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Enteral Stents in the Treatment of Colonic Obstruction
Uncovered self-expandable metal stent (USEMS) in malignant colonic
stricture process
Management of Spigelian, Obturator, and Lumbar Hernias
Laparoscopic obturator repair
Laparoscopic lumbar hernia repair
Reverse transversus abdominis release (reverse TAR)
Mesh fixation utilizing bone anchors
Management of Spontaneous and Secondary Pneumothorax
Normal lung sliding
Absence of lung sliding with no shimmering appearance of bright
pleural line
Acute Mesenteric Ischemia
Acute embolic mesenteric ischemia in the setting of chronic SMA
atherosclerosis and IMA occlusion following open exploration,
resection, and SMA endarterectomy
xxxix
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T A B S
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C (O) E
The American Board
of Surgery Certifying
(Oral) Examination
Jo Buyske, MD, and Daniel L. Dent, MD
PRINCIPLE
The American Board of Surgery (ABS) was founded in 1937, with a
mission to protect the public and enhance the profession. At the time,
the standards for becoming a surgeon were vague and inconsistent.
Some people did a Halstedian residency. Some apprenticed themselves to surgeons. Others did internships and then were self-taught,
or they skipped formal training altogether. The public had no way to
distinguish the training or skill of these practitioners. The ABS and the
certification process was a way to set standards for the profession and
to provide a testimonial to patients that their surgeon was qualified.
Certification by the ABS is the culmination of surgical training. It
is a testimonial to quality, knowledge, and judgment based on several
distinct components. First, training in an Accreditation Council for
Graduate Medical Education (ACGME)-accredited training program is a prerequisite for certification in nearly all cases. Second,
candidates must meet the standards of training as set by the ABS,
including things like passing knowledge and skills tests in laparoscopy (FLS), endoscopy (FES), trauma (ATLS), and cardiovascular
events (ACLS). Candidates must meet case minimums both in the
early years of training to “prepare the soil” and also during the chief
year to demonstrate maturation. There are time requirements, and
required observations of both clinical and operative skills. Third is
a knowledge exam, the Qualifying Examination. The Qualifying or
written examination is a 300-plus question, computer-based multiple
choice exam designed to test foundational knowledge.
all of these other qualifications have been met, the Certifying, or oral
examination, is a test of judgment and applied knowledge. The two
tests measure different assets, and candidates’ performance is not
predictable across the two exams. That is to say, doing well on one
exam does not predict doing well on the other exam. They measure
different attributes, and each one is important to fulfill the ABS mission of serving the public and the profession.
The Certifying Examination consists of a series of carefully created scenarios. The scenarios are the tool that supports the examiners
in their charge, which is to “evaluate a candidate’s clinical skills in
organizing the diagnostic evaluation of common surgical problems
and determining appropriate therapy. Emphasis is placed on candidates’ ability to use their knowledge and training to “safely, effectively
and promptly manage a broad range of clinical problems.” Additionally, “Technical details of operations may also be evaluated, as well
as issues related to a candidate’s ethical and humanistic qualities.”
2
1
Finally, after
3
CONTENT
The content of the Certifying Examination is generally aligned with
the ABS SCORE Curriculum Outline. The majority of the exam will
focus on topics that are listed among the core content of the curriculum. The remainder of the exam will be on complications of these
basic scenarios or may be taken from the advanced portion of the
curriculum.
for the exam comes from 13 question-writing committees. There
is some overlap of the content between committees. For example,
a case of septic shock secondary to a colonic perforation from an
incarcerated hernia could have been put forward as content from
the colorectal, hernia, or critical care committees. Each roster of
cases is reviewed for breadth of content and consistency of difficulty
relative to historical performance of the individual questions so exam
difficulty is consistent across all rosters. Because the candidate will
also be tested as to baseline surgical knowledge on the qualifying
(written) exam, it is not generally expected that the candidate will
be asked to regurgitate basic surgical facts. With that said, the candidate can expect that some questions may include a list of questions
asking how the candidate’s management plan might change in the
face of variations of patient presentation or pathologic findings, or
in the setting of intraoperative or postoperative complications. This
should not necessarily be interpreted as meaning that the candidate
is off track, but rather is a way of probing the candidate’s skill and
judgment in managing a variety of situations.
