Gastroesophageal Reflux DiseasePathophysiology and Treatment

George Ferzli, M.D., FACSProfessor of Surgery, SUNY Health

Science Center at Brooklyn

Department of Laparoscopic Surgery, Staten Island University Hospital

44%

13%

Clinical Presentation

Adults

• Heartburn

• Regurgitation

• Cough

• Wheezing

• Hoarseness

• Chest pain

Children

• Vomiting (heartburn, cough, and stridor)

• Aspiration (recurrent bronchopneumonia)

Infants

•Vomiting (causes failure to thrive, and repeated otitis)

•Esophagitis (causes irritability, anemia, and stricture)

•Aspiration (causes bronchopneumonia, asthma, anemic spells, and possibly sudden death.

Incidence of presenting symptoms experiencedas a percent of all patients in study (n=198)

Heartburn 80%Regurgitation 68%Dysphagia 38%Resp. symptoms 27%Chest pain 10%Abdominal pain 10%Nausea or vomiting 7%Belching 6% Bleeding 5%

Hinder, RA, et al: Laparoscopic Nissen Fundoplication is an effective treatment for GERD. Annals of Surgery 220, No. 4

Definition

It is increased exposure of the esophagus to gastric and / or duodenal secretions

Etiology

Protective Mechanisms

Medical Management

• Medical therapy is first line of management

• Pro-motility agents like metoclopramide to enhance esophageal clearance of acid

• Gastric pH enhancing drugs like antacids, antihistamines and proton pump inhibitors

Goals of Treatment

Eliminate symptomsHeal esophagitisManage or prevent complicationsMaintain remission

Lifestyle Modifications

•Avoid fatty foods, fried foods, peppermint, chocolate, alcohol, coffee, citrus fruit, tomato products

•Lose weight if overweight

•Stop smoking

•Elevate head of bed 6 inches

Medical Management

• Esophagitis will heal in 90% of cases

• Doesn’t address etiology of GERD

• 80% recur within one year of stopping therapy

• Alkaline injury may continue to occur

Lifestyle modification non-compliance

Antacids poor long-term control

Prokinetic agents no esophageal healing

H2 Blockers short-term good resultslong-term 50% recur

Proton pump inhibitors good healing, ?safetyrapid relapse

Pitfalls of Medical Management

Risk Factors That Predict A Poor Response To Medical Therapy

1. Nocturnal reflux on 24-hr esophageal pH study

2. Structurally deficient lower esophageal sphincter

3. Mixed reflux of gastric and duodenal juice

4. Mucosal injury on presentation

What is the next step???

Indications for Antireflux Surgery

a) Intractable persistent reflux symptoms despite aggressive medical management

b) Reflux-induced respiratory symptoms after control of acid reflux

c) Recurring severe reflux symptoms, or reflux injury (peptic stricture, esophageal ulceration, bleeding) despite adequate medical therapy

d) Barrett’s esophageal metaplasiae) Lifestyle choice (avoid long-term use of

medicines)

Goals Of Surgical Management

1. Restore LES pressure and length

2. Establish abdominal position of LES (approx. 2cm)

3. Preserve ability to belch and vomit

4. Avoid vagal nerve injury

5. Correct associated diaphragmatic herniation

Surgery vs. Medical TherapyStudy Design

• Prospective non-randomized study

• 41 patients had antireflux surgery (12 Nissen and 29 Toupet) after failure of medical therapy and 18 had only medical therapy

• Dysphagia was assessed prior to therapy and 6 months after therapy

Wetscher GJ, Hinder RA, et.al. Am J Surg;177, Mar 1999

Surgery vs. Medical Therapy Results

• Controls regurgitation

• Improves esophageal peristalsis

• Restores the LES function

• Freedom from reflux-induced dysphagia (92.7% vs. 11.9%, p<0.05)

• Prevents non-acid reflux

• Treats hiatal hernias

Wetscher GJ, Hinder RA, et.al. Am J Surg;177, Mar 1999

Work-up

• 1) Barium swallow– Not diagnostic– Presence and size of hiatal hernia– Presence of stricture– Length of esophagus

Laparoscopic Paraesophageal Hernia Repair

Paraesophageal Hernia RepairSymptomatic Outcomes

0

20

40

60

80

100

Excellent/Good Fair/Poor Satisfied

% p

atie

nts

Laparoscopic (n=26) Open (n=25)

Hashemi et al, J Am Coll Surg 2000;190:553-561

Paraesophageal Hernia RepairTechnique and Recurrence

0

5

10

15

20

% R

ecur

renc

e

PTFE mesh (n=17) No mesh (n=18)

Mesh vs. No Mesh

•Prospective randomized trial

•Hiatal defect >8cm diameter

•Excision of sac, primary closure of crura, Nissen fundoplication in all cases

•Randomized intra-op to mesh vs. no mesh

•Follow-up for 6 months

Frantzides CT et al, Surg Endosc (1999) 13: 906-908

16%

0%

Paraesophageal Hernia RepairSummary

• Symptomatic outcomes: Similar in both groups. Excellent or good in 76% patients after laparoscopic and 88% after open repair

• Hernia recurrence: Significantly higher in laparoscopic group (42%, 9 of 21) compared to open group (15%, 3 of 20)

• Use of mesh reduces paraesophageal hernia recurrence significantly

Work-up

• 2) EGD– Presence of esophagitis– Presence and the type of hiatal hernia– Esophageal length– Presence of Barrett’s, dysplasia or cancer– Presence of stricture

