# Upper Gastrointestinal & Foregut Surgery — GCMD Library living collection

Updated: n/a · 6 episodes · 38 cited statements

## Episodes
### Gastroesophageal Reflux Disease
- [Gastroesophageal Reflux Disease](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751) — podcast · 33:57 · [machine version](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751.md)
- [V119 Use of transoral incisionless fundoplication for recurrent reflux after foregut surgery](https://library.globalcastmd.com/watch/v119-use-of-transoral-incisionless-fundoplication-for-recurrent-reflux-after-foregut-surgery-13729) — video · [machine version](https://library.globalcastmd.com/watch/v119-use-of-transoral-incisionless-fundoplication-for-recurrent-reflux-after-foregut-surgery-13729.md)
- [V119 Use of transoral incisionless fundoplication for recurrent reflux after foregut surgery](https://library.globalcastmd.com/watch/v119-use-of-transoral-incisionless-fundoplication-for-recurrent-reflux-after-foregut-surgery-13730) — video · [machine version](https://library.globalcastmd.com/watch/v119-use-of-transoral-incisionless-fundoplication-for-recurrent-reflux-after-foregut-surgery-13730.md)

### Gastroparesis & Gastric Motility
- [Safety and Feasibility of Per-Oral Pyloromyotomy as Augmentative Therapy after Prior Gastric Electrical Stimulation for Gastroparesis](https://library.globalcastmd.com/watch/safety-and-feasibility-of-per-oral-pyloromyotomy-as-augmentative-therapy-after-prior-gastric-electrical-stimulation-for-gastroparesis-13690) — article · [machine version](https://library.globalcastmd.com/watch/safety-and-feasibility-of-per-oral-pyloromyotomy-as-augmentative-therapy-after-prior-gastric-electrical-stimulation-for-gastroparesis-13690.md)
- [Laparoscopic pyloroplasty versus endoscopic per-oral pyloromyotomy for the treatment of gastroparesis](https://library.globalcastmd.com/watch/laparoscopic-pyloroplasty-versus-endoscopic-per-oral-pyloromyotomy-for-the-treatment-of-gastroparesis-13691) — article · [machine version](https://library.globalcastmd.com/watch/laparoscopic-pyloroplasty-versus-endoscopic-per-oral-pyloromyotomy-for-the-treatment-of-gastroparesis-13691.md)

### Gastric Neoplasms
- [Combined endoscopic/laparoscopic intragastric resection of gastric stromal tumors](https://library.globalcastmd.com/watch/combined-endoscopic-laparoscopic-intragastric-resection-of-gastric-stromal-tumors-13718) — article · [machine version](https://library.globalcastmd.com/watch/combined-endoscopic-laparoscopic-intragastric-resection-of-gastric-stromal-tumors-13718.md)