4
While each exam roster contains 12 cases, the content
PROCESS
The Certifying Examination consists of three exam sessions that
each last 30 minutes. In each session, the candidate will be presented
with four case scenarios. Two examiners are used in each session
to help ensure the validity of the exam. All examiners are in active
practice, currently certified by the ABS, and participating in the
ABS Continuous Certification Program. All of the examiners have
taken the certifying exam themselves, some of them more than once.
Examiners are all volunteers, and they do not receive any financial
compensation for their service.
The examiners will typically alternate in presenting the case
information to the candidate. In presenting the case scenarios, the
goal of the examiners is to provide a clear description of each case.
It is the intent of the examiners to provide sufficient information at
each step in the case so the candidate may make pertinent decisions
on how to progress in the workup and treatment of the patient.
The COVID-19 pandemic presented a new challenge for the
administration of the Certifying Examination. The inability to
administer the exam in person created a need to administer the exam
in a virtual format. In the 2020–2021 academic year, the exam was
administered with all candidates and examiners participating virtually. This necessitated some modifications to the timing of the exam,
specifically that each room was given an extra 5 minutes in case of
5–7
1
2 THE AMERICAN BOARD OF SURGERY CERTIFYING (ORAL) EXAMINATION
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technical difficulties. The time allotted to answering questions did
not change; if the extra time was not needed, then there was simply
a short break between sessions. The candidates found the experience
to be fair and the vast majority support keeping the exam in a virtual
format going forward.
8
PREPARATION
The ideal preparation for the Certifying Examination is to have successfully provided evidence-based care for each condition that will be
covered during the exam. Surgical residency, as currently structured
by the parameters of the ACGME, Residency Review Committee
(RRC), and ABS, provides strong foundation for the exam. Given the
breadth of general surgery, however, it is likely that candidates will
encounter scenarios they have not seen in training. Before taking the
exam, candidates are encouraged to practice taking oral exams with
colleagues who have successfully completed the examination process
as the concise oral presentation of decision making benefits from
repetition and practice. In doing so, the candidate should practice
case scenarios over a wide range of pathologic conditions. Specific
recommendations for preparing for the exam include the following:
■ Practice clarity of communication with regard to explaining the
decision-making process.
■ Practice anatomic descriptions of common procedures (e.g.,
inguinal herniorrhaphy) as verbalizing operative anatomy can be
challenging in a high-stakes setting.
■ Recognize that the goal of the exam is to convey how one would
actually safely manage a patient, not to try to guess what the
examiners want to hear.
■ Plan for management of complications and consequences of treat-
ment decisions. For example, in appropriately selected patients
with colon pathology, it may be appropriate to perform primary
anastomosis. However, the candidate should also know how to
handle the potential consequence of an anastomotic leak. Conversely, if the candidate initially chooses to manage the patient
with a colostomy, it is reasonable to expect that the candidate can
also manage ostomy ischemia and parastomal hernia.
■ Recognize that the exam is not a multiple-choice exam and that
each case discussion is an ongoing conversation. As the case
evolves, the optimal management evolves with it. For example,
it may be appropriate to initially manage a patient nonoperatively but then convert to operative management if the patient’s
condition changes.
ASSESSMENT
Examiners receive standardized training before giving an exam. This
includes practice scoring, implicit bias training, and team review
of the scenarios. In addition, examiners routinely get formative
feedback from observers and their co-examiners. Finally, examiner
scoring patterns are evaluated from a psychometric perspective,
looking at patterns of consistency and severity as well as any evidence
9
of bias.
■ Each examiner records a score for each case to maximize the
number of independent observations that contribute to the candidate’s total score. A total score that reflects the ability to safely
care for the broad array of cases that are presented over the course
of the exam is considered a passing grade. There is no preset pass
or fail rate for the exam. On each scenario, candidates may be
given a passing grade, a failing grade, or an equivocal grade. The
equivocal grade is given when the examiners do not have enough
information to give a passing grade, such as when the candidate
spends more time asking questions than answering them, or
when the candidate makes multiple noncritical errors while also
making a number of correct management choices. The examiners
are charged with assessing the following characteristics of the
candidate’s performance:
■ Demonstrates an organized approach and solid rationale for
planned actions.
