Gastro Esophageal Reflux Disease

Gastro Esophageal Reflux Disease: Medical versus surgical

management for gastro-oesophageal reflux disease (GORD)

in adults

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315 Apollo Medicine, Vol. 7, No. 4, December 2010

BACKGROUND

Gastro-oesophageal reflux disease (GORD) is a commoncondition with up to 20% of patients from Westernisedcountries experiencing heartburn, reflux or bothintermittently. It is unclear whether medical or surgical(laparoscopic fundoplication) management is the mostclinically and cost-effective treatment for controllingGORD.

OBJECTIVES

To compare the effects of medical management versuslaparoscopic fundoplication surgery on health-related andGORD-specific quality of life (QOL) in adults withGORD.

SEARCH STRATEGY

We searched CENTRAL (Issue 2, 2009), MEDLINE (1966to May 2009) and EMBASE (1980 to May 2009). Wehandsearched conference abstracts and reference listsfrom published trials to identify further trials. Wecontacted experts in the field for relevant unpublishedmaterial.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trialscomparing medical management with laparoscopicfundoplication surgery.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data from articlesidentified for inclusion and assessed the methodologicalquality of eligible trials. Primary outcomes were: health-related and GORD-specific QOL, heartburn, regurgitationand dysphagia.

MAIN RESULTS

Four trials were included with a total of 1232 randomised

GASTRO ESOPHAGEAL REFLUX DISEASEMedical versus surgical management for gastro-oesophageal reflux disease

(GORD) in adultsWileman SM, McCann S, Grant AM, Krukowski ZH, Bruce J.

Health Services Research Unit, University of Aberdeen,Foresterhill, Aberdeen, UK, AB25 2ZD. Cochrane Database Syst Rev. 2010 Mar 17;(3):CD003243.

Comment in: Ann Intern Med. 2010 Sep 21;153(6):JC3-10.

participants. Health-related QOL was reported by fourstudies although data were combined using fixed-effectmodels for two studies (Anvari 2006; REFLUX Trial2008). There were statistically significant improvementsin health-related QOL at three months and one year aftersurgery compared to medical therapy (mean difference(MD) SF36 general health score -5.23, 95% CI -6.83 to -3.62; I [2] = 0%). All four studies reported significantimprovements in GORD-specific QOL after surgerycompared to medical therapy although data were notcombined. There is evidence to suggest that symptoms ofheartburn, reflux and bloating are improved after surgerycompared to medical therapy, but a small proportion ofparticipants have persistent postoperative dysphagia.Overall rates of postoperative complications were low butsurgery is not without risk and postoperative adverseevents occurred although they were uncommon. Thecosts of surgery are considerably higher than the cost ofmedical management although data are based on the firstyear of treatment therefore the cost and side effectsassociated with long-term treatment of chronic GORDneed to be considered.

Complete or Partial Fundoplication?

Cai W, Watson DI, Lally CJ, Devitt PG, Game PA,Jamieson GG. Ten-year clinical outcome of a prospectiverandomized clinical trial of laparoscopic Nissen versusanterior 180 (degrees) partial fundoplication. Br. J.Surg.95,1501-1505 (2008)

The choice of surgical technique to provide optimalreflux control while minimizing side effects remainscontroversial. Because fundoplication is associated with anincidence of postoperative dysphagia, gas bloat andincreased flatulence, the relative merits of the Nissenfundoplication procedure versus various partialfundoplication variants have been debated for many years.A recent meta-analysis of 11 randomized clinical trialsconcluded that partial fundoplication is a safe and effectivealternative to total fundoplication, resulting in fewer

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reoperations and better functional outcomes.

Six prospective randomized trials of Nissen versusposterior partial fundoplication have been reported. If onecombines the data from all of these trials, the outcomessupport the view that side effects are less commonfollowing posterior partial fundoplication, particularly forgas-related problems. Overall symptom improvement,quality of life and patient satisfaction measures are at leastequivalent for the two procedures, and long-termoutcomes from the study reported by Sgromo, et al. didnot identify any significant differences between the twoprocedures. In all of these studies, however, there was atrend toward less dysphagia following posterior partialfundoplication, although the hypothesis that dysphagia isless of a problem following a posterior partialfundoplication has been substantiated only by the twolargest trials.

Nonrandomized cohort studies evaluating outcomesfollowing laparoscopic antireflux surgery report similaroverall outcomes for Nissen versus anterior partialfundoplications. However, these studies have suggestedthat although anterior partial fundoplication is associatedwith fewer side effects, this advantage might, to someextent, be offset by a higher risk of recurrent reflux. Thisissue has been examined in four randomized trials ofanterior partial versus Nissen fundoplication. Three of thesetrials were conducted in our unit. In the first, we comparedNissen fundoplication with an anterior 180° partialfundoplication, and patients have now been followed-upfor 10 years. The outcomes from this trial demonstratedless dysphagia and gas-related side effects from early to 5years follow-up, although dysphagia outcomes weresimilar at 10 years. The outcome for reflux control wasacceptable, and the overall satisfaction with surgery waseither equivalent to or better than Nissen fundoplication atall follow-up intervals, with more than 90% of patientshighly satisfied with the outcome 10 years after surgery.There was, however, a degree of tradeoff between refluxcontrol and side effects, with the overall balance somewhatin favor of partial fundoplication. Results from the othertrials of anterior fundoplication support these outcomes,and suggest that anterior partial fundoplication doesachieve satisfactory reflux control, a reduced incidence ofpostfundoplication dysphagia and other side effects and agood overall clinical outcome compared with Nissenfundoplication.

