1. antireflux surgery1 Gastro Oesophageal Reflux Disease Mr Dip Mukherjee Consultant upper GI & Laparoscopic surgeon Queens Hospital.BHRT. Romford A surgical perspective

2. antireflux surgery2 Impact of GORD Upto 40% and rising 4% of all GP consultations are for dyspepsia 7% of children need GP input for reflux 50% rise in oesophageal adenoca. In 10 years 50% of Barretts do not have heartburn 10% of national drug bill £500 million per year £11.25 per person $14 Billion in US

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4. 4 The presence of documented (photographic or histologic) esophageal mucosal injury (esophagitis) OR Excessive reflux during 24-hour intraesophageal pH monitoring. Diagnosis Demonstration of:

5. antireflux surgery5 Pathophysiology Antireflux barrier Oesophageal motility Gastric hyperacidity Visceral sensation Mucosal defence Antireflux surgery PPI Antireflux surgery

6. antireflux surgery6 GORD – The quandary Multifactorial etiology Complex Pathophysiology No obvious anatomical surrogate Symptoms do not always predict the diagnosis Endoscopy often negative pH metry fraught with problems Poor response to PPI also mean poor response to surgery LNF and Barretts regression The perfect operation – an unrealised dream

7. antireflux surgery7 Barretts and cancer risk Rising incidence of reflux related adenocarcinoma Needs acid and bile Dysplasia carcinoma sequence Problems of diagnosis &surveillance Problem of ablation No reliable molecular markers for prediction of cancer

8. antireflux surgery8 Intestinal metaplasia Mucin stain Intramucosal cancer Optical coherence tomography

9. antireflux surgery9 Does fundoplication prevent cancer? Does fundoplication prevent benign complications? Efficacy of Nissen fundoplication versus medical therapy in the regression of low-grade dysplasia in patients with Barrett esophagus: a prospective study. Ann Surg. 2006 Jan;243(1):58-63Ann Surg. 2006 Jan;243(1):58-63. Ann Surg. 2006 Jan;243(1):58-63.

10. antireflux surgery10 Management Medical Vs Surgical Medical & Surgical

11. antireflux surgery11 PPI and Laparoscopic antireflux surgery are the only two proven treatment for GORD in 2007 J Richter

12. antireflux surgery12 PPI Total acid suppression market in US : $ 9.5 billion 77% captured by PPI Maintains pH less than 4 for 15-21 hours;8 hours for H2 blockers More effective than placebo in healing oesophagitis( RR=0.23 NNT =2)* Superior to H2RA in maintaining remission of oesophagitis over 6-12 months**Relapse rate 22% for PPI and 58% for H2RA Superior to placebo & H2RA in endoscopy negative GORD and undiagnosed reflux in primary care*** Esomeprazole 40 mg is better than Omeprazole and lansoprazole in severe esophagitis.higher bioavailability and less interpatient variability *Moyayeyedi et al.Lancet 2006;367:2086-2100(Recent Cochrane review) **Donnellan C et al.The Cochrane database of systematic reviews2004;3:CD003245 *** Van Pinxteren et al. The Cochrane database of systematic reviews2004;3:CD002095

13. antireflux surgery13 Impact Of PPI 33% decline in stricture rate since 1995 Reduces stricture relapse after dilatation Patients with Non cardiac chest pain respond better than placebo (NNT=3)* No clear data on chronic cough asthma or ENT disorders Good for reflux related sleep disturbances Cremmini et al. Am J Gastroenterol2005;100:1226-32 *Wang et al.Arch Intern Med 2005;165:1222-28

14. antireflux surgery14 Pill not working! 25-42% patients after 4-8 weeks trial of PPI Difficult to manage group Increase dose to twice daily 25% respond Timing and compliance Switch to second generation( Esomeprazole, Pantoprazole)multicentre study Consider endoscopy

15. antireflux surgery15 Problem of PPI No increased risk of gastric malignancy in humans Increased risk of fundic gland polyps caused by parietal cell hyperplasia Increased risk of community acquired pneumonia7 enteric infections( RR+1.89)* Impaired vitamin D absorption elderly women and osteoporosis risk *Laheji et al.JAMA2004;292:1955-60- population based study Leonard J et al.Am J gastroenterol2007(In press)- systematic review