■ Rapidly determines and interprets key findings in a clinical
presentation.
■ Effectively and efficiently uses clinical knowledge to solve clinical
problems; effectively addresses key management points.
■ Avoids errors and critical fails (omission and commission) asso-
ciated with the case.
■ Recognizes personal limitations in knowledge and expertise
when diagnosing and treating clinical problems.
■ Reacts in a prompt but flexible manner to alterations in the
patient’s course (e.g., disease or treatment complications).
■ Overall, demonstrates appropriate surgical judgment, clinical
reasoning skills, and problem-solving ability.
2,3
In answering the examiners’ questions, candidates should be able
to not only state what they would do, but also concisely explain how
and why they would provide the stated care.
5
SUMMARY
The ABS Certifying Examination is an assessment of a surgeon’s
thought processes in managing surgical conditions. Board certification is the culmination of targeted training in accredited programs,
meeting specific training requirements in order to be eligible for the
exam process, and then passing a written foundational knowledge
exam and an oral exam of judgment delivered by trained surgical
examiners. The process serves as a testimonial that board-certified
surgeons have met the standards established by the profession.
S u g g e S t e d R e a d i n g S
1. The American Board of Surgery. Training and Certification. General
Surgery Qualifying Examination (QE) https://www.absurgery.org/default.
jsp?certgsqe.
2. Kopp J, Ibanez B, Jones A, etal. Association between American Board
of Surgery General Surgery Initial Certification and risk of receiv-
ing severe disciplinary actions against medical licenses. JAMA Surg.
2020;155(5):e200093.
3. The American Board of Surgery. Training and Certification. General
Surgery Qualifying Examination (QE). https://www.absurgery.org/
default.jsp?certcehome.
4. The American Board of Surgery. Training and Certification. SCORE
Curriculum Outline for General Surgery. https://www.absurgery.org/
default.jsp?scre_booklet.
5. The American Board of Surgery. Training and Certification. Taking
the CE—What to Expect. https://www.absurgery.org/default.jsp?certce_
whattoexpect.
6. The American Board of Surgery. Training and Certification, CE Candidate
Video. https://www.absurgery.org/default.jsp?certce_video.
7. The American Board of Surgery. Training and Certification. FAQs.
htttp://www.absurgery.org/default.jsp?faq_gsce.
8. Chen H, Tseng JF, Chaer R, etal. Outcomes of the First Virtual General
Surgery Certifying Exam of the American Board of Surgery. Ann Surg.
2021;274(3):467–472.
9. Ong TQ, Kopp JP, Jones AT, Malangoni MA. Is there gender bias on the
American Board of Surgery General Surgery Certifying Examination?
J Surg Res. 2019;237:131–135.
E
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Esophageal Function
Tests
Wasay Nizam, MBBS, Hamza Khan, MD, and
Malcolm V. Brock, MD
he esophagus is a muscular, tubelike structure located in the
posterior mediastinum. It spans from the posterior oropharynx
T
to the cardia of the stomach with three functional regions: the upper
esophageal sphincter (UES), esophageal body, and lower esophageal
sphincter (LES). With the aid of peristalsis and coordinated relaxation/contraction of sphincters, the esophagus allows the transport
of food boluses to the stomach and prevents the reflux of corrosive
stomach contents. Assessment of esophageal motility requires evaluating its structural integrity, peristalsis, and synchronized pressure
changes of the sphincters. The diagnostic tools assessing these functions are termed esophageal function tests. Utilizing pressure sensors,
these tests provide a dynamic demonstration of esophageal motility
and an assessment of alternating pressures within the LES.
Patients presenting with dysphagia, reflux, or non-cardiac chest
pain should undergo endoscopic or radiologic examination first to
rule out structural lesions such as malignancy. Once these are ruled
out, functional disorders secondary to esophageal dysmotility are
considered (Box 1). This chapter will review commonly used tests,
such as manometry and esophageal pH monitoring. Esophageal
integrity may be evaluated both directly and indirectly by endoscopy or radiologic tools, respectively. These modalities will also be
discussed in depth in subsequent chapters along with details on
management of esophageal dysmotility disorders such as achalasia.
tip in the stomach. Characteristics of the pressure waveform after a
swallowing event allow for the recognition of the UES, the esophageal body, the LES, and the gastric cardia (Fig. 1). However, conventional manometry has several limitations including: (1) widely
spaced sensors that preclude information on motor activity less than
5 cm apart, (2) unidirectional sensors unable to record pressures
accurately in an asymmetrical lumen, and (3) false pressure readings
during swallowing because of the tendency of the sphincters to move
cephalad, dislodging the catheter.
