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Treatment of Gastroesophgeal Reflux

Treatment of Gastroesophgeal Reflux. Joint Hospital Surgical Grand Round Hui Wei Han. Patho-physiology Anti-reflux surgery Endoscopic therapies for reflux. Introduction. Gastric contents reflux into esophagus USA - 40% population once per month; 7% daily

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Treatment of Gastroesophgeal Reflux

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  1. Treatment of Gastroesophgeal Reflux Joint Hospital Surgical Grand Round Hui Wei Han

  2. Patho-physiology • Anti-reflux surgery • Endoscopic therapies for reflux

  3. Introduction • Gastric contents reflux into esophagus • USA - 40% population once per month; 7% daily • HK (Study by HKU 2003): ~10% population

  4. Typical Heartburn Regurgitation Waterbrash Dysphagia Extra-esophageal Dental erosions Laryngitis Hoarseness Chronic cough Symptoms

  5. Anti-reflux barrier at OGJ • Sling & clasp fibres of gastric cardia • Diaphragmatic crura • Intra-abdominal esophageal compression • Lower esophageal sphincter (LES)

  6. Intra-abdominal esophageal compression • Height of insertion of phreno-esophageal ligament determines length of esophagus within abdomen • Length of sphincter exposed to intra-abdominal pressure important for prevention of reflux • DeMeester el al. found low basal LES pressure (<5mmHg) +/- short intra-abdominal sphincter length (<1cm) resulted in 90% abnormal reflux

  7. Pathophysiology of GERD • LES pressure abnormalities • Transient lower esophageal sphincter relaxations • Hiatus hernia • Poor esophageal clearance • Delayed gastric emptying • Impaired mucosal defensive factors

  8. LES Pressure Abnormalities • LES resting pressure influenced by: Respiration Gastric activity Body position Circadian variations Food and Smoking • Decreased LES resting pressure associated with increased GERD

  9. Transient LES Relaxations • Postprandial and sleep studies identified reflux episodes due to TLERS • 48-73% of reflux episodes in GERD patients • Visceral reflexes through vagus pathway • Gastric distension - major inducing factor • Influenced by food (fat, chocolate), smoking & alcohol

  10. Hiatus Hernia • Ambulatory esophageal pH monitoring showed increased freq. of reflux and prolonged esophageal acid exposure in patients with hiatus hernia • 94% incidence in patient with reflux esophagitis • Permissive role - promoting LES dysfunction • Cameron AJ 1999 found that hiatus hernia size is the strongest predictor of esophagitis severity

  11. Medical Proton pump inhibitor H2 blocker Prokinetic agents Surgical Anti-reflux surgery Endoscopic therapies Treatment of GERD

  12. Selection Criteria for Surgery • Objective evidence of reflux • Patients failed response to medical treatment • Patients not wish to continue life-long medications (symptoms fully controlled with PPI)

  13. Medical vs Surgical Therapy • Several RCTs • Some before era of PPI and laparoscopic anti-reflux surgery

  14. Surgery similar or even superior results to medical treatment • Better endoscopic outcome in cases of Barrett’s esophagus

  15. Anti-reflux surgery • Fundoplication complete partial anterior vs posterior • Hill procedure • Collis procedure • Angelchik prosthesis

  16. Mechanisms of action • Creation of a floppy valve (close apposition between abd. esophagus & gastric fundus) • Exaggeration of flap valve at angle of His • Increase basal pressure of LES • Reduction in triggering of TLESR • Reduction in capacity of fundus, speeding gastric emptying • Prevention of effacement of LES

  17. Fundoplication • Nissen - 360° • Toupet - 270° posterior partial • Lind - 300° posterior partial • Belsey Mark IV - 240° anterior partial • Dor - anterior hemi-fundoplication

  18. Laparoscopic or Open • Non-randomized comparisons showed laparoscopic surgery: longer operation time reduced postop complications shorten length of hospital stay (by 3-7days) return full physical function quicker reduced overall hospital cost

  19. Laparoscopic anti-reflux surgery has short term advantages in terms of reduced morbidity and quicker recovery • Control of reflux and risks of side effects at late follow up (up to 11years) is similar

  20. Complete or Partial Fundoplication • Nissen - ? Over-competent OGJ causing dysphagia & gas-related symptoms • Partial fundoplication reduce risk of over-competence but ? less durable anti-reflux repair

  21. Nissen vs Posterior partial fundoplication

  22. Side effects less common following posterior partial fundoplication esp gas-related problems • Hypothesis of less dysphagia supported by 2 larger trials only

  23. Nissen vs Anterior Fundoplication

  24. Both satisfactory control of reflux • Less dysphagia and other side-effects (anterior) • Higher risks of recurrent reflux (anterior)

  25. Division of short gastric vessels? • Hunter 1996 & Dalemagne 1996 reported increased problems with postoperative dysphagia following Nissen fundoplication without division of short gastric vessels • 4 RCTs investigation this aspect of technique

  26. Belief that dividing short gastric vessels will improve outcome following Nissen fundoplication not supported • Dividing vessels increase complexity, produce poorer outcome in 2/4 trials • Increase incidence of gas-related symptoms

  27. Paraoesphageal hiatus hernia Hiatal stenosis (dysphagia) Pulmonary embolism Bilobed stomach Pneumothorax Pneumomediastinum Major vascular injury Perforation of upper GI tract Complications of laparoscpic anti-reflux surgery More common follow laparoscopic surgery Unique to laparoscopic surgery

  28. Summary from present evidences for fundoplication • Laparoscopic Nissen fundoplication associated with less complications and shorter convalescence than open method • Longer-term result of laparoscopic fundoplication as good as open surgery • Division of short gastric blood vessels not improve outcome in Nissen fundoplication • Incidence of recurrent reflux similar following posterior partial and Nissen fundoplication • Incidence of dysphagia and gas-related complications reduced following anterior partial fundoplication

  29. Endoscopic therapies for reflux • 2 approaches: narrow gastro-esophageal junction create a partial fundoplication

  30. RCT compared with sham endoscopy showed no differences at 6 months follow up Withdrawn due to catastrophic complications

  31. EndoCinch • Reflux improved in a minority of patient • 90% suture disappear in 12 months & 80% resumed PPI

  32. NDO Plicator

  33. Controlled trial showed reduction in esophageal acid exposure from 10% to 7% at 3 months • 50% plicator patient able to cease PPI compared to 25% of sham-treated patient • Inferior result to laparoscopic fundoplication

  34. EsophyX • Requires general anesthesia • Fashion 200-300º anterior partial fundoplication

  35. Cadiere et al Surg Endosc 2007 • 12 months outcome of 17 patients • 14 patients (82%) not using PPI • 7 patients (44%) normal pH study • Result inferior to laparoscpic anterior partial fundoplication

  36. Summary of endoscopic anti-reflux procedures • None of the initial approaches (suturing, injection or RF) achieve comparable outcome to fundoplication • Application limited to milder forms of reflux disease

  37. Thank you!

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