Medical Articles

Anti-Reflux Surgery

What is GERD?

Gastro-Esophageal Reflux Disease:

  • Symptoms of mucosal damage produced by abnormal reflux of gastric contents into the esophagus

How common is GERD?

  • It is one of the most common conditions affecting the gastrointestinal system.
  • 7% have daily heartburn
  • 14-20% have weekly heartburn
  • 15-50% have monthly heartburn
  • $6 billion spent annually in USA

Pathophysiology

Lower esophageal sphincter pressure

  • Intrinsic muscle of distal esophagus
  • Sling fibers of cardia
  • Diaphragm (Crurae)
  • Transmitted pressure of abdominal cavity

Reflux occurs when the pressure within the highpressure zone in the distal esophagus is too low or when a sphincter with normal pressure undergoes spontaneous relaxation

Anti-Reflux Surgery

Pathophysiology of GERD

A complex interaction of many problems can cause reflux:

  • Esophageal Dysmotility
  • Inadequate saliva.
  • Excess acid production
  • Impaired resistance
  • LES dysfunction
  • Delayed emptying of the stomach
  • Hiatal hernia Loose hiatus muscle fibers

Anti-Reflux Surgery

A comparison of the normal stomach, sliding hiatal hernia and rolling hiatal hernia

Anti-Reflux Surgery

Factors contributing to decreased lower esophageal sphincter pressure

  • Fatty foods
  • Caffeinated beverages
  • Chocolate
  • Nicotine
  • Calcium channel blockers
  • Nitrates
  • Peppermint
  • Alcohol
  • Anticholinergic drugs
  • High levels of estrogen and progesterone
  • NG tube placement

Complications of GERD

  • Esophagitis
  • Stricture formation
  • Ulceration
  • Barrett’s change

Complications of GERD – Reflux esophagitis

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Anti-Reflux Surgery

Complications of GERD - Ulceration and stricture

  • More in patient with Barrett’s esophagus (10-15%) than in GERD with normal mucosa.
  • Ulcer penetrates the columnar epithelium (like gastric ulceration)
  • Leads to bleeding, pain, obstruction (30%) perforation, iron deficiency anemia, dysphagia, perforation into pleural space, lung, pericardium.
  • Stricture always forms at squamocolumnar junction.

Complications of GERD - Barrett’s Change

  • Normal distal esophagus
  • may display short cephalad extention of columnar epithelium above the gastroesophageal junction.
  • Barrett’s Change
  • An endoscopic diagnosis.
  • Columnar epithelial lining of distal esophagus extending at least 3 cm above the gastroesophageal junction.

Pathogenesis – Barrett’s

  • Gastroesophageal reflux
  • Leads to destruction of the normal squamous lining of esophagus
  • Allows subsequent cephalad migration of columnar gastric lining to re-epithelized the injured area (metaplasia).
  • Alkaline reflux
  • Also involved, particularly in developing complication.

Anti-Reflux Surgery

Barrett’s Prevalence

  • 2% of patients undergoing gastroscopy for GERD.
  • Autopsy 376/100000.
  • Most Barrett’s esophagus cases are asymptomatic.

Complications of GERD - Dysplasia

  • Low grade progresses to high grade.
  • Loss of nuclear polarity, hyperchromatism, nuclear enlargement, stratification, pleomorphism, abnormal mitoses.
  • Distinguishing between high and low grade is difficult.

High-grade dysplasia

  • 22-73% chance unsuspected invasive carcinoma.
  • 100% cure rate - patients without invasive tumour on histology.
  • Thermal laser, photodynamic therapy - long term efficacy and costeffectiveness unknown.

Anti-Reflux Surgery

Adenocarcinoma

  • Distinguish adenocarcinomna in Barrett’s esophagus from carcinoma of cardia is difficult.
  • 30-125 times the risk of normal population.
  • 1 case per 100 patient-years,
  • annual risk = 1%.

Anti-Reflux Surgery

Symptoms of GERD

  • Heartburn – burning or tightness behind the sternum or in the epigastric area.
  • Acid regurgitation – sour or bitter taste in the throat or mouth.
  • Water brash – a hot sensation in the stomach followed by a large amount of watery liquid in the mouth.
  • Dysphagia - difficulty swallowing or painful swallowing (odynophagia). The sensation of a lump in the throat or food getting “stuck” after swallowing.
  • Asthma, laryngitis and chronic cough are unusual symptoms, but can be caused by GERD.

