Antireflux surgery1 Gastro Oesophageal Reflux Disease Mr Dip Mukherjee Consultant upper GI &...

antireflux surgery 1

Gastro Oesophageal Reflux Disease

Mr Dip Mukherjee

Consultant upper GI & Laparoscopic surgeon

Queens Hospital.BHRT. Romford

A surgical perspective


Impact of GORD

Upto 40% and rising

4% of all GP consultations are for dyspepsia

7% of children need GP input for reflux

50% rise in oesophageal adenoca. In 10 years

50% of Barretts do not have heartburn

10% of national drug bill

£500 million per year

£11.25 per person

$14 Billion in US


The presence of documented (photographic or histologic) esophageal mucosal injury (esophagitis)

ORExcessive reflux during 24-hour intraesophageal pH monitoring.

DiagnosisDemonstration of:

http://images.google.com/imgres?imgurl=http://www.merck.com/mrkshared/mmanual/plates/p20_4.jpg&imgrefurl=http://www.merck.com/mrkshared/mmanual/plates/20pla4.jsp&h=350&w=350&sz=45&hl=en&start=4&tbnid=45o0HUGvstsn8M:&tbnh=116&tbnw=116&prev=/images%3Fq%3Desophagitis%26svnum%3D10%26hl%3Den%26lr%3D


PathophysiologyAntireflux barrier

Oesophageal motility

Gastric hyperacidity

Visceral sensation

Mucosal defence

Antireflux surgery

PPI

Antireflux surgery


GORD – The quandary

Multifactorial etiology

Complex Pathophysiology

No obvious anatomical surrogate

Symptoms do not always predict the diagnosis

Endoscopy often negative

pH metry fraught with problems

Poor response to PPI also mean poor response to surgery

LNF and Barretts regression

The perfect operation – an unrealised dream


Barretts and cancer riskRising incidence of reflux related adenocarcinoma

Needs acid and bile

Dysplasia carcinoma sequence

Problems of diagnosis &surveillance

Problem of ablation

No reliable molecular markers for prediction of cancer


Intestinal metaplasia

Mucin stain Intramucosal

cancer

Optical coherence tomography


Does fundoplication prevent cancer?

Does fundoplication prevent benign complications?

Efficacy of Nissen fundoplication versus medical therapy in the regression of low-grade dysplasia in patients with Barrett esophagus: a prospective study.Ann Surg. 2006 Jan;243(1):58-63Ann Surg. 2006 Jan;243(1):58-63.

Ann Surg. 2006 Jan;243(1):58-63.


Management• Medical Vs Surgical

• Medical & Surgical


PPI and Laparoscopic antireflux surgery are the only two proven treatment for GORD in 2007

J Richter


PPITotal acid suppression market in US : $ 9.5 billion 77% captured by PPI

Maintains pH less than 4 for 15-21 hours;8 hours for H2 blockers

More effective than placebo in healing oesophagitis( RR=0.23 NNT =2)*

Superior to H2RA in maintaining remission of oesophagitis over 6-12 months**Relapse rate 22% for PPI and 58% for H2RA

Superior to placebo & H2RA in endoscopy negative GORD and undiagnosed reflux in primary care***

Esomeprazole 40 mg is better than Omeprazole and lansoprazole in severe esophagitis .higher bioavailability and less interpatient variability*Moyayeyedi et al.Lancet 2006;367:2086-2100(Recent Cochrane review)

