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The Non-Medical Treatments of the Gastroesophageal Reflux Disease (GERD)

The Non-Medical Treatments of the Gastroesophageal Reflux Disease (GERD). Joint Hospital Grand Round 25.1.2014 Prepared by Siu Yin Yu, Eva North District Hospital. Definition.

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The Non-Medical Treatments of the Gastroesophageal Reflux Disease (GERD)

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  1. The Non-Medical Treatments of the Gastroesophageal Reflux Disease (GERD) Joint Hospital Grand Round 25.1.2014 Prepared by Siu Yin Yu, Eva North District Hospital

  2. Definition • AGA: There can be no criterion standard definition of GERD because the threshold distinction between physiologic reflux and reflux disease is ultimately arbitrary • Montreal consensus 1 • Reflux of stomach contents • Troublesome symptoms and/or • Complications Am J Gastroenterol 2006;101:1900-20

  3. Background • Prevalence: • 10-20% in Western world, even up to 42%2 • 2.5-6.7% in east/east-southern Asia3 • Symptoms : Esophageal Vs Extraesophageal • Investigations: • OGD • 24Hr pH monitoring • Manometry • Mutichannel Intraluminal Impedence study 2. Gut 2005;54:710-7 3. Clin Gastroenterol Hepatol. 2006 Apr;4(4):398-407.

  4. Treatment • Life style modification • Acid-suppressive drugs • Antireflux Surgery • Endoscopic Therapy Non-Medical Treatment

  5. Questions… • When do we consider antireflux surgery? • Which approach? Open? Laparoscopic ? Robotic-assisted? • Total Vs Partial? • Does short gastric vessel division improve the outcomes? • Recent development of endoscopic therapy ? Effectivenss ? Safety?

  6. Questions… • When do we consider antireflux surgery? • Which approach? Open Vs Laparoscopic Vs Robotic-assisted • Total Vs Partial? • Does short gastric vessel division improve the outcomes? • Recent development of endoscopic therapy ? Effectiveness ? Safety?

  7. Antireflux Surgery • Indications • Patients with esophageal symptoms intolerant of PPIs • For atypical symptoms, no conclusive evidence to support

  8. Questions… • When do we consider antireflux surgery? • Which approach? Open Vs Laparoscopic Vs Robotic-assisted • Total Vs Partial? • Does short gastric vessel division improve the outcomes? • Recent development of endoscopic therapy ? Effectiveness ? Safety?

  9. Antireflux Surgery • Variety of fundoplications • Approaches • Open • Laparoscopic • Robotic-assisted • The newer • The better?

  10. Open Vs Laparoscopic • A meta-analysis, the American Journal of Gastroenterology 2009 6 • 12 RCTs, 503 Vs 533 pt (Open Vs Lap) • Results: Favors Laparoscopic approach significantly • Shorter hospital stay (2.68 days) • Faster return to work (7.75 days) • Lower Cx rate (relative odds reduction in 65%) But… • Comparable Tx failure rate though further surgery rate higher in the Lap group (odd ratio 1.79) • Longer operating time in Lap group (39 mins ) 6. Am J Gastroenterol. 2009;104(6):1548.

  11. Laparoscopic Vs Robotic-assisted • RCT Italy, 50 patients, Nissen, Da Vinci system7 • Results • Comparable outcomes/ conversion rate/ Cx rate • But in Robotic group… • Significantly longer operating time • Higher cost 7. J Am Coll Surg. 2012;215(1):61.

  12. Laparoscopic Vs Robotic-assisted • Meta-analysis 2010, 11 trials (3 RCTs) • Slightly lower post-operative Cx rate in robotic group • Longer operation time and higher costs 8. Surg Endosc (2010) 24:1803–1814

  13. Approach • Laparoscopic fundoplication > Open • Robotic-assisted fundoplication was found to achieve comparable outcome and might be a slightly lower post-operative Cx rate compared to the laparoscopic approach • BUT…The Significant higher cost and longer operative time of the robotic-assisted fundoplication make it LESS cost-effective than laparoscopic approach

  14. Questions… • When do we consider antireflux surgery? • Which approach? Open Vs Laparoscopic Vs Robotic-assisted • Total Vs Partial? • Does short gastric vessel division improve the outcomes? • Recent development of endoscopic therapy ? Effectiveness ? Safety?

