Joint Hospital Surgical Grand Round

Surgical Management of GERD

Department of SurgeryThe Prince of Wales Hospital

YF Yeung

GERD

Exposed to the risk of physical complications from gastroesophageal reflux

Experience clinically significant impairment of health-related well-being as a result of reflux-related symptoms

Genval conference 1999

Epidemiology

Dent et al GUT 2005

27%

23%

4.8%

3.1%

2.5%

0 5 10 15 20 25 30

Black

White

Chinese

Chinese

Chinese Hong Kong, APT 2003Hong Kong, APT 2003

Beijing & Shanghai, Chi J Dig Dis 2000Beijing & Shanghai, Chi J Dig Dis 2000

Hong Kong, APT 2002Hong Kong, APT 2002

Houston, US, Gastro 2004Houston, US, Gastro 2004

Treatment Options

Antacids H2-receptor

antagonists Sucralfate Prokinetics Proton pump

inhibitors

Surgical

Medical

Types of Fundoplication

Complete Nissen 360o

Partial Posterior

Toupet 270o

Lind 300o

Anterior Belsey Mark IV Dor

hemifundoplication

Toupet fundoplication

Physiological mechanisms

LES pressure enhanced with the wrap of fundus After meal, gastric

distension (1) pressure transmitted from

stomach to fundus (2) Fundal pressure pressed on

the esophagus (3)

Effect of Fundoplication

Surgery or Medication?

Lundell et al. European Journal of Gastroenterology and Hepatology 2000

Long-term management of gastro-oesophageal reflux disease with omeprazole or open antireflex surgery: results of a prospective, randomized clinical trial

Surgery or Medication?

298 patients included Omeprazole (20mg daily) group: 154 patients Open Antireflux surgery group: 144 patients

3-year follow-up

Outcome measures Symptoms 24-h pH monitoring Endoscopy QoL assessment

Surgery or Medication?

Results

No significant difference in symptoms relapse, oesophagitis and QoL if dose of omeprazole adjusted to 40mg or 60mg accordingly

Surgery (129) Omeprazole (139)

Symptoms relapse

17 (13.1%) 50 (35.9%)

Oesophagitis 14 (10.8%) 18 (12.9%)

Remission 97 (75.1%) 77 (55.3%)

Surgery or Medication?

Conclusion

Omeprazole is as effective as antireflux surgery in controlling GERD

Indications of surgery

Patients do not accept long term medical therapy

Patients who do not respond or only partially respond to medical therapy

Antireflux surgery considered as equivalent alternative

SSAT guidelines

Open Vs Laparoscopic

Author Year Groups No. of patients

Hiatal plasty

DSGV

Laine 1997 Open

Lap

55

55

1

4

5

5

Bais 2000 Open

Lap

46

57

Yes

Yes

Yes

Yes

Chrysos 2002 Open

Lap

50

56

Yes

Yes

No

No

Ackroyd 2004 Open

Lap

47

52

Yes

Yes

No

No

Open Vs Laparoscopic

Author Group Conver-sion (%)

Morbidity (%)

Average Length (min)

Average Hospital Stay

(days)

Average Sick Leave

(days)

Laine Open

Lap 9.1

12.7

5.5

57

88

6.4

3.2

37.2

15.3

Bais Open

Lap 8.8

17.4

8.9

NR

NR

NR

NR

NR

NR

Chrysos Open

Lap --

76.0

21.4

83

77

5.9

2.4

--

--

Ackroyd Open

Lap --

NR

NR

46

82

5

3

49

28

Open Vs Laparoscopic

Author Follow-up (mth)

Groups A/V at FU

Recurrence (%)

Dysphagia

(%)

Bloating (%)

Laine 12 Open

Lap

30

18

10.0

--

13.3

--

6.7

16.7

Bais 3 Open

Lap

46

57

2.2

3.5

--

12.3

NR

NR

Chrysos 12 Open

Lap

50

56

2.0

3.6

4.0

3.6

6.0

--

Ackroyd 12 Open

Lap

39

42

NR

NR

23.0

26.1

17.9

26.1

Open Vs Laparoscopic

Conclusion

Perioperative recovery of laparoscopic fundoplication is better than that of open fundoplication

Short-term FU show no differences concerning recurrence, dysphagia and bloating

Division Vs No Division of SGV

Author Year Type Hiatal repair DSGV

(no. of patients)

NDSGV

(no. of patients)

Luostarinen 1995-99 Open Selective 26 23

Watson 1997-2002 Lap Routine 52 50

Blomqvist 2000 Lap Routine 52 47

Chrysos 2001 Lap Routine 24 32

Division Vs No Division of SGV

Author DSGV ND DSGV ND DSGV ND DSGV ND

Luostarinen NR NR NR NR 5/62 8/23 1/26 1/23

Watson 7/52 6/50 95 71 15/52 17/50 3/52 5/50

Blomqvist 15/52 5/47 120 104 11/39 15/41 1/52 1/47

Chrysos 2/24 3/32 100 60 4/24 5/32 1/24 0/32

Morbidity Length (min) Dysphagia Recurrence

Division Vs No Division of SGV

Conclusion

No significant differences regarding morbidity, dysphagia and recurrence

Shorter operation time for the non-division group

Complete or Partial

Author Year Type Follow-up Procedures No. of patients

DSGV

Lundell 1991-2002 Open >3 yrs Nissen

Toupet

65

72

Yes

Yes

Csendes 2000 Open 8 yrs Nissen

Hill

76

88

Yes

Yes

Watson 1999 Lap 6 mths Nissen

Anterior

53

53

No

No

Fibbe 2001-2002 Lap 4 mths Nissen

Toupet

100

100

Yes

Yes

Complete Vs Partial

Author Procedure Morbidity Average length (min)

Dysphagia Recurrence Re-operation

Lundell Nissen

Toupet

0/65

3/72

NR

NR

6/62

12/71

3/62

4/71

5/65

2/72

Csendes Nissen

Hill

3/76

5/88

NR

NR

NR

NR

29/76

33/88

NR

NR

Watson Nissen

Anterior

8/53

10/53

58

60

21/53

8/53

1/20

3/22

1/53

1/53

Fibbe Nissen

Toupet

NR

NR

45

60

18/100

6/100

18/93

10/95

13/100

1/100

PWH experience

2001 to 2006

28 cases – antireflux surgery 19 Laparoscopic Nissen Fundoplication 9 Lap Toupet Fundoplication

Nissen Toupet p

Age 41.1 50.2 0.07

Smoker 3 2 0.53

No. of co-morbid 0 0 0.21

Heartburn 16 (84.2%) 7 (77.8%) 0.53

Acid reflux 19 (100%) 8 (88.9%) 0.32

% time pH < 4 4.97 2.30 0.06

DeMeester score 31.4 23.9 0.65

Nissen Toupet p

OT duration 130 170 0.04†

Conversion 0 0

Hospital Stay 4.1 3.3 0.40

Redo fundoplication

1 (5.3%) 1 (11.1%) 0.55

Recurrence 2 (10.5%) 4 (44.4%) 0.04†

Summary

Long term outcome of surgery versus medical treatment to GERD is equivalent

Laparoscopic surgery is a better approach

?Complete or partial fundoplication

Further evaluation is required