GERD - Alarm Symptoms

Suggest complicated disease

  • Dysphagia – difficulty swallowing
  • Odynophagia – painful swallowing
  • Bleeding
  • Weight loss
  • Anemia
  • Long duration of symptoms with progression
  • Poor response despite treatment

GERD - Extraesophageal Manifestations

Anti-Reflux Surgery

Diagnosis

Modalities:

  • Empirical Treatment
  • Endoscopy
  • Ambulatory Reflux Monitoring (pH/Impedance)
  • Esophageal Manometry
  • Barium swallow – other imaging modalities

Empirical Treatment

  • Symptomatic response to antisecretory therapy with proton pump inhibitor (PPI) -> assume diagnosis of GERD
  • Trial of high-dose (40mg/d) PPI: 75% sensitivity, 55% specificity
  • Consider further testing if no response to treatment or alarm symptoms are present

Gastroscopy

  • Allows examination and biopsy of the esophageal mucosa
  • Identifies presence of esophagitis and allows grading of severity
  • Can identify other pathology, such as diverticula, hiatal hernia, webs, rings, or strictures
  • Can diagnose cause of GERD – Hiatus hernia

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Gastroscopy Images

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Normal GE junction with regular Z-line (arrows)

Erosive esophagitis (erosions indicated by arrows)

Anti-Reflux Surgery

Preoperative retroflexed view of GE junction with hiatus hernia (arrow)

Retroflexed view of GE junction after Nissen fundoplication

Ambulatory Reflux Monitoring

  • Gold Standard for diagnosis
  • Quantifies reflux occurring over time

Indications:

  • Trial of acid suppression has failed
  • No evidence for mucosal damage on endoscopy
  • Monitor control of reflux in patients with continued symptoms on therapy or post surgery
  • Method: trans-nasally placed catheter or wireless device attached to distal esophageal mucosa
  • pH sensor connected to portable data logger
  • Data collection time: traditionally 24 hrs
  • Consume normal diet
  • Correlate with symptoms

Normal 48h pH study

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pH study note multiple episodes of pH<4(arrows)

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pH Monitoring

  • Calculate % time that pH < 4 at distal esophagus
  • Produce a DeMeester score (N<14)

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Non acid reflux

  • Definition: The reflux of gastric contents into the esophagus with pH > 4
  • Bilitec monitor
  • Multichannel Intraluminal Impedance (detects any fluid in lumen)

Esophageal Manometry

  • Lower Esophageal Sphincter (LES)
    • Mean resting pressure
    • Total length
  • Esophageal Body
    • To determine effectiveness of peristalsis
    • Amplitude of esophageal wave

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Defective lower esophageal sphincter

  • Considered mechanically defective when on manometry
  • Pressure <6mmhg
  • Total length <2cm
  • Abdominal length <1cm
  • Reflux occurs in
    • 74% when one abnormality is present
    • 75% when two abnormalities are present
    • 92% when all three abnormalities are present

Treatment

Goals:

  • Eliminate symptoms
  • Heal esophagitis
  • Prevent relapse
  • Prevent complications

Modalities:

  • Lifestyle Modification
  • Patient-directed therapy
  • Acid Suppression
  • Surgery
  • Endoscopic Therapy

Lifestyle Modification

  • Most effective for infrequent heartburn
  • Modify factors that may precipitate reflux:
    • Elevate head of bed
    • Decrease fat intake
    • Stop smoking (tobacco inhibits saliva, stimulates gastric acid, relaxes LES)
    • Avoid recumbency 3 hrs after eating
    • Lose weight if obese

Acid Suppression: Proton Pump Inhibitors (PPIs)

  • Eliminate symptoms & heal esophagitis more frequently & more rapidly than other agents
  • Provides complete endoscopic mucosal healing of esophagitis at 6-8 weeks in 75-100% of cases
  • Remission retained if used chronically
  • Economic concern – range from R120 to more than R900 per month

PPI Therapy Does Not Change Number of Reflux Episodes

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Acid suppression with PPIs

  • Esomeprazolle 40 mg bd 70%
  • Esomeprazolle 40 mg dlly 50%
  • Lansoprazolle 30 mg bd 61%
  • Lansoprazolle 30 mg dlly 48%

Possible long term side effects of PPIs

  • Achlorhydria
  • Pneumonia risk
  • Risk of hip fracture
  • C-difficile infection
  • Mucosal hyperplasia

Mucosal hyperplasia due to PPIs

Anti-Reflux Surgery

Acid Suppression: H2 Receptor Blockers

  • Lower cost than PPIs
  • Eliminates symptoms in up to 50% of pts with BD dosing
  • Increased dosing may be required for healing of esophagitis
  • Remission maintained in 25% of patients

Seven-year follow-up of a randomized clinical trial comparing proton-pump inhibition with surgical therapy for reflux esophagitis.

