antireflux surgery 1 Gastro Oesophageal Reflux Disease Mr Dip Mukherjee Consultant upper GI & Laparoscopic surgeon Queens Hospital.BHRT. Romford A surgical perspective
Jan 11, 2016
antireflux surgery 1
Gastro Oesophageal Reflux Disease
Mr Dip Mukherjee
Consultant upper GI & Laparoscopic surgeon
Queens Hospital.BHRT. Romford
A surgical perspective
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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
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The presence of documented (photographic or histologic) esophageal mucosal injury (esophagitis)
ORExcessive reflux during 24-hour intraesophageal pH monitoring.
DiagnosisDemonstration of:
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PathophysiologyAntireflux barrier
Oesophageal motility
Gastric hyperacidity
Visceral sensation
Mucosal defence
Antireflux surgery
PPI
Antireflux surgery
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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
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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
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Intestinal metaplasia
Mucin stain Intramucosal
cancer
Optical coherence tomography
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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.
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Management• Medical Vs Surgical
• Medical & Surgical
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PPI and Laparoscopic antireflux surgery are the only two proven treatment for GORD in 2007
J Richter
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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
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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
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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
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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
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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
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Failure to improve
Oesophagitis No oesophagitis
Nocturnal breakthrough
Nonacid GOR
Wrong diagnosis
Achalasia
gastroparesis
Functional heartburn
OGD
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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
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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
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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.
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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?
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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
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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
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Patient selection• Clinical assessment
• Endoscopy– Esophagitis– Hiatus hernia
• pH Manometry
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Acid exposure
Symptom score
Defective LOS
pressure
Length
position
Body motility
pH Manometry
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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
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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.
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•To increase LES pressure and therefore prevent acid back flow (reflux)
•To repair any present hiatal hernia.
Goal of surgery
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How Fundoplication works?
• Reduces fundic distension and TLOSR
• Increase basal LOS pressure
• Lengthens LOS
• Restores intraabdominal sphincter
• Accentuates angle of His
• Speeds gastric emptying
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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
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Dallemagne B, Weerts JM, Jehaes C, et al. Laparoscopic Nissen fundoplication: preliminary report. Surg Laparosc Endosc 1991; 1:138-143.
Laparoscopic Nissen Fundoplication
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Set Up for surgery
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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
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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.
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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.
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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
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Complications of LNF
• Operative problems• Wrap migration- post op contrast swallow• Gas bloat ,early satiety• Flatulence• Persistent Dysphagia0.9%
• Failure and reoperation0.7-
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Type 1 Type 2
Type 3Type 4
Complex Hiatus hernia needs surgical referral irrespective of reflux symptoms
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Endoscopic treatment of GORD – The future?
Escharification
Stretta
Injection
Enteryx
Gatekeeper
Plication
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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
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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
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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