Anti reflux surgery

Laparoscopic Anti-Reflux SurgerySafe and Effective Treatment for GORD

Abeezar I. Sarela MSc MS FRCS (Gen Surg)Consultant in Upper Gastrointestinal & Minimally Invasive

SurgeryThe Leeds Nuffield Hospital

The General Infirmary at LeedsWharfedale General Hospital

Hon. Senior Lecturer, University of Leeds School of Medicine

Clincal Meeting at Leeds Nuffield Hospital, 17 October, 2005

Laparoscopic Fundoplication

The Problem of GORD

• Afflicts 40% of adult population p.a.

• 2% consult GP

• Prescribed drugs & endoscopies: £ 600m

• Over the counter drugs: £ 100m

NICE, 2005


National Health ServiceStressed outOct 13th 2005The Economist•The NHS has to prepare for a stretch of modest years after so many abundant ones. Which is why it must become more efficient. •By the end of next year, the number of PCTs, which have sometimes been ineffective, is to be cut by half. More important, GP practices will be playing a much bigger role in commissioning treatments, with budgetary incentives for them to lower costs.


GORD Predicts Oesophageal Cancer

Lagergren J et al. N Engl J Med 1999; 340 (11): 825-831.

Heartburn (>5 years duration) Odds ratios

Once-a-week x 8

Nocturnal x 11

>20 yrs, and score >4.5* x 43.5


Figures quoted from UK respondents (n=201).

64%

22%

48%

14%

25%29%

% o

f pati

ents

AstraZeneca UK Data on File NEX/084/FEB2003.

0

10

20

30

40

50

60

70

80

Symptomsunbearable

Interests Sleep Sex life Sport +exercise

Concentratingon job

Poor Quality of Life with GORD

N=230 confirmed GORD patients


Debate

Is laparoscopic fundoplication the

treatment of choice for gastro-

esophageal reflux disease?

Gut, 2002


Anti-Reflux SurgeryNICE Guidance, 2005

Surgery is not recommended for the routine

management of uncomplicated GORD, BUT

individual patients whose quality of life

remains significantly impaired may value this

form of treatment.


Agenda

• Limitations of pharmacological therapy

• Indications for surgery

• Pre-operative assessment

• The operation

• Immediate post-operative care

• Outcomes


GORD Treatment

• Full-dose PPI for one or two months

• Recurrent symptoms: PPI at lowest dose

to control symptoms, with minimal repeat

prescriptions

• Treatment “on demand” basis

NICE, 2005


PPI Maintenance Therapy: Limitations

• Nocturnal acid breakthrough

• Twice-daily dose for severe GORD

• Insufficient control of regurgitation

• ? Interaction with H.pylori

• Continuing biliary-pancreatic reflux

• ? Long-term (> 10 years) safety

• Cost


PPI Maintenance Therapy: Limitations

• Recurrent symptoms in 20-30% of patients on regular maintenance, low-dose PPI

• Full dose PPI needs to be maintained for complicated GORD (NICE, 2005)

• PPIs did not eradicate need for caution and restraint (NICE, 2005)

• Most patients want to dispense with need for long-term PPIs (NICE, 2005)


Indications for Surgery

1.

Chronic, uncomplicated GORD with partial

or total response to PPI but need for long-

term maintenance therapy



2.

Poor response of confirmed GORD to PPI

therapy due to refractoriness, PPI

intolerance, hypersensitivity or bile reflux



3.

Peptic oesophageal

stricture with need for

repeated dilatation

and long-term, full-

dose PPI therapy



4.

Barrett’s oesophagus –

potential protection

from neoplastic

transformation


Leeds Experience



5.

Respiratory complications of GORD

• Laryngitis

• Bronchitis

• Asthma

• Pneumonia

• Sinusitis


Pre-operative Assessment

• Detailed history

• Endoscopy

• Barium swallow

• Oesophageal manometry

• Oesophageal pHmetry

• Bile reflux monitoring (Bilitec)


24-hr Ambulatory Oesophageal pHmetry


Normal Results

• DeMeester Score < 14.7

• % Total time pH<4 = 4.5%

• % Upright time pH<4 = 4%

• % Supine time pH<4 = 8%

24-hr Ambulatory Oesophageal pHmetry


Bile Reflux Monitoring


The Operation

• Laparoscopic Nissen (complete or 360

degree, short, floppy) Fundoplication

• Laparoscopic Toupet (partial, posterior

270 degree) Fundoplication

• Laparoscopic Watson (anterior, 180

degree) Fundoplication


Immediate Post-operative Issues

• Overnight stay in hospital• Immediate resumption of routine activity• Return to work in 5-7 days• PPI stopped immediately after operation• Simple analgesia for 3-5 days• “Sloppy” diet for 2-4 weeks• Follow-up visit after one month• No need for long-term follow-up


Outcomes

• Immediate and complete heartburn-control in > 90% of patients.

• Excellent relief of regurgitation, water-brash and respiratory symptoms.

• Very effective response of postural and nocturnal symptoms

• Significant improvement in quality of life• Decreased incidence of malignant

transformation


Side-Effects

• Dysphagia

• Difficulty to belch or vomit

• Post-prandial fullness & bloating

• Flatulence


Durability

• Careful evaluation of recurrent dyspepsia

• Majority of recurrent dyspepsia is NOT

due to recurrent GORD

• PPI therapy should not be routine

management of recurrent dyspepsia


Persistent or Recurrent GORD

• Inadequate or failed operation

– Supplementary PPI

– Laparoscopic re-do fundoplication

• Functional heart-burn

• Psychological


• Results are highly surgeon-dependent

• Best results reported from high-volume,

high-quality centres

• Expertise and technology

• Particularly important to offer prompt, high-

quality service for problems or failures

CHOICE


Summary

• Long-term, maintenance PPI therapy is problematic

• Consider anti-reflux surgery for patients with chronic symptoms or complications

• Laparoscopy has significantly increased utilisation of surgery

• Low-threshold for referral to surgeons with upper GI and laparoscopic expertise

Anti reflux surgery

Health & Medicine

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