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Cumulative proportion of patients staying in remission over the 7 years after randomization to antireflux surgery or continuous omeprazole therapy. Patients maintained on 20 mg omeprazole

Seven-year follow-up of a randomized clinical trial comparing proton-pump inhibition with surgical therapy for reflux esophagitis.

Anti-Reflux Surgery

Cumulative proportion of patients staying in remission over the 7 years after randomization to antireflux surgery or continuous omeprazole therapy. Inclusion of patients who relapsed on the initial dose and had a dose adjustment to 40 or 60 mg omeprazole.

Refractory GERD

Persistent GERD symptoms/esophagitis despite double dose PPI x 30-60 days

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Refractory GERD - Causes

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Eosinophilic esophagitis

When to suspect?

  • Long standiing esophageall symptoms such as dysphagia wiith or wiithout food impaction.
  • Refractory heartburn on PPIs
  • Allllergiic hiistory
  • Periipherall Eosiinophiilliia
  • Ellevated IgE

Hypersensitive Esophagus (Neuropathy)

  • Typical meal/food association;
  • No/little PPI response
  • pH probe (48 hr) no/miiniimall esophageall aciid refllux
  • No evidence of bile/nonacidic reflux
  • Endoscopy usually normal.. Consider biopsy for eosinophilic esophagitis

Management

  • Life long PPI treatment

or

  • Antireflux surgery
  • What are the indications for surgery in patients with GERD in 2011?
  • Which procedure should be done?

Accepted indications for surgery:

  • Persistent symptoms despite medication
  • Volume reflux to mouth
  • Extraesophageal symptoms
  • Intractable esophagitis on endoscopy.
  • Non-compliance with treatment or patient aversion to long term medication.
  • Complications
  • Barrett’s
  • Stricture
  • Ulceration

Antireflux Surgery Principles

  • Closure of hiatus to physiological diameter
  • Replace the GE junction in the high pressure zone by
  • Reestablishment of intra-abdominal esophageal length (2-3 cm)
  • Recreation of valve mechanism by stomach wrap around the esophagus
  • The gold standard remains the laparoscopic
  • Nissen fundoplication (as originally described with takedown of the short gastrics)

History – Nissen fundoplication

  • First performed by Dr Rudolph Nissen in 1954
  • In 1987 12 000 open Nissen procedures in USA (1% mortality)
  • In 2003 64 000 Laparoscopic Nissen procedures in USA

Complications of Surgery - Acute

  • Injury to the bowel, stomach, or esophagus
  • Bleeding
  • Acute dysphagia (10%)
  • Acute slippage and reherniation
  • Paraesophageal herniation
  • Vagus nerve injury
  • Conversion to open surgery (<5%)

Complications – long term

  • Dysphagia <1%
  • Technical
  • Misdiagnosed achalasia/dysmotile esophagus
  • Recurrent reflux requiring PPI (5-25%)
  • Abdominal bloating
  • Chest pain
  • Diarrhoea
  • Severe fibrosis or total failure of esophageal body function

Endoscopic Therapy

  • Attempt to augment the LES by
    1. Suturing – EndoCinch
    2. Radiofrequency energy – Stretta
    3. Plexiglass injection – polymethylmethacrylate
    4. Biocompatible polymer injection - Enteryx

Endoclinch

Results:

  • 18 months after EndoCinch 56/70 patients (80%) were considered treatment failures as their heartburn symptoms did not improve or PPI medication exceeded 50% of initial dose
  • Endoscopy showed all sutures in situ in 12/70 (17%), while no sutures remained in 18/70 (26%)
  • No significant changes in 24h pH monitoring or LES pressure

Radiofrequency Thermal Therapy -- Stretta

  • Delivery of low-power, temperature controlled radiofrequency energy to the GEJ
  • Two mechanisms
    1. mechanically altering the GEJ
    2. inducing the ablation of nerves that
    3. trigger transient lower esophageal relaxation

