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