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Gerdblu Presentation Transcript

  • 1. Gastroesophageal Reflux DiseaseAm e rican C olle ge of S u rge ons Am e rican C olle ge of S u rge o ns
  • 2. Definition of Gastroesophageal Reflux DiseaseSymptoms and/or esophagealinjury due to the abnormal refluxof gastric content into theesophagus Am e rican C olle ge of S u rge o ns
  • 3. GERD Is a Common Disease Heartburn in North American adults t 7% daily, 14% weekly, 36% monthlye 3% have severe disease (525,000 in US)i Worldwide occurrence e Minnesota: 73% weekly symptoms e Finland: 66% monthly symptoms t Sweden: 25% frequent heartburn Am e rican C olle ge of S u rge o ns
  • 4. Changing Trends in Foregut Disease 350 300 1970-74 250 1990-95Proportional rate / 100,000 200hospitalizations 150 100 50 0 Peptic Ulcer GERD El-Serag HB. Gut 1998; 43:327 Am e rican C olle ge of S u rge o ns
  • 5. Esophageal Findings in Self Medicated Subjects Symptoms Only 51.0%N=168 Barretts 7.0% Esophagitis Grade II-IV 42.0% Robinson et al. Gastroenterol 1996; 110:A241 Am e rican C olle ge of S u rge o ns
  • 6. Natural History of Reflux Esophagitis N=701 Recurrent Non-Progressive 31.0%Isolated Episode 46.0% Recurrent Progressive 23.0%Ollyo JB et al. Gullett 1993; 3 Am e rican C olle ge of S u rge o ns
  • 7. Symptoms in GERDHeartburn Regurgitation 9 44 6 64 14 7 8 Dysphagia Am e rican C olle ge of S u rge o ns
  • 8. GERD: Atypical Symptoms y Chest pain y Hoarseness y Cough y Asthma y Recurrent Pneumonia Am e rican C olle ge of S u rge o ns
  • 9. 24 Hour pH Findings in Patients With Atypical Symptoms of GERD Symptom Prevalence of + 24hr pH testAngio neg chest pain 48%Chronic hoarseness 75%Asthma 80% Am e rican C olle ge of S u rge o ns
  • 10. Prevalence of GERD in Asthmatics Without Reflux Symptomsy Asthma defined by American Thoracic Society criteriay 22 Asthmatics, non-smokers, no reflux symptomso Esophageal pH & manometry compared to 30 age matched asthmatics with reflux symptoms & + 24 Hr pHc 16/22 (73%) + 24 Hr pH – similar to asthmatics with reflux symptoms Harding et al. 1997 Gastroenterol A; 1997 Am e rican C olle ge of S u rge o ns
  • 11. Features of Reflux Induced Asthma s Late (adult) onset e Non-smoker e Non-allergic e Cough present e Worse with meals e Poor response to asthma meds Am e rican C olle ge of S u rge o ns
  • 12. Symptoms Suggesting Gastric Motility Abnormalities Epigastric Pain Nausea Anorexia Weight Loss Early satiety Am e rican C olle ge of S u rge o ns
  • 13. Symptom Based Diagnosis of GERD a Sensitivity 61.4% 1 Specificity 58.6% Am e rican C olle ge of S u rge o ns
  • 14. Complications of GERD Esophagitis Stricture Barrett’s Recurrent Pneumonia/Pulmonary Fibrosisn Adenocarcinoma Am e rican C olle ge of S u rge o ns
  • 15. Risk Factors for Barrett’s Esophagus g Age of onset of GERD GDuration of symptoms t Presence of complications l Structurally defective sphincter e Gastroduodenal refluxEisen et al: Am J Gastroenterol 92:27, 1997Stein et al: J Thorac Cardiovasc Surg 105:107; 1993Fein et al. J Gastrointest Surg 1:27, 1997 Am e rican C olle ge of S u rge o ns
  • 16. Risk of Adenocarcinoma in Barrett’s Esophagus a 0.5-1% per year a 5-10% lifetime Am e rican C olle ge of S u rge o ns
  • 17. Factors Important in theGastroesophageal Barrier Hiatal hernia Competence of lower esophageal sphincterw Gastric distention Am e rican C olle ge of S u rge o ns
  • 18. Hiatal Hernia Diaphragm Am e rican C olle ge of S u rge o ns
  • 19. Sphincter Competence & the Probability of RefluxSphincter Abnormality % + 24 hr pHPressure (<6) 73%Abdominal length (<1cm) 69%Total Length (<2cm) 76%All three 92% Am e rican C olle ge of S u rge o ns
