Sabiston GERD and HH

Question 1

LES is made up of four anatomic structures

Answer 1

1-The intrinsic musculature of the distal esophagus
2- Sling fibers of the gastric cardia
3-The crura of the diaphragm
4- increased intra abdominal pressure is transmitted to the GEJ

Question 2

Best time to measure LES

Answer 2

at mid-expiration or end-expiration.

Question 3

Hypotensive LES is frequently associated with

Answer 3

hiatal hernia because of displacement of the GEJ into the posterior mediastinum

Question 4

A type I hernia

Answer 4

when the GEJ migrates cephalad into the posterior mediastinum.

This occurs because of laxity of the phrenoesophageal membrane

Question 5

water brash phenomenon

Answer 5

Regurgitation of gastric contents to the oropharynx and mouth > produce a sour taste that patients will describe as either acid or bile

Question 6

Two mechanisms may lead to extraesophageal symptoms of GERD

Answer 6

-proximal esophageal reflux and microaspiration of gastroduodenal contents cause direct caustic injury to the larynx and lower respiratory tract

-distal esophageal acid exposure triggers a vagal nerve reflex that results in bronchospasm and cough

Question 7

GERD with extraesophageal symptoms should be referred to

Answer 7

a laryngologist or a pulmonologist to determine if a nongastrointestinal condition is causing these symptoms

Question 8

In patients with asthma and GERD

Answer 8

antireflux surgery appears to be more effective than medical therapy at managing pulmonary symptoms

Question 9

Proximal esophageal reflux with microaspiration of acid and nonacid gastric contents can lead to

Answer 9

Idiopathic pulmonary fibrosis > severe, chronic, and progressive lung disease that generally results in death

Tx : Laparoscopic antireflux surgery

Question 10

Signs of proximal esophageal reflux and regurgitation of gastric contents

Answer 10

-erosion of their dentition (revealing yellow teeth caused by the loss of dentin)
-injected oropharyngeal mucosa
-signs of chronic sinusitis
-constantly drinks water ( To clear Acid )
-sit leaning forward > To flattens diaphragm, narrows the anteroposterior diameter of the hiatus, and increases the LES pressure

Question 11

pathognomonic for GERD ( By Endoscopy )

Answer 11

peptic strictures and LA class C and D esophagitis

Question 12

LA class A and B esophagitis should undergo

Answer 12

pH testing

Question 13

HH measurement in Endoscopy

Answer 13

hernia should be measured in both cranial-caudal and lateral dimensions

Question 14

most common cause of dysphagia in GERD

Answer 14

is a reflux-associated inflammatory process of the esophageal wall

Question 15

What can cause a false-negative pH study

Answer 15

presence of a tight stricture may prevent reflux of acid

Question 16

The majority of peptic strictures are effectively treated with

Answer 16

-dilation and PPI therapy

Refractory peptic strictures are defined as strictures that recur despite dilation and PPI therapy > Tx with LARS / steroid injections

Question 17

Another cause of dysphagia in patients with GERD

Answer 17

Schatzki ring >
submucosal fibrotic bands (as opposed to mucosal strictures).

Question 18

Ineffective esophageal motility

Answer 18

at least 50% weak or failed peristaltic swallows on high-resolution manometry.

patients with GERD and ineffective esophageal motility > (Toupet or Dor) fundoplication should be performed

Nissen fundoplication > greater postoperative dysphagia

Question 19

For barret Based on endoscopic measurements

Answer 19

long segment (≥3 cm) and short segment (<3 cm).

Question 20

present with typical symptoms of GERD Tx

Answer 20

8-week course of PPI therapy is recommended

Question 21

How long to stop PPI for ambulatory pH monitoring

Answer 21

patients must stop PPI therapy 1 week

Question 22

PPI use has been associated with the following

Answer 22

-loss of bone density and risk of fracture
-dementia
-myocardial infarction
-micronutrient (magnesium, iron, B-12) deficiencies
-Clostridioides difficile infection
-kidney disease
-interactions with antiplatelet medication

Question 23

Intraoperative Management of Short Esophagus

Answer 23

-unilateral vagotomy > additional 1 to 2 cm of esophageal length

-division of both vagus nerves > 3 to 4 cm of additional esophagus

Question 24

Operative Complications of LARS

Answer 24

-Pneumothorax
When identified intraoperatively, the pleura should be closed with a suture
postoperative radiograph should be obtained.

