anti reflux surgery
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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
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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.
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Laparoscopic Fundoplication
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
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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
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Debate
Is laparoscopic fundoplication the
treatment of choice for gastro-
esophageal reflux disease?
Gut, 2002
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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.
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Agenda
• Limitations of pharmacological therapy
• Indications for surgery
• Pre-operative assessment
• The operation
• Immediate post-operative care
• Outcomes
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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
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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
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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)
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Indications for Surgery
1.
Chronic, uncomplicated GORD with partial
or total response to PPI but need for long-
term maintenance therapy
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Indications for Surgery
2.
Poor response of confirmed GORD to PPI
therapy due to refractoriness, PPI
intolerance, hypersensitivity or bile reflux
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Indications for Surgery
3.
Peptic oesophageal
stricture with need for
repeated dilatation
and long-term, full-
dose PPI therapy
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Indications for Surgery
4.
Barrett’s oesophagus –
potential protection
from neoplastic
transformation
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Leeds Experience
Laparoscopic Fundoplication
Leeds Experience
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Indications for Surgery
5.
Respiratory complications of GORD
• Laryngitis
• Bronchitis
• Asthma
• Pneumonia
• Sinusitis
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Pre-operative Assessment
• Detailed history
• Endoscopy
• Barium swallow
• Oesophageal manometry
• Oesophageal pHmetry
• Bile reflux monitoring (Bilitec)
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24-hr Ambulatory Oesophageal pHmetry
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24-hr Ambulatory Oesophageal pHmetry
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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
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Bile Reflux Monitoring
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The Operation
• Laparoscopic Nissen (complete or 360
degree, short, floppy) Fundoplication
• Laparoscopic Toupet (partial, posterior
270 degree) Fundoplication
• Laparoscopic Watson (anterior, 180
degree) Fundoplication
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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
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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
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Side-Effects
• Dysphagia
• Difficulty to belch or vomit
• Post-prandial fullness & bloating
• Flatulence
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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
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Persistent or Recurrent GORD
• Inadequate or failed operation
– Supplementary PPI
– Laparoscopic re-do fundoplication
• Functional heart-burn
• Psychological
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• 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
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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