Dr. Arun Prasad’s Conclusions & experience

1. There is evidence that laparoscopic fundoplicationsurgery is more effective than medical managementfor the treatment of GORD at least in the short tomedium term. Surgery does carry some risk and

whether the benefits of surgery are sustained in thelong term remains uncertain. Treatment decisions forGORD should be based on patient and surgeonpreference.

2. Post operative dysphagia and gas bloating arecommon symptoms that have troubled patients andsurgeons after a Nissen’s fundoplication in Indianpatients. We have done 23 Nissen’s fundoplicationand 8 partial fundoplications and have found results tobe similar to what is mentioned above. The patients ofpartial fundoplications did not have the symptoms ofdysphagia and gas bloating. Some authors havesuggested that these patients may have a higherincidence of recurrence so one has to balancebetween the two with careful case selection.

RECTAL CANCER – JOURNAL SCAN

Diseases of the Colon & Rectum

January 2011 - Volume 54 - Issue 1 - pp 6-14

Laparoscopic vs Open Resection for Patients WithRectal Cancer: Comparison of Perioperative Outcomes andLong-Term Survival

Baik, Seung Hyuk M.D. [1,2]; Gincherman, MikhailM.D. [1]; Mutch, Matthew G. M.D. [1]; Birnbaum, ElisaH. M.D. [1]; Fleshman, James W. M.D. [1]

PURPOSE

The aim of the study is to assess the safety andoncologic feasibility of laparoscopic-assisted resection forrectal cancer vs open rectal resection as a phase II pilotstudy for a planned randomized control trial.

METHODS

A case-matched controlled prospective analysis of 54patients who underwent laparoscopic-assisted resectionfor stage I to III (no T4) rectal cancer within 12 cm of theanal verge from 2002 to 2005 was performed. Patientswere matched with contemporary patients who underwentopen rectal cancer surgery (n = 108) in a 1 to 2 fashion.The perioperative clinical outcomes, postoperativepathology, and oncologic outcomes were comparedbetween the groups.

RESULTS

The demographic data did not differ significantlybetween the groups. The laparoscopic group manifestedearly return of bowel function (P = 0.003). Thecomplication rate was 22.2% in the laparoscopic group and32.4% in the open group (P = 0.178). Local recurrence

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317 Apollo Medicine, Vol. 7, No. 4, December 2010

was similar (2.0% laparoscopic, 4.2% open, P = 0.417).The 5-year overall and disease-free survival rate also weresimilar (overall survival, 90.8% laparoscopic, 88.5% open,P = 0.261; disease-free survival, 80.8% laparoscopic,75.8% open. P = 0.390).

CONCLUSION

The laparoscopic-assisted resection for rectal cancerwas acceptable in terms of oncologic outcomes andperioperative clinical outcomes. The present data are thebasis for a large-scale randomized trial for comparison oflaparoscopic and open rectal cancer surgeries

Am J Surg. 2008 Feb;195(2):233-8.

Results of laparoscopic anterior resection for rectaladenocarcinoma: retrospective analysis of 157 cases.

Pugliese R, Di Lernia S, Sansonna F, ScandroglioI, Maggioni D, Ferrari GC, Costanzi A, Magistro C, DeCarli S.

Surgery Department, Niguarda Hospital, PiazzaOspedale Maggiore 3, 20162 Milano, Italy.

BACKGROUND

Laparoscopic excision of rectal tumors has gainedfavor in the last decade and several issues have reportedencouraging results: still, the use of laparoscopy remainsopen to debate. The aim of the current study is to assess thereliability of laparoscopic anterior resection (LAR) forrectal cancer analyzing short-term outcomes and long-termsurvival.

METHODS

The charts of 157 patients were reviewedretrospectively after anterior resection for rectaladenocarcinoma performed by minimal access. Patientsundergoing emergency surgery were excluded. LAR wasexcluded in presence of preoperative features at computedtomography (CT) scan suggesting bulky tumorsunresectable by laparoscopy or in case of anesthesiologiccontraindications. Conversion rate and functional andoncologic outcomes were analyzed. Data on long-termresults and survival were evaluated.

RESULTS

LAR was performed in 157 patients, and conversion tolaparotomy was required in 12 cases. Mean operation timefor nonconverted patients was 229 minutes (overall 238minutes). Total mesorectal excision (TME) was performedin tumors of the mid and low rectum and a temporaryileostomy was performed in 56 patients. The mean lengthof hospital stay (LOS) was 10.5 days. Morbidity ofanterior resection included 17 anastomotic leaks afterlaparoscopic surgery (LS; 5 in the converted patients).Conversion increased significantly the risk of leak (P <0.005). Two leaks caused death. The mean number ofnodes collected was 12. The incidence of local relapse was4%, and the rate of anastomotic recurrence was nil.Survival probability with LS was 0.73 at 5 years. Patientsin stage III took advantage of adjuvant treatment and had abetter survival than patients in stage II (P = not significant[NS]).

CONCLUSIONS

The outcomes of this study suggest that LAR for rectalcancer is a reliable procedure. Oncologic requirementswere respected; parameters such as length of specimen,distal margin, and number of nodes retrieved were quiteacceptable. Incidences of local recurrence and long-termsurvival were comparable with those of other series.

Dr. Arun Prasad’s Conclusions & experience

1. Laparoscopic excision of rectal tumors has gainedfavor in the last decade and several issues havereported encouraging results: still, the use oflaparoscopy remains open to debate in most academicmeetings. Recent trials and reports show that theincidences of local recurrence and long-term survivalwere comparable with those of other series.

2. We have been doing laparoscopic surgery for rectaltumors for over 10 years now with good results.

Dr Arun PrasadSenior Consultant,

Department of General Sergery,Indraprastha Apollo Hospitals,

Sarita Vihar, New Delhi 110076.

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