Gastroesophageal reflux disease and antireflux surgery

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Gastroesophageal reflux disease and antireflux
surgery

• Brannon Hyde, MD

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Learning objectives

• Understand the natural history of reflux disease
• Understand how to identify candidates for
  antireflux surgery
• Understand the complications of antireflux
  surgery and patients satisfaction with surgery

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Why do we care about reflux?

• Americans experience reflux symptoms
• 44 monthly
• 20 weekly
• 4-7 daily
• Most common gastrointestinal diagnosis on
  outpatient physician visits
• Frequency and severity does not predict
  esophagitis, stricture, or cancer development

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Definition of GERD

• Montreal consensus panel (44 experts)
• a condition which develops when the reflux of
  stomach contents causes troublesome symptoms
  and/or complications
• Troublesomepatient gets to decide when reflux
  interferes with lifestyle

Vakil N, et al. Am J Gastroenterol 20061011900
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Clinical presentation

• Heartburn
• 1-2 hours after eating, often at night, antacid
  relief
• Regurgitation
• Spontaneous return of gastric contents proximal
  to GE jxn less well relieved with antacids
• Dysphagia (40)difficulty with swallowing should
  prompt search for pathologic condition

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Clinical presentation

• Atypical symptoms (20-25)
• Cough
• Asthma
• Hoarseness
• Non-cardiac chest pain

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Diagnosis

• Diagnosis based on symptoms alone is correct in
  only 2/3 patients
• Differential (ALL CAN KILL YOU!)
• Achalasia
• Diffuse esophageal spasm
• Other esophageal motility disorder
• Cancer
• Ulcer disease
• Coronary artery disease

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So Ive got GERD, whats going to happen to me?

• Spectrum of disease theory
• Nonerosive disease ? erosive disease ? Barretts
  ? esophageal adenocarcinoma

Am J Gastroenterol 200499946.
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3,894 patients had baseline and repeat endoscopy
at 2 years, regardless of symptoms. Conclusion
progression and regression occur despite PPI
therapy
ProGERD study
Am J Gastroent 20061012457-62
Severe esophagitis
Mild esophagitis
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So I can diagnose it, and I know how bad it can
get, but why does heartburn and regurgitation
happen in the first place?

• Answer alteration from normal physiology
• Normally, the lower esophageal sphincter exists
  as a zone of high pressure between esophagus and
  stomach when the HPZ is lost, reflux occurs

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Proximal esophagus
Swallow

• Transducer tracing identifies the LES
• High pressure drops only after a swallow or when
  fundus is distended with gas (to belch)

Distal esophagus
Distal esophagus
Distal esophagus
Distal esophagus
Relaxation of LES
Gastric baseline
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Physiology of antireflux barrier

• Three components of high pressure zone
• Absolute pressure
• Overall length
• Intra-abdominal length

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Overall length shortens as stomach distends,
increasing the pressure necessary to maintain
competence (neck on a balloon)
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Physiology of antireflux barrier

• If intra-abdominal length is short, LES pressure
  can be overcome by small increases in
  intra-abdominal pressure
• Increased abdominal pressure needs even
  distribution over high pressure zone abdominal
  length to prevent reflux

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Normal physiology
If sufficient intraabdominal length is present,
squeeze (increased abdominal pressure) will occur
around neck of balloon, and reflux will not
occur
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Physiology of antireflux barrier
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Pathophysiology of GERD

• Fundic distention (overeating) delayed gastric
  emptying (high fat)
• Lower esophageal sphincter is pulled distally by
  expanding fundus
• Squamous epithelium exposed to gastric juice
• Repeated exposure ? columnarization

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What does my body do to compensate for reflux
esophagitis?

• Compensation
• Increased swallowing ? saliva bathes injured
  mucosa, alleviating discomfort
• Results in aerophagia, bloating, and belching
• Distention leads to further repetitive injury to
  the terminal squamous epithelium in distal
  esophagus

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Pathophysiology of GERD

• Extension of inflammation into muscularis propria
  causes progressive loss in length and pressure of
  the LESesophageal shortening
• Loss of LES leads to regurgitation, heartburn,
  and subsequent severe esophagitis

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What role does a hiatal hernia play?

• Greater gastric dilatation is necessary to open
  LES in patients with intact angle of HIS compared
  to those with a hiatal hernia
• Reflux occurs easier

lt 3 cm
gt 3 cm
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So I have a defective sphincter, what
complications will I have?

