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Heartburn and Acid Reflux: Causes & New Treatment Options
 

Heartburn and Acid Reflux: Causes & New Treatment Options

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What may have seemed like science fiction, surgery without an incision, is now a reality that is making lives better for patients suffering from chronic acid reflux also known as gastroesophageal ...

What may have seemed like science fiction, surgery without an incision, is now a reality that is making lives better for patients suffering from chronic acid reflux also known as gastroesophageal reflux disease (GERD). Peter Janu, MD, a general surgeon, provides basic information about GERD as well as common treatment options including the new TIF (transoral incisionless fundoplication) procedure for the treatment of GERD.

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    Heartburn and Acid Reflux: Causes & New Treatment Options Heartburn and Acid Reflux: Causes & New Treatment Options Presentation Transcript

    • Acid Reflux:New Treatment Options Peter Janu, M.D. SurgeonCalumet Medical Center St. Elizabeth Hospital
    • Is This You?
    • Overview•  Understanding GERD•  Medical/Surgical Management•  Incisionless Surgical Therapy
    • USA GERD Incidence•  > 40% of population suffers from heartburn at least once a month•  10 - 15% of adult population suffers from daily GERD (~ 15 million)•  Incidence of GERD rises rapidly after 40 years of age•  6 million suffer from both GERD and asthma•  Esophageal cancer is 8 X more likely to occur in patients with weekly heartburn or regurgitation
    • Symptoms of GERD•  Heartburn•  Acid regurgitation –  Sour or bitter taste in throat or mouth –  Esp. after large, late meals•  Water brash –  Hot sensation in stomach –  Excess salivation•  Dysphagia and Odynophagia –  Difficulty or painful swallowing
    • Other Symptoms of GERDPulmonary ENTAsthma HoarsenessAspiration pneumonia LaryngitisChronic bronchitis Sore throat Chronic coughOther Frequent swallowingRegurgitation Burning in the throat orChest pain mouthDental erosionAtypical symptoms
    • Normal AnatomyNormally, the lining of theesophagus and stomach aremade of different types ofcells. The cells which line theesophagus are not as resistantto acid as the cells which linethe stomach.There is normally a sphinctermuscle (a “gate”) between theesophagus and stomach calledthe LES (lower esophagealsphincter) which serves as abarrier and protects theesophagus from acid.
    • Pathologic AnatomyHiatus of the Diaphragm (coloredarea)– where the esophagus passesthrough the diaphragm to connect withthe stomach. Muscular fibers of thediaphragm wrap around theesophagus as it passes into theabdomen. When this area is too looseor lax , the stomach can “slip” or “slide”through up into the chest. This createsa pressure differential which allowsstomach acid to freely wash up into theesophagus. This condition is known asa hiatal hernia.
    • Causes of GERDHiatal hernia– allows acid to wash up into the esophagus due to pressure differences between the abdomen and chest.– Loose hiatus muscle fibers causes reflux even without a hiatal hernia.
    • Hiatal Hernia Classification
    • What causes GERD?Intrinsic Factors: Esophageal clearance of acid Mucosal resistance to acid Ability of the stomach to empty Duodenal-gastric refluxThese can often be medically managed
    • What Causes GERD?Extrinsic Factors:Deterioration of natural barrier to reflux; the Antireflux Valve Normal Anatomy Normal AnatomyFully Functional Valve Prevents Reflux Antireflux Valve Tight to the Scope
    • What Causes GERD?Extrinsic Factors:Deterioration of natural barrier to reflux; the Antireflux Valve Dysfunctional Valve Dysfunctional Valve Can’t close to prevent reflux of Can’t close. Loose to the scope. stomach contentsThis requires surgical management
    • Consequences of GERDReflux Esophagitis– Injury and inflammation of the inner lining of the esophagus from prolonged exposure to acid and digestive enzymes.– This produces pain as well as sometimes painful swallowing (known as “dysphagia”), may cause bleeding.
    • Effect of GERD on the Esophagus•  Barrett’s esophagus- is one of the serious complications of GERD. It is a precancerous condition that can cause cancer of the esophagus. It is thought to be caused by ongoing injury, inflammation and damage to the lining of the esophagus.
    • Clinical Progression of GERD
    • Overview•  Understanding GERD•  Medical/Surgical Management•  Surgical Therapy- New Procedures
    • Lifestyle/Behavior Modification•  Diet•  Weight loss•  No late night eating•  Bed position•  Sleeping in a chair…
    • Types of Medications •  Antacids –  Neutralize or buffer stomach acid •  H2 blockers (ranitidine, cimetidine) –  Blocks the body’s signal to the stomach to produce acid •  Proton Pump Inhibitors (PPIs) –  Blocks the secretion of acid into the stomach*May be satisfactory for some patients
    • Continued Reflux Symptoms on Medications Gallup Poll Reflux* 72% on Medication 79% Nighttime symptoms 50% Nighttime reflux worse than daytime reflux 63% Ability to sleep affected 40% Daytime function affected 70% Nighttime discomfort moderate to severe 75% Can not fall asleep or wakes them up 45% Medication does not relieve all symptoms 20- 40% of patients dissatisfied with PPI medication*Gallup Poll 2000 for AGA N = 1000 American Journal of Gastroenterology 2003; vol. 98 Shaker et al
    • Severe and Chronic GERDPPIs are not the solution for severeor chronic refluxDoes not stop •  Reflux •  Non Erosive Reflux Disease (NERD) Normal •  RegurgitationANATOMICALCHANGES NEEDANATOMICAL REPAIRS Chronic GERD
