1. The Non-Medical Treatments of the Gastroesophageal Reflux Disease (GERD) Joint Hospital Grand Round 25.1.2014 Prepared by Siu Yin Yu, Eva North District Hospital

2. Definition AGA: There can be no criterion standard definition of GERD because the threshold distinction between physiologic reflux and reflux disease is ultimately arbitrary Montreal consensus 1 Reflux of stomach contents Troublesome symptoms and/or Complications 1.Am J Gastroenterol 2006;101:1900-20

3. Background Prevalence: 10-20% in Western world, even up to 42% 2 2.5-6.7% in east/east-southern Asia 3 Symptoms : Esophageal Vs Extraesophageal Investigations: OGD 24Hr pH monitoring Manometry Mutichannel Intraluminal Impedence study 2. Gut 2005;54:710-7 3. Clin Gastroenterol Hepatol. 2006 Apr;4(4):398-407.

4. Treatment Life style modification Acid-suppressive drugs Antireflux Surgery Endoscopic Therapy

5. When do we consider antireflux surgery? Which approach? Open? Laparoscopic ? Robotic- assisted? Total Vs Partial? Does short gastric vessel division improve the outcomes? Recent development of endoscopic therapy ? Effectivenss ? Safety? Questions…

6. When do we consider antireflux surgery? Which approach? Open Vs Laparoscopic Vs Robotic- assisted Total Vs Partial? Does short gastric vessel division improve the outcomes? Recent development of endoscopic therapy ? Effectiveness ? Safety? Questions…

7. Antireflux Surgery Indications Patients with esophageal symptoms intolerant of PPIs For atypical symptoms, no conclusive evidence to support

8. When do we consider antireflux surgery? Which approach? Open Vs Laparoscopic Vs Robotic- assisted Total Vs Partial? Does short gastric vessel division improve the outcomes? Recent development of endoscopic therapy ? Effectiveness ? Safety? Questions…

9. Antireflux Surgery Variety of fundoplications Approaches Open Laparoscopic Robotic-assisted

10. Open Vs Laparoscopic A meta-analysis, the American Journal of Gastroenterology 2009 6 12 RCTs, 503 Vs 533 pt (Open Vs Lap) Results: Favors Laparoscopic approach significantly Shorter hospital stay (2.68 days) Faster return to work (7.75 days) Lower Cx rate (relative odds reduction in 65%) But… Comparable Tx failure rate though further surgery rate higher in the Lap group (odd ratio 1.79) Longer operating time in Lap group (39 mins ) 6. Am J Gastroenterol. 2009;104(6):1548.

11. Laparoscopic Vs Robotic-assisted RCT Italy, 50 patients, Nissen, Da Vinci system 7 Results Comparable outcomes/ conversion rate/ Cx rate But in Robotic group… Significantly longer operating time Higher cost 7. J Am Coll Surg. 2012;215(1):61.

12. Meta-analysis 2010, 11 trials (3 RCTs) Slightly lower post-operative Cx rate in robotic group Longer operation time and higher costs Laparoscopic Vs Robotic-assisted 8. Surg Endosc (2010) 24:1803–1814

13. Approach Laparoscopic fundoplication > Open Robotic-assisted fundoplication was found to achieve comparable outcome and might be a slightly lower post- operative Cx rate compared to the laparoscopic approach BUT… The Significant higher cost and longer operative time of the robotic-assisted fundoplication make it LESS cost-effective than laparoscopic approach

14. When do we consider antireflux surgery? Which approach? Open Vs Laparoscopic Vs Robotic- assisted Total Vs Partial? Does short gastric vessel division improve the outcomes? Recent development of endoscopic therapy ? Effectiveness ? Safety? Questions…

15. Total Vs Partial Fundoplication Variety of fundoplications Total Vs Partial Nissen (total posterior 360) Toupet (Posterior 270) Dor (Anterior 180-200) Belsey (anterior 270)