To overcome these challenges, manometry systems have evolved
to utilize more sensors (20–36) placed 1 cm apart that also record circumferentially. As a result, data on various pressure points are gathered
and plotted using computer software as a smooth contour plot giving a
high-resolution manometry (HRM) image. Readings are presented in
color-coded spatiotemporal pressure graphs called esophageal pressure
topography (EPT) or Clouse plots, named after Ray Clouse, who estab-
lished the technique. These topographical plots represent time on the
x-axis, location of the pressure wave on the y-axis, and color denoting
pressure (Fig. 2). With the advent of HRM, a smooth continuous pressure wave along the esophagus in real-time is now available. This led
to advances in our understanding of many esophageal motor diseases
that were previously puzzling, such as achalasia.
A standard protocol for esophageal manometry conduction
has been outlined in version 4.0 of the Chicago Classification. The
original classification scheme, proposed in 2009 by the International HRM Working Group, was in response to rapid advances in
HRM technology. But the scheme became so clinically useful that
BOX 1 Indications and Contraindications for
Esophageal Function Tests
ESOPHAGEAL MANOMETRY
Esophageal manometry remains the gold standard for assessing
esophageal motility. This test permits evaluation of the contractility and coordination of esophageal muscles. It measures a series of
pressure events along the esophageal length and presents them as
curves of amplitude over time. Originally developed in the 1950s,
esophageal manometry underwent numerous modifications before
becoming the state-of-the-art diagnostic tool it is today. Briefly, all
versions of the manometer contain a series of sensors placed on a
thin catheter that transduce intraluminal esophageal pressure into
electrical signals that are then displayed as pressure waves. The original version was based on a pneumo-hydraulic system that has since
been replaced by a solid-state catheter that provides a faster response
and requires less technical expertise.
Conventional manometry utilizes information from sensors
placed at fixed locations (∼5 cm) along the length of the catheter.
This catheter is placed transnasally into the esophagus with its distal
Indications
• Noncardiacchestpainorheartburnwithnoimprovementfrom
acid suppression and no explanation on radiologic or endoscopic examination
• Nonobstructivedysphagiaorodynophagiathatisunexplained
• Evaluatingesophagealperistalsisbeforeforegutsurgery
• LocalizingLEStoplaceimpendenceprobeinpreparationof
pH monitoring study
• Evaluatingdysphagiaafterforegutsurgery
• Workupofscleroderma
Contraindications
• Esophagealmasscausingobstruction
• Abnormalnasal-oropharyngealanatomyprecludingcatheter
placement
• Nonresponsivepatientsunabletofollowcommands
• Patientsonanticoagulationwithhighriskofbleeding
3
4 ESOPHAGEAL FUNCTION TESTS
Pressure, mm Hg
5 channels placed 5 cm apart
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Water-perfused catheter with
Cricopharyngeal sphincter
Esophageal body
10
30
50
80
%
cm
1
6
11
60
40
20
FIG. 1 Esophageal manometry
showing a transnasally placed catheter that records a normal waveform
progression. Newer solid-state catheters have sensors placed 1 cm apart.
Fifth channel
with 4 sensors
at the same
level
Lower esophageal sphincter
Length
70
90
100
16
21
Resp.