16. antireflux surgery16 Works for most especially when patient has oesophagitis safe and effective Prevents recurrence of strictures Helps in sleep disturbances Less effective with extraesophgeal symptoms and aspiration Trial of PPI ok without endoscopy but acknowledge failure Message

17. antireflux surgery17 Failure to improve OesophagitisNo oesophagitis Nocturnal breakthrough Nonacid GOR Wrong diagnosis Achalasia gastroparesis Functional heartburn OGD

18. antireflux surgery18 8. Behar J, Sheahan DG, Biancani P, Spiro HM, Storer EH. Medical and surgical management of reflux esophagitis. A 38-month report on a prospective trial. N Engl J Med 1975; 293: 263–268. 9. Spechler SJ. Comparison of medical and surgical therapy for complicated gastroesophageal reflux disease in veterans. The Department of Veterans Affairs Gastroesophageal Reflux Disease Study Group. N Engl J Med 1992; 326: 786–792. 10. Spechler SJ, Lee E, Ahnen D, Goyal RK, Hirano I, Ramirez F et al. Long-term outcome of medical and surgical therapies for gastroesophageal reflux disease: follow-up of a randomized controlled trial. JAMA 2001; 285: 2331–2338. 11. Lundell L, Miettinen P, Myrvold HE, Pedersen SA, Liedman B, Hattlebakk JG et al. Continued (5- year) followup of a randomized clinical study comparing antireflux surgery and omeprazole in gastroesophageal reflux disease. J Am Coll Surg 2001; 192: 172–179. Medical Vs Surgical

19. antireflux surgery19 LOSPAcid exposure GI Symptom P=0.003 General well being P=0.003 PPI8.136.934.398.5 7.9 17.7 P < 0·001 35.0100.4 LNF6.342.731.795.4 17.2 P < 0·001 8.6 P < 0·001 37.0106.2 Randomized clinical trial of laparoscopic Nissen fundoplication compared with proton-pump inhibitors for treatment of chronic gastro-oesophageal reflux [Randomized clinical trial] Mahon, D. 1 ; Rhodes, M. 1 ; Decadt, B. 1 ; Hindmarsh, A. 1 ; Lowndes, R. 2 ; Beckingham, I. 3 ; Koo, B. 1 ; Newcombe, R. G. 4

20. antireflux surgery20 LNF leads to significantly less acid exposure of the lower oesophagus at 3 months and significantly greater improvements in both gastrointestinal and general well-being after 12 months compared with PPI treatment.

21. antireflux surgery21 Some Basics Why refer for surgery ? Who should have surgery? When not to do it? How does surgery work how is it done and how effective is it? What are the complications? Where does the future lie?

22. antireflux surgery22 When to call surgeon? Medical therapy is effective in most patients, but not in patients with advanced disease or in those with an associated incompetent lower esophageal sphincter Pills do not work! Problems despite pills! Acid suppression only addresses one factor in a multifactorial disease. In severe disease there is a significant failure rate of long-term standard dose medical therapy and progression of disease is often noted Monnier P, Ollyo JB, Fontolliet C, Savary M. Epidemiology and natural history of reflux esophagitis. Sem Lap Surg 1995; 2:2-9. Grande L, Toledo-Pimentel V, Manterola C, et al. Value of Nissen fundoplication in patients with gastro- oesophageal reflux judged by long-term symptom control. Br J Surg 1994; 81:548-550. Liebermann DA. Medical therapy for chronic reflux esophagitis: long-term follow-up. Arch Intern Med 1987; 147:1717-1720

23. antireflux surgery23 Indications For Antireflux Surgery Pills do not work ! symptomatic relapse on continuous drug therapy early relapse after cessation of drug therapy non-compliance to medication financial non-compliance to medication Problems despite pills! Recurrent strictures Severe pulmonary symptoms Severe esophagitis Symptomatic Barrett's esophagus Large symptomatic paraesophageal hernia

24. antireflux surgery24 Patient selection Clinical assessment Endoscopy –Esophagitis –Hiatus hernia pH Manometry

25. antireflux surgery25 Acid exposure Symptom score Defective LOS pressure Length position Body motility pH Manometry

26. antireflux surgery26 Detects acid reflux Discriminates normal from abnormal Determines temporal association between symptom and reflux Detects oesophageal clearance of acid Detects adequacy of medical or surgical therapy Detects laryngopharyngeal Reflux Disease(LPRD) Ambulatory 24 hour pH test

27. antireflux surgery27 Beware Multiple somatic complaints- ruminants Scleroderma Achalasia Poor response to PPI It is important to adequately evaluate patients before surgery, because an inappropriately performed operation can have disastrous effects 14 Richter JE. Surgery for reflux disease - reflections of a gastroenterologist. N Engl J Med 1992; 326:825-827.

