Gastro Esophageal Reflux Disease

1. Gastro Esophageal Reflux Disease: Medical versus surgical
management for gastro-oesophageal reflux disease (GORD)
in adults

2. Journal Scan
315 Apollo Medicine, Vol. 7, No. 4, December 2010
BACKGROUND
Gastro-oesophageal reflux disease (GORD) is a common
condition with up to 20% of patients from Westernised
countries experiencing heartburn, reflux or both
intermittently. It is unclear whether medical or surgical
(laparoscopic fundoplication) management is the most
clinically and cost-effective treatment for controlling
GORD.
OBJECTIVES
To compare the effects of medical management versus
laparoscopic fundoplication surgery on health-related and
GORD-specific quality of life (QOL) in adults with
GORD.
SEARCH STRATEGY
We searched CENTRAL(Issue 2, 2009), MEDLINE (1966
to May 2009) and EMBASE (1980 to May 2009). We
handsearched conference abstracts and reference lists
from published trials to identify further trials. We
contacted experts in the field for relevant unpublished
material.
SELECTION CRITERIA
All randomised or quasi-randomised controlled trials
comparing medical management with laparoscopic
fundoplication surgery.
DATACOLLECTIONANDANALYSIS
Two authors independently extracted data from articles
identified for inclusion and assessed the methodological
quality of eligible trials. Primary outcomes were: health-
related and GORD-specific QOL, heartburn, regurgitation
and dysphagia.
MAIN RESULTS
Four trials were included with a total of 1232 randomised
GASTRO ESOPHAGEAL REFLUX DISEASE
Medical versus surgical management for gastro-oesophageal reflux disease
(GORD)inadults
Wileman SM, McCann S, Grant AM, Krukowski ZH, Bruce J.
Health Services Research Unit, University of Aberdeen,
Foresterhill, Aberdeen, UK, AB25 2ZD. Cochrane Database Syst Rev. 2010 Mar 17;(3):CD003243.
Comment in: Ann Intern Med. 2010 Sep 21;153(6):JC3-10.
participants. Health-related QOL was reported by four
studies although data were combined using fixed-effect
models for two studies (Anvari 2006; REFLUX Trial
2008). There were statistically significant improvements
in health-related QOL at three months and one year after
surgery compared to medical therapy (mean difference
(MD) SF36 general health score -5.23, 95% CI -6.83 to -
3.62; I [2] = 0%). All four studies reported significant
improvements in GORD-specific QOL after surgery
compared to medical therapy although data were not
combined. There is evidence to suggest that symptoms of
heartburn, reflux and bloating are improved after surgery
compared to medical therapy, but a small proportion of
participants have persistent postoperative dysphagia.
Overall rates of postoperative complications were low but
surgery is not without risk and postoperative adverse
events occurred although they were uncommon. The
costs of surgery are considerably higher than the cost of
medical management although data are based on the first
year of treatment therefore the cost and side effects
associated with long-term treatment of chronic GORD
need to be considered.
Complete or Partial Fundoplication?
Cai W, Watson DI, Lally CJ, Devitt PG, Game PA,
Jamieson GG. Ten-year clinical outcome of a prospective
randomized clinical trial of laparoscopic Nissen versus
anterior 180 (degrees) partial fundoplication. Br. J.
Surg.95,1501-1505 (2008)
The choice of surgical technique to provide optimal
reflux control while minimizing side effects remains
controversial. Because fundoplication is associated with an
incidence of postoperative dysphagia, gas bloat and
increased flatulence, the relative merits of the Nissen
fundoplication procedure versus various partial
fundoplication variants have been debated for many years.
A recent meta-analysis of 11 randomized clinical trials
concluded that partial fundoplication is a safe and effective
alternative to total fundoplication, resulting in fewer

