GERD And Diaphragmatic Hernia-1 (1).pptx

Power point presentation about gastro- esophageal reflux disease and diaphragmatic hernia.
Definition, management, investigations and differential diagnosis.
Types of diaphragmatic hernia, congenital diaphragmatic hernia and treatment.
Steps of fundoplication surgery, types and complications.

1. GERD And Diaphragmatic Hernia Anushka Kalia Roll no- 25 Batch-2020

2. Sabiston Textbook of Surgery Schwartz Principles of Surgery Bailey And Love’s Short Practice of Surgery ACG Clinical Guideline for Diagnosis and Management of Gastroesophageal Reflux Disease Bibliography

3. GERD Definition Clinical Features Etiology and Pathogenesis Lower Esophageal Sphincter Differentials Investigations Management: LARS+ Fundopication Diaphragmatic Hernia Definition Etiology and Pathogenesis Clinical Features Anatomical Classification Congenital Diaphragmatic hernia Investigations Treatment Objectives

4. Oesophagus Extent- C6 (Base of Pharynx) to T11 (joins cardia of stomach) Length - 25-30 cm Anatomic Narrowing- 3. (UES, LES) The esophagus is a two-layered, mucosa-lined muscular tube that travels through the neck, chest, and abdomen and rests in the posterior mediastinum

5. It is a chronic UGIT disease which occurs when there is retrograde flow of gastric contents through the LES with the typical symptoms including heartburn, regurgitation and dysphagia. GERD

6. Extra- esophageal symptoms

7. 1) DECREASED LOWER ESOPHAGEAL SPHINCTER PRESSURE Primary barrier to gastro esophageal reflux is the lower esophageal sphincter If barrier disrupted, acid goes from stomach to esophagus May be due to- Spontaneous transient LES relaxations Transient increase in intra abdominal pressure An atonic LES Etiology And Pathogenesis

8. 2)DISRUPTION OF ANATOMICAL BARRIERS Associated with hiatal hernia The size of hiatal hernia is proportional to the frequency of LES relaxations Hypotensive LES pressures and large hiatal hernia- more chance of GERD following abrupt increase in intra abdominal pressure 3) DELAYES GASTRIC EMPTYING Contd …

9. The LES has the primary role of preventing reflux of gastric contents into the esophagus. Protective Mechanism- Intrinsic distal esophageal muscles tonically contracted Muscular sling fibers of gastric cardia Diaphragmatic crura Transmitted pressure from the abdominal cavity Protective Function of LES

10. Not all Reflux are abnormal- spontaneous opening of the LES. Competent sphincter- α-blockers and β-stimulants decrease its pressure  Reflux Gastrin and motilin  increase LES pressure Cholecystokinin, estrogen , glucagon, progesterone , somatostatin, and secretin  decrease LES pressure Reflux Mechanism Length - 3-5 cm Pressure - 6 to 25 mm of Hg Abdominal Length – 2-4 cm Relaxation Time- 8.4 seconds

11. Permanently defective sphincter is defined by >=1 of the following: LES with a mean resting pressure of < 6 mmHg, overall sphincter length of <2 cm, intra-abdominal sphincter length of <1 cm Compared to normal subjects without GERD these values are below the 2.5 percentile for each parameter

12. Pathological v/s Physiological GERD Physiologic GERD Postprandial Short lived Asymptomatic No nocturnal sx Pathologic GERD Symptoms Mucosal injury Nocturnal sx

13. Differential Diagnosis Abdominal Pain Acute Gastritis Chronic Gastritis Esophageal spasm Esophagitis Peptic Ulcer Disease Angina pectoris (CAD) Dysphagia

14. Ambulatory pH and Impedance Monitoring Oesophageal Manometry Esophagogastroduodenoscopy Barium Oesophagram Investigations

15. Gold Standard Investigation . A 24-hour pH monitoring is conducted with a thin catheter, passed into the esophagus through the patient’s nares. Catheter is - dual-probe pH catheter. Contains two solid state electrodes that are spaced 10 cm apart and detect fluctuations in pH between 2 and 7. Distal electrode must be placed 5 cm proximal to the LES. Ambulatory pH and Impedance

16. Data gathered – ( i ) Total number of reflux episodes (pH <4) cutoff value (ii) Longest episode of reflux, (iii) Number of episodes lasting >5 minutes, (iv) Percentage of time spent in reflux in the upright and supine positions. DeMeester score- To quantify the capacity to cause esophageal injury. Abnormal distal esophageal acid exposure is- DeMeester score of 14.7 or higher . Interpretation

