Antireflux Antireflux SurgerySurgery

Parissa Tabrizian M.D.Parissa Tabrizian M.D.

Team IV 11/10/06Team IV 11/10/06

AnatomyAnatomy

Esophageal PhysiologyEsophageal Physiology

Lower Esophageal Lower Esophageal SphincterSphincter

Intrinsic distal esophageal muscles – tonically Intrinsic distal esophageal muscles – tonically contractedcontracted

Muscular Sling fibers of the gastric cardiaMuscular Sling fibers of the gastric cardia Diaphragmatic cruraDiaphragmatic crura Transmitted pressure of the abdominal cavityTransmitted pressure of the abdominal cavity

IntroductionIntroduction

Increased rate during the 90’s.Increased rate during the 90’s. 4.4 to 12 procedures per 100 000 4.4 to 12 procedures per 100 000

adultsadults Popularity of minimally invasive Popularity of minimally invasive

surgerysurgery 65% 65%

Historical AspectHistorical Aspect

Rudolf Nissen ( 1896-1981)Rudolf Nissen ( 1896-1981) Thoracic surgery- lobectomy and pneumonectomyThoracic surgery- lobectomy and pneumonectomy Professor of Surgery in Istanbul, Turkey 1933Professor of Surgery in Istanbul, Turkey 1933 Mid 1930s: began work that would lead to his 1Mid 1930s: began work that would lead to his 1stst performed performed

fundoplication in 1955fundoplication in 1955 1956 Swiss journal, 1956 Swiss journal, Schweizerische Medizinische WochenschriftSchweizerische Medizinische Wochenschrift Brooklyn Jewish Hospital and Maimonides Hospital 1941Brooklyn Jewish Hospital and Maimonides Hospital 1941 Chairman of Surgery at the University of Basel, Switzerland 1951Chairman of Surgery at the University of Basel, Switzerland 1951

Gastroesophageal reflux Gastroesophageal reflux diseasedisease

MC GI disorder of the western world. MC GI disorder of the western world.

44% adults in US have abnormal reflux of 44% adults in US have abnormal reflux of acidic gastric juices into the esophagus on a acidic gastric juices into the esophagus on a montly basis.montly basis.

10% of patients require daily acid 10% of patients require daily acid suppression medicationsuppression medication

Over 1.0 million out patients visit per yearOver 1.0 million out patients visit per year

GERDGERD

Pathophysiology:Pathophysiology:Defective lower esophageal sphincter (LES) functionDefective lower esophageal sphincter (LES) function

transient LES relaxations ( TLESRs)transient LES relaxations ( TLESRs)

hypotonic LES ** ( e.g. sleroderma)hypotonic LES ** ( e.g. sleroderma)

disruption of LES ** ( e.g. resection, balloon rupture)disruption of LES ** ( e.g. resection, balloon rupture)

Hiatal hernia ** ( mal alignment of LES and crural Hiatal hernia ** ( mal alignment of LES and crural diaphragm)diaphragm)

Poor esophageal clearance **Poor esophageal clearance **

Decreased salivary protectionDecreased salivary protection

decreased volume ( e.g. sicca syndrome)decreased volume ( e.g. sicca syndrome)

deficient production of epidermal growth factordeficient production of epidermal growth factor

Poor gastric emptyingPoor gastric emptying

Increased intra-abdominal pressure ( e.g. straining, Increased intra-abdominal pressure ( e.g. straining, obesity, pregnancy)obesity, pregnancy)

Duodenogastric reflux (bile)Duodenogastric reflux (bile)

** predisposes to severe GERD** predisposes to severe GERD

Hiatal HerniasHiatal Hernias

Clinical presentationClinical presentationPrevalence of Symptoms in 1000 Patients Evaluated for Prevalence of Symptoms in 1000 Patients Evaluated for

Gastroesophageal Reflux Disease *Gastroesophageal Reflux Disease *

Extraesophageal Manifestations Extraesophageal Manifestations of GERDof GERD

PulmonaryPulmonary

AsthmaAsthma

Aspiration pneumoniaAspiration pneumonia

Chronic bronchitisChronic bronchitis

Pulmonary fibrosisPulmonary fibrosis

OtherOther

Chest painChest pain

Dental erosionDental erosion

ENTENTHoarsenessHoarsenessLaryngitisLaryngitisPharyngitisPharyngitisChronic coughChronic coughGlobus sensationGlobus sensationSinusitisSinusitisSubglottic stenosisSubglottic stenosisLaryngeal cancerLaryngeal cancer

