Transcript Gastroesophageal Reflux Disease (GERD)

Joint Hospital Surgical Grand Round
Surgical Management of
GERD
Department of Surgery
The Prince of Wales Hospital
YF Yeung
GERD
 Exposed to the risk of physical
complications from gastroesophageal
reflux
 Experience clinically significant
impairment of health-related well-being
as a result of reflux-related symptoms
Genval conference 1999
Epidemiology
2.5%
Chinese
Hong Kong, APT 2003
3.1%
Chinese
Beijing & Shanghai, Chi J Dig Dis 2000
4.8%
Chinese
Hong Kong, APT 2002
23%
Houston, US, Gastro 2004
27%
White
Black
0
5
10
15
20
25
Dent et al GUT 2005
30
Medical



Treatment
Options


Surgical
Antacids
H2-receptor
antagonists
Sucralfate
Prokinetics
Proton pump
inhibitors
Types of Fundoplication
 Complete
 Nissen 360o
 Partial


Posterior
 Toupet 270o
 Lind 300o
Anterior
 Belsey Mark IV
 Dor
hemifundoplication
Toupet fundoplication
Physiological mechanisms
 LES pressure enhanced
with the wrap of fundus



After meal, gastric
distension (1)
pressure transmitted from
stomach to fundus (2)
Fundal pressure pressed on
the esophagus (3)
Effect of Fundoplication
Surgery or Medication?
 Lundell et al. European Journal of
Gastroenterology and Hepatology 2000
 Long-term management of gastro-
oesophageal reflux disease with
omeprazole or open antireflex surgery:
results of a prospective, randomized
clinical trial
Surgery or Medication?
 298 patients included


Omeprazole (20mg daily) group: 154 patients
Open Antireflux surgery group: 144 patients
 3-year follow-up
 Outcome measures




Symptoms
24-h pH monitoring
Endoscopy
QoL assessment
Surgery or Medication?
 Results
Surgery (129)
Omeprazole (139)
Symptoms
relapse
17 (13.1%)
50 (35.9%)
Oesophagitis
14 (10.8%)
18 (12.9%)
Remission
97 (75.1%)
77 (55.3%)
 No significant difference in symptoms relapse,
oesophagitis and QoL if dose of omeprazole adjusted to
40mg or 60mg accordingly
Surgery or Medication?
 Conclusion

Omeprazole is as effective as antireflux
surgery in controlling GERD
Indications of surgery
 Patients do not accept long term medical
therapy
 Patients who do not respond or only
partially respond to medical therapy
 Antireflux surgery considered as
equivalent alternative
SSAT guidelines
Open Vs Laparoscopic
Author
Year
Groups
No. of
patients
Hiatal
plasty
DSGV
Laine
1997
Open
Lap
55
55
1
4
5
5
Bais
2000
Open
Lap
46
57
Yes
Yes
Yes
Yes
Chrysos
2002
Open
Lap
50
56
Yes
Yes
No
No
Ackroyd
2004
Open
Lap
47
52
Yes
Yes
No
No
Open Vs Laparoscopic
Author
Group
Laine
Open
Lap
Bais
Chrysos
Ackroyd
Open
Lap
Open
Lap
Open
Lap
Conversion (%)
Morbidity
(%)
Average
Length
(min)
Average
Hospital Stay
(days)
Average
Sick Leave
(days)
9.1
12.7
5.5
57
88
6.4
3.2
37.2
15.3
8.8
17.4
8.9
NR
NR
NR
NR
NR
NR
--
76.0
21.4
83
77
5.9
2.4
---
--
NR
NR
46
82
5
3
49
28
Open Vs Laparoscopic
Author
Follow-up
(mth)
Groups
A/V at
FU
Recurrence (%)
Dysphagia
(%)
Bloating
(%)
Laine
12
Open
Lap
30
18
10.0
--
13.3
--
6.7
16.7
Bais
3
Open
Lap
46
57
2.2
3.5
-12.3
NR
NR
Chrysos
12
Open
Lap
50
56
2.0
3.6
4.0
3.6
6.0
--
Ackroyd
12
Open
Lap
39
42
NR
NR
23.0
26.1
17.9
26.1
Open Vs Laparoscopic
 Conclusion

Perioperative recovery of laparoscopic
fundoplication is better than that of open
fundoplication

Short-term FU show no differences concerning
recurrence, dysphagia and bloating
Division Vs No Division of
SGV
Author
Year
Type
Hiatal repair
DSGV
(no. of
patients)
NDSGV
(no. of
patients)
Luostarinen
1995-99
Open
Selective
26
23
Watson
1997-2002
Lap
Routine
52
50
Blomqvist
2000
Lap
Routine
52
47
Chrysos
2001
Lap
Routine
24
32
Division Vs No Division of
SGV
Morbidity
Author
Length (min)
Dysphagia
Recurrence
DSGV
ND
DSGV
ND
DSGV
ND
DSGV
ND
Luostarinen
NR
NR
NR
NR
5/62
8/23
1/26
1/23
Watson
7/52
6/50
95
71
15/52
17/50
3/52
5/50
Blomqvist
15/52
5/47
120
104
11/39
15/41
1/52
1/47
Chrysos
2/24
3/32
100
60
4/24
5/32
1/24
0/32
Division Vs No Division of
SGV
 Conclusion

No significant differences regarding
morbidity, dysphagia and recurrence

Shorter operation time for the non-division
group
Complete or Partial
Author
Year
Type
Follow-up
Procedures
No. of
patients
DSGV
Lundell
1991-2002
Open
>3 yrs
Nissen
Toupet
65
72
Yes
Yes
Csendes
2000
Open
8 yrs
Nissen
Hill
76
88
Yes
Yes
Watson
1999
Lap
6 mths
Nissen
Anterior
53
53
No
No
2001-2002
Lap
4 mths
Nissen
Toupet
100
100
Yes
Yes
Fibbe
Complete Vs Partial
Author
Procedure
Morbidity
Average
length
(min)
Dysphagia
Recurrence
Re-operation
Lundell
Nissen
Toupet
0/65
3/72
NR
NR
6/62
12/71
3/62
4/71
5/65
2/72
Csendes
Nissen
Hill
3/76
5/88
NR
NR
NR
NR
29/76
33/88
NR
NR
Watson
Nissen
Anterior
8/53
10/53
58
60
21/53
8/53
1/20
3/22
1/53
1/53
Fibbe
Nissen
Toupet
NR
NR
45
60
18/100
6/100
18/93
10/95
13/100
1/100
PWH experience
 2001 to 2006
 28 cases – antireflux surgery


19 Laparoscopic Nissen Fundoplication
9 Lap Toupet Fundoplication
Age
Nissen
41.1
Toupet
50.2
p
0.07
Smoker
No. of co-morbid
Heartburn
3
0
16 (84.2%)
2
0
7 (77.8%)
0.53
0.21
0.53
Acid reflux
% time pH < 4
DeMeester score
19 (100%)
4.97
31.4
8 (88.9%)
2.30
23.9
0.32
0.06
0.65
Nissen
Toupet
p
OT duration
130
170
0.04†
Conversion
0
0
Hospital Stay
4.1
3.3
0.40
Redo
fundoplication
Recurrence
1 (5.3%)
1 (11.1%)
0.55
2 (10.5%)
4 (44.4%) 0.04†
Summary
 Long term outcome of surgery versus
medical treatment to GERD is equivalent
 Laparoscopic surgery is a better
approach
 ?Complete or partial fundoplication
Further evaluation is required