Gastroesophageal Reflux Disease Pathophysiology and Treatment George Ferzli, M.D., FACS Professor of Surgery, SUNY Health ...
44% 13%
Clinical Presentation <ul><li>Adults </li></ul><ul><li>Heartburn </li></ul><ul><li>Regurgitation </li></ul><ul><li>Cough <...
Incidence of presenting symptoms experienced as a percent of all patients in study (n=198) Heartburn 80% Regurgitation 68%...
Definition It is increased exposure of the esophagus to gastric and / or duodenal secretions
Etiology
Protective Mechanisms
Medical Management <ul><li>Medical therapy is first line of management </li></ul><ul><li>Pro-motility agents like metoclop...
Goals of Treatment Eliminate symptoms Heal esophagitis Manage or prevent complications Maintain remission
Lifestyle Modifications   <ul><li>Avoid fatty foods, fried foods, peppermint,  </li></ul><ul><li>chocolate, alcohol, coffe...
Medical Management <ul><li>Esophagitis will heal in 90% of cases </li></ul><ul><li>Doesn’t address etiology of GERD </li><...
Lifestyle modification non-compliance Antacids poor long-term control Prokinetic agents no esophageal healing H2 Blockers ...
Risk Factors That Predict A Poor Response To Medical Therapy <ul><li>Nocturnal reflux on 24-hr esophageal pH  study </li><...
What is the next step???
Indications for Antireflux Surgery <ul><li>Intractable persistent reflux symptoms despite aggressive medical management </...
Goals Of Surgical Management <ul><li>Restore LES pressure and length </li></ul><ul><li>Establish abdominal position of LES...
Surgery vs. Medical Therapy Study Design <ul><li>Prospective non-randomized study </li></ul><ul><li>41 patients had antire...
Surgery vs. Medical Therapy   Results <ul><li>Controls regurgitation </li></ul><ul><li>Improves esophageal peristalsis </l...
Work-up <ul><li>1) Barium swallow </li></ul><ul><ul><li>Not diagnostic </li></ul></ul><ul><ul><li>Presence and size of hia...
Laparoscopic Paraesophageal Hernia Repair
Paraesophageal Hernia Repair Symptomatic Outcomes Hashemi et al, J Am Coll Surg 2000;190:553-561
Paraesophageal Hernia Repair Technique and Recurrence <ul><li>Mesh vs. No Mesh </li></ul><ul><li>Prospective randomized tr...
Paraesophageal Hernia Repair Summary <ul><li>Symptomatic outcomes: Similar in both groups. Excellent or good in 76% patien...
Work-up <ul><li>2) EGD </li></ul><ul><ul><li>Presence of esophagitis </li></ul></ul><ul><ul><li>Presence and the type of h...
Laparoscopic Nissen For Barrett’s
Long-Term Outcome of Antireflux Surgery in Patients With Barrett's Esophagus <ul><li>At 5-years median follow-up: </li></u...
Long-Term Outcome of Antireflux Surgery in Patients With Barrett's Esophagus <ul><li>44% regression of low-grade dysplasia...
Dysplasia and Adenocarcinoma After Classic Antireflux Surgery in Patients With Barrett's Esophagus <ul><li>161 patients ha...
Results Csendes A et.al. Annals of Surgery,235(2),p.178-185,Feb.2002 - 86% 5.3 + 1.6%  30.9 + 19% % time with bilirubin 10...
Conclusions <ul><li>Patients with failed antireflux surgery are a high-risk group for development of dysplasia and carcino...
Barrett’s Esophagus Can and Does Regress after Antireflux Surgery <ul><li>91 patients with symptomatic Barrett’s esophagus...
Work-up <ul><li>3) Manometry </li></ul><ul><ul><li>Not diagnostic </li></ul></ul><ul><ul><li>Esophageal body motility </li...
 
Normal LES Parameters <ul><li>Basal resting pressure of <37 mmHg </li></ul><ul><li>Single peak 40-180 mmHg </li></ul><ul><...
Work-up <ul><li>4) 24 h pH </li></ul><ul><ul><li>Perform on all patients without erosive esophagitis (grade I and II)  </l...
 
DeMeester Score <ul><li>Based on six variables: </li></ul><ul><li>a) percent total time pH<4 </li></ul><ul><li>b) percent ...
Workup <ul><li>5) Radionuclide gastric emptying study </li></ul><ul><ul><li>when symptoms of delay gastric emptying, diabe...
Surgical Management - Approaches <ul><li>A) Surgical approaches include (Open or Laparoscopic) </li></ul><ul><li>1) Total ...