3. Apollo Medicine, Vol. 7, No. 4, December 2010 316
Journal Scan
reoperations and better functional outcomes.
Six prospective randomized trials of Nissen versus
posterior partial fundoplication have been reported. If one
combines the data from all of these trials, the outcomes
support the view that side effects are less common
following posterior partial fundoplication, particularly for
gas-related problems. Overall symptom improvement,
quality of life and patient satisfaction measures are at least
equivalent for the two procedures, and long-term
outcomes from the study reported by Sgromo, et al. did
not identify any significant differences between the two
procedures. In all of these studies, however, there was a
trend toward less dysphagia following posterior partial
fundoplication, although the hypothesis that dysphagia is
less of a problem following a posterior partial
fundoplication has been substantiated only by the two
largest trials.
Nonrandomized cohort studies evaluating outcomes
following laparoscopic antireflux surgery report similar
overall outcomes for Nissen versus anterior partial
fundoplications. However, these studies have suggested
that although anterior partial fundoplication is associated
with fewer side effects, this advantage might, to some
extent, be offset by a higher risk of recurrent reflux. This
issue has been examined in four randomized trials of
anterior partial versus Nissen fundoplication. Three of these
trials were conducted in our unit. In the first, we compared
Nissen fundoplication with an anterior 180° partial
fundoplication, and patients have now been followed-up
for 10 years. The outcomes from this trial demonstrated
less dysphagia and gas-related side effects from early to 5
years follow-up, although dysphagia outcomes were
similar at 10 years. The outcome for reflux control was
acceptable, and the overall satisfaction with surgery was
either equivalent to or better than Nissen fundoplication at
all follow-up intervals, with more than 90% of patients
highly satisfied with the outcome 10 years after surgery.
There was, however, a degree of tradeoff between reflux
control and side effects, with the overall balance somewhat
in favor of partial fundoplication. Results from the other
trials of anterior fundoplication support these outcomes,
and suggest that anterior partial fundoplication does
achieve satisfactory reflux control, a reduced incidence of
postfundoplication dysphagia and other side effects and a
good overall clinical outcome compared with Nissen
fundoplication.
Dr. Arun Prasad’s Conclusions & experience
1. There is evidence that laparoscopic fundoplication
surgery is more effective than medical management
for the treatment of GORD at least in the short to
medium term. Surgery does carry some risk and
whether the benefits of surgery are sustained in the
long term remains uncertain. Treatment decisions for
GORD should be based on patient and surgeon
preference.
2. Post operative dysphagia and gas bloating are
common symptoms that have troubled patients and
surgeons after a Nissen’s fundoplication in Indian
patients. We have done 23 Nissen’s fundoplication
and 8 partial fundoplications and have found results to
be similar to what is mentioned above. The patients of
partial fundoplications did not have the symptoms of
dysphagia and gas bloating. Some authors have
suggested that these patients may have a higher
incidence of recurrence so one has to balance
between the two with careful case selection.
RECTALCANCER – JOURNALSCAN
Diseases of the Colon & Rectum
January 2011 - Volume 54 - Issue 1 - pp 6-14
Laparoscopic vs Open Resection for Patients With
Rectal Cancer: Comparison of Perioperative Outcomes and
Long-Term Survival
Baik, Seung Hyuk M.D. [1,2]; Gincherman, Mikhail
M.D. [1]; Mutch, Matthew G. M.D. [1]; Birnbaum, Elisa
H. M.D. [1]; Fleshman, James W. M.D. [1]
PURPOSE
The aim of the study is to assess the safety and
oncologic feasibility of laparoscopic-assisted resection for
rectal cancer vs open rectal resection as a phase II pilot
study for a planned randomized control trial.
METHODS
A case-matched controlled prospective analysis of 54
patients who underwent laparoscopic-assisted resection
for stage I to III (no T4) rectal cancer within 12 cm of the
anal verge from 2002 to 2005 was performed. Patients
were matched with contemporary patients who underwent
open rectal cancer surgery (n = 108) in a 1 to 2 fashion.
The perioperative clinical outcomes, postoperative
pathology, and oncologic outcomes were compared
between the groups.
RESULTS
The demographic data did not differ significantly
between the groups. The laparoscopic group manifested
early return of bowel function (P = 0.003). The
complication rate was 22.2% in the laparoscopic group and
32.4% in the open group (P = 0.178). Local recurrence

