonists, corticosteroidsAntihistamines, beta-2 agonists, corticosteroids Other TestsOther Tests

46. SE sxs GERD sxs Very Prevalent (PND, Asthma, Allergies, TOB) Very Prevalent Why is Making the Diagnosis so Difficult?