Proper diagnostic workup is essential.  It may alter the algorithm of management
Paradigm Shift in the Management of Gastroesophageal Reflux Disease <ul><li>75 patients underwent laparoscopic fundoplicat...
Proper preoperative workup will help manage recurrent postoperative symptoms
Symptoms are a poor indicator of reflux status after fundoplication for GERD: the role of esophageal function tests <ul><l...
Take home message :  In order to achieve good postoperative results, there must be a thorough  preoperative workup
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Gastroesophageal Reflux Disease Pathophysiology and Treatment

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  • 44 percent of the adult american population have symptoms of gastroesophageal reflux disease (GERD), and 13 percent of them take some form of medication weekly for this condition.
  • First line of therapy is lifestyle modification. This includes diet modification, weight loss, smoking cessation, change in sleeping habits, but unfortunately these are not adhered to consistently.
  • Medical therapy is the first line of management of GERD. Esophagitis will heal in ~90% of cases with intensive medical therapy. However, medical management does not address the condition’s mechanical etiology, thus symptoms recur in more than 80% of cases within one year of drug withdrawals. In addition, while medical therapy may effectively treat the acid-induced symptoms of GERD, esophageal mucosal injury may continue due to ongoing ALKALINE REFLUX.
  • Antacids, while the cheapest and most accessible form of medical management, provide long-term symptomatic relief in only 20% of the patients, a rate only slightly better than that observed with placebo treatments. Prokinetic agents, while a logical approach to treating a defect in esophagogastric motility, provide symptomatic relief in a variable percentage of patients, but have not been shown to be effective in healing esophagitis. Until recently, H2 blockers were the mainstay of medical management of GERD. Multiple controlled trials have evaluated the alleviation of symptoms, both short-term and long-term, as well as rates of endoscopically proven healing. Short term symptomatic relief occurs in ~61% of patients and resolution of esophagitis occurs in approximately 45% of patients. In addition, symptomatic improvement does not regularly correlate with endoscopic healing. Also, long-term H2 blocker therapy is associated with a symptomatic recurrence rate of 50% which does not differ significantly from placebo therapy. Proton pump inhibitors have consistently shown superior rates of symptomatic relief when compared to H2 blockers. More importantly, since symptomatic relief does not always correlate with healing of esophagitis, studies have shown superior rates of endoscopically proven healing with omeprazole. Long-term use of proton-pump inhibitors is questionable in terms of safetly and efficacy. PPI therapy induces hypergastrinemia which has been demonstrated to induce carcinoid tumors in a species of rats. Although this has not been demonstrated in humans. Also, studies have demonstrated a rapid rate of relapse when PPI doses are reduced.
  • As above, Symtoms thought to be indicative of GERD such as heartburn or acid regurgitation are very common in the general population and cannot be used alone to guide therapeutic decisions, particularly when considering antireflux surgery. A common error is to define the presence of GERD by the endoscopic finding of esophagitis. Limiting the diagnosis to patients with endoscopic esophagitis ignores a large population of patients without mucosal injury who may have severe symptoms of gastroesophageal reflux and could be candidates for antireflux surgery.