Radiofrequency Thermal Therapy - Stretta

Anti-Reflux Surgery

  • Although the incidence of complications is decreased compared with operative intervention, success of therapy does not approach that of surgical intervention
  • After Stretta 30-50% of patients still require PPI therapy at one year

Injection/implantation techniques - Enteryx

  • Injectable biocompatible solution consisting of 8% ethylene vinyl alcohol copolymer
  • When injected into the LES, the solution interacts with the surrounding fluid to become an inert spongy solid mass
  • Mechanism: may impart an alteration in the compliance of tissues preventing sphincter shortening and improving the barrier function of the GEJ

Laparoscopic Nissen Fundoplication

Lafullarde T, Watson DI, Jamieson GG, Myers JC, Game PA, Devitt PG. Laparoscopic Nissen fundoplication: five-year results and beyond. Arch Surg. 2001 Feb;136(2):180-4 – 87% of the 176 patients remained free of significant reflux. The long-term outcome was considered "good or excellent" by 90% of patients.

Surgery: Long-term efficacy meta analysis

  • Laparoscopic fundoplication vs. PPI therapy
  • Surgical group with greater improvement of symptoms & quality of life compared with medical group at 1 year of follow-up
  • Both groups with similar effectiveness at up to 2 years of follow-up
  • Data available does not support one modality over another in preventing complications of GERD or healing of esophagitis

RCT of Laparoscopic Nissen Vs PPIs for chronic GERD

  • Between 1997-2001, 340 patients randomized.
  • F/U: endoscopy, pH studies, and manometry.
  • LES improved from 6.3 to 17.2 mmHg in LNF, while it did not change with PPIs (P<0.001).

RCT of Laparoscopic Nissen Vs PPIs for chronic GERD

  • LNF leads to significantly less acid exposure of the Lower esophagus at 3 months, and significantly greater improvement in both gastrointestinal and general wellbeing at 12 months compared to PPIs.

RCT of Laparoscopic Nissen Vs PPIs for chronic GERD

  • De Meester score improved from 42.7 to 8.6 in LNF, and 36.9 to 17.7 with PPIs (P<0.001).
  • Psychological general wellbeing index at 12 months Significant improvement with LNF than PPIs (P<0.003).

Long term outcome of medical and surgical therapy for GERD

  • In both groups: Incidence of esophagitis, Barretts, and esophageal adenocarcinoma is the same.

Short and long term COST effectiveness in LNF Vs PPIs

  • Outcomes and cost for 100 patients over 12 months.
  • On average, LNF cost more than PPIs at one year, and broke even at 8 years.
  • LNF may be cost saving after 8 years compared to maintenance therapy of PPIs.

RCT comparing symptom response and esophageal acid exposure

  • Comparing symptomatic and physiologic response to LNF or PPIs.
  • All 75 patients underwent pH studies.
  • Among the asymptomatic patients:
    • Pathological reflux in 18/30 (60%) on PPIs.
    • Pathological reflux in 2/19 (10.5%) after LNF.

Summary

  • GERD is a very common disease and can be managed medically in most patients
  • PPIs are the gold standard and should be the initial treatment of choice in patients with uncomplicated classic symptoms
  • Patients suspected to have complicated disease (dysphagia, anemia, weight loss, GI bleeding) or with atypical reflux symptoms (hoarseness, asthma, sinusitis, recurrent pneumonias, enamel erosions, severe nausea and vomiting) or do not respond to PPI treatment should undergo further evaluation
  • While ambulatory pH monitoring is the most reliable objective indicator of GERD, a response to a PPI in a symptomatic patient is one of the most reliable clinical indicators of GERD
  • Continuous PPI treatment is the most effective management with cost as a potential problem
  • While surgical therapy may provide greater improvement of symptoms and quality of life than medical therapy, data has not shown one modality to be superior to another in healing of esophagitis or preventing complications of GERD
  • Surgery is a very effective treatment of GERD with symptom resolution in over 90% of patients and excellent quality of life
  • Randomized studies document superior efficacy of surgery compared to PPI in controlling the disease in the short-term but there are concerns that in the long-term a significant percentage of patients may need reinitiate PPI therapy or have redo surgery
  • Patients should be carefully selected for surgery