• Esophagitis (mucosal injury) with or without
  heartburn
• Reflux chest pain syndrome
• Respiratory complications
• Metaplastic and neoplastic complications

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Why is esophagitis bad?

• Acid alone does minimal damage, but is highly
  toxic in combination with pepsin
• Bile reflux alone does minimal damage, but when
  coupled with gastric acid, is destructive to
  esophageal mucosa
• Decrease acid (with PPI or surgery), and
  esophageal lining heals

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What is reflux chest pain syndrome?

• Heartburn without esophagitis
• bile salts inhibit pepsin
• acid pH inactivates trypsin
• pain comes from acidic gastric juice breaking
  mucosal barrier and irritating nerve endings

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Respiratory complications

• Reflux and aspiration of gastric contents induces
  asthma
• Correlation between hiatal hernia and pulmonary
  fibrosis
• Pathologic acid exposure often seen in proximal
  esophagus in patients with asthma
• Simultaneous tracheal and esophageal pH
  monitoring shows acidification of trachea in
  concert with esophagus

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What metaplastic complications can arise?

• Norman Barrett (1950) first described the process
  whereby the esophageal squamous epithelium
  changes to columnar epithelium
• Occurs in 7-10 of patients with GERD
• Factors predisposing to Barretts
• Early-onset GERD
• Abnormal LES or motility disorder
• Mixed reflux of gastric and duodenal contents

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What are the neoplastic complications?
Goblet cells

• Barretts metaplasia harbors dysplasia in 15-25
• 5-10 is high-grade dysplasia

High grade dysplasia structure of glands
becoming disorganized
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So I understand a little about reflux who needs
an operation?

• Need for continuous drug treatment or escalating
  dose of PPI
• Relatively young
• Financial burden or noncompliance with PPI
• Patient choice

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How do you know Im a candidate for surgery?

• Establish GERD as underlying cause of symptoms
• Estimate risk of progressive disease
• Determine presence or absence of esophageal
  shortening
• Evaluate esophageal body function

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How do you know Im a candidate for surgery?

• Factors predictive of successful outcome
  following antireflux surgery (n 199)
• Abnormal score on 24-hour esophageal pH
  monitoring (p lt 0.001)
• Presence of typical symptoms of GERD (heartburn
  and regurgitation) (plt 0.001)
• Symptomatic improvement in response to acid
  suppressive therapy (p 0.02)

J Gastrointest Surg 19993292-300
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What specific studies do I need preoperatively?

• Endoscopy
• 24-hour ambulatory pH monitoring
• Radiograph
• Esophageal body and gastric function

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Preoperative evaluation endoscopy

• Amounts to the physical examination
• Strictures or large hiatal hernia may indicate
  shortened esophagus
• High-grade dysplasia or a mass in the esophageal,
  gastric, or duodenal lumen will change management

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Preoperative evaluation 24-hour pH monitoring

• Rationale gold standard for diagnosis of GERD
• Quantifies actual time the esophageal mucosa is
  exposed to gastric juice
• Measures the ability of the esophagus to clear
  refluxed acid

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Preoperative evaluation 24-hour pH monitoring

• Correlates esophageal acid exposure with patients
  symptoms
• Without abnormal pH study, surgery is unlikely to
  benefit
• Gives a composite score (Johnson-DeMeester score)
  highly sensitive and specific (gt96) for
  diagnosing GERD

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Johnson-DeMeester normal values for esophageal pH
lt 4 (n 50)
J Clin Gastroenterol 8(suppl. 1)52-58, 1986.
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Preop evaluation swallow study

• Only 40 of patients with classic symptoms of
  GERD will have reflux observed on radiography
• Assess for
• Esophageal shortening
• Hiatal hernia (80)
• Paraesophageal hernia
• Stricture or obstructing lesion
• Beading or corkscrewing (motility disorders)

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Manometry
Rules out esophageal motility disorders Esophagea
l body dysfunction (achalasia or aperistalsis)
should change management.
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So I have reflux, and I think I want surgery
what surgery do I have?

• The most common antireflux operation is the
  laparoscopic fundoplication
• Crural dissection, identification and
  preservation of both vagi
• 25 have left hepatic artery coming from left
  gastric artery in the gastrohepatic ligament
• Circumferential dissection of esophagus

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So I have reflux, and I want surgery what
surgery do I have?

• Elements of laparoscopic Nissen
• Crural closure
• Fundic mobilization by division of short gastrics
• Creation of short, loose fundoplication by
  enveloping anterior and posterior wall around
  lower esophagus

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That operation looks nice, are people satisfied
with it?