**Donnellan C et al.The Cochrane database of systematic reviews2004;3:CD003245

*** Van Pinxteren et al. The Cochrane database of systematic reviews2004;3:CD002095


Impact Of PPI

33% decline in stricture rate since 1995

Reduces stricture relapse after dilatation

Patients with Non cardiac chest pain respond better than placebo (NNT=3)*

No clear data on chronic cough asthma or ENT disorders

Good for reflux related sleep disturbances

•Cremmini et al. Am J Gastroenterol2005;100:1226-32

*Wang et al.Arch Intern Med 2005;165:1222-28


Pill not working!25-42% patients after 4-8 weeks trial of PPI

Difficult to manage group

Increase dose to twice daily 25% respond

Timing and compliance

Switch to second generation( Esomeprazole, Pantoprazole)multicentre study

Consider endoscopy


Problem of PPI

No increased risk of gastric malignancy in humans

Increased risk of fundic gland polyps caused by parietal cell hyperplasia

Increased risk of community acquired pneumonia7 enteric infections( RR+1.89)*

Impaired vitamin D absorption elderly women and osteoporosis risk

*Laheji et al.JAMA2004;292:1955-60- population based study

Leonard J et al.Am J gastroenterol2007(In press)- systematic review


Works for most

especially when patient has oesophagitis

safe and effective

Prevents recurrence of strictures

Helps in sleep disturbances

Less effective with extraesophgeal symptoms and aspiration

Trial of PPI ok without endoscopy but acknowledge failure

Message


Failure to improve

Oesophagitis No oesophagitis

Nocturnal breakthrough

Nonacid GOR

Wrong diagnosis

Achalasia

gastroparesis

Functional heartburn

OGD


8. Behar J, Sheahan DG, Biancani P, Spiro HM, Storer EH. Medical and surgical management of reflux esophagitis. A 38-month report on a prospective trial. N Engl J Med 1975; 293: 263–268.

9. Spechler SJ. Comparison of medical and surgical therapy for complicated gastroesophageal reflux disease in veterans. The Department of Veterans Affairs Gastroesophageal Reflux Disease Study Group. N Engl J Med 1992; 326: 786–792.

10. Spechler SJ, Lee E, Ahnen D, Goyal RK, Hirano I, Ramirez F et al. Long-term outcome of medical and surgical therapies for gastroesophageal reflux disease: follow-up of a randomized controlled trial. JAMA 2001; 285: 2331–2338.

11. Lundell L, Miettinen P, Myrvold HE, Pedersen SA, Liedman B, Hattlebakk JG et al. Continued (5-year) followup of a randomized clinical study comparing antireflux surgery and omeprazole in gastroesophageal reflux disease. J Am Coll Surg 2001; 192: 172–179.

Medical Vs Surgical


LOSP Acid exposure

GI Symptom P=0.003

General

well being

P=0.003

PPI 8.1 36.9 34.3 98.5

7.9 17.7

P < 0·00135.0 100.4

LNF 6.3 42.7 31.7 95.4

17.2 P < 0·001

8.6 P < 0·001

37.0 106.2

Randomized clinical trial of laparoscopic Nissen fundoplication compared with proton-pump inhibitors for treatment of chronic

gastro-oesophageal reflux

[Randomized clinical trial]Mahon, D.1; Rhodes, M.1; Decadt, B.1; Hindmarsh, A.1; Lowndes, R.2; Beckingham, I.3; Koo, B.1; Newcombe, R. G.4


LNF leads to significantly less acid exposure of the lower oesophagus at 3 months and significantly greater improvements in both gastrointestinal and general well-being after 12 months compared with PPI treatment.


Some Basics

• Why refer for surgery ?

• Who should have surgery?

• When not to do it?

• How does surgery work how is it done and how effective is it?

• What are the complications?

• Where does the future lie?


When to call surgeon?

Medical therapy is effective in most patients, but not in patients with advanced disease or in those with an associated incompetent lower esophageal sphincter

Pills do not work!

Problems despite pills!

Acid suppression only addresses one factor in a multifactorial disease. In severe disease there is a significant failure rate of long-term standard dose medical therapy and progression of disease is often noted

Monnier P, Ollyo JB, Fontolliet C, Savary M. Epidemiology and natural history of reflux esophagitis. Sem Lap Surg 1995; 2:2-9.

Grande L, Toledo-Pimentel V, Manterola C, et al. Value of Nissen fundoplication in patients with gastro-oesophageal reflux judged by long-term symptom control. Br J Surg 1994; 81:548-550.

Liebermann DA. Medical therapy for chronic reflux esophagitis: long-term follow-up. Arch Intern Med 1987; 147:1717-1720


Indications For Antireflux Surgery

Pills do not work !

symptomatic relapse on continuous drug therapy

early relapse after cessation of drug therapy

non-compliance to medication

financial non-compliance to medication

Problems despite pills!

Recurrent strictures

Severe pulmonary symptoms

Severe esophagitis

Symptomatic Barrett's esophagus Large symptomatic paraesophageal hernia


Patient selection• Clinical assessment

• Endoscopy– Esophagitis– Hiatus hernia

• pH Manometry


Acid exposure

Symptom score

Defective LOS

pressure

Length

position

Body motility

pH Manometry


Detects acid reflux

Discriminates normal from abnormal

Determines temporal association between symptom and reflux

Detects oesophageal clearance of acid

Detects adequacy of medical or surgical therapy

Detects laryngopharyngeal Reflux Disease(LPRD)

Ambulatory 24 hour pH test


Beware

• Multiple somatic complaints- ruminants

• Scleroderma

• Achalasia

• Poor response to PPI

It is important to adequately evaluate patients before surgery, because an inappropriately performed operation can have disastrous effects14

Richter JE. Surgery for reflux disease - reflections of a gastroenterologist. N Engl J Med 1992;

326:825-827.