18
Time
FIG. 2 Clouse plot showing a peristaltic wave after swallowing in a healthy individual. (From Baldwin D, Puckett Y. Esophageal manometry. Updated Sep 28,
2021. In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2021. https://www.ncbi.nlm.nih.gov/books/NBK559237/.)
it helped accelerate esophageal HRM’s current position as the stateof-the-art diagnostic tool that has thoroughly replaced conventional
line tracing. Before the procedure, patients are obliged to fast for a
minimum of 4 hours, and then the procedure begins with patients in
the supine position for 10 wet (5-mL) swallows spaced 30 seconds
apart. This is followed by a single multiple rapid swallow sequence
(five 2-mL swallows, 2–3 seconds apart) that can be repeated up to
three times. Following this, the patient is placed upright and given
ESOPHAGUS
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5
five additional wet swallows and one rapid drink challenge (200 mL
of water ingested as fast as possible). More provocative testing may
include the utilization of a solid swallow test, a solid test meal, or
even pharmacologic provocation. Pressure sensors within the body
of the catheter then record intraluminal pressure that is transmitted
to an external recording device. Clouse plots generated from HRM
are interpreted with consideration of the following five metrics:
1. Integrated relaxation pressure (IRP): the average deglutitive relax-
ation pressure in a 4-second window beginning at UES relaxation
2. Distal contractile integral: the product of amplitude, duration,
and length of the distal esophageal contraction
3. Distal latency: the interval between UES relaxation and the con-
tractile deceleration point
4. Peristaltic breaks
5. Pressurization patterns
Information from these indices may be applied toward the diagnoses of esophageal motility disorders. The Chicago Classification
broadly divides these disorders into disorders of esophagogastric
junction(EGJ) outflow or of peristalsis. A useful algorithm presented
in the classification then allows for the delineation of specific disorders, based on manometry findings (Fig. 3).
HRM is the preferred diagnostic tool when evaluating esophageal
motor function, especially when radiologic or endoscopic studies are
unable to explain the patient’s symptoms. It is safe, with a low-risk
profile of complications that is similar to those of nasogastric tube
placement, namely, gagging, oropharyngeal discomfort, epistaxis,
and rarely aspiration or perforation. Diet can be resumed immediately following removal of the catheter because only topical nasal
anesthesia is used. It is an outpatient procedure requiring no sedation, and patients can drive home afterward. It is important, however,
that patients stop H
-blockers, proton pump inhibitors, opioids,
2
nitrates, and calcium channel blockers before the study to avoid any
interference with testing. Furthermore, it must be remembered that
patients with a history of esophageal surgery, peptic stricture, or
those with a current hiatal hernia are prone to false readings.
ESOPHAGEAL pH MONITORING
Acid reflux into the esophagus may be assessed with intraluminal pH
monitoring. This can be performed with catheter-based devices or a
wireless device (Bravo probe, Medtronic, Minneapolis, MN). Catheter-based devices are inserted transnasally, with the distal pH probe
located approximately 5 cm above the LES. This device is then left in
situ for 24 hours with patients instructed to record meals, symptoms,
and periods of sleep by pressing buttons on a recorder. A wireless
device is placed endoscopically in the distal esophagus and attached to
the esophageal mucosa with a clip. This device then transmits information to a recorder. As there is no external component to this method,
patient activities, dietary patterns, and comfort levels are more natural.
Furthermore, because this is a single device, pH levels are only assessed
at a single level, rather than across the length of the esophagus.
pH monitoring is used to determine whether or not acid exposure to the esophagus is physiologic. Data gathered from the probe
are correlated with symptoms, patient positioning, and relation to
meals. The information from the device is then used to calculate a
composite pH or DeMeester score. Scores of 14.72 (95th percentile
of normal) or greater are considered abnormal. The components of
the DeMeester score include the following:
FIG. 3 Esophageal motility disorders on high-resolution manometry: Chicago classification version 4.0 Hierarchical Classification Scheme. EGJOO,
Esophagogastric junctionoutflow obstruction; FLIP, functional lumen imaging probe; IBP, intrabolus pressurization; IRP, integrated relaxation pressure; LES,
lower esophageal sphincter; MRS, multiple rapid swallows; PEP, pan-esophageal pressurization; RDC, rapid drink challenge; TBE, timed barium esophagram.
(From Yadlapati R, Kahrilas PJ, Fox MR, etal. Esophageal motility disorders on high-resolution manometr y: Chicago classification version 4.0. Neurogastroenterol Motil.
2021;33:e14058.)
6 ESOPHAGEAL FUNCTION TESTS
AB
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FIG. 4 Impedance testing showing (A) normal
downward movement of the bolus after swallowing
and (B) reflux of the swallowed bolus.
