2. GERD / Foregut Pathway

GERD / Foregut Pathway

Clinic

  • History documentation
    • Classic symptoms (epigastric pain, regurgitation, sour taste in mouth).
    • Silent / atypical symptoms (dysphagia, bloating, cough, asthma, bronchitis, chest pain, esophageal spasms)
  • Review conservative measures (dietary changes, complete smoking cessation, weight loss).
  • Complete GERD HQRL score
  • Document medication intervention and responses (H2 blockers, PPI)
  • Document prior diagnostic workup (EGD, UGI, manometry, gastric emptying studies)
  • Document gastric AND abdominal surgical history
  • Document medical and surgical weight loss history (including GLP-1 medications)

Diagnostic workup

  • Classic symptoms and PPI responded requires UGI and EGD. No further testing if objective evidence of GERD (UGI showing moderate/severe GERD or esophagitis on EGD).
  • Bloating, nausea, emesis or history of GLP-1 requires gastric emptying study.
  • Significant dysphagia requires esophageal manometry.
  • Significant spasms or chest pain requires esophageal manometry
  • PPI nonresponder or atypical symptoms requires pH testing and manometry.
  • EGD and UGI showing no objective evidence of GERD with persistent symptoms proceed with pH testing and manometry.
  • Previous history of anti reflux surgery requires gastric emptying study.
  • Patients 45 or older require colonoscopy or Cologuard prior to proceeding with gastric operation.

Recommended operative criteria for LBJGH

  • Complete smoking cessation for 6-8 weeks with negative urine cotinine levels.
  • BMI < 35.
  • Diagnostic workup confirming significant hiatal hernia / GERD.
  • No previous gastric operations.

Recommended criteria for referral to MHH clinics

  • Previous hiatal hernia repair.
  • Previous weight loss surgery.
  • BMI > 35 to facilitate evaluation for weight loss surgery / gastric bypass.
  • Prior Ivor Lewis esophagectomy with associated hernia.
  • Recurrent achalasia should be referred to Dr. Todd Wilson for POEM.

Pre operative preparation

  • If BMI < 30, full liquid diet for 3 days prior to operation.
  • If BMI 30-35, full liquid diet for 7 days prior to operation.
  • If BMI 33-35 needs weight check within 2 weeks of operation with documented weight stability or weight loss.
  • Urine cotinine negative within 2 weeks if history of smoking.
  • Hold all GLP-1 medications for 10 days prior to any operation.
  • Clinic visit within 30 days of operation.

Post operative pathway

  • No routine UGI unless requested by operating surgeon.
  • Clear liquids POD 1-3.
  • Full liquids POD 4-14.
  • Soft diet POD 15-28.
  • No straws or carbonation.
  • Encourage patients to ambulate and sit up straight when drinking/eating.
  • Discharge on PPI for 30 days.
  • If first start case and nausea controlled consider same day discharge.

Follow up schedule

  • Operating resident contact patient 48 hours post op to ensure no dietary issues.
  • Clinic 2 weeks: document symptoms
  • Clinic 6 weeks: GERD HQRL and ensure weaned off PPI.
  • Clinic 6 months: GERD HQRL scoring.