Diagnostic Tests for Diagnostic Tests for GERDGERD

Barium swallowBarium swallow

EndoscopyEndoscopy

Ambulatory pH Ambulatory pH monitoringmonitoring

Esophageal manometryEsophageal manometry

Barium SwallowBarium Swallow

Useful first diagnostic test for patients Useful first diagnostic test for patients with dysphagiawith dysphagia Stricture (location, length)Stricture (location, length) Mass (location, length)Mass (location, length) Bird’s beakBird’s beak Hiatal hernia (size, type)Hiatal hernia (size, type)

LimitationsLimitations Detailed mucosal exam for erosive Detailed mucosal exam for erosive

esophagitis, Barrett’s esophagusesophagitis, Barrett’s esophagus

EndoscopyEndoscopy

IndicationsIndications Alarm symptomsAlarm symptoms Empiric therapy failureEmpiric therapy failure Preoperative Preoperative

evaluationevaluation Detection of Barrett’s Detection of Barrett’s

esophagusesophagus

Ambulatory 24 hr. pH Ambulatory 24 hr. pH MonitoringMonitoring

Physiologic studyPhysiologic study

Quantify reflux in Quantify reflux in proximal/distal proximal/distal esophagusesophagus

--% time pH < 4--% time pH < 4

Prox esophagus: <1%Prox esophagus: <1%

Distal esophagus <4%Distal esophagus <4%

--DeMeester score --DeMeester score

( < 14.7 nl)( < 14.7 nl)

Symptom correlationSymptom correlation

Ambulatory 24 hr. pH MonitoringAmbulatory 24 hr. pH Monitoring

NormalNormal

GERDGERD

Wireless, Catheter-Free Esophageal pH Wireless, Catheter-Free Esophageal pH MonitoringMonitoring

• Improved patient comfort Improved patient comfort and acceptanceand acceptance

• Continued normal work, Continued normal work, activities and diet studyactivities and diet study

• Longer reporting periods Longer reporting periods possible (48 hours)possible (48 hours)

• Maintain constant probe Maintain constant probe position relative to SCJposition relative to SCJ

Potential AdvantagesPotential Advantages

Esophageal ManometryEsophageal Manometry

Assess LES pressure, Assess LES pressure, location and relaxationlocation and relaxation Assist placement of Assist placement of

24 hr. pH catheter24 hr. pH catheter Assess peristalsisAssess peristalsis

Prior to antireflux Prior to antireflux surgery surgery

Limited role in GERDLimited role in GERD

Treatment Goals for Treatment Goals for GERDGERD

Eliminate symptomsEliminate symptoms

Heal esophagitisHeal esophagitis

Manage or prevent complicationsManage or prevent complications

Maintain remissionMaintain remission

Lifestyle ModificationsLifestyle Modifications

Elevate head of bed 4-6 inches Elevate head of bed 4-6 inches Avoid eating within 2-3 hours of bedtimeAvoid eating within 2-3 hours of bedtime Lose weight if overweightLose weight if overweight Stop smokingStop smoking Modify dietModify diet

Eat more frequent but smaller mealsEat more frequent but smaller meals Avoid fatty/fried food, peppermint, Avoid fatty/fried food, peppermint,

chocolate, alcohol, carbonated chocolate, alcohol, carbonated beverages, coffee and teabeverages, coffee and tea

OTC medications prnOTC medications prn

Acid Suppression Therapy for Acid Suppression Therapy for GERDGERD

HH22-Receptor Antagonists-Receptor Antagonists

(H(H22RAs)RAs)

Cimetidine Cimetidine (Tagamet(Tagamet®®))

Ranitidine (ZantacRanitidine (Zantac®®))

Famotidine (PepcidFamotidine (Pepcid®®))

NizatidineNizatidine (Axid (Axid®®))

Proton Pump InhibitorsProton Pump Inhibitors (PPIs)(PPIs)

Omeprazole (PrilosecOmeprazole (Prilosec®®))Lansoprazole Lansoprazole (Prevacid(Prevacid®®))Rabeprazole (AciphexRabeprazole (Aciphex®®))Pantoprazole Pantoprazole (Protonix(Protonix®®))Esomeprazole (Nexium Esomeprazole (Nexium ®®) )