Laparoscopic Nissen For Barrett’s

Long-Term Outcome of Antireflux Surgery in Patients With Barrett's Esophagus

At 5-years median follow-up:• Reflux symptoms absent in 79%• Recurrent symptoms in 20%. Most common in

patients undergoing Collis-Belsey (33%)• 24-hour pH monitoring results normal in 81%• 77% patients considered themselves cured, 22%

considered themselves improved, and 97% were satisfied

Hofstetter WL et.al. Annals of Surgery, 234(4), Oct.2001

Long-Term Outcome of Antireflux Surgery in Patients With Barrett's Esophagus

• 44% regression of low-grade dysplasia to nondysplastic Barrett’s

• 14% regression of intestinal metaplasia to cardiac mucosa

• Low-grade dysplasia developed in 6% patients

• No patient developed high-grade dysplasia or cancer in median 5-year follow-up

Hofstetter WL et.al. Annals of Surgery, 234(4), Oct.2001

Dysplasia and Adenocarcinoma After Classic Antireflux Surgery in Patients With

Barrett's Esophagus• 161 patients had antireflux surgery between 1978

and 1992. Prospective follow-up ended Dec.1999• 17 (10.5%) who developed dysplasia and 4 (2.5%)

who developed adenocarcinoma were compared to 126 patients with long-segment Barrett’s in whom dysplasia did not develop

• Patients were evaluated with clinical questionnaire, multiple EGD and biopsy, and 24-hour pH and bilirubin monitoring

Csendes A et.al. Annals of Surgery,235(2),p.178-185,Feb.2002

Results Visick Visick I-II (n=52) III-IV (n=74)

Dysplasia (n=17)

Adenoca. (n=4)

Symptoms 0% 95% 82% 100%

Length of Barrett’s (mm)

65 68 77 65

Incompetent LES

21% 61% 70% 100%

Pathologic acid reflux

12.5% 96% 93% 100%

% time with bilirubin

5.3+1.6% 30.9+19% 86% -

Csendes A et.al. Annals of Surgery,235(2),p.178-185,Feb.2002

Conclusions• Patients with failed antireflux surgery are a high-

risk group for development of dysplasia and carcinoma

• Metaplastic changes from fundic to cardiac mucosa and then intestinal metaplasia, dysplasia and adenocarcinoma can clearly be documented

• Patients with Barrett’s who undergo antireflux surgery require long-term subjective and objective follow-up

Csendes A et.al. Annals of Surgery,235(2),p.178-185,Feb.2002

Barrett’s Esophagus Can and Does Regress after Antireflux Surgery

• 91 patients with symptomatic Barrett’s esophagus: 77 treated with surgery and 14 with proton pump inhibitors

• 28 of 77 (36.4%) after surgery had histologic regression of Barrett’s

• 1 of 14 patients (7.1%) had regression with medical therapy

• Patients with Barrett’s less than 3 cm. had greater likelihood of regression

Gurski R, Peters J, Hagen J, et al Journal of the Amer Coll Surg 2003 196 (5): 706-713

Work-up

• 3) Manometry– Not diagnostic– Esophageal body motility– LES function– LES position

Normal LES Parameters

• Basal resting pressure of <37 mmHg

• Single peak 40-180 mmHg

• Duration of 2-5 seconds

• Velocity of 3-4 cm./sec.

Work-up

• 4) 24 h pH– Perform on all patients without erosive

esophagitis (grade I and II) – Remains the gold standard– Stop proton pump inhibitor 2 weeks before– Presence of abnormal reflux– Correlate between symptoms and reflux

DeMeester Score

• Based on six variables:

a) percent total time pH<4

b) percent upright time pH<4

c) percent supine time pH<4

d) number of episodes pH<4 lasting >5 min.

e) longest episode pH<4 (min.)

f) total number episodes pH<4

Normal score <14.7

Workup

• 5) Radionuclide gastric emptying study– when symptoms of delay gastric emptying, diabetes,

peptic ulcer disease

– when severe reflux on the 24h pH with normal LES on the manometry

• Simultaneous 24-hour pH and intraesophageal impedance may be useful in evaluating the role of non-acid reflux in symptoms that persist despite adequate acid suppression

Surgical Management - Approaches

A) Surgical approaches include (Open or Laparoscopic)

1) Total fundoplication (Nissen procedure)

2) Partial fundoplication (Belsey, Toupet, or Dor procedure)

B) Endoluminal techniques such as the Stretta procedure

Proper diagnostic workup is essential. It may alter the algorithm of management

Paradigm Shift in the Management of Gastroesophageal Reflux Disease

• 75 patients underwent laparoscopic fundoplication and 65 patients underwent the Stretta procedure

• Only patients who did not have a hiatal hernia larger than 2 cm., LES pressure less than 8 mmHg, or Barrett’s esophagus were offered the Stretta procedure

• They concluded that the patients in both groups had comparable improvement in GERD symptoms and quality of life even though the more severe symptomatic patients underwent surgery

Richards W, Houston H, Torquati A et al Ann Surg 2003; 237(5): 638-649

Proper preoperative workup will help manage recurrent postoperative symptoms

Symptoms are a poor indicator of reflux status after fundoplication for GERD: the role of

esophageal function tests• 124 patients who developed GERD

symptoms after laparoscopic fundoplication underwent esophageal manometry and pH monitoring

• 76 (61%) patients had normal esophageal acid exposure

• Symptoms, except for regurgitation, are an unreliable index of the presence of reflux

Galvani C, Fisichella P, Gorodner M, et al. Arch Surg 2003; 138: 514-519

Take home message: In order to achieve good postoperative results, there must be a thorough preoperative workup