Antireflux Surgery

Parissa Tabrizian M.D. Team IV 11/10/06

Anatomy

Esophageal Physiology

Lower Esophageal Sphincter

Intrinsic distal esophageal muscles tonically contracted Muscular Sling fibers of the gastric cardia Diaphragmatic crura Transmitted pressure of the abdominal cavity

Introduction
Increased rate during the 90s. 4.4 to 12 procedures per 100 000 adults Popularity of minimally invasive surgery 65%

Historical Aspect

Rudolf Nissen ( 1896-1981) Thoracic surgery- lobectomy and pneumonectomy Professor of Surgery in Istanbul, Turkey 1933 Mid 1930s: began work that would lead to his 1st performed fundoplication in 1955 1956 Swiss journal, Schweizerische Medizinische Wochenschrift Brooklyn Jewish Hospital and Maimonides Hospital 1941 Chairman of Surgery at the University of Basel, Switzerland 1951

Gastroesophageal reflux disease

MC GI disorder of the western world. 44% adults in US have abnormal reflux of acidic gastric juices into the esophagus on a montly basis. 10% of patients require daily acid suppression medication Over 1.0 million out patients visit per year

GERD
Pathophysiology:
Defective lower esophageal sphincter (LES) function transient LES relaxations ( TLESRs) hypotonic LES ** ( e.g. sleroderma) disruption of LES ** ( e.g. resection, balloon rupture) Hiatal hernia ** ( mal alignment of LES and crural diaphragm) Poor esophageal clearance ** Decreased salivary protection decreased volume ( e.g. sicca syndrome) deficient production of epidermal growth factor Poor gastric emptying Increased intra-abdominal pressure ( e.g. straining, obesity, pregnancy) Duodenogastric reflux (bile) ** predisposes to severe GERD

Hiatal Hernias

Clinical presentation
Prevalence of Symptoms in 1000 Patients Evaluated for Gastroesophageal Reflux Disease *

Extraesophageal Manifestations of GERD

ENT Hoarseness Laryngitis Pharyngitis Chronic cough Globus sensation Sinusitis Subglottic stenosis Laryngeal cancer

Pulmonary Asthma Aspiration pneumonia Chronic bronchitis Pulmonary fibrosis

Other Chest pain Dental erosion

Diagnostic Tests for GERD

Barium swallow
Endoscopy Ambulatory pH monitoring Esophageal manometry

Barium Swallow

Useful first diagnostic test for patients with dysphagia Stricture (location, length) Mass (location, length) Birds beak Hiatal hernia (size, type)

Limitations Detailed mucosal exam for erosive esophagitis, Barretts esophagus

Endoscopy

Indications Alarm symptoms Empiric therapy failure Preoperative evaluation Detection of Barretts esophagus

Ambulatory 24 hr. pH Monitoring

Physiologic study Quantify reflux in proximal/distal esophagus --% time pH < 4 Prox esophagus: <1% Distal esophagus <4% --DeMeester score ( < 14.7 nl)

Symptom correlation

Ambulatory 24 hr. pH Monitoring

Normal

GERD

Wireless, Catheter-Free Esophageal pH Monitoring

Potential Advantages

Improved patient comfort

and acceptance Continued normal work, activities and diet study Longer reporting periods possible (48 hours)

Maintain constant probe position relative to SCJ

Esophageal Manometry
Limited role in GERD

Assess LES pressure, location and relaxation Assist placement of 24 hr. pH catheter Assess peristalsis Prior to antireflux surgery

Treatment Goals for GERD

Eliminate symptoms
Heal esophagitis Manage or prevent complications Maintain remission

Lifestyle Modifications

Elevate head of bed 4-6 inches Avoid eating within 2-3 hours of bedtime Lose weight if overweight Stop smoking Modify diet Eat more frequent but smaller meals Avoid fatty/fried food, peppermint, chocolate, alcohol, carbonated beverages, coffee and tea OTC medications prn

Acid Suppression Therapy for GERD

H2-Receptor Antagonists (H2RAs) Cimetidine (Tagamet) Ranitidine (Zantac) Famotidine (Pepcid) Nizatidine (Axid) Proton Pump Inhibitors (PPIs)
Omeprazole (Prilosec) Lansoprazole (Prevacid) Rabeprazole (Aciphex) Pantoprazole (Protonix) Esomeprazole (Nexium )

Effectiveness of Medical Therapies for GERD

Treatment Lifestyle modifications/antacids H2-receptor antagonists Single-dose PPI Increased-dose PPI 20 % 50 % 80 %

Response

up to 100 %

Complications of GERD

Erosive/ulcerative esophagitis Esophageal (peptic) stricture Barretts esophagus Adenocarcinoma

Indications for Surgery

Intractable GERD rare Difficult to manage strictures Severe bleeding from esophagitis ( grade III-IV) Non-healing ulcers GERD requiring long-term PPI-BID in a healthy young patient LES < 10 Large hiatal hernia Persistent regurgitation/aspiration symptoms Not Barretts esophagus alone Noncompliance Patients preference ( cost, life style)

Mechanism of Antireflux Operations

Creation of a floppy valve by maintaining close apposition b/w the abdominal esophagus and the gastric fundus Exaggeration of the flap valve at the angle of His Increase in the basal pressure generated by the lower esophageal sphincter Reduction in the triggering of TLES relaxations Reduction in the capacity of the gastric fundus speeding prox. and a total gastric emptying Prevention of effacement of the lower esophagus

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

Nissen Fundoplication

Postoperative Complications

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

Overall: 96.5 % satisfied vs 3.5 % * Persistent Sx: abd bloating ( 20%), diarrhea ( 12%), regurgitation ( 6.4%), heartburn ( 5.8%) 27 % dysphagia 7% dilatation 14% postop PPI ( 79% vague abd symptoms) * Excellent long term treatment

Complete vs. partial fundoplication

Ant. partial fundoplication Thal/Dor procedure

Post. partial fundoplication Toupet procedure

Endoscopic Therapy

Endoscopic antireflux therapies Radiofrequency energy delivered to the LES Stretta procedure Suture ligation of the cardia Endoscopic plication Submucosal implantation of inert material in the region of the lower esophageal sphincter Enteryx