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Anti reflux surgery
1. Laparoscopic anti-reflux surgery is a safe and effective treatment for gastroesophageal reflux disease (GORD) that provides complete heartburn control in over 90% of patients and significantly improves quality of life. 2. While pharmacological therapy with PPIs is often initially recommended, it has limitations including nocturnal breakthrough and failure to control symptoms in 20-30% of patients. 3. Surgery is indicated for patients with chronic GORD symptoms despite PPI therapy or those with complications such as strictures or Barrett's esophagus.
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Anti reflux surgery
- 1. Laparoscopic Anti-Reflux SurgerySafe 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
- 2. The Problem ofGORD Afflicts 40% of adult population p.a. 2% consult GP Prescribed drugs & endoscopies: £ 600m Over the counter drugs: £ 100m NICE, 2005
- 3. National Health ServiceStressed 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.
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- 5. GORD Predicts OesophagealCancer 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
- 6. Poor Quality ofLife 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
- 7. Debate Is laparoscopicfundoplication the treatment of choice for gastro-esophageal reflux disease? Gut, 2002
- 8. Anti-Reflux Surgery NICEGuidance, 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.
- 9. Agenda Limitations ofpharmacological therapy Indications for surgery Pre-operative assessment The operation Immediate post-operative care Outcomes
- 10. GORD Treatment Full-dosePPI for one or two months Recurrent symptoms: PPI at lowest dose to control symptoms, with minimal repeat prescriptions Treatment “on demand” basis NICE, 2005
- 11. 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
- 12. 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)
- 13. Indications for Surgery1. Chronic, uncomplicated GORD with partial or total response to PPI but need for long-term maintenance therapy
- 14. Indications for Surgery2. Poor response of confirmed GORD to PPI therapy due to refractoriness, PPI intolerance, hypersensitivity or bile reflux
- 15. Indications for Surgery3. Peptic oesophageal stricture with need for repeated dilatation and long-term, full-dose PPI therapy
- 16. Indications for Surgery4. Barrett’s oesophagus – potential protection from neoplastic transformation
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- 19. Indications for Surgery5. Respiratory complications of GORD Laryngitis Bronchitis Asthma Pneumonia Sinusitis
- 20. Pre-operative Assessment Detailedhistory Endoscopy Barium swallow Oesophageal manometry Oesophageal pHmetry Bile reflux monitoring (Bilitec)
- 21. 24-hr Ambulatory OesophagealpHmetry
- 22. 24-hr Ambulatory OesophagealpHmetry
- 23. Normal Results DeMeesterScore < 14.7 % Total time pH<4 = 4.5% % Upright time pH<4 = 4% % Supine time pH<4 = 8% 24-hr Ambulatory Oesophageal pHmetry
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- 25. The Operation LaparoscopicNissen (complete or 360 degree, short, floppy) Fundoplication Laparoscopic Toupet (partial, posterior 270 degree) Fundoplication Laparoscopic Watson (anterior, 180 degree) Fundoplication
- 26. Immediate Post-operative IssuesOvernight 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
- 27. Outcomes Immediate andcomplete 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
- 28. Side-Effects Dysphagia Difficultyto belch or vomit Post-prandial fullness & bloating Flatulence
- 29. Durability Careful evaluationof recurrent dyspepsia Majority of recurrent dyspepsia is NOT due to recurrent GORD PPI therapy should not be routine management of recurrent dyspepsia
- 30. Persistent or RecurrentGORD Inadequate or failed operation Supplementary PPI Laparoscopic re-do fundoplication Functional heart-burn Psychological
- 31. Results are highlysurgeon-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
- 32. Summary Long-term, maintenancePPI 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