Swallow
Swallow
Bolus entry
Bolus entry
Bolus movement
Bolus movement
downward
downward
Bolus movement
Bolus movement
upward
upward
1. Percent total time pH <4
2. Percent upright time pH <4
3. Percent supine time pH <4
4. Number of reflux episodes
5. Number of reflux episodes ≥5 minutes
6. Longest reflux episode (in minutes)
IMPEDANCE TESTING
Impedance testing utilizes the principles of current resistance. A
long flexible catheter with 6 to 8 sensors is placed transnasally for
24 hours, with patients instructed to proceed with normal activity.
The tube is connected to a small receiver for data recording. A small
voltage is applied between two electrodes. In principle, at resting
state, an electrical charge within the esophageal mucosa carries
current between the catheter sensors. Because liquids permit faster
ion conductivity, a liquid bolus will be sensed as a rapid decrease in
impedance (resistance) between the sensors. In contrast, air is a poor
conductor, and swallowed air boluses will be detected as increased
impedance. Based on the direction of change, this can assess both
antegrade and retrograde movement (normal peristalsis or gastroesophageal reflux). Data on change in impedance gathered from
multiple electrodes along the catheter is then used to determine the
position of a bolus after swallowing and whether there is reflux back
into the esophagus after it has entered the stomach (Fig. 4). Special
impedance catheters are also available that combine impedance
testing with assessment of esophageal pH sensors and manometry
testing (high-resolution impedance manometry [HRIM]), allowing
for improved diagnosis.
FUNCTIONAL LUMINAL IMAGING PROBE
PANOMETRY
Functional luminal imaging probe (FLIP) panometry is an emerging technology in esophageal function testing used in concert
with endoscopy. It is performed with a catheter possessing a distal
overlying balloon. The tip of the catheter functions as an imaging
probe, and within the balloon, electrodes are present, enabling the
detection of impedance. The balloon may be inflated with saline in
10-mL increments up to 70 mL. The data from the sensors are then
converted in real time to allow for assessment of the various metrics
such as wall stiffness, pressure changes, diameter, volume, and EGJ
dynamics. FLIP panometry may be used as a complementary tool in
diagnosing esophageal motility disorders as well as intraoperatively
during antireflux procedures to assess the adequacy of esophageal
wraps.
CONCLUSION
Esophageal function testing can provide valuable information regarding the biomechanics of esophageal motility. The practicing surgeon
must be well aware of the utility of these tests and be able to interpret
them in light of the patient’s symptoms. Optimal outcomes require
close collaboration between the radiologist, gastroenterologist, and
surgeon within the clinical realm to treat these complex patients.
As technology evolves, newer testing techniques may improve our
understanding of complicated esophageal disease and assist with
intervention.
S u g g e S t e d R e a d i n g S
Gyawali CP, Bredenoord AJ, Conklin JL, etal. Evaluation of esophageal motor
function in clinical practice. Neurogastroenterol Motil. 2013;25(2):99–133.
Hamer PW, Holloway RH, Crosthwaite G, etal. Update in achalasia: what the
surgeon needs to know. ANZ J Surg. 2016;86(7-8):555–559.
Pandolfino JE, Kahrilas PJ; American Gastroenterological Association.
AGA technical review on the clinical use of esophageal manometry.
Gastroenterology. 2005;128(1):209–224.
van Hoeij FB, Bredenoord AJ. Clinical application of esophageal high-res-
olution manometry in the diagnosis of esophageal motility disorders. J
Neurogastroenterol Motil. 2016;22(1):6–13.
Yadlapati R, Kahrilas PJ, Fox MR, et al. Esophageal motility disorders
on high-resolution manometry: Chicago classification version 4.0©.
Neurogastroenterol Motil. 2021;33(1):e14058.
ESOPHAGUS
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7
Surgical Management
of Gastroesophageal
Reflux Disease
Jay Zhu, MD, and Brant K. Oelschlager, MD
astroesophageal reflux occurs when the contents and secretions
of the stomach flow retrograde into the esophagus across an
G
inappropriately relaxed or compromised lower esophageal sphincter. Although nearly everyone experiences symptomatic episodes
of reflux to some degree in their lifetime, gastroesophageal reflux
disease (GERD) is a condition characterized by chronic symptoms
or complications related to gastroesophageal reflux. GERD is a common diagnosis, affecting up to 20% to 30% of the US population and
costing an estimated $12 billion to $20 billion in direct healthcare
expenditure annually. The high incidence of GERD in the United
States and other Western countries is also thought to be the primary
reason behind the rising incidence of esophageal adenocarcinoma
over the past four decades. In this chapter, we discuss the surgical
evaluation and technical approach to gastroesophageal reflux disease.
