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Fisiopatologia del Reflusso e delle Plastiche Antireflusso

C. I I I. Sez. Chirurgia Esofago-Gastrica U.Fumagalli. UO Chirurgia Generale e Mininvasiva Resp: R.Rosati. Istituto Clinico HUMANITAS Rozzano - Italy. Fisiopatologia del Reflusso e delle Plastiche Antireflusso. XXIV Congr. Naz. ACOI , Montecatini 2005. GERD pathophysiology.

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Fisiopatologia del Reflusso e delle Plastiche Antireflusso

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  1. C II I Sez. Chirurgia Esofago-Gastrica U.Fumagalli UO Chirurgia Generale e Mininvasiva Resp: R.Rosati Istituto Clinico HUMANITAS Rozzano - Italy • Fisiopatologia del Reflusso e delle Plastiche Antireflusso XXIV Congr. Naz. ACOI , Montecatini 2005

  2. GERD pathophysiology Impaired mucosal defense Poor esophageal clearance Hiatal hernia (promotes LES dysf.) TLESR • LES pressure abn • Hypotensive sphincter Acid Pepsin Bile Food Delayed gastric emptying

  3. Transient LES Relaxations • Vagally mediated, spontaneous, non-swallow-induced decreases in LESRP, triggered by postprandial gastric fundic distension • Antireflux operations result in decreased duration and frequency of TLESR, possibly by preventing distension of the gastric fundus

  4. GERD Pyrosis, regurgitation Aggravated by recumbency or bending Relieved by antacids Dysphagus, odynophagia, bleeding, weight loss, anemia Long standing symptoms Symptoms of complicated disease Risk for BE History: uncomplicated GERD Empirical therapy (incl. lifestyle) Endoscopy Symptoms do not predict degree of esophagitis Mucosal injury in less than 50% of patients Guidelines for diagnosis and treatment of GERD Am.Coll.Gastroent. 2005

  5. GERD Diagnosis: pH metry Confirms diagnosis in patients with persistent symptoms (typical and atypical) without evidence of mucosal damage (especially if a trial of acid suppression has failed) Monitor the control of reflux in patients with symptoms in therapy Combined impedance and acid testing has been developed: allows measurement of acid and non acid (volume) reflux

  6. Preoperative pH metry? Symptomatic GERD patients with normal preoperative 24-hour pH test results have significantly worse subjective outcomes after Nissen fundoplication compared with patients having abnormal preoperative pH test results. Preoperative normal DMS (n 15) Preoperative abnormal DMS (n 208) Khajanchee Am J Surg 2004

  7. EXTRAESOHAGEAL MANIFESTATIONS OF GERD

  8. Suspected GERD extraesophageal manifestations success PPI twice daily for 3-6 months failure Taper down to lower PPI dose that controls symptoms 24 pH metry on therapy - + Consider non GERD related manifestations Increase PPI dose

  9. Outcomes of typical and atypical symptoms attributed to GERD treated by laparoscopic fundoplication So JB Surgery, 1998

  10. GERD - Diagnosis: manometry Ensure accurate placement of monitoring probes Exclude motility disorders such as achalasia or aperistalsis associated with disorders such as scleroderma Helpful prior to antireflux surgery (?)

  11. GERD – Defective peristalsis Partial and total fundopl.are effective in controlling symptoms of GERD in defective peristalsis. Total fundoplication does not cause dysphagia of new onset Partial fundopl. (n 39) Total fundopl. (n 57) Oleynikov Pellegrini, Surg Endosc 2002

  12. C II I UO Chirurgia Generale e Mininvasiva Resp: R.Rosati Sez. Chirurgia Esofago-Gastrica U.Fumagalli GERD – Taylored surgery May 1996 – April 2005: 228 op. for GERD

  13. How to evaluate the results of antireflux surgery? Symptoms after medical or surgical treatment of GERD do not correlate with physiologic response (low specificity/sensibility) Jenkinson AD, Br J Surg 2004 48% of patients with Barrett esophagus, asymptomatic under PPI have pathologic acid reflux Sarela AI, Arch Surg 2004

  14. C II I UO Chirurgia Generale e Mininvasiva Resp: R.Rosati Sez. Chirurgia Esofago-Gastrica U.Fumagalli Symptoms and pH metry after fundoplication 26 patients who underwent pH-metry a mean of 15 months after surgery (1-58 mos) (*)2 patients had hernia recurrence

  15. Conclusions • pH-metry is an important tool in the diagnosis of GERD and of its atypical symptoms; • It still has indication in the preoperative work up of patients candidate to fundoplication; • It should be used to objectively evaluate the results of antireflux treatments • Esophageal manometry is an important tool for the diagnosis of esophageal diseases: it may correct a wrong diagnosis or suggest an underlying diagnosis (achalasia – scleroderma); • Great expectations exist for the results of impedance monitoring in patients with gastroesophageal reflux disease

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