Gastroesophageal Reflux Disease and Antireflux Surgery
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Transcript of Gastroesophageal Reflux Disease and Antireflux Surgery
Gastroesophageal Reflux Disease and Antireflux Surgery
Dr Hasan Muhammad SaeedPGR Surgical Unit-1Services Hospital, Lahore
Learning Objectives
Understand the natural history of reflux disease Understand how to identify candidates for antireflux
surgery Understand the complications of antireflux surgery
and patient’s satisfaction with surgery
10% of US adults report heartburn daily and 40% monthly More than 40,000 antireflux operations performed yearly in the
US GERD is a strong risk factor for adenocarcinoma of the esophagus $ 6-13 billion annual sales for PPIs (up to 6 times the yearly sales
of McDonald’s, Burger King, Taco Bell, Pizza Hut and Kentucky Fried Chicken)
Frequency and severity does not predict esophagitis, stricture or cancer development
Why Care?
Definition of GERD
Montreal consensus panel (44 experts):
“a condition which develops when reflux of stomach contents causes troublesome symptoms and/or complications”
Troublesome- Patient gets to decide when reflux interferes with lifestyle.
Clinical Presentation
Heartburn 1-2 hours after eating, often at night, antacid relief
Regurgitation Spontaneous return of gastric contents proximal to GEJ; less well relieved with antacid
Dysphagia- difficulty in swallowing should prompt search for pathological condition
Clinical Presentation
Atypical Symptoms (20-25%) Cough Hoarseness Asthma Non-cardiac chest pain
Diagnosis
Diagnosis based on symptoms alone is correct only in 2/3rd of the patients
Differential (ALL CAN KILL YOU) Achalasia Diffuse esophageal spasm Other esophageal motility disorders Ulcer disease Cancer Coronary artery disease
Norerosive disease
Erosive disease
Barrett’s esophagus
Esophageal Adenocarcinoma
Spectrum of disease theory
Pathophysiology of GERD
Normally, gastric contents don’t back up into the esophagus because LES creates enough pressure around the lower end of the esophagus to close it
Reflux occurs when LES pressure is deficient or pressure in the stomach exceeds LES pressure
When this happens, the LES relaxes, allowing gastric contents to regurgitate into the esophagus
The acidity of gastric content and amount of time in contact with the esophageal mucosa are related to the degree of mucosal damage
Extension of inflammation into muscularis propria causes progressive loss in length and pressure of LES-- esophageal shortening
Loss of LES leads to regurgitation, heartburn and subsequent severe esophagitis
Pathophysiology of GERD
Predisposing factors
Pylorus surgery (alteration or removal of the pylorus), which allows reflux of bile and pancreatic juice
Nasogastric intubation for more than 4 days Hiatal hernia with incompetent sphincter Any condition or position that increase intraabdominal
pressure
complications
Esophagitis (mucosal injury) with or without heartburn Reflux chest pain syndrome Respiratiory complications Metaplastic and neoplastic complications
Reflux chest pain syndrome
Heartburn without esophagitis Bile salts inhibit pepsin Acidic pH inactivates trypsin Pain comes from acidic gastric juice breaking mucosal
barrier and irritating nerve endings
Respiratory Complications
Reflux and aspiration of gastric contents induces asthma Correlation between hiatal hernia and pulmonary fibrosis Pathologic acid exposure often seen in proximal esophagus
in patients with asthma Simultaneous esophageal and tracheal pH shows
acidification of trachea in concert with esophagus
Metaplastic and Neoplastic Complications
Norman Barrett (1950) first described the process whereby the esophageal squamous epithelium changes to columnar epithelium
Occurs in 7-10% of patients with GERD Factors predisposing to Barrett’s Early onset GERD Abnormal LES or motility disorder Mixed reflux of gastric and duodenal contents Barrett’s metaplasia harbors dysplasia in 15-25% patients High grade dysplasia in 5-10% of the patients
Mangement
Lifestyle Modifications
Educate about lifestyle modifications that may alleviate symptomsSmoking, alcohol and caffeine cessationAvoid meals before bedtimeElevate head of bedWeight loss if patient obese
Start treatment with Proton Pump Inhibitors Arrange for follow-up visit
Medical Therapy
Acid suppression is the mainstay of GERD treatment today
70-90% of patients will experience relapse within 12 months of healing of acute disease without prophylactic medical treatment
Agents used Proton Pump Inhibitors Histamine blockers Prokinetic agents
Histamine blockers
Reversible competitive blockade of H2 receptors of the parietal cell
Acid suppression by 70% Esophagitis healing rates up to 70% Healing rates dependent on dosage, treatment duration
and severity of disease Ranitidine, cimetidine, famotidine, nizatidine
Proton Pump Inhibitors (PPI)
Most effective available pharmacologic agent for GERD Acid suppression by 99% Esophagitis healing rates 80-100% Inhibit H+/K+ ATPase enzyme system on parietal cells Omeprazole, lansoprazole, rabeprazole, pantoprazole,
esomeprazole
Indications for surgery
Patients with incomplete symptom control or disease progression on PPI therapy
Patients with well-controlled disease who do not want to be on life-long antisecretory treatment
Patients with proven extra-esophageal manifestations of GERD like cough, wheezing, aspiration, hoarseness, sore throat, otitis media, or enamel erosion.