If a pneumothorax is identified on this radiograph, the patient may be maintained on oxygen therapy to facilitate its resolution

Question 25

Dysphagia post LARS

Answer 25

If the patient cannot tolerate liquids, a UGI series should be obtained to ensure that no anatomic abnormality, such as an early hiatal hernia, exists

Question 26

If the patient cannot maintain hydration or dysphagia persists beyond 3 months

Answer 26

UGI series > check for anatomic abnormality If the UGI series > appropriately positioned fundoplication below the diaphragm esophagogastroduodenoscopy with empirical dilation of the GEJ should be performed.

Question 27

most common symptoms of failed LARS

Answer 27

are typical symptoms of GERD WorkUp: -Anatomic problems > persistent or recurrent hiatal hernia, slipped fundoplication, and incorrectly constructed fundoplication. All patients who present with recurrent or persistent symptoms of GERD > esophageal manometry and ambulatory pH study. If the pH study > elevated distal esophageal acid exposure > an esophagram and upper endoscopy PPI therapy should be instituted

Question 28

If the patient’s symptoms are not effectively managed by medical therapy

Answer 28

reoperation should be performed to create an effective antireflux valve.

Question 29

The late development of dysphagia after LARS suggests

Answer 29

esophageal obstruction results from a recurrent hiatal hernia or a slipped fundoplication UGI series and EGD > initial studies If a clear anatomic abnormality is visualized > reoperation If concurrent GERD symptoms > ambulatory pH testing and manometry To achieve resolution of symptoms, reoperation is almost always necessary in these patients.

Question 30

incorrectly constructed fundoplication

Answer 30

-created out of the body of the stomach and not the fundus -Failure to completely excise the sac of a hiatal hernia or PEH

Question 31

Operative management strategies for GERD in patients following SG and RYGB

Answer 31

patients following RYGB: -closure of gastrogastric fistula -correction of hiatal hernia -revision of large gastric pouch following SG: -conversion to RYGB -correction of hiatal hernia

Question 32

Alternative Operative Therapies for GERD

Answer 32

-Transoral Incisionless Fundoplication > endoluminal fundoplication can be created up to 4 cm in length and 270 degrees. -Magnetic Sphincter Augmentation

Question 33

PEH Vs HH

Answer 33

PEH is frequently associated with obstructive symptoms and, less frequently, typical symptoms of GERD dysphagia, odynophagia, and postprandial chest pain, as well as early satiety

Question 34

PEH did endoscopy

Answer 34

Check for Cameron ulcers and Barrett’s esophagus

Question 35

four key steps to PEH repair

Answer 35

(1) reduction of the hernia contents to the abdominal cavity (2) complete excision of the hernia sac from the posterior mediastinum (3) mobilization of the distal esophagus to achieve a minimum of 3 cm of intra abdominal esophageal length (4) an antireflux operation.

Question 36

The most challenging aspect of the sac dissection is encountered during the mobilization of the posterior sac

Answer 36

esophagus and posterior vagus nerve are intimately associated with the sac posteriorly and can be easily injured during this dissection. A lighted bougie helps identify the exact location of the esophagus.

Question 37

If a tension-free closure of esophageal haitus is not possible, two options are available

Answer 37

(1) close the hiatus under tension and reinforce the closure with biologic mesh (2) perform a diaphragmatic relaxing incision to allow primary tension-free closure of the hiatus and reinforce the relaxing incision and hiatal closure with biologic mesh. Importantly, permanent synthetic mesh should never be used at the esophageal hiatus as it is associated with esophageal erosion and stenosis

Question 38

The C configuration Mesh

Answer 38

has the advantage of reinforcing the anterior and posterior hiatus

Question 39

biologic mesh reinforcement of the hiatal closure in PEH repair and recurrence

Answer 39

decreases early but not late recurrent hiatal hernias.

Question 40

Initial management of acute gastric volvulus

Answer 40

-nasogastric tube -esophagoscopy can facilitate gastric decompression and nasogastric tube placement -endoscopic reduction of volvulus is possible, allows assessment of the gastric mucosa -if gastric ischemia is present, emergent operation is indicated.