17. Done for- Assessing function of the esophageal body and the LES. Procedure- 32-channel flexible catheter with pressure-sensing devices arranged at 1-cm intervals is placed into the esophagus through the nares. Study is conducted in approximately 15 minutes, during which time the patient performs 10 swallows. Oesophageal Manometry

18. A color-contour plot is generated and shows-: 1.Response of the UES and LES as well as of the esophageal body; 2.Time is on the x-axis, 3.Oesophageal length is on the y-axis, 4.Pressure is represented by a color scale

19. Endoscopy is essential in the evaluation of patients with GERD who are being considered for LARS. Esophagus should be examined for- mucosal injury due to GER, including ulcerations, peptic strictures, and Barrett esophagus. EGD also identifies possible presence and severity of complications- esophagitis, Barret’s esophagus, strictures etc The LA (Los Angeles) System of classification of EE is the most widely used and validated scoring system Esophagogastroduodenoscopy

20. Barium esophagram provides a detailed anatomic evaluation of the esophagus and stomach. Of particular importance are the presence, size, and anatomic characteristics of a hiatal hernia or PEH Barium Esophagogram

21. Goals of therapy- —Symptomatic relief —Heal esophagitis —Prevent & Treat complications —Maintain remission Treatment

22. Avoid Alcohol, chocolate, citrus juice and tomato-based products (Ref- 2005 guidelines from the American College of Gastroenterology) Losing weight (if overweight) Smoking cessation- Tobacco causes acid reflux Wait at least 2-3 hours after eating before laying down to sleep. Gravity is one of biggest protection against acid reflux. Elevating head of bed by 6-10 inches. Avoid large meals Management : Lifestyle Modifications

23. H2 Receptor Antagonist DOC- PPI for 8 weeks (ADR on long term use- loss of bone density, dementia, myocardial infarction, micronutrient (magnesium, iron, B-12) deficiencies, kidney disease, and interactions with antiplatelet medications) Prokinetics - Metoclopramide has been shown to increase LES pressure, enhance esophageal peristalsis, and augment gastric emptying Baclofen - GABA agonist, reduces the transient LES relaxations that enable reflux episodes. Sucralfate – Mucosal Protective Agent Medical Management

24. Considered for- Patient not responding to medical management. Patient suffering from complications of GERD like- Barret’s esophagus , stricture formation or cancer. GERD+ hiatal hernia Surgical Management

25. To restore adequate intra-abdominal length of esophagus ( at least 2 cm) Increase in the pressure of the LES to a level twice the resting gastric pressure (i.e., 12 mmHg for a gastric pressure of 6 mmHg) Wrap the fundus around esophagus Principles Of Surgery

26. Position of Patient : Low Lithotomy Reverse Trendelenburg. Access to the abdomen- Veress needle passed at Palmer point in the left upper quadrant of the abdomen. Three additional trocars are placed. Surgeon operates through the two most cephalad ports , Assistant operates through the two caudad ports LARS: Laparoscopic Anti-Reflux Surgery

27. 1. Begin dissection at the left crus by dividing the phrenogastric membrane and then enter the lesser sac at the level of the inferior edge of the spleen. 2. After the fundus is mobilized, the phreno-esophageal membrane is divided to expose the entire length of the left crus. Steps In Surgery

28. 3. Right crural dissection is then performed. The gastro-hepatic ligament is divided, and the right phreno-esophageal membrane is opened to expose the right crus. 4. A retroesophageal window is created.

29. 5. The esophagus is mobilized in the posterior mediastinum to obtain a minimum of 3 cm of intra abdominal esophagus. 6. After that, the crura are approximated posteriorly with permanent sutures 7. The esophagus should maintain a straight orientation without angulation. At this point, the fundoplication is created

30. Fundoplication Complete Wrap: Nissen’s (360) Partial Wrap

31. 1. Posterior aspect of the fundus is marked with a suture 3 cm distal to the GEJ and 2 cm off the greater curvature  To maintain proper orientation of Fundus. Nissen’s Fundoplication (360 degree)

32. 2. The posterior fundus is then passed behind the esophagus from the patient’s left to right. 3. The anterior fundus on the left side of the esophagus is then grasped 2 cm from the greater curvature and 3 cm from the GEJ. 4. Both portions of the fundus are positioned on the anterior aspect of the esophagus.