  • Gastroesophageal Reflux Disease Pathophysiology and Treatment

    1. 1. Gastroesophageal Reflux Disease Pathophysiology and Treatment George Ferzli, M.D., FACS Professor of Surgery, SUNY Health Science Center at Brooklyn Department of Laparoscopic Surgery, Staten Island University Hospital
    2. 2. 44% 13%
    3. 3. Clinical Presentation <ul><li>Adults </li></ul><ul><li>Heartburn </li></ul><ul><li>Regurgitation </li></ul><ul><li>Cough </li></ul><ul><li>Wheezing </li></ul><ul><li>Hoarseness </li></ul><ul><li>Chest pain </li></ul><ul><li>Children </li></ul><ul><li>Vomiting (heartburn, cough, and stridor) </li></ul><ul><li>Aspiration (recurrent bronchopneumonia) </li></ul><ul><li>Infants </li></ul><ul><li>Vomiting (causes failure to thrive, and repeated otitis) </li></ul><ul><li>Esophagitis (causes irritability, anemia, and stricture) </li></ul><ul><li>Aspiration (causes bronchopneumonia, asthma, anemic spells, and possibly sudden death. </li></ul>
    4. 4. Incidence of presenting symptoms experienced as a percent of all patients in study (n=198) Heartburn 80% Regurgitation 68% Dysphagia 38% Resp. symptoms 27% Chest pain 10% Abdominal pain 10% Nausea or vomiting 7% Belching 6% Bleeding 5% Hinder, RA, et al: Laparoscopic Nissen Fundoplication is an effective treatment for GERD. Annals of Surgery 220, No. 4
    5. 5. Definition It is increased exposure of the esophagus to gastric and / or duodenal secretions
    6. 6. Etiology
    7. 7. Protective Mechanisms
    8. 8. Medical Management <ul><li>Medical therapy is first line of management </li></ul><ul><li>Pro-motility agents like metoclopramide to enhance esophageal clearance of acid </li></ul><ul><li>Gastric pH enhancing drugs like antacids, antihistamines and proton pump inhibitors </li></ul>
    9. 9. Goals of Treatment Eliminate symptoms Heal esophagitis Manage or prevent complications Maintain remission
    10. 10. Lifestyle Modifications <ul><li>Avoid fatty foods, fried foods, peppermint, </li></ul><ul><li>chocolate, alcohol, coffee, citrus fruit, tomato </li></ul><ul><li>products </li></ul><ul><li>Lose weight if overweight </li></ul><ul><li>Stop smoking </li></ul><ul><li>Elevate head of bed 6 inches </li></ul>
    11. 11. Medical Management <ul><li>Esophagitis will heal in 90% of cases </li></ul><ul><li>Doesn’t address etiology of GERD </li></ul><ul><li>80% recur within one year of stopping therapy </li></ul><ul><li>Alkaline injury may continue to occur </li></ul>
    12. 12. Lifestyle modification non-compliance Antacids poor long-term control Prokinetic agents no esophageal healing H2 Blockers short-term good results long-term 50% recur Proton pump inhibitors good healing, ?safety rapid relapse Pitfalls of Medical Management
    13. 13. Risk Factors That Predict A Poor Response To Medical Therapy <ul><li>Nocturnal reflux on 24-hr esophageal pH study </li></ul><ul><li>2. Structurally deficient lower esophageal sphincter </li></ul><ul><li>3. Mixed reflux of gastric and duodenal juice </li></ul><ul><li>4. Mucosal injury on presentation </li></ul>
    14. 14. What is the next step???
    15. 15. Indications for Antireflux Surgery <ul><li>Intractable persistent reflux symptoms despite aggressive medical management </li></ul><ul><li>Reflux-induced respiratory symptoms after control of acid reflux </li></ul><ul><li>Recurring severe reflux symptoms, or reflux injury (peptic stricture, esophageal ulceration, bleeding) despite adequate medical therapy </li></ul><ul><li>Barrett’s esophageal metaplasia </li></ul><ul><li>Lifestyle choice (avoid long-term use of medicines) </li></ul>
    16. 16. Goals Of Surgical Management <ul><li>Restore LES pressure and length </li></ul><ul><li>Establish abdominal position of LES (approx. 2cm) </li></ul><ul><li>Preserve ability to belch and vomit </li></ul><ul><li>Avoid vagal nerve injury </li></ul><ul><li>Correct associated diaphragmatic herniation </li></ul>
    17. 17. Surgery vs. Medical Therapy Study Design <ul><li>Prospective non-randomized study </li></ul><ul><li>41 patients had antireflux surgery (12 Nissen and 29 Toupet) after failure of medical therapy and 18 had only medical therapy </li></ul><ul><li>Dysphagia was assessed prior to therapy and 6 months after therapy </li></ul>Wetscher GJ, Hinder RA, et.al. Am J Surg;177, Mar 1999