•To increase LES pressure and therefore prevent acid back flow (reflux)

•To repair any present hiatal hernia.

Goal of surgery


How Fundoplication works?

• Reduces fundic distension and TLOSR

• Increase basal LOS pressure

• Lengthens LOS

• Restores intraabdominal sphincter

• Accentuates angle of His

• Speeds gastric emptying


The laparoscopic Nissen fundoplication offers less morbidity and mortality than the open procedure with at least the same short-term outcome as the open procedure and better results compared to medical therapy

Spechler SJ. Comparison of medical and surgical therapy for complicated gastroesophageal reflux disease in veterans. N Engl J Med 1992; 326:786-792


Dallemagne B, Weerts JM, Jehaes C, et al. Laparoscopic Nissen fundoplication: preliminary report. Surg Laparosc Endosc 1991; 1:138-143.

Laparoscopic Nissen Fundoplication


Set Up for surgery


More than 90% of patients are free of heartburn after the operation and satisfied with their choice, even after five years.

The procedure relieved GERD-induced coughs and some other respiratory symptoms in up to 85% of patients

Overall long-term benefits


Does the operation work?

• 100 patients

• Follow up1-13 yrs

• Reflux control 91%*

• Symptom control

.* DeMeester TR, Bonavina L, Albertucci M. Nissen fundoplication for gastroesophageal reflux disease. Evaluation of primary repair in 100 consecutive patients. Ann Surg 1986; 204:9-20.


Grande L, Toledo-Pimentel V, Manterola C, et al. Value of Nissen fundoplication in patients with gastro-oesophageal reflux judged by long-term symptom control. Br J Surg 1994; 81:548-550

160 patients

Follow up3-20 years (Mean 136 months)

71 out of 160 followed up for more than 10 years

92% success rate

I am fine now – will this bliss last?

Currently laparoscopic Nissen fundoplication has a 3.4 % recurrence rate of symptoms with only 0.7 % rate of need for reoperation.


What are the benefits of laparoscopic fundoplication?

Less post-operative pain

Faster recovery

Short hospital stay

Less post-operative complications like wound infection, adhesion, hernia, etc.

Cost-effective in working group


Complications of LNF

• Operative problems• Wrap migration- post op contrast swallow• Gas bloat ,early satiety• Flatulence• Persistent Dysphagia0.9%

• Failure and reoperation0.7-

http://www.ajronline.org/content/vol178/issue4/images/large/04_AB0928_01B.jpeg


Type 1 Type 2

Type 3Type 4

Complex Hiatus hernia needs surgical referral irrespective of reflux symptoms

http://www.ddc.musc.edu/ddc_pro/pro_development/case_studies/images/case015c.jpg

http://www.ddc.musc.edu/ddc_pro/pro_development/case_studies/images/case015a.jpg

http://www.ddc.musc.edu/ddc_pro/pro_development/case_studies/images/case015b.jpg


Endoscopic treatment of GORD – The future?

Escharification

Stretta

Injection

Enteryx

Gatekeeper

Plication


NOTES

Natural Orifice Transluminal Endoscopic Surgery

Transgastric gastropexy and hiatal hernia repair for GERD under EUS control: a porcine model.

Fritscher-Ravens A, Mosse CA, Mukherjee D, Yazaki E, Park PO, Mills T, Swain P Gastrointest Endosc. 2004 Jan;59(1):89-95.

Endoscopic Gastroplasty

NDO Plicator


Conclusions

• Some patients will need to see a surgeon.

• Surgery is safe,effective and offers one off permanent cure in selected patients.

• Laparoscopic surgery makes the recovery simple and fast.

• Surgery is the only treatment that abolishes acid bile insult to oesophageal mucosa


Thank You for your time and patience

“Man will occasionally stumble over the truth but most of the time he will pick himself up and carry on” Winston Churchill

Antireflux surgery1 Gastro Oesophageal Reflux Disease Mr Dip Mukherjee Consultant upper GI &...

Documents

Transcript of Antireflux surgery1 Gastro Oesophageal Reflux Disease Mr Dip Mukherjee Consultant upper GI &...