PRESENTATIONS OF GERD
Symptoms related to GERD can be divided into typical, atypical,
and alarm symptoms (Box 1). Typical symptoms of GERD are the
classic esophageal manifestations of gastroesophageal reflux, which
include heartburn and regurgitation. Atypical symptoms encompass the extraesophageal manifestations of reflux such as cough,
dysphonia, sore throat, globus sensation, and noncardiac chest pain.
Although GERD can be clinically diagnosed in patients presenting
with typical symptoms, patients presenting primarily with atypical
symptoms require further investigation to rule out other causes. For
surgeons, distinguishing typical from atypical symptoms is useful in
assessing the likelihood that a patient’s symptoms are attributable
to GERD and thus will respond to surgical intervention. Patients
with heartburn and regurgitation tend to be more responsive to
acid suppression therapy and experience higher rates of symptom
resolution after antireflux surgery (ARS) when compared with those
presenting with atypical symptoms.
Alarm symptoms are ones that raise suspicion for malignancy
and other complications of GERD. These include weight loss, early
satiety, dysphagia, odynophagia, and signs of gastrointestinal bleeding. Alarm symptoms should never be attributed solely to uncomplicated GERD, and patients presenting with these symptoms require
further workup. The chronic inflammation and irritation associated
with reflux can lead to intraesophageal complications such as peptic
stricture, Barrett’s metaplasia, and esophageal adenocarcinoma. Less
commonly, reflux can also lead to extraesophageal complications
such as laryngopharyngeal reflux and lung injury from aspiration.
Exacerbations of asthma or interstitial lung diseases are unusual
manifestations of GERD but clear reasons to consider surgical intervention. It is important to mention that decisions regarding ARS in
patients with complications of GERD are often shared across disciplines. When treating patients with GERD-related complications, we
often work closely with colleagues in gastroenterology, otolaryngology, or pulmonology depending on the specific complication.
DIAGNOSIS AND PREOPERATIVE
EVALUATION
The primary purpose of preoperative of testing in the surgical evaluation of GERD is to (1) confirm the correct diagnosis, (2) evaluate the
anatomy (e.g., the presence of a hiatal hernia), and (3) rule out concurrent esophageal or gastric pathology before surgery. We routinely
obtain the following tests before surgical consultation for GERD.
■ pH testing: Ambulatory pH monitoring in patients off acid
suppression therapy is the gold standard for diagnosing GERD.
This is accomplished using either a 24-hour dual-probe catheter
system placed transnasally or a 48-hour wireless capsule placed
endoscopically. Both tests rely on correct spacing above the lower
esophageal sphincter and generate a composite score based on the
frequency and duration of distal esophageal acid exposure (i.e.,
pH below 4). A DeMeester composite score above 14.72 or total
distal esophageal acid exposure time greater than 5% to 6% are
commonly used thresholds indicative of pathologic reflux.
■ Upper endoscopy: The presence of LA Grade C or D esophagi-
tis (Table 1; Fig. 1), Barrett’s metaplasia, or a peptic stricture on
BOX 1 Presenting Symptoms of Gastroesophageal
Reflux
Typical Symptoms
Heartburn (also known as pyrosis)
Regurgitation
Acid brash
Atypical Symptoms
Cough
Wheezing
Dyspnea/shortness of breath
Voice changes
Sore throat
Globus sensation
Alarm Symptoms
Dysphagia
Odynophagia
Anorexia/early satiety
Weight loss
Gastrointestinal bleeding
TABLE 1 The Los Angeles Classification of
Esophagitis
Grade Lesion
A One (or more) mucosal break <5 mm long
that does not extend between the tops of
two mucosal folds
B One (or more) mucosal break >5 mm long
that does not extend between the tops of
two mucosal folds
C One (or more) mucosal break that is con-
tinuous between the tops of two or more
mucosal folds but that involves <75% of
the circumference
D One (or more) mucosal break that
involves at least 75% of the esophageal
circumference
8 SURGICAL MANAGEMENT OF GASTROESOPHAGEAL REFLUX DISEASE
Grade A
Grade C
https://t.me/medicina_free
Grade B
Grade D
FIG. 1 The Los Angeles classification of esophagitis. Grades A to D are illustrated as described in Table 1. (From Nayar DS, Vaezi MF. Classifications of esophagi-
tis: Who needs them? Gastrointest Endosc. 2004;60[2]:253–257.)
