Anti reflux surgery

Laparoscopic Anti-Reflux Surgery Safe and Effective Treatment for GORD Abeezar I. Sarela MSc MS FRCS (Gen Surg) Consultant in Upper Gastrointestinal & Minimally Invasive Surgery The Leeds Nuffield Hospital The General Infirmary at Leeds Wharfedale General Hospital Hon. Senior Lecturer, University of Leeds School of Medicine Clincal Meeting at Leeds Nuffield Hospital, 17 October, 2005

The Problem of GORD Afflicts 40% of adult population p.a. 2% consult GP Prescribed drugs & endoscopies: £ 600m Over the counter drugs: £ 100m NICE, 2005

National Health Service Stressed out Oct 13th 2005 The Economist The NHS has to prepare for a stretch of modest years after so many abundant ones. Which is why it must become more efficient. By the end of next year, the number of PCTs, which have sometimes been ineffective, is to be cut by half. More important, GP practices will be playing a much bigger role in commissioning treatments, with budgetary incentives for them to lower costs.

GORD Predicts Oesophageal Cancer Lagergren J et al. N Engl J Med 1999; 340 (11): 825-831. Heartburn (>5 years duration) Odds ratios Once-a-week x 8 Nocturnal x 11 >20 yrs, and score >4.5* x 43.5

Poor Quality of Life with GORD Figures quoted from UK respondents (n=201). 64% 22% 48% 14% 25% 29% % of patients AstraZeneca UK Data on File NEX/084/FEB2003. 0 10 20 30 40 50 60 70 80 Symptoms unbearable Interests Sleep Sex life Sport + exercise Concentrating on job N=230 confirmed GORD patients

Debate Is laparoscopic fundoplication the treatment of choice for gastro-esophageal reflux disease? Gut, 2002

Anti-Reflux Surgery NICE Guidance, 2005 Surgery is not recommended for the routine management of uncomplicated GORD, BUT individual patients whose quality of life remains significantly impaired may value this form of treatment.

Agenda Limitations of pharmacological therapy Indications for surgery Pre-operative assessment The operation Immediate post-operative care Outcomes

GORD Treatment Full-dose PPI for one or two months Recurrent symptoms: PPI at lowest dose to control symptoms, with minimal repeat prescriptions Treatment “on demand” basis NICE, 2005

PPI Maintenance Therapy: Limitations Nocturnal acid breakthrough Twice-daily dose for severe GORD Insufficient control of regurgitation ? Interaction with H.pylori Continuing biliary-pancreatic reflux ? Long-term (> 10 years) safety Cost

PPI Maintenance Therapy: Limitations Recurrent symptoms in 20-30% of patients on regular maintenance, low-dose PPI Full dose PPI needs to be maintained for complicated GORD (NICE, 2005) PPIs did not eradicate need for caution and restraint (NICE, 2005) Most patients want to dispense with need for long-term PPIs (NICE, 2005)

Indications for Surgery 1. Chronic, uncomplicated GORD with partial or total response to PPI but need for long-term maintenance therapy

Indications for Surgery 2. Poor response of confirmed GORD to PPI therapy due to refractoriness, PPI intolerance, hypersensitivity or bile reflux

Indications for Surgery 3. Peptic oesophageal stricture with need for repeated dilatation and long-term, full-dose PPI therapy

Indications for Surgery 4. Barrett’s oesophagus – potential protection from neoplastic transformation

Indications for Surgery 5. Respiratory complications of GORD Laryngitis Bronchitis Asthma Pneumonia Sinusitis

Pre-operative Assessment Detailed history Endoscopy Barium swallow Oesophageal manometry Oesophageal pHmetry Bile reflux monitoring (Bilitec)

24-hr Ambulatory Oesophageal pHmetry

Normal Results DeMeester Score < 14.7 % Total time pH<4 = 4.5% % Upright time pH<4 = 4% % Supine time pH<4 = 8% 24-hr Ambulatory Oesophageal pHmetry

The Operation Laparoscopic Nissen (complete or 360 degree, short, floppy) Fundoplication Laparoscopic Toupet (partial, posterior 270 degree) Fundoplication Laparoscopic Watson (anterior, 180 degree) Fundoplication

Immediate Post-operative Issues Overnight stay in hospital Immediate resumption of routine activity Return to work in 5-7 days PPI stopped immediately after operation Simple analgesia for 3-5 days “Sloppy” diet for 2-4 weeks Follow-up visit after one month No need for long-term follow-up

Outcomes Immediate and complete heartburn-control in > 90% of patients. Excellent relief of regurgitation, water-brash and respiratory symptoms. Very effective response of postural and nocturnal symptoms Significant improvement in quality of life Decreased incidence of malignant transformation

Side-Effects Dysphagia Difficulty to belch or vomit Post-prandial fullness & bloating Flatulence

Durability Careful evaluation of recurrent dyspepsia Majority of recurrent dyspepsia is NOT due to recurrent GORD PPI therapy should not be routine management of recurrent dyspepsia

Persistent or Recurrent GORD Inadequate or failed operation Supplementary PPI Laparoscopic re-do fundoplication Functional heart-burn Psychological

Results are highly surgeon-dependent Best results reported from high-volume, high-quality centres Expertise and technology Particularly important to offer prompt, high-quality service for problems or failures CHOICE

Summary Long-term, maintenance PPI therapy is problematic Consider anti-reflux surgery for patients with chronic symptoms or complications Laparoscopy has significantly increased utilisation of surgery Low-threshold for referral to surgeons with upper GI and laparoscopic expertise

Anti reflux surgery

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Anti reflux surgery