4. Journal Scan
317 Apollo Medicine, Vol. 7, No. 4, December 2010
was similar (2.0% laparoscopic, 4.2% open, P = 0.417).
The 5-year overall and disease-free survival rate also were
similar (overall survival, 90.8% laparoscopic, 88.5% open,
P = 0.261; disease-free survival, 80.8% laparoscopic,
75.8% open. P = 0.390).
CONCLUSION
The laparoscopic-assisted resection for rectal cancer
was acceptable in terms of oncologic outcomes and
perioperative clinical outcomes. The present data are the
basis for a large-scale randomized trial for comparison of
laparoscopic and open rectal cancer surgeries
Am J Surg. 2008 Feb;195(2):233-8.
Results of laparoscopic anterior resection for rectal
adenocarcinoma: retrospective analysis of 157 cases.
Pugliese R, Di Lernia S, Sansonna F, Scandroglio
I, Maggioni D, Ferrari GC, Costanzi A, Magistro C, De
Carli S.
Surgery Department, Niguarda Hospital, Piazza
Ospedale Maggiore 3, 20162 Milano, Italy.
BACKGROUND
Laparoscopic excision of rectal tumors has gained
favor in the last decade and several issues have reported
encouraging results: still, the use of laparoscopy remains
open to debate. The aim of the current study is to assess the
reliability of laparoscopic anterior resection (LAR) for
rectal cancer analyzing short-term outcomes and long-term
survival.
METHODS
The charts of 157 patients were reviewed
retrospectively after anterior resection for rectal
adenocarcinoma performed by minimal access. Patients
undergoing emergency surgery were excluded. LAR was
excluded in presence of preoperative features at computed
tomography (CT) scan suggesting bulky tumors
unresectable by laparoscopy or in case of anesthesiologic
contraindications. Conversion rate and functional and
oncologic outcomes were analyzed. Data on long-term
results and survival were evaluated.
RESULTS
LAR was performed in 157 patients, and conversion to
laparotomy was required in 12 cases. Mean operation time
for nonconverted patients was 229 minutes (overall 238
minutes). Total mesorectal excision (TME) was performed
in tumors of the mid and low rectum and a temporary
ileostomy was performed in 56 patients. The mean length
of hospital stay (LOS) was 10.5 days. Morbidity of
anterior resection included 17 anastomotic leaks after
laparoscopic surgery (LS; 5 in the converted patients).
Conversion increased significantly the risk of leak (P <
0.005). Two leaks caused death. The mean number of
nodes collected was 12. The incidence of local relapse was
4%, and the rate of anastomotic recurrence was nil.
Survival probability with LS was 0.73 at 5 years. Patients
in stage III took advantage of adjuvant treatment and had a
better survival than patients in stage II (P = not significant
[NS]).
CONCLUSIONS
The outcomes of this study suggest that LAR for rectal
cancer is a reliable procedure. Oncologic requirements
were respected; parameters such as length of specimen,
distal margin, and number of nodes retrieved were quite
acceptable. Incidences of local recurrence and long-term
survival were comparable with those of other series.
Dr. Arun Prasad’s Conclusions & experience
1. Laparoscopic excision of rectal tumors has gained
favor in the last decade and several issues have
reported encouraging results: still, the use of
laparoscopy remains open to debate in most academic
meetings. Recent trials and reports show that the
incidences of local recurrence and long-term survival
were comparable with those of other series.
2. We have been doing laparoscopic surgery for rectal
tumors for over 10 years now with good results.
Dr Arun Prasad
Senior Consultant,
Department of General Sergery,
Indraprastha Apollo Hospitals,
Sarita Vihar, New Delhi 110076.

5. Apollohospitals:http://www.apollohospitals.com/
Twitter:https://twitter.com/HospitalsApollo
Youtube:http://www.youtube.com/apollohospitalsindia
Facebook:http://www.facebook.com/TheApolloHospitals
Slideshare:http://www.slideshare.net/Apollo_Hospitals
Linkedin:http://www.linkedin.com/company/apollo-hospitals
Blog:Blog:http://www.letstalkhealth.in/