endoscopy are all findings that confirm the diagnosis of GERD. In
the case of peptic strictures, serial endoscopic dilations can provide therapy before ARS. Furthermore, endoscopic examinations
are useful in identifying hiatal hernias, retained food suggestive
of delayed gastric emptying, and other gross pathology involving
the esophagus and stomach.
■ Manometry: We use esophageal manometry in the setting of
GERD primarily to help determine the type of fundoplication
to perform. Our preference is to perform a complete 360-degree
posterior (Nissen) fundoplication for patients who exhibit normal esophageal motility as this is likely the most durable treatment for reflux. For patients who have ineffective esophageal
motility according to Chicago Classification version 4.0 (updated
in 2020), we consider performing a partial 270-degree posterior
(Toupet) fundoplication to avoid issues with postoperative dysphagia. Obtaining a manometry study also serves to rule out
achalasia and other named esophageal motility disorders, which
can sometimes present with symptoms that overlap with GERD.
• Barium Esophagram: Combined with the aforementioned stud-
ies, an upper GI barium esophagram increases the sensitivity of
diagnosing a hiatal hernia or identifying other anatomic abnormalities such as an esophageal diverticulum. This is especially
relevant when the treating surgeon is not the one performing
the preoperative endoscopy. Furthermore, a high-quality barium
esophagram is particularly useful in understanding the anatomy
and geometry of a previously constructed wrap in patients with
postoperative concerns or complications.
INITIAL MANAGEMENT AND
INDICATIONS FOR SURGERY
With rare exception, all patients should be on acid suppression
therapy with a proton pump inhibitor (PPI) before being considered
for ARS. It is important to ensure that patients are taking PPIs consistently and correctly (usually 40 mg daily) to maximize the drug’s
efficacy and assess for a clinical response in symptoms. In general,
PPIs are well-tolerated, and adverse reactions or side effects such
as nausea, diarrhea, constipation, and abdominal discomfort are
rare. Patients who report preoperative issues with bloating may be
evaluated for delayed gastric emptying and should be counseled on
the risk of worsening gas bloat when weighing the risks and benefits
of ARS.
Indications for Surgical Management of GERD
The primary reason to perform ARS is for symptomatic control to
reduce suffering and improve patients’ quality of life. Fundoplication
has not been shown to reduce rates of esophageal adenocarcinoma or
improve survival outcomes. Accordingly, the most common indication for ARS is the presence of persistent symptoms that affect quality of life despite maximal medical therapy. As previously discussed,
patients who exhibit atypical or alarm symptoms should undergo
appropriate workup and/or interdisciplinary consultation as indicated. In patients with atypical symptoms and objectively confirmed
reflux, we estimate that approximately one-third of these patients
may not see improvement in their symptoms following ARS. Thus,
it is important to counsel such patients carefully when weighing the
risks and benefits of an operation. In general, patients presenting
with typical GERD symptoms that are partially mitigated with acid
suppression (or worsen when stopping acid suppression) are most
likely to experience significant improvement following ARS.
Although the inability to tolerate acid suppression therapy is an
indication for surgical management, true medication intolerance in
the treatment of GERD should be rare. More commonly, patients
will present with hesitancy or concerns surrounding long-term acid
suppression therapy, with many seeking a definitive solution to their
reflux. In patients who have well-controlled symptoms on a PPI, we
typically advise against surgical intervention because the risks and
side effects of ARS outweigh the risks of regular acid suppression
therapy. Stated differently, it is very difficult to improve upon medically well-managed symptoms through an operation.
Finally, some patients with interstitial lung disease and objective
findings of GERD may benefit from ARS. Data suggest that ARS
can slow the deterioration of pulmonary function in these patients,
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