16. Laparoscopic Nissen fundoplication is a popular anti-reflux surgery Successful rate ~ 90% Recommended by the European Study Group for Antireflux Surgery in 1997 But… Dysphagia (8-12% ), may require dilation Gas-related symptoms (19%) Especially in those with a pre-operative esophageal dysmotility Laparoscopic Toupet procedure (posterior 270 deg) as an alternative Less common x ? Less satisfactory reflux control Total Vs Partial Fundoplication

17. A systematic review and meta-analysis, British Journal of Surgery 2010 9 Laparoscopic Nissen Vs Toupet 7 RCTs from 1997-2000, at least 12 months FU (up to 60months) Results: NO sig difference in effectiveness and recurrence (eg. post operative esophagitis, abnormal acid exposure durations or subjective recurrence/ satisfaction ) Significantly HIGHER prevalence of dysphagia (requiring dilatation / surgical intervention) and gas-related symptoms (inability to belch/ gas bloating) in the laparoscopic Nissen group 9. British Journal of Surgery 2010; 97: 1318–1330

18. British Journal of Surgery 2010; 97: 1318–1330 Dysphagia Post op dilatation and reoperation is also higher in the Nissen group RR : 2.45 and 2.19

19. Lap Posterior Vs Anterior Fundoplication ? Laparoscopic anterior fundoplication has an even lower dyphagia rate Higher recurrence of reflux ？ A meta-analysis and systematic review, Annuals of Surgery 10 2011 7 RCTs, 1999-2010 Laparoscopic posterior Vs anterior 10. Ann Surg 2011;254:39–47

20. Long-term dysphagia scores, inability to belch, gas bloating and satisfaction showed NO significant different Ann Surg 2011;254:39–47 Lap Posterior Vs Anterior Fundoplication Result: Lap Posterior> Lap Anterior

21. Laparoscopic Toupet > Nissen Comparable effectiveness and recurrence But Laparoscopic Nissen was associated with more dyphagia that required intervention (dilatation/ reoperation) and gas- related symptoms Laparoscopic posterior fundoplication > anterior Better heartburn/ acid exposure/ reoperation rate in Lap posterior fundoplication The short-term benefit of lower dysphagia rate in the Lap anterior fundoplication group disappeared in long term FU (after 12m) Total Vs Partial Fundoplication

22. When do we consider antireflux surgery? Which approach? Open Vs Laparoscopic Vs Robotic- assisted Total Vs Partial? Does short gastric vessel division improve the outcomes? Recent development of endoscopic therapy ? Effectiveness ? Safety? Questions…

23. Short Gastric Vessel Division Complication of fundoplication: dysphagia/ gas-related symptoms Modification of surgery -> Short Gastric Vessel Division (SGVD) in laparoscopic Nissen fundoplication 11. Surg Endosc (2012) 26:970–978

24. A meta-analysis, Surgical Endoscopy 2012 11 5 RCTs, 194 Vs 194 (SGVD Vs No-SGVD) 3 trials FU 1 yr, 2 trials FU 10 yrs Results: No-SGVD > SGVD No significant difference in dysphagia/gas-related syms/ effectiveness / conversion rate in both 1yr & 10yrs FU No-SGVD has a significant SHORTER operative time and length of stay Short Gastric Vessel Division 11. Surg Endosc (2012) 26:970–978

25. When do we consider antireflux surgery? Which approach? Open Vs Laparoscopic Vs Robotic- assisted Total Vs Partial? Does short gastric vessel division improve the outcomes? Recent development of endoscopic therapy ? Effectiveness ? Safety? Questions…

26. Endoscopic Therapy Principles: To improve the LOS length and pressure To remodel the smooth muscles of the GEJ

27. Endoscopic Therapy Endoscopic Radiofrequency (Stretta procedure) Reduce the postprandial LOS relaxation and GEJ compliance? ? Fibrosis ?

