The role of surgery in the modern management of

dyspepsia

Mr Paras Jethwa Bsc MD FRCSSurrey & Sussex NHS Trustand Spire Gatwick Hospital

GORDVery significant modern diseaseHigh prevalence and incidenceSubstantial drug budgetVariable prescribing rationale (everyone in hospital)Correlation with obesity, diet, alcohol, coffee etc....

Mechanics of reflux

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

➡What about the guidelines?

➡significant number were mis-referred

➡(i.e should have been urgent)

➡2% incidence of OG cancer

➡98% sensitive

Barrett’s

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

Current treatment• Treatment dose of a PPI• Consider NSAIDs/ Aspirin

• Surveillance• Duration• Interval• Aneuploidy/tetraploidy

• Anti reflux surgery• Oesophagectomy for HGD or Cancer

Surveillance limitations

• Surveillance probably doesn't work

• Time consuming, inaccurate, distressing for patients, expensive

• Lack of an easily identifiable high risk group?

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

Long term effects of GORD

PEPTIC STRICTURE

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

Surgical correction

OESOPHAGUS

R CRUS

L CRUS

Effect of operation

Who should you consider referring?

Clear indication:Poorly controlled symptomsHiatus hernia causing dysphagia +/- refluxYoung patients with IM/marked oesophagitisIntolerant of conventional therapyMass reflux Respiratory compromise

Probably not for:Reasonable control with occasional flare-ups

Cost of therapy Drug Dose Cost (£, 28

days) Annual(£)Omeprazole 20mg 28.56 571.2Lansoprazol

e 30mg £23.75 712.5Pantoprazol

e 40mg £23.65 946Rabeprazole 20mg £22.75 455Esomeprazo

le 20mg £18.50 370Esomeprazo

le 40mg £28.56 1142.4

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

• (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

Surgical considerationsBMI <35 (men store fat at GOJ) woman up to 40

(Similar area to LAGB placement)Reasonable health/respiratory compromiseNo major motility issues (HRM/Ba swallow)Hiatus hernia/OGD proven reflux without pH studiesPsychological onlay/effect of dietary changePhysiological studies

pH StudiesOnly method of objectively proving refluxIn cases of odd symptoms/symptom correlationPre/Post operative comparisonMedico legal aspectsBravo or conventional systems

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

Complications & SE• Dysphagia - acute revision

• Gas bloating

• GI dysmotility (non vagal)

• Recurrent symptoms

• Injury (GOJ/vagus/spleen/other)

Advanced technique - presented in Europe and UKLargest series of mesh reinforced hiatal closuresCommon practice at ESH/Spire

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

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 trainees

Links to Imperial College

The role of surgery in the modern management of

dyspepsia

Mr Paras Jethwa Bsc MD FRCSSurrey & Sussex NHS Trustand Spire Gatwick Hospital