    • Long-Term PPIs•  May be a significant risk for long-term complications with chronic drug therapy •  At risk for osteoporosis •  At risk for gastric polyps •  Barrett’s and esophageal cancer risks increase •  Drug-drug interaction issues •  Adverse events from PPIs•  Patients who do not want to take drugs for life•  Non-Erosive Reflux Disease (NERD)•  Expense
    • Indications for Surgery•  Esophagitis•  PPIs required for control•  Persistent symptoms despite medications•  Presence of Barrett’s esophagus•  Non-acid symptoms of reflux (asthma, chronic cough, laryngitis…)
    • Tests for SurgeryPatients mightneed one or moreof the followingtests:•  Endoscopy•  Barium swallow•  pH monitoring•  Manometry
    • Diagnostic TestsUpper Endoscopy– The most commonly used test to evaluate the esophagus and stomach.– This is a test that requires mild sedation (medication to make you comfortable) to perform. It is the most accurate way to evaluate damage to or inflammation of the upper gastrointestinal tract.– A flexible scope with a camera and light on the end is placed through the mouth and guided into the esophagus, stomach, and small intestine.
    • Diagnostic Tests• Upper endoscopy– The scope and camera allow for clear and detailed viewing of the lining of the esophagus and stomach as well as the ability to take small biopsies to examine the cells if irregularities are noted.
    • Surgical Treatment Aims to recreate the natural valve that stops fluids from the stomach refluxing back to the esophagus.
    • Nissen Fundoplication
    • Laparoscopic FundoplicationLaparoscopic FundoplicationIs performed using a telescopiccamera, a TV monitor and five ½inch incisions. Small instruments areplaced through the incisions allowingsurgeons to complete the surgery.Most patients are able to leave thehospital the day after their surgery isperformed.
    • Lap Nissen Fundoplication1,000 cases•  Average hospital stay 1.2 days•  Resolution of symptoms at 1 year: 94%•  Major complications: 2%•  Long term complications: 2 - 62% –  Gas bloat –  Difficulty swallowing
    • Overview•  Understanding GERD•  Medical/Surgical Management•  Incisionless Surgical Therapy
    • Treatment Options TIF with EsophyX® “Front Line Surgical Management” Mild Severe Anatomical Changes GERD GERD Today’s Lifestyle Pharmaceutical SurgicalApproach Change (Rx and OTC)
    • TIF (Transoral Incisionless Fundoplication)No incisions •  No scarring •  No incisional herniation •  Less potential for infection - nosocomial infection minimizedPatient friendly •  Rapid return to work and normal activities Unique Surgical Approach
    • TIF and Principles of Antireflux Surgery
    • TIF ExperienceReconstructs the natural primarybarrier to reflux by creating arobust valve•  45 - 60 minute procedure•  Overnight stay (general anesthesia)•  Post-op discomfort minimal•  Rapid recovery – Most patients are back to work and most activities in a couple of days Unique Surgical Approach
    • What Can Be Expected from Surgery
    • Laparoscopic Hiatal Hernia Repair
    • TIF Meets Surgical Objectives Nissen Fundoplication TIFRecreates Angle of HIS Yes YesInvolves multiple sutures/fasteners Yes YesReduces Hiatal Hernia Yes YesCreates a substantive nipple valve Yes YesLengthens Intraabdominal Esophagus Yes YesTighten LES/high pressure zone Yes YesGEV anchored Yes YesCrura closed Yes NoUndone/redone** No YesCan be revised (adjusted) No YesIncisionless No YesNoninvasive no dissection No Yes
    • 3D ManometryPost-TIF manometry similar to both normal and Nissen
    • Multi Center Trial (1 year) N=79 85% of Patients OFF daily PPIs •  Minimal risk of adverse events •  Excellent QOL improvement 73% •  Elimination of PPI use 85% •  Esophagitis resolution 59% •  Hiatal hernia reduction 71% •  pH normalization 49%Clinically Safe & Effective
    • Multi-Center Trial (2 years) N=79•  Minimal risk of adverse events•  Patients satisfied: 86%•  Patients can consume reflux causing foods without symptoms: 60-80%•  No long-term adverse events Clinically Safe & Effective
    • Effectiveness - Conclusions•  TIF was shown to be effective in treating chronic GERD as indicated by the significantly improved quality of life and reduced dependency on daily PPIs.•  The results at 12 and 24 months supported a long-term maintenance of the anatomical integrity of TIF valves.
    • Surgical Society SupportIncisionless Surgery•  Recognized as Future of Surgery•  Offers patients improved safety and recovery time
    • Medical/Surgical Therapies Incisionless TIF Fundoplication
    • Appropriate for Patients Who:•  Are on double-dose PPIs•  Have nighttime symptoms even on medication•  Have non-heartburn symptoms of reflux that can’t be treated with medications•  Are dissatisfied with current treatment•  Are concerned about long-term use of PPIs•  Are currently taking Plavix
    • Contraindications to Esophyx TIF•  Hiatal hernia > 3X3 cm•  Previous surgery on the upper part of the stomach, previous resection of the stomach, previous bariatric surgery•  Morbid obesity with BMI>35•  Barrett’s Esophagus with high grade dysplasia/ cancer of the esophagus/stomach•  High risk of general anesthesia due to advanced heart or lung disease
    • Conclusions•  Medical treatment of GERD provides symptomatic relief to majority of patients but does not address the cause of the disease.•  Patients with moderate-to-severe GERD, atypical symptoms, resistant to therapy with medications or unwilling to continue taking them, may be candidates for surgical treatment.•  Laparoscopic Fundoplication while being a “gold standard” of surgery might be effectively replaced by less invasive TIF procedure in patients with no or small hiatal hernia.•  Current experience with TIF demonstrates good safety profile and efficacy comparable to Laparoscopic Fundoplication without potential side effects of that procedure.•  Patients with hiatal hernia >3cm or more complex hernia would benefit from Laparoscopic Fundoplication.