28. antireflux surgery28 To increase LES pressure and therefore prevent acid back flow (reflux) To repair any present hiatal hernia. Goal of surgery

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30. antireflux surgery30 How Fundoplication works? Reduces fundic distension and TLOSR Increase basal LOS pressure Lengthens LOS Restores intraabdominal sphincter Accentuates angle of His Speeds gastric emptying

31. antireflux surgery31 The laparoscopic Nissen fundoplication offers less morbidity and mortality than the open procedure with at least the same short-term outcome as the open procedure and better results compared to medical therapy Spechler SJ. Comparison of medical and surgical therapy for complicated gastroesophageal reflux disease in veterans. N Engl J Med 1992; 326:786-792

32. antireflux surgery32 Dallemagne B, Weerts JM, Jehaes C, et al. Laparoscopic Nissen fundoplication: preliminary report. Surg Laparosc Endosc 1991; 1:138-143. Laparoscopic Nissen Fundoplication

33. antireflux surgery33 Set Up for surgery

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35. antireflux surgery35 More than 90% of patients are free of heartburn after the operation and satisfied with their choice, even after five years. The procedure relieved GERD-induced coughs and some other respiratory symptoms in up to 85% of patients Overall long-term benefits

36. antireflux surgery36 Does the operation work? 100 patients Follow up1-13 yrs Reflux control 91%* Symptom control. * DeMeester TR, Bonavina L, Albertucci M. Nissen fundoplication for gastroesophageal reflux disease. Evaluation of primary repair in 100 consecutive patients. Ann Surg 1986; 204:9-20.

37. antireflux surgery37 Grande L, Toledo-Pimentel V, Manterola C, et al. Value of Nissen fundoplication in patients with gastro-oesophageal reflux judged by long-term symptom control. Br J Surg 1994; 81:548-550 160 patients Follow up3-20 years (Mean 136 months) 71 out of 160 followed up for more than 10 years 92% success rate I am fine now – will this bliss last? Currently laparoscopic Nissen fundoplication has a 3.4 % recurrence rate of symptoms with only 0.7 % rate of need for reoperation.

38. antireflux surgery38 What are the benefits of laparoscopic fundoplication? Less post-operative pain Faster recovery Short hospital stay Less post-operative complications like wound infection, adhesion, hernia, etc. Cost-effective in working group

39. antireflux surgery39 Complications of LNF Operative problems Wrap migration- post op contrast swallow Gas bloat,early satiety Flatulence Persistent Dysphagia0.9% Failure and reoperation 0.7-

40. antireflux surgery40 Type 1 Type 2 Type 3 Type 4 Complex Hiatus hernia needs surgical referral irrespective of reflux symptoms

41. antireflux surgery41 Endoscopic treatment of GORD – The future? Escharification Stretta Injection Enteryx Gatekeeper Plication

42. antireflux surgery42 NOTES Natural Orifice Transluminal Endoscopic Surgery Transgastric gastropexy and hiatal hernia repair for GERD under EUS control: a porcine model. Fritscher-Ravens A, Mosse CA, Mukherjee D, Yazaki E, Park PO, Mills T, Swain P Gastrointest Endosc. 2004 Jan;59(1):89-95. Endoscopic Gastroplasty NDO Plicator

43. antireflux surgery43 Conclusions Some patients will need to see a surgeon. Surgery is safe,effective and offers one off permanent cure in selected patients. Laparoscopic surgery makes the recovery simple and fast. Surgery is the only treatment that abolishes acid bile insult to oesophageal mucosa

44. antireflux surgery44 Thank You for your time and patience “Man will occasionally stumble over the truth but most of the time he will pick himself up and carry on”Winston Churchill