## Chapters
- [0:00](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=0) Initial evaluation and medical management of GERD (Ep 1)
- [3:34](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=214) Diagnostic workup: endoscopy, pH monitoring, and manometry (Ep 1)
- [7:12](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=432) Surgical technique: Nissen fundoplication (Ep 1)
- [18:35](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1115) Toupet fundoplication for weak esophageal motility (Ep 1)
- [21:00](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1260) Postoperative dysphagia and pseudoachalasia (Ep 1)
- [26:05](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1565) Reoperative surgery for wrap complications (Ep 1)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- Surgery for gastroesophageal reflux disease should be far down the treatment line after appropriate medical management and workup — Michael Rosen (clinical) [Ep 1 · 1:38](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=98)
- Initial trial of 20 mg daily Prilosec (omeprazole) for 6 weeks is appropriate first-line therapy for GERD symptoms — Michael Rosen (clinical) [Ep 1 · 2:27](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=147)
- There is mounting data that a lifetime of proton pump inhibitors has consequences associated with it — Michael Rosen (clinical) [Ep 1 · 3:34](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=214)
- Endoscopy is needed at minimum to assess esophagitis and in particular to rule out Barrett's esophagus in patients with persistent reflux symptoms — Michael Rosen (clinical) [Ep 1 · 4:06](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=246)
- 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 — Michael Rosen (opinion) [Ep 1 · 5:02](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=302)
- A pH study is needed to confirm the diagnosis of gastroesophageal reflux disease when endoscopy does not show evidence of esophagitis — Michael Rosen (clinical) [Ep 1 · 5:33](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=333)
- The Bravo test should be done off PPIs to provide symptom correlation, which is important for setting patient expectations about what surgery will improve — Michael Rosen (clinical) [Ep 1 · 6:19](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=379)
- Manometry is essential before any surgical discussion and should be part of the preoperative workup for patients potentially going down the operative road — Michael Rosen (clinical) [Ep 1 · 6:51](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=411)
- The basic reason for manometry is number one to rule out achalasia, because wrapping someone with achalasia destroys their esophageal function — Michael Rosen (clinical) [Ep 1 · 11:19](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=679)
- Manometry findings consistent with reflux include total relaxation of the lower esophageal sphincter with swallowing and low resting pressure of the LES — Michael Rosen (clinical) [Ep 1 · 12:25](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=745)
- 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 — Michael Rosen (clinical) [Ep 1 · 12:38](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=758)
- 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 — Michael Rosen (clinical) [Ep 1 · 13:27](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=807)
- 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 — Michael Rosen (clinical) [Ep 1 · 14:20](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=860)
- 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 — Michael Rosen (clinical) [Ep 1 · 14:38](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=878)
- 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 — Michael Rosen (opinion) [Ep 1 · 14:55](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=895)
- 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 — Jeff Ponsky (clinical) [Ep 1 · 15:18](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=918)
- 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 — Michael Rosen (clinical) [Ep 1 · 16:19](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=979)
- 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 — Michael Rosen (clinical) [Ep 1 · 16:43](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1003)
- 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 — Michael Rosen (clinical) [Ep 1 · 17:42](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1062)
- 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 — Michael Rosen (clinical) [Ep 1 · 19:05](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1145)
- 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 — Michael Rosen (clinical) [Ep 1 · 19:44](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1184)
- 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 — Michael Rosen (opinion) [Ep 1 · 21:33](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1293)
- 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 — Michael Rosen (clinical) [Ep 1 · 22:03](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1323)
- 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 — Michael Rosen (clinical) [Ep 1 · 22:17](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1337)
- 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 — Michael Rosen (clinical) [Ep 1 · 22:48](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1368)
- 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 — Michael Rosen (clinical) [Ep 1 · 23:17](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1397)
- 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 — Michael Rosen (clinical) [Ep 1 · 24:06](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1446)
- For pseudoachalasia, nutrition should be optimized before reoperation, with consideration of PEG tube feeding if needed — Michael Rosen (clinical) [Ep 1 · 24:57](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1497)
- For complex reoperative foregut surgery, the best approach is to plan to start over and take down the entire wrap, though sometimes dividing it and leaving half a wrap (Toupet) may be acceptable if the wrap cannot be fully taken down — Michael Rosen (clinical) [Ep 1 · 26:40](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1600)
- For morbidly obese patients with BMI over 35 and reflux, gastric bypass should be considered instead of fundoplication as the primary operation because Nissen does not work well in morbidly obese patients — Michael Rosen (clinical) [Ep 1 · 27:36](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1656)
- For symptomatic herniated wrap, reevaluation should include 48-hour Bravo study for symptom correlation, repeat manometry, and gastric emptying study especially if nausea and vomiting are prominent symptoms — Michael Rosen (clinical) [Ep 1 · 28:17](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1697)
- Nausea and vomiting as a large component of foregut patients' complaints are red flags to put the brakes on rushing to surgery and to understand what is going on, particularly regarding gastric emptying — Michael Rosen (clinical) [Ep 1 · 29:02](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1742)
- In reoperative fundoplication, the first goal is to reach the right crus to identify where the cava is and avoid injury; the liver and wrap often obliterate the right crus and drifting off the wrap can lead to caval injury — Michael Rosen (clinical) [Ep 1 · 30:18](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1818)
- When taking the liver off the wrap in reoperative surgery, sharp dissection with hook or scissors accepting bleeding is preferred over harmonic to avoid injuring the wrap that will be used later — Michael Rosen (clinical) [Ep 1 · 30:44](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1844)
- Most surgeons do not take the dissection low enough to the base of the crus; getting the crus at the base provides a choice of going right or straight up with known anatomy to avoid the cava — Michael Rosen (clinical) [Ep 1 · 31:11](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1871)
- Many fundoplications recur because there is not enough scar tissue in the chest; if struggling with dissection below, getting up in the chest and working back down is a useful strategy — Michael Rosen (clinical) [Ep 1 · 31:33](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1893)
- In reoperative surgery, the key is identifying named structures and digging them out in a systematic fashion rather than trying to make a space without proper dissection, or the surgeon will get lost quickly — Michael Rosen (clinical) [Ep 1 · 32:01](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1921)
- If the anterior vagus nerve is injured during reoperative fundoplication but the posterior vagus is intact, no acute intervention is needed in the operating room; postoperative upper GI on day 1 or 2 should assess gastric emptying, and early Botox of the pylorus is preferred over pyloroplasty if delayed emptying is a concern — Michael Rosen (clinical) [Ep 1 · 32:36](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1956)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- PPIs are preferred over H2 blockers because they are more effective at reducing gastric acid secretion and require less frequent dosing — Jeff Ponsky summarizes what Dr. Michael Rosen said [Ep 1 · 2:56](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=176)
- 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 — Jeff Ponsky summarizes what Dr. Michael Rosen said [Ep 1 · 5:50](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=350)
- Patients with achalasia can present with heartburn due to stasis and fermentation of food in the esophagus — Jeff Ponsky summarizes what Dr. Michael Rosen said [Ep 1 · 12:03](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=723)
- Treatment options for pseudoachalasia include taking down the Nissen, performing a Heller myotomy with Dor fundoplication, or taking down the Nissen, doing a long Heller, and converting to a Toupet — Jeff Ponsky summarizes what Dr. Michael Rosen said [Ep 1 · 25:22](https://library.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1522)

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