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Fisiopatologia del Reflusso e delle Plastiche Antireflusso







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

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Slide 1

C

II I

Sez. Chirurgia Esofago-Gastrica

U.Fumagalli

UO Chirurgia Generale e Mininvasiva

Resp: R.Rosati

Istituto Clinico

HUMANITAS

Rozzano - Italy

  • Fisiopatologia del Reflusso e delle Plastiche Antireflusso

XXIV Congr. Naz. ACOI , Montecatini 2005

Slide 2

GERD pathophysiology

Impaired mucosal defense

Poor esophageal clearance

Hiatal hernia

(promotes LES dysf.)

TLESR

  • LES pressure abn

    • Hypotensive sphincter

Acid

Pepsin

Bile

Food

Delayed gastric emptying

Slide 3

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

Slide 4

GERD

Pyrosis, regurgitation

Aggravated by recumbency or bending

Relieved by antacids

Dysphagus, odynophagia, bleeding, weight loss, anemia

Long standing symptoms

Symptoms of complicated disease

Risk for BE

History: uncomplicated GERD

Empirical therapy (incl. lifestyle)

Endoscopy

Symptoms do not predict degree of esophagitis

Mucosal injury in less than 50% of patients

Guidelines for diagnosis and treatment of GERD Am.Coll.Gastroent. 2005

Slide 5

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

Slide 6

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 normal DMS (n 15)

Preoperative abnormal DMS (n 208)

Khajanchee Am J Surg 2004

Slide 7

EXTRAESOHAGEAL MANIFESTATIONS OF GERD

Slide 8

Suspected GERD extraesophageal manifestations

success

PPI twice daily for 3-6 months

failure

Taper down to lower PPI dose that controls symptoms

24 pH metry on therapy

-

+

Consider non GERD related manifestations

Increase PPI dose

Slide 9

Outcomes of typical and atypical symptoms attributed to GERD treated by laparoscopic fundoplication

So JB Surgery, 1998

Slide 10

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 (?)

Slide 11

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

Partial fundopl. (n 39)

Total fundopl. (n 57)

Oleynikov Pellegrini, Surg Endosc 2002

Slide 12

C

II I

UO Chirurgia Generale e Mininvasiva

Resp: R.Rosati

Sez. Chirurgia Esofago-Gastrica

U.Fumagalli

GERD – Taylored surgery

May 1996 – April 2005: 228 op. for GERD

Slide 13

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)

Jenkinson AD, Br J Surg 2004

48% of patients with Barrett esophagus, asymptomatic under PPI have pathologic acid reflux

Sarela AI, Arch Surg 2004

Slide 14

C

II I

UO Chirurgia Generale e Mininvasiva

Resp: R.Rosati

Sez. Chirurgia Esofago-Gastrica

U.Fumagalli

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

Slide 15

  • Conclusions

  • 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 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);

  • Great expectations exist for the results of impedance monitoring in patients with gastroesophageal reflux disease


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