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Gastroesophageal Reflux Disease
and Antireflux Surgery
Dr Hasan Muhammad Saeed
PGR Surgical Unit-1
Services Hospital, Laho...
Learning Objectives
 Understand the natural history of reflux disease
 Understand how to identify candidates for antiref...
 10% of US adults report heartburn daily and 40% monthly
 More than 40,000 antireflux operations performed yearly in the...
Definition of GERD
 Montreal consensus panel (44 experts):
“a condition which develops when reflux of stomach contents
ca...
Clinical Presentation
 Heartburn
1-2 hours after eating, often at night, antacid relief
 Regurgitation
Spontaneous retur...
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)
A...
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 ...
 The acidity of gastric content and amount of time in contact with the
esophageal mucosa are related to the degree of muc...
Predisposing factors
 Pylorus surgery (alteration or removal of the pylorus), which
allows reflux of bile and pancreatic ...
complications
 Esophagitis (mucosal injury) with or without heartburn
 Reflux chest pain syndrome
 Respiratiory complic...
Reflux chest pain syndrome
 Heartburn without esophagitis
 Bile salts inhibit pepsin
 Acidic pH inactivates trypsin
 P...
Respiratory Complications
 Reflux and aspiration of gastric contents induces asthma
 Correlation between hiatal hernia a...
Metaplastic and Neoplastic Complications
 Norman Barrett (1950) first described the process whereby the
esophageal squamo...
Mangement
Lifestyle Modifications
Educate about lifestyle modifications that may alleviate symptoms
Smoking, alcohol and caffeine c...
Medical Therapy
 Acid suppression is the mainstay of GERD treatment today
 70-90% of patients will experience relapse wi...
Histamine blockers
 Reversible competitive blockade of H2 receptors of the parietal
cell
 Acid suppression by 70%
 Esop...
Proton Pump Inhibitors (PPI)
 Most effective available pharmacologic agent for GERD
 Acid suppression by 99%
 Esophagit...
Indications for surgery
 Patients with incomplete symptom control or disease progression on
PPI therapy
 Patients with w...
Predictors of Successful Outcome
• Typical symptoms
• Clinical response to acid suppression therapy
• Abnormal 24-hour pH ...
Preoperative Investigations
 Edoscopy
 24 Hour ambulatory pH monitoring
 Radiograph
 Esophageal and gastric body funct...
Preoperative Evaluation:
Endoscopy
 Amount to the physical examination
 Strictures and large hiatal hernia may indicate ...
24 Hour pH Monitoring
 Rationale: gold standard for diagnosis of GERD
 Quantifies actual time the esophageal mucosa is e...
Swallow Study
 Only 40% of patients with classic symptoms of GERD will have
reflux observed on radiography
 Assess for
E...
Sliding hiatal hernia with
narrowed sphincter and crural
opening
Sliding hiatal hernia with lax
sphincter and diaphragm is...
Manometry
 Measure the length and pressure of the LOS and
assess motility in the body of the oesophagus during
swallowing...
Surgery
 Works by restoring the barrier function of the LES
 Careful selection of patients with well documented GERD is ...
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, identificati...
Fundoplication
 Elements of laparoscopic Nissen
 Crural closure
 Fundic mobilization by division of short gastrics
 Cr...
Patient Satisfaction
 Patient satisfaction is high (86-97%)
 Long term symptom (heartburn and regurgitation) relief in 8...
Complications
 Review of 10,489 laparoscopic antireflux procedures
 Bloating and increased flatulence (9-53%)
Most commo...
Persistent side effects (>1 month)
Bloating 9%
Reflux 4%
Dysphagia 3%
JACS 2001: 193(4);428-39
Surgeon, August 2009:224.
C...
After a Decade
 10 Year follow up of 250 patients
 83% highly satisfied with outcome
 84% had good or excellent control...
 Use of acid-suppressive medication after antireflux
surgery varies (21-62%)
 But only 20-30% with “reflux like” symptom...
Randomized Trial
 Randomized trial comparing treatment of GERD with omeprazole and
antireflux surgery
 Treatment success...
Cancer Risk
 Cancer risk in patients with reflux symptoms is <1 in 10,000 patients
per year
 No benefit to avoidance of ...
What does all of this mean, should I have surgery or
not?
 Surgery wins over PPI’s if you don’t mind trading heartburn an...
Complete vs. Partial Wrap
 Complete fundoplication offers superior protection to reflux
 Increased incidence of dysphagi...
Complete vs. Partial Wrap
 Complete now considered superior to partial even in patients with
weak esophageal peristalsis
...
Antireflux Surgery in Reflux
Induced Asthma
 Once reflux induced asthma is established, PPI therapy is
instituted
 25-50...
Barrett’s esophagus can and does regress after
antireflux surgery: a study of prevalence and predictive
factors
Gurski RR ...
Does a surgical antireflux procedure decrease the
incidence of esophageal adenocarcinoma in
Barrett’s esophagus?
 Meta-an...
Summary
 PPI’s work to control symptoms and esophagitis, but require life long
treatment
 Successful antireflux surgery ...
 Randomized studies document superior efficacy of surgery compared to
PPI in controlling the disease in the short-term bu...
Gastroesophageal Reflux Disease and Antireflux Surgery
Gastroesophageal Reflux Disease and Antireflux Surgery
Gastroesophageal Reflux Disease and Antireflux Surgery
Gastroesophageal Reflux Disease and Antireflux Surgery
Gastroesophageal Reflux Disease and Antireflux Surgery
Gastroesophageal Reflux Disease and Antireflux Surgery
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Gastroesophageal Reflux Disease and Antireflux Surgery