Effectiveness of Medical Therapies for Effectiveness of Medical Therapies for GERDGERD

Treatment ResponseResponse

Lifestyle modifications/antacidsLifestyle modifications/antacids 20 %20 %

HH22-receptor antagonists-receptor antagonists 50 %50 %

Single-dose PPI Single-dose PPI 80 %80 %

Increased-dose PPIIncreased-dose PPI up to 100 %up to 100 %

Complications of GERDComplications of GERD

Erosive/ulcerative esophagitisErosive/ulcerative esophagitis

Esophageal (peptic) strictureEsophageal (peptic) stricture

Barrett’s esophagusBarrett’s esophagus

AdenocarcinomaAdenocarcinoma

Indications for SurgeryIndications for Surgery

Intractable GERD – rareIntractable GERD – rare Difficult to manage stricturesDifficult to manage strictures Severe bleeding from esophagitis ( grade III-IV)Severe bleeding from esophagitis ( grade III-IV) Non-healing ulcers Non-healing ulcers

GERD requiring long-term PPI-BID in a healthy young GERD requiring long-term PPI-BID in a healthy young patient patient

LES < 10LES < 10 Large hiatal herniaLarge hiatal hernia Persistent regurgitation/aspiration symptomsPersistent regurgitation/aspiration symptoms Not Barrett’s esophagus aloneNot Barrett’s esophagus alone NoncomplianceNoncompliance Patient’s preference ( cost, life style…)Patient’s preference ( cost, life style…)

Mechanism of Antireflux Mechanism of Antireflux OperationsOperations

Creation of a floppy valve by maintaining close apposition Creation of a floppy valve by maintaining close apposition b/w the abdominal esophagus and the gastric fundusb/w the abdominal esophagus and the gastric fundus

Exaggeration of the flap valve at the angle of HisExaggeration of the flap valve at the angle of His

Increase in the basal pressure generated by the lower Increase in the basal pressure generated by the lower esophageal sphincteresophageal sphincter

Reduction in the triggering of TLES relaxationsReduction in the triggering of TLES relaxations

Reduction in the capacity of the gastric fundusReduction in the capacity of the gastric fundus speeding speeding prox. and a total gastric emptyingprox. and a total gastric emptying

Prevention of effacement of the lower esophagus Prevention of effacement of the lower esophagus

* Restrospective analysis* Restrospective analysis* Medical or surgical treatment for > 1 yr* Medical or surgical treatment for > 1 yr* 120 pts undergoing surgery* 120 pts undergoing surgery* 51 pts nonoperative mgt* 51 pts nonoperative mgt* QOL: surgery > medical* QOL: surgery > medical

Nissen FundoplicationNissen Fundoplication

Postoperative Postoperative ComplicationsComplications

* 171 patients, mean f/u 6.4 yrs* 171 patients, mean f/u 6.4 yrs* computerized log / questionnaire* computerized log / questionnaire

•Overall: 96.5 % satisfied vs 3.5 %Overall: 96.5 % satisfied vs 3.5 %

* Persistent Sx: abd bloating ( 20%), diarrhea ( 12%), * Persistent Sx: abd bloating ( 20%), diarrhea ( 12%), regurgitation ( 6.4%), heartburn ( 5.8%)regurgitation ( 6.4%), heartburn ( 5.8%)

27 % dysphagia27 % dysphagia 7% dilatation 7% dilatation

14% postop PPI ( 79% vague abd symptoms)14% postop PPI ( 79% vague abd symptoms)

* Excellent long term treatment* Excellent long term treatment

Complete vs. partial Complete vs. partial fundoplicationfundoplication

Ant. partial Ant. partial fundoplicationfundoplication

Thal/Dor procedureThal/Dor procedure

Post. partial Post. partial fundoplicationfundoplication

Toupet procedureToupet procedure

Endoscopic Therapy Endoscopic Therapy

Endoscopic antireflux therapiesEndoscopic antireflux therapies Radiofrequency energy delivered to the Radiofrequency energy delivered to the

LESLES Stretta procedureStretta procedure

Suture ligation of the cardiaSuture ligation of the cardia Endoscopic plicationEndoscopic plication

Submucosal implantation of inert material Submucosal implantation of inert material in the region of the lower esophageal in the region of the lower esophageal sphinctersphincter

EnteryxEnteryx