Testing before GERD / FUNDOPLICATION SURGERY

Dr Pravin John& Dr John Thanakumar discuss preop testing and counseling in GERD surgery. #LAPAROSCOPIC SURGERY #NISSENFUNDO #TOUPET #REFLUXSURGERY

1. ANURAG HOSPITAL, COIMBATORE. WWW.ANURAG-HOSPITAL.COM TIPS ON TESTS BEFORE ANTIREFLUX SURGERY Dr PRAVIN HECTOR JOHN MS, FIAGES, FALS, FIBC & Dr JOHN AC THANAKUMAR MBBS, MS, MNAMS, FRCS (Ed), FRCS (G), Dip MIS (Strasbourg), FICS, FALS.

2. GENERAL COMMENTS POOR DIAGNOSIS POOR OUTCOME SUCCESS OF REOPERATIONS IS LESS SPASTIC DISTURBANCES CAN PRODUCE HEART BURNS

3. OTHER CAUSES OF DEFECTIVE LES AND ESOPHAGITIS RED FLAGS APART FROM GERD, XEROSTOMIA, HYPO-MOTILITY OF ESOPAHGUS DELAYED GASTRIC EMPTYING DUODENO GASTRIC REFLUX

4. SO BEFORE SURGERY, CONSIDER 1) THOROUGH HISTORY & COUNSELLING

5. 2) pH MONITORING 24 Hour pH for extent of eosphageal exposure to acid 24 hour tranasnasal probe or a small capsule (Bravo) attached to mucosa which transmits pH via radio-teletry Both valid & reproducible Demonstrates if reflux is postprandial, duration, time of day, with ref to symptoms Avoid surgery with normal 24 Hr pH reading - results are poor SO BEFORE SURGERY, CONSIDER

6. Cautions before pH monitoring PPI off for a week Histamine H2Blockers off for 2 days Beware of cheats who don’t comply when the pH result is normal SO BEFORE SURGERY, CONSIDER Withholding PPI Good test when symptoms recur If no response, use caution

7. pH TEST NOT ALWAYS NECESSARY Obvious defective LES (manometry) Obvious esophagitis (endoscopy) In very large paraesophageal hernias

8. 3) IMPEDANCE TESTING - (a corollary to 24 pH monitoring) Current is conducted by ions on mucosa in empty esophagus Liquids with more ions increase conductivity and decrease resistance By measuring impedence at various sites in catheter, direction can be made out as antegrade (bolus) and retrograde reflux (acid) Combine pH monitoring with impedance testing - all reflux can be measured Impedance testing is useful for cough, with normal pH studies SO BEFORE SURGERY, CONSIDER

9. 4) MANOMETRY - measures up/lower esophageal sphincters, functions High resolution manometry with pressure transducers are useful Oesophago-gastric outflow junctions Major peristaltic disorders (eg nutcracker) Minor peristaltic disorders SO BEFORE SURGERY, CONSIDER MANOMETRY WITH IMPEDENCE 1.Guides surgeon to functional surgery 2.Warns of contra-indications for surgery 3.If test impossible, do partial fundo

10. 5) IMPEDENCE MANOMETRY - for different bolus in different positions New Done with different bolus consistencies in different body positions Studies esophageal function before and after surgery SO BEFORE SURGERY, CONSIDER

11. 6) BARIUM ESOPHAGOGRAM - Functional info of oesophagus In pts unable to tolerate manometric studies Identifies nature & position of hiatal hernia Newer effervescent crystals show Mucosa ( ulcers, infections, tumors) Propulsion of oesophagus Anatomical facts like strictures Free reflux +/- SO BEFORE SURGERY, CONSIDER Communicate with radiologist

12. 7) ENDOSCOPY - Critical & biopsy HPE - Barrett, ca, eosinophilic esophagitis Length of Barrett’s esophagus Size of Hiatal hernia Presence of esophagitis Stricture SO BEFORE SURGERY, CONSIDER LOS ANGELES CLASS OF ESOPHAGITIS Grade: mucosal break < 5 mm Grade: mucosal break > 5 mm Grade: mucosal break < 75% Oce Grade: mucosal break > 75% Oce

13. 8) GASTRIC EMPTYING STUDIES Radiolabelled low-fat eggwhites with imaging upto 4 hours after meals Delayed gastric emptying time mars Nissen fundoplication results SO BEFORE SURGERY, CONSIDER RED FLAGS indicate GASTRIC EMPTYING STUDIES Nausea & vomiting Postprandial fulness / bloating

14. In summary -1 TESTS for BARRET’S ESOPHAGUS Endoscopy , biopsy Manometry for hypo motility TESTS for LARGE PARAESOPHAGEAL HERNIAS Ba / CT studies Endoscopy PS: Manometry / pH studies not required

15. TESTS for MYOTOMY /DIVERTICULAE Barium / CT Endoscopy Manometry - to assess types In summary -2 TEST for RE-SURGERY AFTER FUNDO FAILED FUNO HISTORY Endoscopy CT scans Manometry Gastric emptying studies

16. Thank you www.anurag-hospital.com