    18. 18. Surgery vs. Medical Therapy Results <ul><li>Controls regurgitation </li></ul><ul><li>Improves esophageal peristalsis </li></ul><ul><li>Restores the LES function </li></ul><ul><li>Freedom from reflux-induced dysphagia (92.7% vs. 11.9%, p<0.05) </li></ul><ul><li>Prevents non-acid reflux </li></ul><ul><li>Treats hiatal hernias </li></ul>Wetscher GJ, Hinder RA, et.al. Am J Surg;177, Mar 1999
    19. 19. Work-up <ul><li>1) Barium swallow </li></ul><ul><ul><li>Not diagnostic </li></ul></ul><ul><ul><li>Presence and size of hiatal hernia </li></ul></ul><ul><ul><li>Presence of stricture </li></ul></ul><ul><ul><li>Length of esophagus </li></ul></ul>
    20. 20. Laparoscopic Paraesophageal Hernia Repair
    21. 21. Paraesophageal Hernia Repair Symptomatic Outcomes Hashemi et al, J Am Coll Surg 2000;190:553-561
    22. 22. Paraesophageal Hernia Repair Technique and Recurrence <ul><li>Mesh vs. No Mesh </li></ul><ul><li>Prospective randomized trial </li></ul><ul><li>Hiatal defect >8cm diameter </li></ul><ul><li>Excision of sac, primary closure of crura, Nissen fundoplication in all cases </li></ul><ul><li>Randomized intra-op to mesh vs. no mesh </li></ul><ul><li>Follow-up for 6 months </li></ul>Frantzides CT et al, Surg Endosc (1999) 13: 906-908 16% 0%
    23. 23. Paraesophageal Hernia Repair Summary <ul><li>Symptomatic outcomes: Similar in both groups. Excellent or good in 76% patients after laparoscopic and 88% after open repair </li></ul><ul><li>Hernia recurrence: Significantly higher in laparoscopic group (42%, 9 of 21) compared to open group (15%, 3 of 20) </li></ul><ul><li>Use of mesh reduces paraesophageal hernia recurrence significantly </li></ul>
    24. 24. Work-up <ul><li>2) EGD </li></ul><ul><ul><li>Presence of esophagitis </li></ul></ul><ul><ul><li>Presence and the type of hiatal hernia </li></ul></ul><ul><ul><li>Esophageal length </li></ul></ul><ul><ul><li>Presence of Barrett’s, dysplasia or cancer </li></ul></ul><ul><ul><li>Presence of stricture </li></ul></ul>
    25. 25. Laparoscopic Nissen For Barrett’s
    26. 26. Long-Term Outcome of Antireflux Surgery in Patients With Barrett's Esophagus <ul><li>At 5-years median follow-up: </li></ul><ul><li>Reflux symptoms absent in 79% </li></ul><ul><li>Recurrent symptoms in 20%. Most common in patients undergoing Collis-Belsey (33%) </li></ul><ul><li>24-hour pH monitoring results normal in 81% </li></ul><ul><li>77% patients considered themselves cured, 22% considered themselves improved, and 97% were satisfied </li></ul>Hofstetter WL et.al. Annals of Surgery, 234(4), Oct.2001
    27. 27. Long-Term Outcome of Antireflux Surgery in Patients With Barrett's Esophagus <ul><li>44% regression of low-grade dysplasia to nondysplastic Barrett’s </li></ul><ul><li>14% regression of intestinal metaplasia to cardiac mucosa </li></ul><ul><li>Low-grade dysplasia developed in 6% patients </li></ul><ul><li>No patient developed high-grade dysplasia or cancer in median 5-year follow-up </li></ul>Hofstetter WL et.al. Annals of Surgery, 234(4), Oct.2001
    28. 28. Dysplasia and Adenocarcinoma After Classic Antireflux Surgery in Patients With Barrett's Esophagus <ul><li>161 patients had antireflux surgery between 1978 and 1992. Prospective follow-up ended Dec.1999 </li></ul><ul><li>17 (10.5%) who developed dysplasia and 4 (2.5%) who developed adenocarcinoma were compared to 126 patients with long-segment Barrett’s in whom dysplasia did not develop </li></ul><ul><li>Patients were evaluated with clinical questionnaire, multiple EGD and biopsy, and 24-hour pH and bilirubin monitoring </li></ul>Csendes A et.al. Annals of Surgery,235(2),p.178-185,Feb.2002
    29. 29. Results Csendes A et.al. Annals of Surgery,235(2),p.178-185,Feb.2002 - 86% 5.3 + 1.6% 30.9 + 19% % time with bilirubin 100% 93% 12.5% 96% Pathologic acid reflux 100% 70% 21% 61% Incompetent LES 65 77 65 68 Length of Barrett’s (mm) 100% 82% 0% 95% Symptoms Adenoca. (n=4) Dysplasia (n=17) Visick Visick I-II (n=52) III-IV (n=74)
    30. 30. Conclusions <ul><li>Patients with failed antireflux surgery are a high-risk group for development of dysplasia and carcinoma </li></ul><ul><li>Metaplastic changes from fundic to cardiac mucosa and then intestinal metaplasia, dysplasia and adenocarcinoma can clearly be documented </li></ul><ul><li>Patients with Barrett’s who undergo antireflux surgery require long-term subjective and objective follow-up </li></ul>Csendes A et.al. Annals of Surgery,235(2),p.178-185,Feb.2002
