Gastro Oesophageal Reflux Disease

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Gastro Oesophageal Reflux Disease
A surgical perspective
Mr Dip Mukherjee Consultant upper GI
Laparoscopic surgeon Queens Hospital.BHRT.
Romford
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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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Diagnosis Demonstration of
The presence of documented (photographic or
histologic) esophageal mucosal injury
(esophagitis) OR Excessive reflux during
24-hour intraesophageal pH monitoring.
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Pathophysiology
Antireflux barrier
Antireflux surgery
Gastric hyperacidity
PPI
Oesophageal motility
Antireflux surgery
Visceral sensation
Mucosal defence
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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 risk
Rising 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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Mucin stain
Intramucosal cancer
Intestinal metaplasia
Optical coherence tomography
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Does fundoplication prevent cancer? Does
fundoplication prevent benign complications?
Ann Surg. 2006 Jan243(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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PPI
Total acid suppression market in US 9.5
billion 77 captured by PPI Maintains pH less
than 4 for 15-21 hours8 hours for H2
blockers More effective than placebo in healing
oesophagitis( RR0.23 NNT 2) Superior to H2RA
in maintaining remission of oesophagitis over
6-12 monthsRelapse 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 20063672086-2100(Recent
Cochrane review) Donnellan C et al.The
Cochrane database of systematic
reviews20043CD003245 Van Pinxteren et al.
The Cochrane database of systematic
reviews20043CD002095
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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 (NNT3) No clear data on chronic cough
asthma or ENT disorders Good for reflux related
sleep disturbances

• Cremmini et al. Am J Gastroenterol20051001226-32
  
• Wang et al.Arch Intern Med 20051651222-28

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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( RR1.89) Impaired vitamin D
absorption elderly women and osteoporosis risk
Laheji et al.JAMA20042921955-60- population
based study Leonard J et al.Am J
gastroenterol2007(In press)- systematic review
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Message
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
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Failure to improve
OGD
Oesophagitis
No oesophagitis
Nocturnal breakthrough Nonacid GOR Wrong
diagnosis Achalasia gastroparesis Functional
heartburn
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Medical Vs Surgical
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
263268.
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
23312338.
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 786792.
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 172179.
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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
LOSP Acid exposure GI Symptom P0.003 General well being P0.003
PPI 8.1 36.9 34.3 98.5
PPI 7.9 17.7 P lt 0001 35.0 100.4
LNF 6.3 42.7 31.7 95.4
LNF 17.2 P lt 0001 8.6 P lt 0001 37.0 106.2
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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?
Pills do not work!
Medical therapy is effective in most patients,
but not in patients with advanced disease or in
those with an associated incompetent lower
esophageal sphincter
Liebermann DA. Medical therapy for chronic reflux
esophagitis long-term follow-up. Arch Intern Med
1987 1471717-1720
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 22-9. 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 81548-550.
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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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pH Manometry
Acid exposure Symptom score Defective
LOS pressure Length position Body motility
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Ambulatory 24 hour pH test
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)
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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 326825-827.
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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
326786-792
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Laparoscopic Nissen Fundoplication
Dallemagne B, Weerts JM, Jehaes C, et al.
Laparoscopic Nissen fundoplication preliminary
report. Surg Laparosc Endosc 1991 1138-143.
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Set Up for surgery
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Overall long-term benefits
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
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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 2049-20.
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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.
160 patients Follow up3-20 years (Mean 136
months) 71 out of 160 followed up for more than
10 years 92 success rate
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 81548-550
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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 reoperation
• 0.7-

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Type 1
Type 2
Complex Hiatus hernia needs surgical referral
irrespective of reflux symptoms
Type 4
Type 3
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Endoscopic treatment of GORD The future?
Escharification Stretta Injection Enteryx Ga
tekeeper Plication
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NOTES Natural Orifice Transluminal
Endoscopic Surgery
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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Man will occasionally stumble over the truth but
most of the time he will pick himself up and
carry on Winston Churchill
Thank You for your time and patience