Gastro Oesophageal Reflux Disease A surgical perspective Mr

Gastro Oesophageal Reflux Disease A surgical perspective Mr Dip Mukherjee Consultant upper GI & Laparoscopic surgeon antireflux surgery Queens Hospital. BHRT. Romford 1

Impact of GORD Upto 40% and rising 4% of all GP consultations are for dyspepsia 7% of children need GP input for reflux 10% of national drug bill 50% rise in oesophageal adenoca. In 10 years £ 11. 25 person 50% of Barretts do not have heartburn £ 500 million per year $14 Billion in US antireflux surgery 2

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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 p. H monitoring. antireflux surgery 4

Pathophysiology Antireflux barrier PPI Antireflux surgery Gastric hyperacidity Antireflux surgery Oesophageal motility Visceral sensation Mucosal defence antireflux surgery 5

GORD – The quandary Multifactorial etiology Complex Pathophysiology No obvious anatomical surrogate Symptoms do not always predict the diagnosis Endoscopy often negative p. H metry fraught with problems Poor response to PPI also mean poor response to surgery LNF and Barretts regression antireflux surgery The perfect operation – an unrealised dream 6

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 antireflux surgery 7

Mucin stain Intramucosal cancer Intestinal metaplasia Optical coherence tomography antireflux surgery 8

Does fundoplication prevent cancer? Does fundoplication prevent benign complications? Efficacy of Nissen fundoplication versus medical therapy in the regression of low-grade dysplasia in patients with Barrett esophagus: a prospective study. Ann Surg. 2006 Jan; 243(1): 58 -63. antireflux surgery 9

Management • Medical Vs Surgical • Medical & Surgical antireflux surgery 10

PPI and Laparoscopic antireflux surgery are the only two proven treatment for GORD in 2007 J Richter antireflux surgery 11

PPI Total acid suppression market in US : $ 9. 5 billion 77% captured by PPI Maintains p. H less than 4 for 15 -21 hours; 8 hours for H 2 blockers More effective than placebo in healing oesophagitis( RR=0. 23 NNT =2)* Superior to H 2 RA in maintaining remission of oesophagitis over 6 -12 months**Relapse rate 22% for PPI and 58% for H 2 RA Superior to placebo & H 2 RA 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 2006; 367: 2086 -2100(Recent Cochrane review) antireflux surgery **Donnellan C et al. The Cochrane database of systematic reviews 2004; 3: CD 003245 12

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 (NNT=3)* No clear data on chronic cough asthma or ENT disorders Good for reflux related sleep disturbances • Cremmini et al. Am J Gastroenterol 2005; 100: 1226 -32 *Wang et al. Arch Intern Med 2005; 165: 1222 -28 antireflux surgery 13

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 antireflux surgery 14

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 pneumonia 7 enteric infections( RR+1. 89)* Impaired vitamin D absorption elderly women and osteoporosis risk *Laheji et al. JAMA 2004; 292: 1955 -60 - population based study Leonard J et al. Am J gastroenterol 2007(In press)- systematic review antireflux surgery 15

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 antireflux surgery 16

Failure to improve OGD Oesophagitis No oesophagitis Nocturnal breakthrough Nonacid GOR Wrong diagnosis Achalasia antireflux surgery gastroparesis 17

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: 263– 268. 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: 2331– 2338. 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: 786– 792. 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 18 Surg antireflux surgery 2001; 192: 172– 179.

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 PPI LNF LOSP Acid exposure GI Symptom P=0. 003 General well being P=0. 003 8. 1 7. 9 36. 9 34. 3 35. 0 98. 5 100. 4 6. 3 17. 2 42. 7 8. 6 31. 7 37. 0 95. 4 106. 2 P < 0· 001 antireflux surgery P < 0· 001 17. 7 P < 0· 001 19

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. antireflux surgery 20

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? antireflux surgery 21

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; 147: 1717 -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; 2: 2 -9. Grande L, Toledo-Pimentel V, Manterola C, etantireflux surgery al. Value of Nissen fundoplication in patients with 22 gastrooesophageal reflux judged by long-term symptom control. Br J Surg 1994; 81: 548 -550.

Indications For Antireflux Surgery Pills do not work ! Problems despite pills! Recurrent strictures symptomatic relapse on continuous drug therapy early relapse after cessation of drug therapy non-compliance to medication financial non-compliance to medication Severe pulmonary symptoms Severe esophagitis Symptomatic Barrett's esophagus Large symptomatic paraesophageal hernia antireflux surgery 23

Patient selection • Clinical assessment • Endoscopy – Esophagitis – Hiatus hernia • p. H Manometry antireflux surgery 24

p. H Manometry Acid exposure Symptom score Defective LOS pressure Length position Body motility antireflux surgery 25

Ambulatory 24 hour p. H 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) antireflux surgery 26

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 effects 14 Richter JE. Surgery for reflux disease - reflections of a gastroenterologist. N Engl J Med 1992; 326: 825 -827. antireflux surgery 27

Goal of surgery • To increase LES pressure and therefore prevent acid back flow (reflux) • To repair any present hiatal hernia. antireflux surgery 28

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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 antireflux surgery 30

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; 326: 786 -792 antireflux surgery 31

Laparoscopic Nissen Fundoplication Dallemagne B, Weerts JM, Jehaes C, et al. Laparoscopic Nissen fundoplication: preliminary report. Surg Laparosc Endosc 1991; 1: 138 -143. antireflux surgery 32

Set Up for surgery antireflux surgery 33

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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 antireflux surgery 35

Does the operation work? • • 100 patients Follow up 1 -13 yrs Reflux control 91%* Symptom control . * De. Meester TR, Bonavina L, Albertucci M. Nissen fundoplication for gastroesophageal reflux disease. Evaluation of primary repair in 100 consecutive patients. Ann Surg 1986; 204: 9 -20. antireflux surgery 36

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 up 3 -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; 81: 548 -550 antireflux surgery 37

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 antireflux surgery 38

Complications of LNF • Operative problems • Wrap migration- post op contrast swallow • Gas bloat , early satiety • Flatulence • Persistent Dysphagia 0. 9% • Failure and reoperation 0. 7 antireflux surgery 39

Type 1 Type 2 Complex Hiatus hernia needs surgical referral irrespective of reflux symptoms Type 3 Type 4 antireflux surgery 40

Endoscopic treatment of GORD – The future? Escharification Stretta Injection Enteryx Gatekeeper Plication antireflux surgery 41

NOTES Natural Orifice Transluminal Endoscopic Surgery Endoscopic Gastroplasty NDO Plicator Transgastric gastropexy and hiatal hernia repair for GERD under EUS control: a porcine model. antireflux surgery 42 Fritscher-Ravens A, Mosse CA, Mukherjee D, Yazaki E, Park PO, Mills T, Swain P Gastrointest Endosc. 2004 Jan; 59(1): 89 -95.

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 antireflux surgery 43

“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 antireflux surgery 44