Gastroesopheal Reflux Disease
With Dr. Michael Rosen · hosted by Dr. Jeff Ponsky · StayCurrentMD
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
PPIs reduce gastric acid secretion more effectively than H2 blockers and are more convenient as once-daily medication
Mounting data shows that lifetime use of proton pump inhibitors has consequences
Patients with reflux symptoms requiring chronic PPI use need endoscopy at minimum to assess esophagitis and rule out Barrett's esophagus
In 2016, patients without esophagitis, hiatal hernia, or Barrett's on endoscopy require additional workup before indefinite PPI therapy, especially young patients at risk for osteoporosis
Bravo pH study is preferred over nasal catheter for patient comfort, measuring 48 hours of pH data via endoscopically placed capsule 6cm above GE junction
Bravo pH testing off PPIs is preferred to establish symptom correlation, which is important for setting patient expectations about surgical outcomes
Manometry is required before any surgical discussion for reflux, though not necessary for initial medical management
For mild reflux (pH <4 for 6-8% of time, DeMeester score 20) without esophagitis or Barrett's, lifestyle modifications and PPI trial are appropriate before considering surgery
Long-term PPI use in women is associated with osteoporosis risk; calcium supplementation and periodic bone density testing may be protective
PPIs should be taken within 30 minutes before a meal, not at night before bed or in the morning without breakfast, to maximize effectiveness
The primary reason for manometry before fundoplication is to rule out achalasia, as wrapping a patient with achalasia destroys esophageal function
Patients with achalasia can present with heartburn due to stasis and fermentation of food in the esophagus
Manometry findings guide fundoplication type: total LES relaxation with low resting pressure supports full Nissen, while poor distal esophageal amplitudes may indicate need for partial wrap to avoid postoperative dysphagia
Full Nissen fundoplication (360-degree wrap) is appropriate for patients with normal peristalsis (amplitude 30mmHg or higher), total LES relaxation, and DeMeester score around 28
Laparoscopic fundoplication has the disadvantage of producing less scar tissue than open surgery; full mediastinal dissection helps create scarring to reduce recurrence rates
Mediastinal dissection during fundoplication provides additional esophageal length, which is critical for a tension-free repair
Taking down short gastric vessels during Nissen makes it easier to avoid twisting the wrap and ensures proper orientation of posterior to anterior stomach
Nissen fundoplication technique is highly variable among surgeons with poor standardization, making it difficult to reproduce outcomes; proper wrap geometry is critical
Common technical error in Nissen is grabbing the greater curve too low on the left side, which traps fundus above the wrap and creates improper geometry
Nissen wrap should be approximately 2cm long with 3 sutures; making the wrap too long (wrapping all available intraabdominal esophagus) is a common mistake that increases dysphagia
First suture in Nissen should be stomach-to-stomach so the knot can be used to position the wrap before securing it; subsequent sutures are stomach-esophagus-stomach
Posterior gastropexy (fixing posterior stomach to crura) should be done after wrap creation to ensure stomach sits without tension, not beforehand
Crural closure should create a 'triangle of air' or 'V sunlight' below the esophagus; experienced surgeons can achieve this without routine bougie use
With increasing experience, surgeons tend to make crural closure progressively tighter
Patients with weak esophageal peristalsis (amplitude below 20mmHg) and connective tissue disease require clear discussion that full Nissen may cure reflux but create dysphagia due to inadequate esophageal pump function
Toupet fundoplication (270-degree posterior wrap) is indicated for patients with weak motility to prevent pseudoachalasia
Toupet wrap is made slightly longer than Nissen (2.5-3cm vs 2cm) with 3 sutures on each side, all esophagus-to-stomach, plus single posterior gastropexy
Fixing Toupet wrap to lateral crura is not recommended as it angulates anatomy awkwardly and pulls the stomach
Fundoplication changes how patients swallow, how the stomach works, and how acid moves through the body; setting these expectations preoperatively is critical for patient satisfaction
Fundoplication is tightest immediately after surgery and loosens over time; early dysphagia is expected and desired
Patients with no dysphagia at 2 weeks post-Nissen likely have a wrap that is too loose and will have long-term problems
Dysphagia in the first 6 weeks post-fundoplication should not prompt intervention, even if patient maintains liquid-only diet
Endoscopic intervention for persistent dysphagia should not be considered until 3 months postoperatively with no progression and inability to tolerate anything beyond liquids
Workup for dysphagia at 6-8 months post-fundoplication includes upper GI to rule out hernia recurrence and identify anatomic causes, followed by endoscopy with dilation if wrap is too tight
Pseudoachalasia presents as dilated esophagus with bird's beak appearance, retained fluid pool, tight GE junction, loss of peristalsis, and non-relaxing LES on manometry after fundoplication
Pseudoachalasia likely results from overly tight wrap causing esophageal burnout where the esophagus loses ability to pump food through
Pseudoachalasia requires nutritional optimization before reoperation; PEG tube feeding may be necessary if nutrition is compromised
Treatment options for pseudoachalasia include taking down Nissen with Heller myotomy plus Dor, or converting to Toupet with long Heller on both sides
Alternative approach for pseudoachalasia is to open the wrap at 180 degrees and perform large Heller myotomy between the opened sides without complete takedown
For reoperative foregut surgery, the best approach is to plan to start over and take down the entire wrap, though this may not always be necessary or possible
Gastric bypass is an excellent operation for morbidly obese patients with failed fundoplication
For primary reflux surgery in patients with BMI over 35, gastric bypass should be considered instead of Nissen because fundoplication does not work well in morbidly obese patients
Reoperative fundoplication patients require repeat Bravo pH study for symptom correlation, repeat manometry, and gastric emptying study, especially if nausea and vomiting are prominent symptoms
Nausea and vomiting as large component of reflux symptoms are red flags to delay surgery and investigate further, as symptoms of delayed gastric emptying overlap with reflux
In reoperative fundoplication, prior port placement indicates extent of original dissection: umbilical incision suggests no chest dissection, while 5 ports with lowest 5cm from umbilicus indicates thorough original operation
First goal in reoperative fundoplication is to identify the right crus at its base to know where the IVC is and avoid major vascular injury
Taking liver off wrap in reoperative surgery can be done sharply accepting some bleeding, which is compressed by paddle retractor, rather than risking wrap injury with harmonic scalpel
Many fundoplications recur because there is insufficient scar tissue in the chest; if struggling with dissection from below, alternative approach is to enter chest wherever possible and work back down
Reoperative foregut surgery requires identifying named structures and systematic dissection rather than trying to make spaces, or the surgeon gets lost quickly
If anterior vagus nerve is injured during reoperative fundoplication but posterior vagus is intact, no acute intervention is needed; postoperative upper GI on day 1-2 assesses gastric emptying
For vagal injury with poor gastric emptying, early Botox of pylorus is preferred over pyloroplasty unless both vagal nerves were clearly transected
Barrett's esophagus may be subtle and asymptomatic, with risk of progression through low-grade and high-grade dysplasia to gastric cancer
Manometry before routine reflux surgery now identifies achalasia cases that were previously missed when manometry was not standard practice
There is some evidence that bilateral vagal injury may not require pyloroplasty