  • 20. Role of the Lower Esophageal Sphincter &Hiatal Hernia in the Pathogenesis of GERD 100esophageal acid exposure Prevalence of increased p> 0.01 80 p > 0.01 60 40 20 0 no HH HH no HH HH* normal LES normal LES defective LES defective LES Fein M et al. J Gastrointest Surg 1999; 3:405-410 Am e rican C olle ge of S u rge o ns
  • 21. Helicobacter Pylori: Friend of the Esophagus?• Protects against reflux• Makes PPI therapy more effective• Protects against Barrett’s• Protects against adenocarcinoma Am e rican C olle ge of S u rge o ns
  • 22. Preoperative Evaluationl Video barium esophagramp Upper endoscopyp 24 hr pHp Esophageal motility studies Am e rican C olle ge of S u rge o ns
  • 23. Importance of Pre-op Studies to Surgical Approach to GERDh Prove the diagnosiss Understand the reasons for refluxe Assess esophageal body functionl Stratify severity of diseasey Exclude subclinical gastric pathology Am e rican C olle ge of S u rge o ns
  • 24. The Role of Radiology in GERDo Exclude other pathologyt Assess esophageal functionl Determine structural abnormalities u Hernia, strictures, ringse Detect mucosal abnormalities b Esophagitis, Barrett’sr Detect associated abnormalitiesd Aid surgical decision making i Short esophagus, poor motility Assess results of therapy Am e rican C olle ge of S u rge o ns
  • 25. Importance of Upper Endoscopyp Understand the magnitude of the problema Discover the unsuspectedu Assessment of esophageal length and hernia sizeo Plan the operationo Educate the patient Am e rican C olle ge of S u rge o ns
  • 26. Indications for 24 Hr Ph Monitoring 1. To verify GERD in patients with typical symptoms 2. To assess acid exposure in patients with atypical symptoms 3. To evaluate the effect of medical or surgical treatment Am e rican C olle ge of S u rge o ns
  • 27. Important Considerations in pH Monitoring1. Stop antisecretory medications 7-14 days2. Accurate placement of probe n 5 cm above LES (requires manometry, not EGD)3. Dietary restrictions4. Particularly valuable in patients with: u Poor response to medical Rx Atypical symptoms Am e rican C olle ge of S u rge o ns
  • 28. DeMEESTER SCORE Time pH < 4.0 (1) Total (2) Upright (3) Supine (4) Number of times pH < 4.0m(5) Number of reflux episodes > 5minf (6) Duration of longest reflux episode Am e rican C olle ge of S u rge o ns
  • 29. Patterns of Reflux • Physiologic reflux • Upright reflux • Supine reflux • Combined reflux • Postprandial reflux Am e rican C olle ge of S u rge o ns
  • 30. Reflujo Fisioló gico Am e rican C olle ge of S u rge o ns
  • 31. Upright Reflux Pattern Am e rican C olle ge of S u rge o ns
  • 32. Bi-positional Reflux Pattern Am e rican C olle ge of S u rge o ns
  • 33. Mucosal Injury & Esophageal Bilirubin Exposure Group % Incr. % Incr. Acid Bilirubin Exposure ExposureNo mucosal injury 35% 30%Esophagitis 80% 61%Short segment Barrett’s 93% 73%Long segment Barrett’s 96% 84% Am e rican C olle ge of S u rge o ns
  • 34. Esophageal Manometrye Not a diagnostic tool Necessary for placement of pH probea Provides insight into severity of disease: LES competence Esophageal body function Am e rican C olle ge of S u rge o ns
  • 35. ABDOMINAL THOR.mmHg RIP 30 20 10 Esophageal baseline Gastric baseline cm 47 46 45 44 43 42 Am e rican C olle ge of S u rge o ns
  • 36. Prevalence of Defective LES in GERDPrevalence of Defective LES 100 90 80 70 60 50 40 30 20 10 0 Controls GERD No Esophagitis Stricture Barretts Injury Am e rican C olle ge of S u rge o ns
  • 37. Am e rican C olle ge of S u rge o ns
  • 38. Manometric Indicators of Esophageal Body FailureF Contraction amplitudes < 20mm Hg (lower third of esophagus)e Non-peristatic waves > 40% Am e rican C olle ge of S u rge o ns
  • 39. GERD Treatment Goals*o Eliminate symptomsmHeal mucosal injuryu Prevent complications *Maintain for life of the patient Am e rican C olle ge of S u rge o ns
