Transcript Treatment of Gastroesophageal Reflux

Treatment of Gastroesophgeal Reflux
Joint Hospital Surgical Grand Round
Hui Wei Han
 Patho-physiology
 Anti-reflux surgery
 Endoscopic therapies for reflux
Introduction
 Gastric contents reflux into esophagus
 USA - 40% population once per month; 7%
daily
 HK (Study by HKU 2003): ~10%
population
Symptoms
 Typical
Heartburn
Regurgitation
Waterbrash
Dysphagia
 Extra-esophageal
Dental erosions
Laryngitis
Hoarseness
Chronic cough
Anti-reflux barrier at OGJ
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Sling & clasp fibres of gastric cardia
Diaphragmatic crura
Intra-abdominal esophageal compression
Lower esophageal sphincter (LES)
Intra-abdominal esophageal compression
 Height of insertion of phreno-esophageal ligament
determines length of esophagus within abdomen
 Length of sphincter exposed to intra-abdominal
pressure important for prevention of reflux
 DeMeester el al. found low basal LES pressure
(<5mmHg) +/- short intra-abdominal sphincter
length (<1cm) resulted in 90% abnormal reflux
Pathophysiology of GERD
 LES pressure
abnormalities
 Transient lower
esophageal sphincter
relaxations
 Hiatus hernia
 Poor esophageal clearance
 Delayed gastric emptying
 Impaired mucosal
defensive factors
LES Pressure Abnormalities
 LES resting pressure influenced by:
Respiration
Gastric activity
Body position
Circadian variations
Food and Smoking
 Decreased LES resting pressure associated
with increased GERD
Transient LES Relaxations
 Postprandial and sleep studies identified
reflux episodes due to TLERS
 48-73% of reflux episodes in GERD
patients
 Visceral reflexes through vagus pathway
 Gastric distension - major inducing factor
 Influenced by food (fat, chocolate),
smoking & alcohol
Hiatus Hernia
 Ambulatory esophageal pH monitoring showed
increased freq. of reflux and prolonged esophageal
acid exposure in patients with hiatus hernia
 94% incidence in patient with reflux esophagitis
 Permissive role - promoting LES dysfunction
 Cameron AJ 1999 found that hiatus hernia size is
the strongest predictor of esophagitis severity
Treatment of GERD
 Medical
Proton pump inhibitor
H2 blocker
Prokinetic agents
 Surgical
Anti-reflux surgery
Endoscopic therapies
Selection Criteria for Surgery
 Objective evidence of reflux
 Patients failed response to medical
treatment
 Patients not wish to continue life-long
medications (symptoms fully controlled
with PPI)
Medical vs Surgical Therapy
 Several RCTs
 Some before era of PPI and laparoscopic
anti-reflux surgery
Spechler
1992
247
patients
H2 blockers vs
open
fundoplication
Patient satisfaction
higher in 1-2yr
Further followup 2001,
reasonable outcome both
medically and surgically treated
groups
Ortiz etal
1996
59 patients
(Barrett’s
esophagus
)
H2 blockers &
PPI vs open
fundoplication
Better endoscopic
improvement in
surgically treated
cases
PPI used in last few years of
study
Parrilla et
al 2003
101
patients
(Barrett’s
esophagus
)
H2 blockers &
PPI vs open
fundoplication
Both 91% satisfaction
in 5 yrs
Progression to
dysplasia similar
Lundell et
al 2000
310
patients
(complete
control
with PPI)
PPI vs open
fundoplication
Surgery better
outcome up to 3yrs
More side effects like
dysphagia
Rhodes et
al 2005
(BJS)
217
patients
PPI vs lap
fundoplication
Surgery: less
esophageal acid
exposure in 3 months
& better symptom
control in 12 months
Anvari et
al 2006
104
patients
PPI vs lap
fundoplication
Control reflux better in
surgery up to 12
months
Not include patient not respond
well to PPI
 Surgery similar or even superior results to
medical treatment
 Better endoscopic outcome in cases of
Barrett’s esophagus
Anti-reflux surgery
 Fundoplication
complete
partial
anterior vs posterior
 Hill procedure
 Collis procedure
 Angelchik prosthesis
Mechanisms of action
 Creation of a floppy valve (close apposition
between abd. esophagus & gastric fundus)
 Exaggeration of flap valve at angle of His
 Increase basal pressure of LES
 Reduction in triggering of TLESR
 Reduction in capacity of fundus, speeding gastric
emptying
 Prevention of effacement of LES
Fundoplication
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Nissen - 360°
Toupet - 270° posterior partial
Lind - 300° posterior partial
Belsey Mark IV - 240° anterior partial
Dor - anterior hemi-fundoplication
Laparoscopic or Open
 Non-randomized comparisons showed
laparoscopic surgery:
longer operation time
reduced postop complications
shorten length of hospital stay (by 3-7days)
return full physical function quicker
reduced overall hospital cost
Franzen et al 96
Heikkinen et al 99
Perttila et al 99
20-42
patients
Nissen fundoplication
Similar short term outcomes
Shorten hospital stay by 1 day
Longer OT time (extend 30mins)
Reduced postop complications
Chrysos et al 2002
Ackroyd et al 2004
106
99
Nissen fundoplication
12 months: less complications and
quicker recovery
Laine et al
110
Nissen fundoplication
Halved hospital stay
Quicker return to work
OT time longer (31mins)
11yr followup: open surgery more
wrap disruption & incisional hernia
Bais et al 2000*
103
Nissen fundoplication
Premature stop at 3 months due to
postop dysphagia ?? Too short follow
up period
Subsequent 5yr followup: similar
