Hiatal Hernia Repair, Hiatal Hernia Repair, Vagotomy, Vagotomy,

Gastrectomy for Gastrectomy for GERD GERD

Bill Richards, MD FACSBill Richards, MD FACSProfessor and Chair SurgeryProfessor and Chair SurgeryUniversity of South AlabamaUniversity of South Alabama

College of MedicineCollege of Medicine

Mixed Reflux of Gastric and Duodenal Mixed Reflux of Gastric and Duodenal Juices is more Harmful to the Esophagus Juices is more Harmful to the Esophagus

than Gastric Juice Alone than Gastric Juice Alone Kauer WK et al Ann Surg 222: 525-533Kauer WK et al Ann Surg 222: 525-533

0

20

40

60

80

Normals No injury Esophagitis Barrett's

NormalsNo injuryEsophagitisBarrett's

Prevalence of esophageal bilirubinPrevalence of esophageal bilirubin exposureexposure

Antireflux SurgeryAntireflux Surgery 1976 Donahue and 1976 Donahue and

Bombeck defined a Bombeck defined a technique of "floppy" technique of "floppy" Nissen fundoplication Nissen fundoplication (FNF) that prevented (FNF) that prevented experimental experimental pathologic reflux pathologic reflux without preventing without preventing gaseous eructations gaseous eructations or vomiting (normal or vomiting (normal reflux) when reflux) when appropriate appropriate

LES Pressure Returns to LES Pressure Returns to Normal After Normal After

Laparoscopic FundoplicationLaparoscopic Fundoplication

0

2

4

6

8

10

12

14

16

Pressure (mm Hg)

NORMAL PRE-OP POST-OP

N=26

Peters JH et al. Ann Surg 1998;228:40-50.

24 Hour pH Studies after 24 Hour pH Studies after Laparoscopic Laparoscopic

FundoplicationFundoplication

AuthorAuthor # patients # patients

pH NegativepH NegativeFollow-up Follow-up

(months)(months)

HinderHinder (87%)(87%) 3-123-12

HunterHunter (91%)(91%) 1212

WatsonWatson (87%)(87%) 33

PetersPeters (93%)(93%) 2121

Does Nissen reduce NonAcid Does Nissen reduce NonAcid Reflux?Reflux?

8 patients with Barrett’s 8 patients with Barrett’s

24 hour pH and nonacid relfux24 hour pH and nonacid relfux

- before (on omeprazole 20 mg BID)- before (on omeprazole 20 mg BID)

- after laparoscopic Nissen - after laparoscopic Nissen fundoplicationfundoplication

PPI Nissen

0

10

20

30

40

50

60ac

id e

pis

od

es (

n)

Data are shown as median (horizontal line), interquartile range (box), and 5th to 95th percentile (vertical line)

Acid Episodes

PPI Nissen

0

10

20

30

40

50

60

70

80

90

no

n-a

cid

ep

iso

des

(n

)

9

Data are shown as median (horizontal line), interquartile range (box), and 5th to 95th percentile (vertical line)

Non-Acid Episodes

P=0.001

Conclusions: PConclusions: Patients with atients with Barrett’s esophagusBarrett’s esophagus

Nissen eliminates acid and non-acid Nissen eliminates acid and non-acid refluxreflux

PPI’s fail to eliminate acid reflux in PPI’s fail to eliminate acid reflux in 33-50% 33-50%

PPI’s do not reduce non-acid refluxPPI’s do not reduce non-acid reflux

W/u persistent GERD W/u persistent GERD after Nissenafter Nissen

Barium swallowBarium swallow Esophageal pH studiesEsophageal pH studies

On or off PPIOn or off PPI EndoscopyEndoscopy Tc 99 scrambled egg gastric Tc 99 scrambled egg gastric

emptying studyemptying study

Obese patient GERD Obese patient GERD after Nissenafter Nissen

Subtotal gastrectomy and Roux-en-Y Subtotal gastrectomy and Roux-en-Y reconstructionreconstruction Diverts acid and bile Diverts acid and bile Weight loss reduces IA pressureWeight loss reduces IA pressure Improves gastric emptyingImproves gastric emptying Improves blood glucose controlImproves blood glucose control

Recurrent GERD +Hiatal Recurrent GERD +Hiatal Hernia after NissenHernia after Nissen

Never redo same operationNever redo same operation Ask yourself why did they fail?Ask yourself why did they fail?