this presentation describes the pathophysiology and presentaion of gastroesophageal reflux disease. It also discusses the medical and surgical management of gastroesophageal reflux disease. What makes this presentaion unique is that it also explains the short and long term effects of antireflux surgery and patient's satisfaction with surgery with references.

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Gastroesophageal Reflux Disease and Antireflux Surgery

  1. 1. Gastroesophageal Reflux Disease and Antireflux Surgery Dr Hasan Muhammad Saeed PGR Surgical Unit-1 Services Hospital, Lahore
  2. 2. 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
  3. 3.  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?
  4. 4. 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.
  5. 5. 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
  6. 6. Clinical Presentation  Atypical Symptoms (20-25%) Cough Hoarseness Asthma Non-cardiac chest pain
  7. 7. 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
  8. 8. Norerosive disease Erosive disease Barrett’s esophagus Esophageal Adenocarcinoma Spectrum of disease theory
  9. 9. 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
  10. 10.  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
  11. 11. 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
  12. 12. complications  Esophagitis (mucosal injury) with or without heartburn  Reflux chest pain syndrome  Respiratiory complications  Metaplastic and neoplastic complications
  13. 13. 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
  14. 14. 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
  15. 15. 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
  16. 16. Mangement
  17. 17. Lifestyle Modifications Educate about lifestyle modifications that may alleviate symptoms Smoking, alcohol and caffeine cessation Avoid meals before bedtime Elevate head of bed Weight loss if patient obese Start treatment with Proton Pump Inhibitors Arrange for follow-up visit
  18. 18. 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
  19. 19. 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
  20. 20. 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
  21. 21. 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
  22. 22. 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%
  23. 23. Preoperative Investigations  Edoscopy  24 Hour ambulatory pH monitoring  Radiograph  Esophageal and gastric body function
  24. 24. 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
  25. 25. 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
  26. 26. Swallow Study  Only 40% of patients with classic symptoms of GERD will have reflux observed on radiography  Assess for Esophageal shortening Hiatal hernia (80%) Paraesophageal hernia Stricture or obstructing lesion Beading or corkscrewing (motility disorders)
  27. 27. Sliding hiatal hernia with narrowed sphincter and crural opening Sliding hiatal hernia with lax sphincter and diaphragm is wide open
  28. 28. 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
  29. 29. 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
  30. 30. Goals of Surgery  Prevent significant reflux  Improve quality of life  Minimize complications (dysphagia)
  31. 31. 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
  32. 32. 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
  33. 33. 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 regurgitation Does not correlate with acidic reflux exposure  Operation did nothing for 3-13%! Surgeon, August 2009:224.
  34. 34. 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);428-39 Surgeon, August 2009:224.
  35. 35. Persistent side effects (>1 month) Bloating 9% Reflux 4% Dysphagia 3% JACS 2001: 193(4);428-39 Surgeon, August 2009:224. Complications
  36. 36. 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
  37. 37.  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
  38. 38. 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.
  39. 39. 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.
  40. 40. 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.
  41. 41. 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
  42. 42. 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)
  43. 43. 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 function 33% of children and 70% of adults have relief Am J Gastroenterol 2003;98:987
  44. 44. 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
  45. 45. 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.
  46. 46. 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
  47. 47.  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

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