33. 5. With use of three or four interrupted permanent sutures, the fundoplication is created to a length of 2.5 to 3 cm. 6. Completed fundoplication should allow the easy passage of a 52 Fr bougie 7. After removal of the bougie, the wrap is anchored to the esophagus and crura to prevent herniation into the mediastinum. 8. The suture line of the fundoplication should lie parallel to the right anterior aspect of the esophagus.

34. Most Commonly performed- Toupet fundoplication Similar to 360 degrees fundoplication. Key difference- Fundus of stomach is wrapped 180 to 270 degrees (compared with 360 degrees) around the posterior aspect of the esophagus. Partial Fundoplication

35. Postoperative ileus Pneumothorax Urinary retention Dysphagia Liver and/or Spleen trauma Acute herniation Perforated viscus Death Operative Complications of LARS

36. Patients are given a clear liquid diet the evening of the operation and are advanced to a full liquid diet on postoperative day 1. After discharge from the hospital, patients can slowly introduce soft foods into their diet, and they should expect to resume a diet without limitations in about 4 to 6 weeks. Post-operative Care And Recovery

37. Diaphragmatic Hernia

38. Diaphragmatic hernia (DH) is a protrusion of abdominal contents into the thoracic cavity due to a defect within the diaphragm. Diaphragmatic Hernia

39. Idiopathic Congenital Hiatal hernias are often associated with GERD because their abnormal anatomy compromises the efficacy of the LES Mostly sporadic but familial cases have also been reported Genetics CHD is also a part of several syndrome: trisomy 21 , trisomy 13 , trisomy 18 and turner syndrome] Etiology

40. Two key events that facilitate the formation of a PEH are-  Widening of the diaphragmatic crura at the esophageal hiatus. S tretching of the phreno-esophageal membrane Hernia enlarges  phreno-esophageal membrane balloons into the posterior mediastinum  Viscera enters sac. Adhesions develop between the wall of the sac and the surrounding thoracic structures  Hernia develops Pathogenesis

41. Type I (Sliding hernia) Most common type Gastroesophageal junction migrates above the diaphragm. The stomach remains in its usual longitudinal alignment and the fundus remains below the gastroesophageal junction. Not life-threatening Type II (Rolling hernia/ Paraesophageal hernia) GEJ remains in its normal anatomic position. Portion of the fundus herniates through the diaphragmatic hiatus adjacent to the esophagus. Herniated portion can undergo volvulus and necrosis  can be life threatening Associated with- Cameron ulcers Anatomic Classification

42. Type III Combination of Types I and II Both the GEJ and the fundus herniate through the hiatus. Fundus lies above the gastroesophageal junction. Type IV Presence of a structure other than stomach, such as the omentum , colon or small bowel within the hernia sac.

43. Development Of Diaphragm Septum transverse :- central tendon of diaphragm [connective tissue, capsules , sinusoids, kupffer cells] Pleuroperitoneal membrane Peripheral body wall muscle Mesentery around esophagus

44. Congenital Diaphragmatic Hernia Bochdalek Hernia Most common congenital diaphragmatic hernia Present- posterolateral Left >right Defect in- pleuroperitoneal membrane Stomach, spleen ,transverse colon can herniate Morgagni Hernia (Retrosternal) less common Present- anteromedial Right> Left Defect in- central tendon of diaphragm Transverse colon usually herniates

45. The symptoms of PEH are diverse and nonspecific. Common symptoms attributed to PEH are Dysphagia, odynophagia, and postprandial chest pain, early satiety When intermittent visceral torsion and distention occur, epigastric and chest pain can develop due to ischemia of the hernia contents. Spontaneous reduction then provides relief of these symptoms Clinical Features

46. Clinical investigations are similar to those of patients undergoing workup for GERD. Barium esophagogram provides the operating surgeon the most accurate image of the gastroesophageal anatomy. A- Type I B- Type II Investigations

47. Endoscopy- E valuates the gastric and esophageal mucosa for- Cameron Ulcers Barrett’s esophagus Manometry- To determine the motor function of the esophageal body, which can affect the type of antireflux operation performed at the time of PEH repair. Ambulatory pH monitoring CECT Investigations: Contd

48. Surgical correction- preferred approach is laparoscopic Hernia R epair . Management 4 key steps to Hernia repair: (1) reduction of the hernia contents to the abdominal cavity; (2) complete excision of the hernia sac from the posterior mediastinum; (3) mobilization of the distal esophagus to achieve a minimum of 3 cm of intra abdominal esophageal length; and (4) an antireflux operation.

49. Thank You