The presence of Barrett esophagus is a controversial indication for surgery
Predictors of Successful Outcome
• Typical symptoms• Clinical response to acid suppression therapy• Abnormal 24-hour pH score
Campos et al. J Gastrointest Surg 1999;3:292-300.
Factors Present “Excellent” Outcome
3 97%
2 75% - 85%1 50%
Preoperative Investigations
Edoscopy 24 Hour ambulatory pH monitoring Radiograph Esophageal and gastric body function
Preoperative Evaluation: Endoscopy
Amount to the physical examination Strictures and large hiatal hernia may indicate shortened
esophagus High-grade dysplasia or a mass in the esophagus, gastric
or duodenal lumen will change management
24 Hour pH Monitoring
Rationale: gold standard for diagnosis of GERD Quantifies actual time the esophageal mucosa is exposed to
gastric juice Measures the ability of esophagus to clear refluxed acid Correlates esophageal acid exposure with patients’ symptoms Without abnormal pH study, surgery is unlikely to benefit
Swallow Study
Only 40% of patients with classic symptoms of GERD will have reflux observed on radiography
Assess forEsophageal shorteningHiatal hernia (80%)Paraesophageal herniaStricture or obstructing lesionBeading or corkscrewing (motility disorders)
Sliding hiatal hernia with narrowed sphincter and crural opening
Sliding hiatal hernia with lax sphincter and diaphragm is wide open
Manometry
Measure the length and pressure of the LOS and assess motility in the body of the oesophagus during swallowing Rules out esophageal motility disorders Esophageal body dysfunction (achalasia or
aperistalsis) should change management
Surgery
Works by restoring the barrier function of the LES Careful selection of patients with well documented GERD is
imperative Laparoscopic fundoplication is considered the gold standard in
antireflux surgery Number of cases risen exponentially
Goals of Surgery
Prevent significant reflux Improve quality of life Minimize complications
(dysphagia)
Fundoplication
The most common antireflux operation is the laparoscopic fundoplication
Crural dissection, identification and preservation of both vagi 25% have left hepatic artey coming from left gastric artery in the
gastrohepatic ligament Circumferential dissection of esophagus Restoration of 2-3 cm of intraabdominal esophageal length
Fundoplication
Elements of laparoscopic Nissen Crural closure Fundic mobilization by division of short gastrics Creation of short, loose fundoplication by
enveloping anterior and posterior wall around lower esophagus
Patient Satisfaction
Patient satisfaction is high (86-97%) Long term symptom (heartburn and regurgitation) relief in
84-97% Symptomatic failure rates (3-13%)
Heartburn and regurgitationDoes not correlate with acidic reflux exposure
Operation did nothing for 3-13%!
Surgeon, August 2009:224.
Complications Review of 10,489 laparoscopic antireflux procedures Bloating and increased flatulence (9-53%)
Most common side effect Dysphagia 20% Wrap herniation (early) 1.3% Pneumothorax 1% All others <1% (perforation, hemorrhage, pneumonia, abscess,
splenic injury, trocar hernia, effusion, pulmonary embolism, ulcer, atelectasis, wound infection, MI, splenectomy)
JACS 2001: 193(4);428-39Surgeon, August 2009:224.