  • 40. Treatment Perspectives inGastroesophageal Reflux Disease GERD is a huge medical and public health probleme There is no effective medical management that alters the natural history of the diseasea Antireflux surgery offers the potential for “cure” given: r Proper technique r Careful patient selection Am e rican C olle ge of S u rge o ns
  • 41. Changes in Lifestyle for Patients with GERDRElevate head of bedb Eliminate bedtime mealse Eat low fat foodss Stop smokings Reduce alcohol consumptiono Avoid tight clothing Am e rican C olle ge of S u rge o ns
  • 42. Principles of Medical Therapy1. Rate of healing influenced by degree of esophagitis2. Rate of healing influenced by dose of Rx3. Dose required to maintain remission is at least the dose required to heal esophagitis Am e rican C olle ge of S u rge o ns
  • 43. Proton Pump Inhibitor Therapy1. Heals GERD Sxs & Signs in 80-90%2. GERD returns when drug is stopped3. Concerns about long term use4. Cost $3-$6/day, $100-200/mo Am e rican C olle ge of S u rge o ns
  • 44. Elimination of Symptoms Does Not Ensure Reflux Controln 5 patients w/ Barrett’s studiedr Patients taking 20-60mg of omeprazole/day2 24 hr pH monitoring on therapyi 4 of 5 asymptomatic patients had abnormal refluxt Concluded: Symptom control inadequate guide to therapy Katzka DA. Am J Gastoenterol 1994; 89:989-991 Am e rican C olle ge of S u rge o ns
  • 45. Indications for Antireflux OperationA Need for continuous drug treatmento Escalating doses of PPI Particularly if: Young age (<50) Financial burden Non-compliance with meds i Patient choice for surgery Castel DO. Practical Gastroenterol 1998; 22:18-46 Am e rican C olle ge of S u rge o ns
  • 46. Considerations Prior to Antireflux Operation 1. Poor esophageal motility 2. Short esophagus 3. Gastric motility abnormalities Am e rican C olle ge of S u rge o ns
  • 47. Spectrum of GERD Mild SevereNormal length Short esophagusNormal contractility Poor contractilityNo scarring StrictureIntermittent/relapsin Progressiveg Am e rican C olle ge of S u rge o ns
  • 48. Characteristics of AdvancedGastroesophageal Reflux Disease Large Hiatal Hernia (>5cm), Short Esophagusn Stricture with persistent dysphagiae Poor esophageal body motility Am e rican C olle ge of S u rge o ns
  • 49. Univariate Analysis of Clinical Features Predicting Short Esophagus Clinical Feature p-valueHiatal hernia >5cm <0.001Stricture <0.001Barrett’s >3cm <0.05Manometric length <5th percentile <0.05Fixed hernia radiographically <0.001 Gastal O. Arch Surg 1999; 134:633-666 Am e rican C olle ge of S u rge o ns
  • 50. Predictors of Success Following Laparoscopic Fundoplication Predictor Odds Ratio* Wald’s p (95% CI) ValuePositive pH score 8.2 (2.7-25) <0.001Typical symptom 6.9 (2.4-19.6) <0.001Good response to medical Rx 4.5 (1.6-12.3) <0.004* Odds of success compared to not present Campos GMR. J Gastrointest Surg 1999; 3:292-300 Am e rican C olle ge of S u rge o ns
  • 51. The best surgical candidate is amedical success! Am e rican C olle ge of S u rge o ns
  • 52. Outcome of Laparoscopic Fundoplication is Not Dependent on Defective LES Symptom Score: Symptom Score: Defective LES Normal LES2.5Mean symptom score 2.5 Mean symptom score 2 Preoperative 2 Preoperative Postoperative Postoperative1.5 1.5 1 10.5 0.5 0 * * * 0 * * * Heartburn Heartburn Regurgitation Regurgitation Dysphagia Dysphagia Ritter MP. J Gastrointest Surg 1998; 2:567-572 Am e rican C olle ge of S u rge o ns
  • 53. Benefits Of Surgical Therapy 1. Restores competency of cardia 2. Prevents reflux 3. Improves esophageal body motility 4. Repairs hiatal hernia 5. Speeds gastric emptying Am e rican C olle ge of S u rge o ns
