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The first 25 slides, exactly as they appear. The full deck has 191 content slides.
General Surgery
Gastroesophageal Reflux Disease and Hiatal Hernia (Including Paraesophageal)
Built from Maingot's Abdominal Operations
What’s inside
7 sections · 191 slides
Overview
- What this deck covers
Reflux disease and how it presents
Definition, typical symptoms, atypical symptoms
- Definition of gastroesophageal reflux disease
- Heartburn and regurgitation
- Nighttime reflux and its burden
- Nighttime reflux symptoms in a national survey
- Atypical symptoms of reflux
- Dysphagia in reflux disease
- Chest pain of esophageal origin
- Typical and atypical presentations
The antireflux barrier
Four parts keep gastric contents where they belong
- Four components of the antireflux mechanism
- Parts of the antireflux mechanism
- Normal relaxation of the lower esophageal sphincter
- Three requirements of an effective sphincter
- Normal manometric values of the lower esophageal sphincter
- The defective sphincter
- Gastric distension takes up the sphincter
- Sphincter shortening as the stomach fills
- Complete take-up of the sphincter by the cardia
- From a large meal to a reflux episode
- Belching, bloating and swallowed air
- Cardia geometry and yield pressure
- Yield pressure falls as hiatal hernia size grows
- What a hiatal hernia does to the barrier
- Esophageal peristalsis and its failure
- The cycle of reflux and failing peristalsis
- The crural diaphragm
- The stomach as a reservoir
Complications of reflux
Mucosal, respiratory, and metaplastic damage
- Three groups of complications
- How reflux complications are grouped
- Sphincter status and the complication seen
- Complications by sphincter status in 150 patients
- What it takes to injure the mucosa
- Acid and alkaline exposure across reflux complications
- Duodenogastroesophageal reflux
- Gastric versus mixed reflux in 53 patients
- Esophageal pH during bilirubin exposure
- Bilirubin exposure across degrees of mucosal injury
- Why symptoms and endoscopy disagree
- 100%
- Limits of acid suppression
- Stricture and esophageal shortening
- 50%
- Reflux and the airway
- Finding silent reflux behind lung symptoms
- Interpreting dual-probe pH monitoring
- Treating reflux-related respiratory disease
- Surgery for asthma with reflux: the randomised trial
- Barrett's esophagus: what it is
- Endoscopic appearance of Barrett's esophagus
- Microscopic appearance of Barrett's esophagus
- From metaplasia to cancer
- Four categories of Barrett's esophagus
- Cardia intestinal metaplasia
- Risk factors for developing Barrett's esophagus
- How Barrett's metaplasia develops
- Sequence of Barrett's metaplasia
- Screening for Barrett's esophagus
- Surveillance endoscopy
- Surveillance intervals in practice
- High-grade dysplasia as the threshold to treat
- Esophagectomy or endoscopic treatment for high-grade dysplasia
- Risk factors when choosing endoscopic treatment of esophageal neoplasia
- Histology and invasion as risk factors
- Radiofrequency ablation: the sham-controlled trial
- Balloon-based radiofrequency ablation catheter
- Scope-mounted radiofrequency ablation device
Assessment before surgery
What each test answers, and its limits
- Purpose of objective esophageal testing
- Barium esophagram
- Upper endoscopy
- Los Angeles classification of esophagitis
- Recognising Barrett's at endoscopy
- Prague C and M classification
- Prague C and M measurement of Barrett's extent
- Hill classification of the gastroesophageal flap valve
- Flap valve grades I and II
- Flap valve grades III and IV
- Endoscopic diagnosis of hiatal hernia
- Ambulatory pH monitoring
- Limitations of catheter pH studies
- The wireless pH capsule
- The DeMeester score
- What the six components measure
- Normal values for esophageal acid exposure
- Impedance-pH monitoring: the principle
- Impedance catheter and the shape of a swallowed bolus
- Impedance tracing of a reflux episode
- What impedance adds, and where it stops
- Esophageal manometry: three reasons to do it
- High-resolution manometry
- Manometric patterns: normal, achalasia and a nonrelaxing wrap
- Manometric patterns: hiatal hernia and nutcracker esophagus
- Manometric definitions
- Gastric emptying study
- When delayed emptying changes the operation
Antireflux surgery
Selection, principles, technique and results
- Evolution of antireflux surgery
- How the operation evolved
- Medical therapy comes first
- Who should be offered antireflux surgery
- Patients with esophageal stricture
- Patients with Barrett's esophagus
- Patients with airway symptoms
- Goal of the operation
- Principles that protect swallowing
- Checking the new valve from inside
- Endoscopic appearance of Nissen and Dor valves
- Endoscopic appearance of the Toupet valve
- Choosing between a complete and a partial wrap
- Key points of laparoscopic Nissen fundoplication
- Patient position and port placement
- Positioning and ports
- Opening the hiatus
- Sequence of the hiatal dissection
- Dividing the attachments at the angle of His
- Dissection of the phrenoesophageal ligament
- Identifying the anterior vagus nerve
- Opening the posterior esophageal window
- Division of the short gastric vessels
- Division of the posterior gastric vessels
- Creating a large retroesophageal space
- Why the fundus must be fully mobilised
- Mediastinal dissection
- Tension-free intraabdominal esophagus achieved
- Protecting the vagal trunks and the pleura
- Approximation of the diaphragmatic crura
- Closing the crura
- Building the wrap
- Shoeshine manoeuvre
- Completed fundoplication
- Finishing the operation and the partial wraps
- Dor fundoplication
- Toupet fundoplication
- Side effects after antireflux surgery
- Long-term results of laparoscopic fundoplication
- Open versus laparoscopic at eleven years
- Quality of life after surgery
- How often antireflux repairs fail
- Working up the failed repair
- Four patterns of failure after primary repair
- Transhiatal herniation of a repair
- Options at reoperation
Hiatal hernia and paraesophageal hernia
Four types, short esophagus, repair and results
- Milestones in hiatal hernia surgery
- How hiatal hernia surgery developed
- Type I: the sliding hiatal hernia
- Type II and type III
- Type IV
- The four types of hiatal hernia
- Symptoms of a paraesophageal hernia
- Who develops these hernias
- Short esophagus
- Preoperative assessment of a paraesophageal hernia
- Contrast study in paraesophageal hernia
- Endoscopy, manometry and emptying studies
- Goals of paraesophageal hernia repair
- The four tenets of the repair
- Transthoracic repair
- Laparoscopic repair: reducing the sac
- Laparoscopic repair: finishing
- Beginning the hernia sac dissection
- Medialising the gastroesophageal fat pad
- Assessing intraabdominal esophageal length
- Wedge gastroplasty
- Neoesophagus with fundoplication
- Mesh at the hiatus
- Results of transthoracic repair
- Laparoscopic repair: the early experience
- Laparoscopic repair today
- Conclusions on paraesophageal hernia repair
- Key points: the disease and its barrier
- Key points: assessment and treatment
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- Maingot's Abdominal Operations, 12th Edition