Educational content from recorded physician discussions — not medical advice. Always talk to your child's care team about your child's situation.
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Gastroesophageal Reflux Disease
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Gastroesophageal Reflux Disease
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An interactive discussion about gastroesophageal reflux disease between Jeffrey Ponsky, MD and Michael Rosen, MD. Dr. Rosen is a professor of surgery at the Cl
podcast33:57 · Jul 2026
Endoscopic Reflux Management2 items
V119 Use of transoral incisionless fundoplication for recurrent reflux after foregut surgery
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This video was part of the Video Loop during the SAGES 2020 Virtual Meeting. Topic: Flexible Endoscopy Use of transoral incisionless fundoplication for recurrent reflux after foregut surgery. Jessica Ardila-Gatas, MD, Joshua Landreneau, MD,
video · Jul 2026
V119 Use of transoral incisionless fundoplication for recurrent reflux after foregut surgery
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V119 Use of transoral incisionless fundoplication for recurrent reflux after foregut surgery Verify to continue To continue, please confirm that you're a human (and not a spambot). Checking if the site connection is secure vimeo.com needs t
video · Jul 2026
Gastroparesis & Gastric Motility
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Pyloromyotomy Techniques2 items
Safety and Feasibility of Per-Oral Pyloromyotomy as Augmentative Therapy after Prior Gastric Electrical Stimulation for Gastroparesis
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Per-oral pyloromyotomy appears to be safe and feasible for patients with recurrent gastroparesis symptoms after GES. Both symptoms and motility significantly improved in the short-term. These data replicate similar data suggesting laparosco
article · Jul 2026
Laparoscopic pyloroplasty versus endoscopic per-oral pyloromyotomy for the treatment of gastroparesis
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Per-oral endoscopic pyloromyotomy (POP) is safe and effective for the treatment of medical refractory gastroparesis. POP has less perioperative morbidity compared to LP with comparative functional outcomes.
article · Jul 2026
Gastric Neoplasms
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Combined endoscopic/laparoscopic intragastric resection of gastric stromal tumors
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Journal of Gastrointestinal Surgery - Myogenic neoplasms of the stomach are the most common submucosal mass. Their natural history is indeterminate, and surgical resection is advised regardless of...
article · Jul 2026
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Surgical management of GERD requires systematic preoperative evaluation after medical optimization. Initial therapy with PPI (20 mg omeprazole daily for 6 weeks) is appropriate, though mounting data suggest long-term PPI use carries consequences including osteoporosis risk, particularly in young patients. Endoscopy is essential to assess esophagitis and exclude Barrett's esophagus. When endoscopy is negative, pH monitoring (preferably 48-hour Bravo off PPIs) confirms reflux and provides symptom correlation critical for setting surgical expectations. Manometry is mandatory preoperatively, primarily to exclude achalasia—wrapping an achalasic esophagus destroys function. Manometric findings guide wrap selection: normal peristalsis (≥30 mmHg amplitude) supports full Nissen, while weak peristalsis (<20 mmHg) necessitates Toupet to avoid dysphagia. Wrap geometry is paramount; the operation lacks standardization, and common errors include excessive length (>2 cm) contributing to dysphagia. Early postoperative dysphagia is expected and should not prompt intervention before 3 months unless the patient tolerates only liquids. Pseudoachalasia—a devastating complication presenting with dilated esophagus and non-relaxing LES—likely results from prolonged tight-wrap dysphagia and requires nutritional optimization before complex reoperation.