Esophageal lengthening Esophageal lengthening Reinforcement of esophageal hiatusReinforcement of esophageal hiatus

The enemy of The enemy of Good isGood is

BETTERBETTER

Early and Late Results of the Acid Suppression and Early and Late Results of the Acid Suppression and Duodenal DiversionDuodenal Diversion

Operation in Patients with Barrett's Esophagus: Operation in Patients with Barrett's Esophagus: Analysis of 210 CasesAnalysis of 210 Cases

Attila Csendes, M.D., et alAttila Csendes, M.D., et al Selective vagotomySelective vagotomy HemigastrectomyHemigastrectomy 360 Nissen360 Nissen 60 cm Roux60 cm Roux

World J. Surg. 26. 566-576, 2002

Nissen V+A RouxNissen V+A RouxReduces Acid production Reduces Acid production

Pre-OPPre-OP Post-Post-OPOP

% % reductireductionon

Basal Acid VolumeBasal Acid Volume 4040 1616 60%60%

Basal acid output Basal acid output mM/hrmM/hr

4.74.7 0.20.2 96%96%

Stimulated Acid Stimulated Acid VolumeVolume

120120 4747 60%60%

Stimulated Acid Stimulated Acid output mM/hroutput mM/hr

1818 33 84%84%

Nissen V+A RouxNissen V+A RouxReduces Bile refluxReduces Bile reflux

PREOPPREOP

N= 56N= 56POSTOPPOSTOP

N=22N=22

Normal studyNormal study 18%18% 91%91%

Pathologic Pathologic bile refluxbile reflux

82%82% 9%9%

World J. Surg. 26. 566-576, 2002

Nissen V+A Roux Nissen V+A Roux Good symptom scores and NO progression of Good symptom scores and NO progression of

Barrett’sBarrett’s

ParameterParameter Primary Primary opop

N=92N=92

ReopReop

N=54N=54TotalTotal

N=14N=1466

Visick IVisick I 90%90% 80%80% 86%86%

Visick IIVisick II 7%7% 2%2% 5%5%

Visick IIIVisick III 3 %3 % 16%16% 8%8%

Visick IVVisick IV 00 2%2% 1%1%

DysplasiaDysplasia 00 00 00

AdenocarcinomaAdenocarcinoma 00 00 00

World J. Surg. 26. 566-576, 2002

Endoscopy after Nissen, Endoscopy after Nissen, V+A, V+A,

Roux ReconstructionRoux ReconstructionPre-OPPre-OP POST-OPPOST-OP

Hiatal herniaHiatal hernia 72%72% 2%2%

Erosive Erosive esophagitisesophagitis

81%81% 2%2%

Esophageal ulcerEsophageal ulcer 86%86% 2%2%

Esophageal Esophageal Stricture Stricture

26%26% 3%3%

Length of Length of Barrett’sBarrett’s

73 mm73 mm 70 mm70 mm

World J. Surg. 26. 566-576, 2002

SummarySummary

Barrett’s associated with Non Acid Barrett’s associated with Non Acid and Acid Reflux and Acid Reflux

Non acid and acid reflux can cause Non acid and acid reflux can cause esophageal cancer in experimental esophageal cancer in experimental animalsanimals

SummarySummary

Nissen significantly reduces acid and Nissen significantly reduces acid and non acid refluxnon acid reflux

PPI’s reduce acid reflux only and PPI’s reduce acid reflux only and normalize 50-80% of patientsnormalize 50-80% of patients

Nissen V+A with Roux reconstruction Nissen V+A with Roux reconstruction Reduces AcidReduces Acid Reduces bile refluxReduces bile reflux Improves endoscopic findings of Improves endoscopic findings of

stricture, ulcers and esophagitisstricture, ulcers and esophagitis

SummarySummary

There is no proof that Nissen There is no proof that Nissen fundoplication can prevent progression to fundoplication can prevent progression to cancer.cancer.

But Nissen fundoplication is the only But Nissen fundoplication is the only modality that can reduce both acid and modality that can reduce both acid and non acid reflux and has been shown to non acid reflux and has been shown to reverse Short Segment Barrett’sreverse Short Segment Barrett’s

Nissen V +A with Roux reconstruction Nissen V +A with Roux reconstruction may prevent progression of dysplasia in may prevent progression of dysplasia in Barrett’sBarrett’s