  15. Total Vs Partial Fundoplication • Variety of fundoplications • Total Vs Partial • Nissen (total posterior 360) • Toupet (Posterior 270) • Dor (Anterior 180-200) • Belsey (anterior 270)

  16. Total Vs Partial Fundoplication • Laparoscopic Nissen fundoplication is a popular anti-reflux surgery • Successful rate ~ 90% • Recommended by the European Study Group for Antireflux Surgery in 1997 • But… • Dysphagia (8-12% ), may require dilation • Gas-related symptoms (19%) • Especially in those with a pre-operative esophageal dysmotility • Laparoscopic Toupet procedure (posterior 270 deg) as an alternative • Less common x ? Less satisfactory reflux control

  17. Total Vs Partial Fundoplication • A systematic review and meta-analysis, British Journal of Surgery 20109 • Laparoscopic Nissen Vs Toupet • 7 RCTs from 1997-2000, at least 12 months FU (up to 60months) • Results: • NO sig difference in effectiveness and recurrence (eg. post operative esophagitis, abnormal acid exposure durations or subjective recurrence/ satisfaction ) • Significantly HIGHER prevalence of dysphagia (requiring dilatation / surgical intervention) and gas-related symptoms (inability to belch/ gas bloating) in the laparoscopic Nissen group 9. British Journal of Surgery 2010; 97: 1318–1330

  18. Dysphagia • Post op dilatation and reoperation is also higher in the Nissen group RR : 2.45 and 2.19 British Journal of Surgery 2010; 97: 1318–1330

  19. Lap Posterior Vs Anterior Fundoplication • ? Laparoscopic anterior fundoplication has an even lower dyphagia rate • Higher recurrence of reflux？ • A meta-analysis and systematic review, Annuals of Surgery 10 2011 • 7 RCTs, 1999-2010 • Laparoscopic posterior Vs anterior 10. Ann Surg 2011;254:39–47

  20. Lap Posterior Vs Anterior Fundoplication Result: Lap Posterior> Lap Anterior • Long-term dysphagia scores, inability to belch, gas bloating and satisfaction showed NO significant different Ann Surg 2011;254:39–47

  21. Total Vs Partial Fundoplication • Laparoscopic Toupet > Nissen • Comparable effectiveness and recurrence • But Laparoscopic Nissen was associated with more dyphagia that required intervention (dilatation/ reoperation) and gas-related symptoms • Laparoscopic posterior fundoplication > anterior • Better heartburn/ acid exposure/ reoperation rate in Lap posterior fundoplication • The short-term benefit of lower dysphagia rate in the Lap anterior fundoplication group disappeared in long term FU (after 12m)

  22. Questions… • When do we consider antireflux surgery? • Which approach? Open Vs Laparoscopic Vs Robotic-assisted • Total Vs Partial? • Does short gastric vessel division improve the outcomes? • Recent development of endoscopic therapy ? Effectiveness ? Safety?

  23. Short Gastric Vessel Division • Complication of fundoplication: dysphagia/ gas-related symptoms • Modification of surgery -> Short Gastric Vessel Division (SGVD) in laparoscopic Nissen fundoplication 11. Surg Endosc (2012) 26:970–978

  24. Short Gastric Vessel Division • A meta-analysis, Surgical Endoscopy 201211 • 5 RCTs, 194 Vs 194 (SGVD Vs No-SGVD) • 3 trials FU 1 yr, 2 trials FU 10 yrs • Results: • No-SGVD > SGVD • No significant difference in dysphagia/gas-related syms/ effectiveness / conversion rate in both 1yr & 10yrs FU • No-SGVD has a significant SHORTER operative time and length of stay 11. Surg Endosc (2012) 26:970–978

  25. Questions… • When do we consider antireflux surgery? • Which approach? Open Vs Laparoscopic Vs Robotic-assisted • Total Vs Partial? • Does short gastric vessel division improve the outcomes? • Recent development of endoscopic therapy ? Effectiveness ? Safety?

