{"type":"rich","version":"1.0","provider_name":"Transistor","provider_url":"https://transistor.fm","author_name":"Board Pearls","title":"Chapter 3, Ep 3 of 3: Refractory Lyon Surgery Functional","html":"","width":"100%","height":180,"duration":961,"description":"Drug failure on twice-daily acid suppression is not refractory reflux, it is a reason to work the patient up, and the workup usually turns up something other than reflux. The Lyon Consensus framework, with its acid-exposure cutoffs and symptom-association tests, sorts persistent symptoms into confirmed reflux, borderline, reflux hypersensitivity, and functional heartburn. Antireflux surgery is matched to proven reflux and to motility, and it is reserved for the small group left standing after the mimics are excluded.\n \nTopics covered\n\nPPI failure is a different diagnosis, not breakthrough reflux\nLyon Consensus: proof, support, and evidence against\nTesting on-drug versus off-drug depends on what you must prove\nFour buckets: confirmed, borderline, hypersensitivity, functional heartburn\nMatching wrap type to esophageal motility\nMagnetic device, incisionless fundoplication, and bariatric options\nThe ordered refractory workup and its mimics\nAtypical presentations and weak reflux linkage\n \n \nKey decisions\n\nAcid exposure time above six percent is proof-level reflux; under four percent is evidence against; four to six is borderline and leans on supporting measures\nTest off-drug (hold about a week) to prove reflux exists; test on-drug with impedance to characterize breakthrough when reflux is already known\nFunctional heartburn gets a neuromodulator alone; reflux hypersensitivity gets a neuromodulator plus acid suppression; the most common cause of fundoplication failure is operating on functional heartburn\nFull 360-degree wrap for normal motility, partial two-thirds wrap for weak or scleroderma esophagus; a full wrap on a weak esophagus causes dysphagia\nMagnetic bead device is excluded by hernia over three centimeters, BMI over thirty-five, Barrett's, severe esophagitis, or absent peristalsis; incisionless fundoplication needs a hernia under two centimeters\nGastric bypass is the antireflux operation of choice in the obese refluxer; avoid the sleeve, and BMI over...","thumbnail_url":"https://img.transistorcdn.com/-FuAdDBcPDLhEoUmroZKtOBRvuBn_FHPpYlh41hOnU4/rs:fill:0:0:1/w:400/h:400/q:60/mb:500000/aHR0cHM6Ly9pbWct/dXBsb2FkLXByb2R1/Y3Rpb24udHJhbnNp/c3Rvci5mbS9iNzlh/ZTU4Y2MzNWExMjQ5/MjA5OWMwMmI3ZTk5/NGFiZS5wbmc.webp","thumbnail_width":300,"thumbnail_height":300}