Persistent side effects (>1 month)Bloating 9%Reflux 4%Dysphagia 3%
JACS 2001: 193(4);428-39Surgeon, August 2009:224.
Complications
After a Decade
10 Year follow up of 250 patients 83% highly satisfied with outcome 84% had good or excellent control of heartburn 17% revision operation (usually 3-7%)
Recurrent hiatal hernia, dysphagia, reflux, bleeding (early takeback protocol
for dysphagia)
21% used acid-suppressive medication
JACS 2007;205:570
Use of acid-suppressive medication after antireflux surgery varies (21-62%)
But only 20-30% with “reflux like” symptoms after surgery have positive pH studies
JACS 2007;205:570
Randomized Trial
Randomized trial comparing treatment of GERD with omeprazole and antireflux surgery
Treatment success- no symptoms or esophagitis 67% surgical 47% medical Dysphagia, bloating, rectal flatulence common in surgical
group
British J Surg 2007;94:198.
Cancer Risk
Cancer risk in patients with reflux symptoms is <1 in 10,000 patients per year
No benefit to avoidance of Barrett’s or adenocarcinoma with surgery compared to PPI therapy
Low morbidity and mortality risks associated with laparoscopic antireflux surgery dwarf potential benefit of avoiding cancer
Gastroent 2008;135:1392.
What does all of this mean, should I have surgery or not?
Surgery wins over PPI’s if you don’t mind trading heartburn and regurgitation for bloating, inability to belch, and excessive flatulence
Not in everybody, BUT IT COULD BE YOU! Nevertheless, 86-97% of patients are satisfied with
surgery.
Gastroent 2008;135:1392.
Complete vs. Partial Wrap
Complete fundoplication offers superior protection to reflux Increased incidence of dysphagia, inability to belch, and
excessive flatulence Partial wrap offers lesser protection against reflux, but also
lesser symptoms Up to 51% may have pathologic esophageal acid exposure on 24
hour pH monitoring
Surg Endos 1997;11:1080
Complete vs. Partial Wrap
Complete now considered superior to partial even in patients with weak esophageal peristalsis
Exceptions: Achalasia- anterior wrap utilized with myotomy Aperistalsis (i.e, Scleroderma)
Antireflux Surgery in Reflux Induced Asthma
Once reflux induced asthma is established, PPI therapy is instituted
25-50% patients have relief of respiratory symptoms
<15% have improvement in pulmonary function Antireflux surgery
90% have improvement in pulmonary function33% of children and 70% of adults have relief
Am J Gastroenterol 2003;98:987
Barrett’s esophagus can and does regress after antireflux surgery: a study of prevalence and predictive factors
Gurski RR et al. J Am Coll Surg 2003; 196(5):706-712.
Retrospective review 91 patients with symptomatic Barrett’s 77 had surgery, 14 on PPI Histopathologic regression occurred in 36% (surgery) vs. 7%
(PPI; p<0.03) On multivariate analysis short segment BE and type of
treatment were significantly associated with regression Median time to regression 18.5 months
Does a surgical antireflux procedure decrease the incidence of esophageal adenocarcinoma in Barrett’s esophagus? Meta-analysis: 1247 abstracts reviewed published 1966-2001,
34 included 4678 (surgical) vs. 4906 (medical) patient-years follow-up Cancer incidence 3.8/ 1000 patient-years (surgical) vs. 5.3/
1000 (medical; p=0.29) Also no significant difference in last 5 years Antireflux surgery in the setting of BE should not be
recommended as an antineoplastic measure
Corey KE. Am J Gastroenterol 2003; 98(11):2390-2394.
Summary
PPI’s work to control symptoms and esophagitis, but require life long treatment
Successful antireflux surgery is based on abnormal 24 hour pH score, typical GERD symptoms, and symptomatic improvement in response to acid-suppression therapy
Surgery is a very effective treatment of GERD with symptom resolution in over 90% of patients and excellent quality of life
Randomized studies document superior efficacy of surgery compared to PPI in controlling the disease in the short-term but there are concerns that in the long-term some patients may need to go back on PPI therapy
Having antireflux surgery is patient-centered decision with a benefit:risk ratio that can only be weighed by the patient
Summary