• Patient satisfaction is high (86-97)
• Long-term symptom relief (heartburn and
  regurgitation) in 84-97
• Symptomatic failure rate 3-13
• heartburn and regurgitation
• Does not correlate with acidic reflux exposure
• OPERATION DID NOTHING for 3-13!

Surgeon, August 2009224.
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How will I feel after that operation?

• Bloating and increased flatulence (9-53)
• Most common side effect
• Different scoring systems account for range
• Pre-operative symptom scores are largely unknown

Surgeon, August 2009224.
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What are the real bad things that can happen to
me?

• Review of 10,489 laparoscopic antireflux
  procedures
• Complications
• Wrap herniation (early) 1.3
• Pneumothorax 1.0
• All others lt 1 (perforation, hemorrhage,
  pneumonia, abscess, splenic injury, trocar
  hernia, effusion, PE, ulcer, atelectasis, wound
  infection, MI, splenectomy)

JACS 2001 193(4) 428-39
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How will I feel several months later?

• Early dysphagia
• usually transient (lt6 weeks)
• Persistent side effects (gt1 month)
• Bloating 9
• Reflux 4
• Dysphagia 3
• Often poorly defined

JACS 2001 193(4) 428-39 Surgeon, August
2009224.
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How do patients fare a decade down the line?

• 10-year follow-up of 250 patients
• 83 highly satisfied with outcome
• 84 had good or excellent control of heartburn
• 17 revision operation (usually 3-7)
• Recurrent hiatal hernia, dysphagia, reflux,
  bleeding (early takeback protocol for dysphagia)
• 21 used acid-suppressive medication

JACS 2007205570
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Well, do I have to take the purple pill after the
operation?

• Use of acid-suppressive medication after
  antireflux surgery varies (21-62)
• But, only 20-30 with reflux-like symptoms
  after surgery have positive pH studies

JACS 2007205570
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Series are great, Doc, but what about a
randomized trial?

• Randomized trial comparing treatment of GERD with
  omeprazole (n 154) and antireflux surgery (n
  144)
• Treatment successno symptoms or esophagitis (p lt
  0.002)
• 67 surgical
• 47 medical
• Dysphagia, bloating, rectal flatulence common in
  surgical group

Brit J Surg 200794198.
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Does surgery offer any benefit to avoiding cancer?

• Cancer risk in patient with reflux symptoms is lt
  1 in 10,000 per patient year
• No benefit to avoidance of Barretts or
  adenocarcinoma with surgery compared to PPI
  therapy
• Low morbidity and mortality risks associated with
  laparoscopic antireflux surgery dwarf potential
  benefit of avoiding cancer

Gastroent 20081351392.
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What does all of this mean, should I have surgery
or not?

• Surgery wins over PPIs if you dont mind trading
  heartburn and reflux for bloating, inability to
  belch, and excessive flatulence
• Not in everybody, BUT IT COULD BE YOU!
• Nevertheless, 86-97 of patients are satisfied
  with surgery

Gastroent 20081351392.
48
Doc, with all that bloating, do you have to make
the wrap so tight?
Toupet
Nissen
270 degree wrap
Anterior (Dor)
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So you dont have to make it so tight? Great!

• Complete fundoplication offers superior
  protection to reflux
• Increased incidence of dysphagia, inability to
  belch, and excessive flatus
• Partial wraps offer less protection against
  reflux, but also less symptoms
• Up to 51 may have pathologic esophageal acid
  exposure on 24-hour pH monitoring

Surg Endos 1997111080.
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So partial wraps really dont help to stop
reflux so who needs one?

• Complete now considered superior to partial even
  in patients with weak esophageal peristalsis
• Exceptions
• achalasiaanterior wrap utilized with myotomy
• Aperistalis (ie, scleroderma)

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Well Doc, Ive got asthma, too. How does that
influence surgery?

• Once reflux induced asthma is established, PPI
  therapy is instituted
• 25-50 have relief of respiratory symptoms
• lt15 have improvement in pulmonary function
• Antireflux surgery
• 90 of children and 70 of adults have relief
• 33 have improvement in pulmonary function

Am J Gastroenterol 200398987
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Just to wrap up

• PPIs work to control symptoms and esophagitis,
  but require life-long treatment
• Successful antireflux surgery is based on
  abnormal 24-hr pH score, typical GERD symptoms,
  and symptomatic improvement in response to acid
  suppression therapy
• Having antireflux surgery is a patient-centered
  decision with a riskbenefit ratio that can
  really only be weighed by the patient

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• ANY QUESTIONS?

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