The role of surgery in the modern management of dyspepsia

1. The role of surgery in the modern management of dyspepsia • Mr Paras Jethwa Bsc MD FRCS • Surrey & Sussex NHS Trust • and Spire Gatwick Hospital

3. GORD • Very significant modern disease • High prevalence and incidence • Substantial drug budget • Variable prescribing rationale (everyone in hospital) • Correlation with obesity, diet, alcohol, coffee etc....

4. Mechanics of reflux

5. Treatment Options • Lifestyle (smoking.red wine, obesity) • PRN Antacids • PRN PPI • Regular PPI (?BD ?Nexium) • OGD (or sooner if red flag) • Addition of antacid for breakthrough (Gaviscon Advanced) • Addition of ranitidine for nocturnal symptoms • ? Surgery - refer for pH/manometry

6. What about the guidelines? • significant number were mis-referred • (i.e should have been urgent) • 2% incidence of OG cancer • 98% sensitive

7. Barrett’s

8. Intestinal Metaplasia • Both endoscopic and histological diagnosis • Caused principally by uncontrolled acid reflux • Confers an increased risk of oesophageal cancer of 30-120x • Rapidly rising incidence • Oesophageal Cancer 5th commonest cause of cancer mortality in the UK

9. Current treatment • Treatment dose of a PPI • Consider NSAIDs/ Aspirin • Surveillance • Duration • Interval • Aneuploidy/tetraploidy • Anti reflux surgery • Oesophagectomy for HGD or Cancer

10. Surveillance limitations • Surveillance probably doesn't work • Time consuming, inaccurate, distressing for patients, expensive • Lack of an easily identifiable high risk group?

11. Current risk markers • High Grade Dysplasia: • Patchy and easily missed • On average HGD occupies only • 1.3cm2/ 32cm2 of Barrett’s • Variable Future Cancer risk: • 13-59% develop Cancer within 5 years • 40% of cancer patients not found to have prior HGD • Aneuploidy: • If no HGD or aneuploidy tiny risk (approaching 0%) of developing cancer in next 5 yrs (87% of patients) • If aneuploidy risk of 38% • If aneuploidy and HGD risk is 66% • Panel of biomarkers: • Ultimately this will be the answer • Still in research setting

13. Long term effects of GORD PEPTIC STRICTURE

14. Anti reflux procedures • UK lags behind Australia and South Africa • Determined by healthcare funding(?) • Poorly accepted by some gastroenterologists • Perception of a high risk/limited procedure • May be underused in high risk groups and in younger patients • Can offer a significant improvement in QoL

15. Surgical correction R CRUS OESOPHAGUS L CRUS

16. Effect of operation

18. Who should you consider referring? • Clear indication: • Poorly controlled symptoms • Hiatus hernia causing dysphagia +/- reflux • Young patients with IM/marked oesophagitis • Intolerant of conventional therapy • Mass reflux • Respiratory compromise • Probably not for: • Reasonable control with occasional flare-ups

19. Cost of therapy

20. Is it cost effective? • (1) The REFLUX Trial(first reported in BMJ 2009) • “The effectiveness and cost-effectiveness of minimal access surgery amongst people with gastro-oesophageal reflux disease - a UK collaborative study”. • Mean cost of Surgery: £2000 - £4000 • But - need to add cost of testing (OGD/pH/manometry) & loss of work etc. • Significant QOL improvement at 12 months+ (SF36) • (2) Systemic review 2011 Surg endoscopy Thijssen et al. • Four publications were suitable, Jan 1990 to 2010 • Surgery more expensive in n=3; • Better QALY in n-=2, fewer symptoms n=1 • C.E. - inconclusive - slight improvement in QALY

21. (3) Fundoplication vs medical management in adults for GORD - Cochrane review 2010 • Four trials elligible n=1232 • Significant improved QOL in surgical group • % of patients have post op dysphagia • Surgery risk uncommon but not without it’s risk • Cost greater - based on 1st year of treatment only. • Need to consider the long term effect of GORD • Summary • Improved QOL/QALY • but ££ at one year

22. Surgical considerations • BMI <35 (men store fat at GOJ) woman up to 40 • (Similar area to LAGB placement) • Reasonable health/respiratory compromise • No major motility issues (HRM/Ba swallow) • Hiatus hernia/OGD proven reflux without pH studies • Psychological onlay/effect of dietary change • Physiological studies

23. pH Studies • Only method of objectively proving reflux • In cases of odd symptoms/symptom correlation • Pre/Post operative comparison • Medico legal aspects • Bravo or conventional systems

24. Results of surgery • Three types of wrap commonly performed: • 180< 270 < 360 • Progressively better but increase risk of dysphagia & gas bloating • Tension free wrap with good crural closure • >85% report major improvement at 5 years • pH retesting - no one with abnormal profile • Not uncommon to return to some medication

25. Complications & SE • Dysphagia - acute revision • Gas bloating • GI dysmotility (non vagal) • Recurrent symptoms • Injury (GOJ/vagus/spleen/other)

26. Advanced technique - presented in Europe and UK • Largest series of mesh reinforced hiatal closures • Common practice at ESH/Spire

27. Advances • Improved training & simulation • Emphasis on dedicated laparoscopic service • Improvement in HD systems/integrated theatre • Anaesthesia and pain control • Improved instrumentation • Enhanced recovery protocols • 3D laparoscopy/robots/NOTES/SILS

28. SASH4 dedicated Laparoscopic specialists - laparoscopic surgery has become a speciality in itself.Very latest laparoscopic facilities and optics.SASH recognised as a high quality training centre amongst KSS traineesLinks to Imperial College

29. The role of surgery in the modern management of dyspepsia • Mr Paras Jethwa Bsc MD FRCS • Surrey & Sussex NHS Trust • and Spire Gatwick Hospital