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Joint Hospital Surgical Grand Round Surgical Management of GERD

Joint Hospital Surgical Grand Round Surgical Management of GERD. Department of Surgery The Prince of Wales Hospital YF Yeung. GERD. Exposed to the risk of physical complications from gastroesophageal reflux

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Joint Hospital Surgical Grand Round Surgical Management of GERD

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  1. Joint Hospital Surgical Grand RoundSurgical Management of GERD Department of Surgery The Prince of Wales Hospital YF Yeung

  2. GERD • Exposed to the risk of physical complications from gastroesophageal reflux • Experience clinically significant impairment of health-related well-being as a result of reflux-related symptoms Genval conference 1999

  3. Epidemiology Hong Kong, APT 2003 Beijing & Shanghai, Chi J Dig Dis 2000 Hong Kong, APT 2002 Houston, US, Gastro 2004 Dent et al GUT 2005

  4. Treatment Options • Antacids • H2-receptor antagonists • Sucralfate • Prokinetics • Proton pump inhibitors Medical Surgical

  5. Types of Fundoplication • Complete • Nissen 360o • Partial • Posterior • Toupet 270o • Lind 300o • Anterior • Belsey Mark IV • Dor hemifundoplication Toupet fundoplication

  6. Physiological mechanisms • LES pressure enhanced with the wrap of fundus • After meal, gastric distension (1) • pressure transmitted from stomach to fundus (2) • Fundal pressure pressed on the esophagus (3)

  7. Effect of Fundoplication

  8. Surgery or Medication? • Lundell et al. European Journal of Gastroenterology and Hepatology 2000 • Long-term management of gastro-oesophageal reflux disease with omeprazole or open antireflex surgery: results of a prospective, randomized clinical trial

  9. Surgery or Medication? • 298 patients included • Omeprazole (20mg daily) group: 154 patients • Open Antireflux surgery group: 144 patients • 3-year follow-up • Outcome measures • Symptoms • 24-h pH monitoring • Endoscopy • QoL assessment

  10. Surgery or Medication? • Results • No significant difference in symptoms relapse, oesophagitis and QoL if dose of omeprazole adjusted to 40mg or 60mg accordingly

  11. Surgery or Medication? • Conclusion • Omeprazole is as effective as antireflux surgery in controlling GERD

  12. Indications of surgery • Patients do not accept long term medical therapy • Patients who do not respond or only partially respond to medical therapy • Antireflux surgery considered as equivalent alternative SSAT guidelines

  13. Open Vs Laparoscopic

  14. Open Vs Laparoscopic

  15. Open Vs Laparoscopic

  16. Open Vs Laparoscopic • Conclusion • Perioperative recovery of laparoscopic fundoplication is better than that of open fundoplication • Short-term FU show no differences concerning recurrence, dysphagia and bloating

  17. Division Vs No Division of SGV

  18. Division Vs No Division of SGV

  19. Division Vs No Division of SGV • Conclusion • No significant differences regarding morbidity, dysphagia and recurrence • Shorter operation time for the non-division group

  20. Complete or Partial

  21. Complete Vs Partial

  22. PWH experience • 2001 to 2006 • 28 cases – antireflux surgery • 19 Laparoscopic Nissen Fundoplication • 9 Lap Toupet Fundoplication

  23. Summary • Long term outcome of surgery versus medical treatment to GERD is equivalent • Laparoscopic surgery is a better approach • ?Complete or partial fundoplication Further evaluation is required

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