  26. Endoscopic Therapy • Principles: • To improve the LOS length and pressure • To remodel the smooth muscles of the GEJ

  27. Endoscopic Therapy • Endoscopic Radiofrequency (Stretta procedure) • Reduce the postprandial LOS relaxation and GEJ compliance? ? • Fibrosis ?

  28. Stretta Procedure • Several RCTs with Sham-controlled/ cohorts showed ~ 55 to 83 % of patients • Satisfactory symptom control or • Cessation of PPI • Acid exposure/ LES pressure • Durable - Average follow-up of 12 to 33 months (even up to 48m) • Safe, minimal invasive & lower cost • But… • Patients selection • Not enough evidence to be comparable with laparoscopic fundoplication

  29. Endoscopic Therapy Endoscopic sewing and full-thickness plication

  30. Endoscopic Sewing • Sham study : symptoms improvement in short-term (3m in EndoCinch 6-9m in plication), but lacking durability • No change in esophageal pH monitoring • Complications: • Perforation • Pharyngitis/ chest pain

  31. Endoscopic Therapy • Transoral Incisionless Fundoplication (TIF), EsophyX • Full-thickness plication to produce a neogastroesophageal valve

  32. TIF • Objective measurement: • Decrease in esophageal acid exposure • Increase in LOS pressure • Subjective measurements: • > 50% improvement in QOLs and Heartburn scores in 68% and 75% of patients respectively 12 • But… • More perforation • Lacking RCTs • Lacking long-term evidence • Not much information in the learning curve of the method World J Surg (2008) 32:1676–1688

  33. Conclusion • Laparoscopic fundoplication is more preferable than open and robotic-assisted approach • Laparoscopic Toupet fundoplication has more potential benefits than Nissen • Laparoscopic posterior fundoplication is more effective than anterior fundoplication • SGVD is not suggested to be performed as a routine procedure • Novel endoscopic therapy might be of some benefits but lacking evidence ground

  34. Thank you!

  35. References Am J Gastroenterol 2006;101:1900-20 Gut 2005;54:710-7 Clin Gastroenterol Hepatol. 2006 Apr;4(4):398-407. Gastroenterology 2010;138:896-904 Am J Gastroenterol. 2009;104(3):752 Am J Gastroenterol. 2009;104(6):1548. J Am Coll Surg. 2012;215(1):61. Surg Endosc (2010) 24:1803–1814 British Journal of Surgery 2010; 97: 1318–1330 Ann Surg 2011;254:39–47 Surg Endosc (2012) 26:970–978 World J Surg (2008) 32:1676–1688

  36. Pathophysiology Failed clearance of acid reflux Hiatus hernia • Short length of LOS • Low basal tone • Transient LOS relaxation • Sling fibre of cardia Diaphragmatic crura • IGP: obesity, delayed gastric emptying

  37. Diagnosis • History • Any hx of typical syms of GERD relieved with PPI is suspicious • Investigations • OGD

  38. Esophagitis Los Angeles (LA) Classification Grade B Grade A Grade C Grade D

  39. 24Hr pH monitoring

  40. Manometry • Standard • High Resolution

  41. Multichannel Intraluminal Impedance • Resistance of current • Bolus of food decreases the impedance • Direction and velocity of food bolus • With pH monitor / manometry

  42. Treatment • PPIs > H2R blockers • PPI once-daily dose ? Twice-daily dose? • Symptoms relief and esophagitis healing • SEs of Esomeprazole 1yr: • Headache (10% ) Abd pain & diarrhoea (9%) Nausea (6%) • Failure of PPI • Inadequate response of heartburn on 2x daily PPI

  43. Predictors of post op outcomes • Factors predictive of dysphagia after laparoscopic Nissen fundoplication. • ~ 150 patients, prospective cohorts • Analyse pre op dysphagia/ DeMeester score/ manometry for LOS pressure and length etc • Only the presence of pre operative dysphagia increases the risk of post-operative dysphagia • Surg Endosc. 1999;13(12):1180. • Dis Esophagus. 2009;22(8):656-63. • Does combined multichannel intraluminal esophageal impedance and manometry predict postoperative dysphagia after laparoscopic Nissen fundoplication? • Even with the development of pre op MII with manometry, result doesn’t showed sig predictor of post op dysphagia except pre op dysphagia

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