    31. 31. Barrett’s Esophagus Can and Does Regress after Antireflux Surgery <ul><li>91 patients with symptomatic Barrett’s esophagus: 77 treated with surgery and 14 with proton pump inhibitors </li></ul><ul><li>28 of 77 (36.4%) after surgery had histologic regression of Barrett’s </li></ul><ul><li>1 of 14 patients (7.1%) had regression with medical therapy </li></ul><ul><li>Patients with Barrett’s less than 3 cm. had greater likelihood of regression </li></ul><ul><li>Gurski R, Peters J, Hagen J, et al Journal of the Amer Coll Surg 2003 196 (5): 706-713 </li></ul>
    32. 32. Work-up <ul><li>3) Manometry </li></ul><ul><ul><li>Not diagnostic </li></ul></ul><ul><ul><li>Esophageal body motility </li></ul></ul><ul><ul><li>LES function </li></ul></ul><ul><ul><li>LES position </li></ul></ul>
    33. 34. Normal LES Parameters <ul><li>Basal resting pressure of <37 mmHg </li></ul><ul><li>Single peak 40-180 mmHg </li></ul><ul><li>Duration of 2-5 seconds </li></ul><ul><li>Velocity of 3-4 cm./sec. </li></ul>
    34. 35. Work-up <ul><li>4) 24 h pH </li></ul><ul><ul><li>Perform on all patients without erosive esophagitis (grade I and II) </li></ul></ul><ul><ul><li>Remains the gold standard </li></ul></ul><ul><ul><li>Stop proton pump inhibitor 2 weeks before </li></ul></ul><ul><ul><li>Presence of abnormal reflux </li></ul></ul><ul><ul><li>Correlate between symptoms and reflux </li></ul></ul>
    35. 37. DeMeester Score <ul><li>Based on six variables: </li></ul><ul><li>a) percent total time pH<4 </li></ul><ul><li>b) percent upright time pH<4 </li></ul><ul><li>c) percent supine time pH<4 </li></ul><ul><li>d) number of episodes pH<4 lasting >5 min. </li></ul><ul><li>e) longest episode pH<4 (min.) </li></ul><ul><li>f) total number episodes pH<4 </li></ul><ul><li>Normal score <14.7 </li></ul>
    36. 38. Workup <ul><li>5) Radionuclide gastric emptying study </li></ul><ul><ul><li>when symptoms of delay gastric emptying, diabetes, peptic ulcer disease </li></ul></ul><ul><ul><li>when severe reflux on the 24h pH with normal LES on the manometry </li></ul></ul><ul><li>Simultaneous 24-hour pH and intraesophageal impedance may be useful in evaluating the role of non-acid reflux in symptoms that persist despite adequate acid suppression </li></ul>
    37. 39. Surgical Management - Approaches <ul><li>A) Surgical approaches include (Open or Laparoscopic) </li></ul><ul><li>1) Total fundoplication (Nissen procedure) </li></ul><ul><li>2) Partial fundoplication (Belsey, Toupet, or Dor procedure) </li></ul><ul><li>B) Endoluminal techniques such as the Stretta procedure </li></ul>
    38. 40. Proper diagnostic workup is essential. It may alter the algorithm of management
    39. 41. Paradigm Shift in the Management of Gastroesophageal Reflux Disease <ul><li>75 patients underwent laparoscopic fundoplication and 65 patients underwent the Stretta procedure </li></ul><ul><li>Only patients who did not have a hiatal hernia larger than 2 cm., LES pressure less than 8 mmHg, or Barrett’s esophagus were offered the Stretta procedure </li></ul><ul><li>They concluded that the patients in both groups had comparable improvement in GERD symptoms and quality of life even though the more severe symptomatic patients underwent surgery </li></ul><ul><li>Richards W, Houston H, Torquati A et al Ann Surg 2003; 237(5): 638-649 </li></ul>
    40. 42. Proper preoperative workup will help manage recurrent postoperative symptoms
    41. 43. Symptoms are a poor indicator of reflux status after fundoplication for GERD: the role of esophageal function tests <ul><li>124 patients who developed GERD symptoms after laparoscopic fundoplication underwent esophageal manometry and pH monitoring </li></ul><ul><li>76 (61%) patients had normal esophageal acid exposure </li></ul><ul><li>Symptoms, except for regurgitation, are an unreliable index of the presence of reflux </li></ul><ul><li>Galvani C, Fisichella P, Gorodner M, et al. Arch Surg 2003; 138: 514-519 </li></ul>
    42. 44. Take home message : In order to achieve good postoperative results, there must be a thorough preoperative workup

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