  • 54. Technique of Laparoscopic Fundoplication1. Hiatal dissection2. Esophageal mobilization3. Fundic mobilization; short gastric division4. Crural Closure5. Creation of fundoplication6. Closure Am e rican C olle ge of S u rge o ns
  • 55. Alternative port for liver retraction Camera Liver Stomach Retraction Retraction Am e rican C olle ge of S u rge o ns
  • 56. Am e rican C olle ge of S u rge o ns
  • 57. Common Complaints AfterLaparoscopic Fundoplication1. Temporary dysphagia2. Early satiety3. Increased flatulence Am e rican C olle ge of S u rge o ns
  • 58. Complications of Laparoscopic Fundoplication N=2,453 Complication Number Percent (%)Pneumothorax 49 2Bleeding 28 1.1Perforation 25 1Splenectomy 2 0.1Total 104 4.2 Pedikis & Hinder. Surg Lap & Endosc 7:17-21; 1997 Am e rican C olle ge of S u rge o ns
  • 59. Complications of Laparoscopic Fundoplication N=2,453 Parameter Number Percent (%)Mortality 4 0.2Conversion 143 5.8Early Dysphagia 500 20Late Dysphagia 114 5.5Re-op for Dysphagia 18 0.9 Pedikis & Hinder. Surg Lap & Endosc 7:17-21; 1997 Am e rican C olle ge of S u rge o ns
  • 60. Patients Assessment of Open and Laparoscopic Fundoplication Parameter Open+ Laparoscopic* N=100 N=100Relief of Primary Symptom 97% 91%Unrestricted diet 93% 98%Satisfied with results 90% 87%Requires medication 3% 4%+DeMeester TR. Ann Surg 1986*Peters JH et al. Ann Surg 1998;228:40-50 Am e rican C olle ge of S u rge o ns
  • 61. Symptomatic Outcome After Laparoscopic Fundoplication Author Year Typical Atypical Symptoms SymptomsHunter 1996 97% 86%So 1998 93% 56%Allen 1998 93% 83%Campos 1999 92% 67% Am e rican C olle ge of S u rge o ns
  • 62. Current Status of Laparoscopic Fundoplicationd Over 5,000 patient outcomes reportedn Success rate; 94%%Morbidity 2%%Mortality < 1/1000 patients0 Rated a safe, effective and established therapy for GERD by AMA-DATTA Am e rican C olle ge of S u rge o ns
  • 63. Healing of Esophagitis After Laparoscopic Fundoplication N=100Erosive esophagitis pre-op 46Returned for follow-up endoscopy 30Esophagitis resolved 28 (93%)Persistent esophagitis 2**one studied and was 24hr pH + Peters JH et al. Ann Surg 1998;228:40-50. Am e rican C olle ge of S u rge o ns
  • 64. 24 Hour pH Studies after Laparoscopic Fundoplication Author # patients Follow-up pH Negative (months)Hinder 21/24 (87%) 3-12Hunter 49/54 (91%) 12Watson 42/48 (87%) 3Peters 26/28 (93%) 21 Am e rican C olle ge of S u rge o ns
  • 65. Lower Esophageal Sphincter Pressure Returns to Normal After Laparoscopic Fundoplication 16 14 12 N=26 10Pressure(mm Hg) 8 6 4 2 0 NORMAL PRE-OP POST-OP Peters JH et al. Ann Surg 1998;228:40-50. Am e rican C olle ge of S u rge o ns
  • 66. Laparoscopic Fundoplication is Cost Effective Sex/Age Lap Omeprazole (Years) fundoplication* 20 mg/dayF 20-24 $5,627 $20,402F 65-69 $5,239 $12,758M 20-24 $5,627 $19,898M 65-69 $5,239 $10,584*Surgery costs including pre-op eval Lifelong medical therapy Viljakka M. Scand J Gastroenterol 1997; 32:7666-772 Am e rican C olle ge of S u rge o ns
  • 67. Most Common Causes of Failure of Laparoscopic FundoplicationReason Prevalence N=31 (%)Re-herniation 18 (56%)Paraesophageal hernia 5 (16%)Poor wrap construction 2 (6%)Other 6 (10%)Horgan S & Pellagrini C. Arch Surg 1999 Am e rican C olle ge of S u rge o ns
  • 68. Laparoscopic Toupet is an Inadequate Procedure for Severe GERDv 48 patients with objective f/u studied at 6mos, 3yrs, 6yrs6 Mean f/u 22 months (18-37)h 46% failed (22/48 with +24hr pH post-op)8 77% of failures were symptomatic, 64% on PPIwPredictors of failure: i LESP < 5mm Hg, 24hr pH score >50 4 Distal esophageal aperistalsis l Grade III esophagitis, stricture or Barrett’sHorvath KD. J Gastrointest Surg 1999; 3:583-591 Am e rican C olle ge of S u rge o ns