1. Hiatal Hernia Repair, Vagotomy, Gastrectomy for GERD
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Hiatal Hernia Repair, Vagotomy, Gastrectomy for GERD
Bill Richards, MD FACS
Professor and Chair Surgery
University of South Alabama
College of Medicine

2. Mixed Reflux of Gastric and Duodenal Juices is more Harmful to the Esophagus than Gastric Juice Alone Kauer WK et al Ann Surg 222:
Prevalence of esophageal bilirubin exposure

3. Antireflux Surgery
1976 Donahue and Bombeck defined a technique of "floppy" Nissen fundoplication (FNF) that prevented experimental pathologic reflux without preventing gaseous eructations or vomiting (normal reflux) when appropriate

4. LES Pressure Returns to Normal After Laparoscopic Fundoplication
Peters JH et al. Ann Surg 1998;228:40-50.

5. 24 Hour pH Studies after Laparoscopic Fundoplication
Author
# patients
pH Negative
Follow-up
(months)
Hinder
(87%)
3-12
Hunter
(91%) 12
Watson 3
Peters
(93%) 21

6. Does Nissen reduce NonAcid Reflux?
8 patients with Barrett’s
24 hour pH and nonacid relfux
- before (on omeprazole 20 mg BID)
- after laparoscopic Nissen fundoplication

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

8. P=0.001
Non-Acid
Episodes
Data are shown as median (horizontal line), interquartile range (box), and 5th to 95th percentile (vertical line)

9. Conclusions: Patients with Barrett’s esophagus
Nissen eliminates acid and non-acid reflux
PPI’s fail to eliminate acid reflux in 33-50%
PPI’s do not reduce non-acid reflux

10. W/u persistent GERD after Nissen
Barium swallow
Esophageal pH studies
On or off PPI
Endoscopy
Tc 99 scrambled egg gastric emptying study

11. Obese patient GERD after Nissen
Subtotal gastrectomy and Roux-en-Y reconstruction
Diverts acid and bile
Weight loss reduces IA pressure
Improves gastric emptying
Improves blood glucose control

12. Recurrent GERD +Hiatal Hernia after Nissen
Never redo same operation
Ask yourself why did they fail?
Esophageal lengthening
Reinforcement of esophageal hiatus

13. The enemy of Good is
BETTER

14. Selective vagotomy Hemigastrectomy 360 Nissen 60 cm Roux
Early and Late Results of the Acid Suppression and Duodenal Diversion Operation in Patients with Barrett's Esophagus: Analysis of 210 Cases Attila Csendes, M.D., et al
Selective vagotomy
Hemigastrectomy
360 Nissen
60 cm Roux
World J. Surg , 2002

15. Nissen V+A Roux Reduces Acid production
Pre-OP
Post-OP
% reduction
Basal Acid Volume 40 16
60%
Basal acid output mM/hr
4.7
0.2
96%
Stimulated Acid Volume
120 47
Stimulated Acid output mM/hr 18 3
84%

16. Nissen V+A Roux Reduces Bile reflux
PREOP
N= 56
POSTOP
N=22
Normal study
18%
91%
Pathologic bile reflux
82% 9%
World J. Surg , 2002

17. Nissen V+A Roux Good symptom scores and NO progression of Barrett’s
Parameter
Primary op
N=92
Reop
N=54
Total
N=146
Visick I
90%
80%
86%
Visick II 7% 2% 5%
Visick III
3 %
16% 8%
Visick IV 1%
Dysplasia
Adenocarcinoma
World J. Surg , 2002

18. Endoscopy after Nissen, V+A, Roux Reconstruction
Pre-OP
POST-OP
Hiatal hernia
72% 2%
Erosive esophagitis
81%
Esophageal ulcer
86%
Esophageal Stricture
26% 3%
Length of Barrett’s
73 mm
70 mm
World J. Surg , 2002

19. Summary Barrett’s associated with Non Acid and Acid Reflux
Non acid and acid reflux can cause esophageal cancer in experimental animals

20. Summary Nissen significantly reduces acid and non acid reflux
PPI’s reduce acid reflux only and normalize 50-80% of patients
Nissen V+A with Roux reconstruction
Reduces Acid
Reduces bile reflux
Improves endoscopic findings of stricture, ulcers and esophagitis

21. Summary
There is no proof that Nissen fundoplication can prevent progression to cancer.
But Nissen fundoplication is the only modality that can reduce both acid and non acid reflux and has been shown to reverse Short Segment Barrett’s
Nissen V +A with Roux reconstruction may prevent progression of dysplasia in Barrett’s