- Manometry is mandatory preoperatively to exclude achalasia; wrapping an achalasic esophagus destroys function. Manometric amplitudes guide wrap selection: ≥30 mmHg supports Nissen, <20 mmHg requires Toupet.[e13751-c10][e13751-c11][e13751-c15][e13751-c23]
- Wrap geometry is the most critical technical factor. Common error: excessive length (>2 cm) increases dysphagia. Use 3 sutures, start stomach-to-stomach for positioning control.[e13751-c19][e13751-c20][e13751-c21]
- Early dysphagia is expected; wraps are tightest immediately postop and loosen over time. No intervention before 3 months unless patient tolerates only liquids.[e13751-c27][e13751-c28]
- Pseudoachalasia after fundoplication presents with dilated esophagus, retained fluid, and non-relaxing LES on manometry—likely from prolonged tight-wrap dysphagia causing esophageal dysfunction.[e13751-c30][e13751-c31]
- In reoperative surgery, identify the right crus first to locate the cava and avoid injury. Most surgeons dissect insufficiently low at the crural base.[e13751-c37][e13751-c39]
For patients & families
When heartburn and reflux symptoms persist, doctors follow a careful step-by-step approach before considering surgery. Treatment typically begins with medication—often a proton pump inhibitor like omeprazole—for at least six weeks. If symptoms continue, physicians use specialized tests to understand what's happening: an endoscopy looks inside the esophagus to check for damage or changes like Barrett's esophagus, a pH study measures acid levels over 48 hours to confirm reflux is actually occurring, and a test called manometry checks how well the esophagus squeezes and relaxes. These tests are important because they help doctors rule out other conditions—like achalasia, where the esophagus doesn't relax properly—that would need different treatment. Surgery, called fundoplication, is reserved for patients who have tried medical management and completed this workup. The operation wraps part of the stomach around the lower esophagus to prevent acid from coming up, but it changes how a person swallows and how their stomach works. Doctors choose between different wrap styles based on how strong the esophagus muscles are.
When heartburn and reflux symptoms persist, doctors follow a careful step-by-step approach before considering surgery. Treatment typically begins with medication—often a proton pump inhibitor like omeprazole—for at least six weeks. If symptoms continue, physicians use specialized tests to understand what's happening: an endoscopy looks inside the esophagus to check for damage or changes like Barrett's esophagus, a pH study measures acid levels over 48 hours to confirm reflux is actually occurring, and a test called manometry checks how well the esophagus squeezes and relaxes. These tests are important because they help doctors rule out other conditions—like achalasia, where the esophagus doesn't relax properly—that would need different treatment. Surgery, called fundoplication, is reserved for patients who have tried medical management and completed this workup. The operation wraps part of the stomach around the lower esophagus to prevent acid from coming up, but it changes how a person swallows and how their stomach works. Doctors choose between different wrap styles based on how strong the esophagus muscles are.
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Every expert statement below comes from the recorded discussions, with its speaker and moment.
Gastroesophageal Reflux Disease
Surgery for gastroesophageal reflux disease should be far down the treatment line after appropriate medical management and workup
clinicalMichael Rosen1:38 ↗
Initial trial of 20 mg daily Prilosec (omeprazole) for 6 weeks is appropriate first-line therapy for GERD symptoms
clinicalMichael Rosen2:27 ↗
PPIs are preferred over H2 blockers because they are more effective at reducing gastric acid secretion and require less frequent dosing
Host summaryJeff Ponsky summarizes what Dr. Michael Rosen said — not the host's own clinical position2:56 ↗
There is mounting data that a lifetime of proton pump inhibitors has consequences associated with it
clinicalMichael Rosen3:34 ↗
Endoscopy is needed at minimum to assess esophagitis and in particular to rule out Barrett's esophagus in patients with persistent reflux symptoms
clinicalMichael Rosen4:06 ↗
In 2016, for a patient without esophagitis, hiatal hernia, or Barrett's, more workup is warranted before keeping them on PPIs indefinitely, especially in young active persons due to concerns about osteoporosis and other issues
opinionMichael Rosen5:02 ↗
A pH study is needed to confirm the diagnosis of gastroesophageal reflux disease when endoscopy does not show evidence of esophagitis
clinicalMichael Rosen5:33 ↗
Bravo study is preferred over traditional pH probe because it is easier for the patient (no nasal tube) and provides 48 hours of pH data