28. Stretta Procedure Several RCTs with Sham-controlled/ cohorts showed ~ 55 to 83 % of patients Satisfactory symptom control or Cessation of PPI Acid exposure/ LES pressure Durable - Average follow-up of 12 to 33 months (even up to 48m) Safe, minimal invasive & lower cost But… Patients selection Not enough evidence to be comparable with laparoscopic fundoplication

29. Endoscopic Therapy Endoscopic sewing and full-thickness plication

30. Endoscopic Sewing Sham study : symptoms improvement in short-term (3m in EndoCinch 6-9m in plication), but lacking durability No change in esophageal pH monitoring Complications: Perforation Pharyngitis/ chest pain

31. Endoscopic Therapy Transoral Incisionless Fundoplication (TIF), EsophyX Full-thickness plication to produce a neogastroesophageal valve

32. TIF Objective measurement: Decrease in esophageal acid exposure Increase in LOS pressure Subjective measurements: > 50% improvement in QOLs and Heartburn scores in 68% and 75% of patients respectively 12 But… More perforation Lacking RCTs Lacking long-term evidence Not much information in the learning curve of the method 1.World J Surg (2008) 32:1676–1688

33. Conclusion Laparoscopic fundoplication is more preferable than open and robotic-assisted approach Laparoscopic Toupet fundoplication has more potential benefits than Nissen Laparoscopic posterior fundoplication is more effective than anterior fundoplication SGVD is not suggested to be performed as a routine procedure Novel endoscopic therapy might be of some benefits but lacking evidence ground

35. References 1.Am J Gastroenterol 2006;101:1900-20 2.Gut 2005;54:710-7 3.Clin Gastroenterol Hepatol. 2006 Apr;4(4):398-407. 4.Gastroenterology 2010;138:896-904 5.Am J Gastroenterol. 2009;104(3):752 6.Am J Gastroenterol. 2009;104(6):1548. 7.J Am Coll Surg. 2012;215(1):61. 8.Surg Endosc (2010) 24:1803–1814 9.British Journal of Surgery 2010; 97: 1318–1330 10.Ann Surg 2011;254:39–47 11.Surg Endosc (2012) 26:970–978 12.World J Surg (2008) 32:1676–1688

37. Pathophysiology Hiatus hernia -Short length of LOS -Low basal tone -Transient LOS relaxation -Sling fibre of cardia Failed clearance of acid reflux  IGP: obesity, delayed gastric emptying Diaphragmatic crura

38. Diagnosis History Any hx of typical syms of GERD relieved with PPI is suspicious Investigations OGD

39. Esophagitis Grade A Grade D Grade B Grade C Los Angeles (LA) Classification

40. 24Hr pH monitoring

41. Manometry Standard High Resolution

42. Multichannel Intraluminal Impedance Resistance of current Bolus of food decreases the impedance Direction and velocity of food bolus With pH monitor / manometry

43. Treatment PPIs > H2R blockers PPI once-daily dose ? Twice-daily dose? Symptoms relief and esophagitis healing SEs of Esomeprazole 1yr: Headache (10% ) Abd pain & diarrhoea (9%) Nausea (6%) Failure of PPI Inadequate response of heartburn on 2x daily PPI

44. Predictors of post op outcomes Factors predictive of dysphagia after laparoscopic Nissen fundoplication. ~ 150 patients, prospective cohorts Analyse pre op dysphagia/ DeMeester score/ manometry for LOS pressure and length etc Only the presence of pre operative dysphagia increases the risk of post-operative dysphagia Surg Endosc. 1999;13(12):1180. Dis Esophagus.Dis Esophagus. 2009;22(8):656-63. Does combined multichannel intraluminal esophageal impedance and manometry predict postoperative dysphagia after laparoscopic Nissen fundoplication? Even with the development of pre op MII with manometry, result doesn’t showed sig predictor of post op dysphagia except pre op dysphagia