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GERD Procedures: When and What?

  • Evidence-Based Current Surgical Practice
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Background

The topic of “when and what” for gastroesophageal reflux disease (GERD) procedures centers on the correct indications for antireflux surgery gleaned from a thorough preoperative evaluation (the “when”) and on the right antireflux operation to perform once the ideal candidate is identified (the “what”).

Aims

The goals of this evidence-based review are the following: (1) to identify the key indications for surgery and predictors of good outcomes in the initial evaluation of patients with symptoms of GERD; (2) to describe the operations for GERD in the armamentarium of the general surgeon and their indications, as well as the technical elements of the operation; and (3) to describe the optimal surgical treatment of GERD and obesity when the two diseases coexist.

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Conflict of Interest

The authors have no conflicts of interest to declare.

Author information

Authors and Affiliations

  1. Department of Surgery, Boston VA Healthcare System, Harvard Medical School, 1400 VFW Parkway, West Roxbury, Boston, MA, 02132, USA

    P. Marco Fisichella

  2. Department of Surgery, Center for Esophageal Diseases, University of Chicago Pritzker School of Medicine, Chicago, IL, USA

    Marco G. Patti

Authors
  1. P. Marco Fisichella
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  2. Marco G. Patti
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Corresponding author

Correspondence to P. Marco Fisichella.

Additional information

Answers:

1. d

2. d

3. a

4. d

5. a

6. b

7. b

8. b

Questions

Questions

CME/MOC question 1

A 55 year-old male with hypertension and a BMI of 27 has been complaining of mild heartburn once a week and daily cough for 5 years. Cough has been worsening despite therapy with pantoprazole 40 mg twice a day and H2-blockers in the evening for the past year and a half. His primary care physician suspected GERD was responsible for this patient’s cough. Upper endoscopy is unremarkable.

What is the best initial diagnostic test in the work-up?

a) Barium esophagogram

b) High-resolution esophageal manometry

c) 48 pH-monitoring on Proton Pump Inhibitors

d) Manometry and multichannel intraluminal impedance pH-monitoring

CME/MOC question 2

A 25 year-old female with hypertension, non-insulin dependent diabetes, and a BMI of 38 has been complaining of daily heartburn and regurgitation. Symptoms have been well controlled with a therapy of 20 mg pantoprazole twice a day. Esophageal manometry shows 70 % peristalsis with a distal esophageal amplitude of 25 mm Hg. Also, pH monitoring shows a pathologic amount of reflux (DeMeester score of 25). Upper endoscopy shows Los Angeles grade B esophagitis

What is the best course of treatment?

a) Laparoscopic total fundoplication

b) Laparoscopic partial fundoplication

c) Laparoscopic sleeve gastrectomy

d) Laparoscopic gastric bypass

CME/MOC question 3

A 28 year-old female with no major medical problems has been complaining of daily heartburn and regurgitation. Symptoms have been well controlled with a therapy of 20 mg pantoprazole once a day. Esophageal manometry shows 100 % peristalsis with a distal esophageal amplitude of 70 mm Hg. Also, pH monitoring off PPIs shows a pathologic amount of reflux (DeMeester score of 56). Upper endoscopy shows Los Angeles grade A esophagitis.

What is the next best in the management?

a) Laparoscopic total fundoplication

b) Laparoscopic partial fundoplication

c) Roux-en-Y gastric bypass

d) Collis gastroplasty

CME/MOC question 4

A 32 year-old male has been complaining of progressive dysphagia with solids, and some mild “reflux” – as he described it. His PCP prescribed him a therapy of 20 mg pantoprazole once a day, which had only mild effects on his symptoms. Upper endoscopy shows an esophageal ulceration in the distal esophagus and pH monitoring off PPIs shows a pathologic amount of reflux (DeMeester score of 289). Manometry was not done before the catheter pH monitoring test.

What is the next best in the management?

a) Laparoscopic total fundoplication

b) Barium swallow

c) Laparoscopic partial fundoplication

d) Esophageal manometry to determine the position of the lower esophageal sphincter followed by ambulatory pH monitoring

CME/MOC question 5

You are doing a laparoscopic Nissen fundoplication in a 56 year-old male who has been complaining of heartburn and regurgitation. Manometry is normal and a pH monitoring test off PPIs showed a pathologic amount of reflux (DeMeester score of 78). Barium swallow and endoscopy failed to show the presence of a hiatal hernia. Which of the steps listed below should not be part of the operation?

a) Collis gastroplasty

b) Division of the short gastric vessels

c) Using a bougie

d) A total fundoplication

CME/MOC question 6

A 45 year-old Caucasian man complains of dysphagia, regurgitation, heartburn, and chest discomfort. Upper endoscopy shows Los Angeles grade A esophagitis. Capsule pH-monitoring showed a pathologic amount of reflux (DeMeester score of 201). The patient undergoes a laparoscopic Nissen fundoplication after which he cannot swallow any no liquids or solids. What is the underlying cause?

a) Ineffective esophageal motility disorder

b) Achalasia

c) Sliding hiatal hernia

d) Severe esophagitis

CME/MOC question 7

A 80 year-old female with dementia has been complaining of daily heartburn, regurgitation, and chest discomfort after eating. Cardiac work-up is normal. Esophageal manometry could not be performed, as she did not tolerate placement of the catheter. Upper endoscopy shows a very large hernia; Barium swallow shows a large type III paraesophageal hernia. Also, pH-monitoring could not be performed.

What is the next best in the management?

a) Percutaneous gastrostomy tube

b) Laparoscopic reduction on the hernia and partial fundoplication

c) Laparoscopic reduction of the hernia and total fundoplication

d) Laparoscopic reduction of thehernia and gastropexy

CME/MOC question 8

A 23 year-old female with scleroderma has been complaining of daily heartburn, regurgitation, and dysphagia. Heartburn has been poorly controlled with 40 mg of pantoprazole twice a day. Regurgitation continues to be severe. Upper endoscopy shows a patulous gastroesophageal junction. Barium swallow shows delayed passage of contrast into the stomach without obstruction. Esophageal manometry shows progression of peristaltic waves but a distalesophageal amplitude of 15 mmHg. Ambulatory pH monitoring off PPIs shows a pathologic amount of reflux (DeMeester score of 81).

What is the next best in the management?

a) Percutaneous gastrostomy tube

b) Laparoscopic partial fundoplication

c) Laparoscopic total fundoplication

d) Collis gastroplasty

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Fisichella, P.M., Patti, M.G. GERD Procedures: When and What?. J Gastrointest Surg 18, 2047–2053 (2014). https://doi.org/10.1007/s11605-014-2558-5

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  • DOI: https://doi.org/10.1007/s11605-014-2558-5

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