Host summaryJeff Ponsky summarizes what Dr. Michael Rosen said — not the host's own clinical position5:50 ↗
The Bravo test should be done off PPIs to provide symptom correlation, which is important for setting patient expectations about what surgery will improve
clinicalMichael Rosen6:19 ↗
Manometry is essential before any surgical discussion and should be part of the preoperative workup for patients potentially going down the operative road
clinicalMichael Rosen6:51 ↗
The basic reason for manometry is number one to rule out achalasia, because wrapping someone with achalasia destroys their esophageal function
clinicalMichael Rosen11:19 ↗
Patients with achalasia can present with heartburn due to stasis and fermentation of food in the esophagus
Host summaryJeff Ponsky summarizes what Dr. Michael Rosen said — not the host's own clinical position12:03 ↗
Manometry findings consistent with reflux include total relaxation of the lower esophageal sphincter with swallowing and low resting pressure of the LES
clinicalMichael Rosen12:25 ↗
Distal esophageal amplitudes on manometry can be used to tailor the fundoplication, with discussion about the difference between a floppy Nissen and a Toupet based on esophageal motility
clinicalMichael Rosen12:38 ↗
A patient with normal peristalsis (amplitude of 30 mmHg or higher), total LES relaxation, DeMeester score of 28, and a 2 cm hiatal hernia should receive a full Nissen fundoplication
clinicalMichael Rosen13:27 ↗
One disadvantage of laparoscopic fundoplication is that it does not create much scar tissue; full mediastinal dissection helps reduce recurrences by creating ability for the area to scar down and provides more esophageal length
clinicalMichael Rosen14:20 ↗
Taking down the short gastric vessels makes it easier to avoid twisting the wrap and to see exactly what is being brought around during fundoplication
clinicalMichael Rosen14:38 ↗
The way a Nissen is created is highly variable and one of the downsides of this operation is lack of standardization, making it hard to reproduce data
opinionMichael Rosen14:55 ↗
The geometry of the wrap is the most important part of the operation; surgeons should take time to ensure proper geometry and not be afraid to take down and reestablish the wrap if it does not look right
clinicalJeff Ponsky15:18 ↗
A common mistake is making the Nissen wrap too long, which adds to dysphagia; the wrap should be about 2 centimeters with typically 3 sutures
clinicalMichael Rosen16:19 ↗
The first stitch in a Nissen should be stomach to stomach so the knot can be used to move the wrap and ensure proper positioning before placing additional sutures
clinicalMichael Rosen16:43 ↗
A bougie is not routinely needed during crural closure in experienced hands; the esophagus should have a little V-shaped triangle of air below it
clinicalMichael Rosen17:42 ↗
In patients with weak peristalsis (amplitude below 20 mmHg) and weak LES, the best operation to prevent reflux is still a Nissen, but the esophageal pump does not work well enough to overcome that barrier, necessitating a Toupet to avoid creating dysphagia
clinicalMichael Rosen19:05 ↗
A Toupet fundoplication is a posterior 270-degree wrap that is about 2.5 to almost 3 centimeters long with 3 sutures on either side through esophagus to stomach
clinicalMichael Rosen19:44 ↗
The hardest transition of becoming an attending doing foregut surgery is managing patient satisfaction after fundoplication and realizing patients come back with complaints and issues
opinionMichael Rosen21:33 ↗
Fundoplication changes the way patients swallow, the way their stomach works, and the way acid moves from their body; patients must be counseled preoperatively about these changes
clinicalMichael Rosen22:03 ↗
The fundoplication is tightest right after surgery and gets looser over time; early dysphagia is expected and the patient who has no dysphagia at 2 weeks likely has a wrap that is too loose
clinicalMichael Rosen22:17 ↗
Dysphagia should not be a concern for the first 6 weeks postoperatively, even if the patient maintains a liquid diet, and endoscopic intervention should not be considered until 3 months with no progression and inability to tolerate anything besides liquids
clinicalMichael Rosen22:48 ↗
For persistent dysphagia at 6-8 months, workup should include upper GI to rule out hernia recurrence and look for anatomic causes, followed by endoscopy with dilation if the wrap appears too tight
clinicalMichael Rosen23:17 ↗
Pseudoachalasia after fundoplication presents with dilated esophagus, retained fluid, tight GE junction on endoscopy, and manometry showing lack of peristalsis and non-relaxing LES; this likely occurs when the wrap is too tight and prolonged dysphagia causes the esophagus to burn out
clinicalMichael Rosen24:06 ↗
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