outcome
Hakanson et al 2007#
192
Posterior partial
fundoplication
Lap gp: more early side effects and
reflux recurrence
3yr followup: no difference in
outcome and satisfaction
 Laparoscopic anti-reflux surgery has short
term advantages in terms of reduced
morbidity and quicker recovery
 Control of reflux and risks of side effects at
late follow up (up to 11years) is similar
Complete or Partial Fundoplication
 Nissen - ? Over-competent OGJ causing
dysphagia & gas-related symptoms
 Partial fundoplication reduce risk of overcompetence but ? less durable anti-reflux
repair
Nissen vs Posterior partial fundoplication
Lundell et al
91
137
Nissen vs
Toupet
5yrs: similar control &
dysphagia, more gasrelated complication
(Nissen)
Zornig et al
2002
200 (half
abnormal
motility)
Nissen vs
Toupet
4 months: similar except
more dysphagia (Nissen)
2yrs: similar
No advantage of Toupet in
case of abnormal motility
Guerin et al
2007
140
Nissen vs
Toupet
3yrs: no difference
Booth et al
2008
127
Nissen vs
Toupet
1yr: control similar,
dysphagia more in Nissen
group
Subgroup analysis: no
difference in cases with
motility problem
 Side effects less common following
posterior partial fundoplication esp gasrelated problems
 Hypothesis of less dysphagia supported by
2 larger trials only
Nissen vs Anterior Fundoplication
Watson et
al 99
107
Nissen vs
anterior 180º
1-3 months: similar
6 months & 5yrs:
reduced dysphagia and
gas-related symptoms
(anterior gp)
Reflux control better in
Nissen gp
Overall satisfaction
better in anterior gp
Baigrie et al 161
2005*
Nissen vs
anterior 180º
2yrs: reflux control same;
reduced dysphagia but
increased reoperation for
reflux (anterior gp)
Watson et
al 2004
Spence et
al 2006
Nissen vs
anterior 90º
Less S/E, better
satisfaction & QOL
More recurrence
112 &
79
 Both satisfactory control of reflux
 Less dysphagia and other side-effects
(anterior)
 Higher risks of recurrent reflux (anterior)
Division of short gastric vessels?
 Hunter 1996 & Dalemagne 1996 reported
increased problems with postoperative
dysphagia following Nissen fundoplication
without division of short gastric vessels
 4 RCTs investigation this aspect of
technique
Luostarinen et al
95 & 96
50
Open
fundoplication
3yrs: trend of increase
disruption of fundoplication &
reflux symptoms (division gp)
Dysphagia & gas-related
symptoms similar
Watson et al 97
& Yang et al
2008*
102
Lap fundoplication 6 months: no difference
5yrs: increase gas-related
symptoms
10yrs: no difference
Blomqvit et al
99
Lap fundoplication 1yr: division gp no
improvement in short-term
outcome
Chrysos et al
56
Lap fundoplication Reflux and dysphagia not
influence by division of
vessels
Increased gas-related
symptoms
 Belief that dividing short gastric vessels
will improve outcome following Nissen
fundoplication not supported
 Dividing vessels increase complexity,
produce poorer outcome in 2/4 trials
 Increase incidence of gas-related symptoms
Complications of laparoscpic
anti-reflux surgery
 Paraoesphageal hiatus
hernia
 Hiatal stenosis
(dysphagia)
 Pulmonary embolism
More common
follow
laparoscopic
surgery
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Bilobed stomach
Pneumothorax
Pneumomediastinum
Major vascular injury
Perforation of upper
GI tract
Unique to
laparoscopi
c surgery
Summary from present evidences
for fundoplication
 Laparoscopic Nissen fundoplication associated with less
complications and shorter convalescence than open method
 Longer-term result of laparoscopic fundoplication as good
as open surgery
 Division of short gastric blood vessels not improve
outcome in Nissen fundoplication
 Incidence of recurrent reflux similar following posterior
partial and Nissen fundoplication
 Incidence of dysphagia and gas-related complications
reduced following anterior partial fundoplication
Endoscopic therapies for reflux
 2 approaches:
narrow gastro-esophageal junction
create a partial fundoplication
Procedures that narrow the gastro-esophageal junction
Radiofrequency
Stretta procedure
Polymer injection
Enteryx
Gatekeeper
PMMA
RCT compared with sham endoscopy showed no
differences at 6 months follow up
Withdrawn due to catastrophic complications
Suturing
EndoCinch
NDO Plicator
Procedure that aim to create a partial fundoplication
EsophyX endoluminal fundoplication procedure
Medigus SRS procedure
EndoCinch
 Reflux improved in a
minority of patient
 90% suture disappear
in 12 months & 80%
resumed PPI
NDO Plicator
 Controlled trial showed reduction in
esophageal acid exposure from 10% to 7%
at 3 months
 50% plicator patient able to cease PPI
compared to 25% of sham-treated patient
 Inferior result to laparoscopic
fundoplication
EsophyX
 Requires general anesthesia
 Fashion 200-300º anterior partial fundoplication
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Cadiere et al Surg Endosc 2007
12 months outcome of 17 patients
14 patients (82%) not using PPI
7 patients (44%) normal pH study
Result inferior to laparoscpic anterior partial
fundoplication
Summary of endoscopic antireflux procedures
 None of the initial approaches (suturing,
injection or RF) achieve comparable
outcome to fundoplication
 Application limited to milder forms of
reflux disease
Thank you!