Laparoscopic Antireflux Surgery Why the decline in numbers

1
Laparoscopic Anti-reflux Surgery- Why the
decline in numbers?

• Mehran Anvari
• Professor of Surgery
• McMaster University

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OntarioTrends in the use of surgery for
gastroesophageal refluxdisease, 19882000 2
2 Urbach DR, Ungar Wj, and Rabeneck L. Whither
surgery in the treatment of gastroesophageal
reflux disease (GERD)? CMAJ. 2004. 170(2) 219
221.
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Primary Outcome Symptom Free days
Mean Difference, 95 CI
p0.0077
4
Secondary outcome Esophageal Acid Exposure
Mean Difference, 95 CI
p0.1301
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Secondary Outcome Quality of Life Measurement
Mean Difference, 95 CI
p0.0124
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GERD Symptoms

• Prevalence 7-10
• Obesity a risk factor
• 25-50 have GERD symptoms
• Increasing population with BMIgt35

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Obesity Trends Among Canadian and U.S. Adults,
1985
8
Obesity Trends Among Canadian and U.S. Adults,
1996
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Obesity Trends Among Canadian and U.S. Adults,
2000
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Obesity Trends Among Canadian and U.S. Adults,
2004
10-14 15-19 ?20 ?25
?30
AH Mokdad, CDC M Shields, Statistics Canada, 2005
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United StatesAnnual number of antireflux surgery
procedures performed (Nationwide Inpatient
Sample, 1994 to 2003) 1
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United StatesAnnual case numbers and
population-based rates, patientand hospital
characteristics, and surgical outcomes from
antireflux surgery in 1999 and 2003 1
1 Finks JF, Yongliang W, and Birkmeyer JD. "The
Rise and Fall of Antireflux Surgery in the United
States". Surg Endosc. 2006. 20 1698 - 1701
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Bariatric Surgery

• Fastest gowing branch of Sx
• Over 100,000 per yr in USA
• Major impact on a number of medical conditions
• Over the same period major fall in number of
  anti-reflux surgery in USA

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United StatesAnnual rate of bariatric procedures
per 100,000 adults 3.
3 Nguyen NT, Root J, Zainabadi K, Sabio A,
Chalifoux S, Stevens CM, Mavandadi S, Longoria M,
and Wilson SE. Accelerated Growth of Bariatric
Surgery With the Introduction of Minimally
Invasive Surgery. Arch Surg. 2005. 140 1198
1202.
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Impact on GERD symptomsnot weight related

• Gastric bypass associated with improvement in
  GERD symptoms Esophagitis
• But not with restrictive procedures

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Evidence
1. Symptom evaluation in patients undergoing
bariatric sx 2. Case reports in patients with
failed anti-reflux surgery 3. Prospective
studies in GERD patients
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Symptomatic improvement in gastroesophageal
reflux disease (GERD) following laparoscopic
Roux-en-Y gastric bypass.Frezza EE. Ikramuddin
S. Gourash W. Rakitt T. Kingston A. Luketich
J. Schauer P. Surgical Endoscopy.
16(7)1027-31, 2002 Jul.

• 435 patients undergoing LGB 238 (55) had GERD
  symptoms
• Mean BMI 48 kg/m2
• Mean excess wt loss 68.8 at one year
• Improvement in
• heartburn from 87 to 22
• Water brash from 18 to 7
• Aspiration from 14 to 2
• Wheezing from 40 to 5
• Use of PPI from 44 to 9

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Effects of gastric bypass on erosive esophagitis
in obese subjectsCsendes J A. Burgos L AM.
Smok S G. Burdiles P P.Revista Medica de Chile.
134(3)285-90, 2006 Mar.

• 62 obese patients with erosive esophagitis
• At 2 years after gastric bypass
• 3 still had some heartburn
• 6.5 had esophagitis

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Effect on Barretts

• Csendes et al J of Gastrointest Surg, 2006
• 12 pts with Barretts, 3 with CIM
• Symptoms resolved in all pts
• 5 patients with Barretts and 2 with CIM showed
  regression after 2 years
• No progression to dysplasia was noted

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LGB after previous LNF

• Indications
• Morbid Obesity with 2 complications
• Recalcitrant GERD
• Scleroderma
• 2 previous repairs
• Take down previous wrap
• No significant increase in morbidity

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How about the Gastric Band?

• Tolonen et al, Finland
• Obesity Surgery 2006
• 31 patients
• 24 hour pH reduced from 9.5 to 3.5 at mean 1.5
  yr FU
• Symptomatic pts from 48 to 16
• No long-term data available
• ?Pouch dilatation

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Summary

• Reduced rate of Lap anti-reflux surgery likely
  due to increase in use of Lap gastric bypass.
• GERD symptoms, QOL, and esophagitis improves
  after gastric bypass
• Case reports of Barretts regression after LGB
• While no study has evaluated the relative merits
  of LGB in comparison to fundoplication in
  patients with BMIgt35, it is increasing becoming
  the operation of choice among this growing
  population