Department of Laparoscopic Surgery, Staten Island University Hospital

Gastroesophageal Reflux Disease Pathophysiology and Treatment

George Ferzli, M.D., FACS
Professor of Surgery, SUNY Health Science Center at Brooklyn

44%
13%

Clinical Presentation

Adults Heartburn Regurgitation Cough Wheezing Hoarseness Chest pain Children Vomiting (heartburn, cough, and stridor) Aspiration (recurrent bronchopneumonia) Infants

Vomiting (causes failure to thrive, and repeated otitis)

Esophagitis (causes irritability, anemia, and stricture) Aspiration (causes bronchopneumonia, asthma, anemic spells, and possibly sudden death.

Incidence of presenting symptoms experienced as a percent of all patients in study (n=198)

Heartburn Regurgitation Dysphagia Resp. symptoms Chest pain Abdominal pain Nausea or vomiting Belching Bleeding 80% 68% 38% 27% 10% 10% 7% 6% 5%

Hinder, RA, et al: Laparoscopic Nissen Fundoplication is an effective treatment for GERD. Annals of Surgery 220, No. 4

Definition
It is increased exposure of the esophagus to gastric and / or duodenal secretions

Etiology

Protective Mechanisms

Medical Management
Medical therapy is first line of management Pro-motility agents like metoclopramide to enhance esophageal clearance of acid Gastric pH enhancing drugs like antacids, antihistamines and proton pump inhibitors

Goals of Treatment
Eliminate symptoms Heal esophagitis Manage or prevent complications Maintain remission

Lifestyle Modifications
Avoid fatty foods, fried foods, peppermint, chocolate, alcohol, coffee, citrus fruit, tomato products Lose weight if overweight Stop smoking Elevate head of bed 6 inches

Medical Management
Esophagitis will heal in 90% of cases
Doesnt address etiology of GERD 80% recur within one year of stopping therapy Alkaline injury may continue to occur

Pitfalls of Medical Management

Lifestyle modification Antacids Prokinetic agents non-compliance poor long-term control no esophageal healing

H2 Blockers

short-term good results long-term 50% recur good healing, ?safety rapid relapse

Proton pump inhibitors

Risk Factors That Predict A Poor Response To Medical Therapy

1. Nocturnal reflux on 24-hr esophageal pH study 2. Structurally deficient lower esophageal sphincter 3. Mixed reflux of gastric and duodenal juice
4. Mucosal injury on presentation

What is the next step???

Indications for Antireflux Surgery

a) Intractable persistent reflux symptoms despite aggressive medical management b) Reflux-induced respiratory symptoms after control of acid reflux c) Recurring severe reflux symptoms, or reflux injury (peptic stricture, esophageal ulceration, bleeding) despite adequate medical therapy d) Barretts esophageal metaplasia e) Lifestyle choice (avoid long-term use of medicines)

Goals Of Surgical Management

1. Restore LES pressure and length 2. Establish abdominal position of LES (approx. 2cm) 3. Preserve ability to belch and vomit 4. Avoid vagal nerve injury 5. Correct associated diaphragmatic herniation

Surgery vs. Medical Therapy

Study Design
Prospective non-randomized study 41 patients had antireflux surgery (12 Nissen and 29 Toupet) after failure of medical therapy and 18 had only medical therapy Dysphagia was assessed prior to therapy and 6 months after therapy
Wetscher GJ, Hinder RA, et.al. Am J Surg;177, Mar 1999

Surgery vs. Medical Therapy

Results
Controls regurgitation Improves esophageal peristalsis Restores the LES function Freedom from reflux-induced dysphagia (92.7% vs. 11.9%, p<0.05) Prevents non-acid reflux Treats hiatal hernias
Wetscher GJ, Hinder RA, et.al. Am J Surg;177, Mar 1999

Work-up
1) Barium swallow
Not diagnostic Presence and size of hiatal hernia Presence of stricture Length of esophagus

Laparoscopic Paraesophageal Hernia Repair

Paraesophageal Hernia Repair

Symptomatic Outcomes
100 80
% patients

60 40 20 0 Excellent/Good Fair/Poor Satisfied Open (n=25)

Laparoscopic (n=26)

Hashemi et al, J Am Coll Surg 2000;190:553-561

Paraesophageal Hernia Repair

Technique and Recurrence
Mesh vs. No Mesh
Prospective randomized trial Hiatal defect >8cm diameter Excision of sac, primary closure of crura, Nissen fundoplication in all cases Randomized intra-op to mesh vs. no mesh
% Recurrence

20

16%
15

10

0%
0 PTFE mesh (n=17) No mesh (n=18)

Follow-up for 6 months

Frantzides CT et al, Surg Endosc (1999) 13: 906-908

Paraesophageal Hernia Repair

Summary

Symptomatic outcomes: Similar in both groups. Excellent or good in 76% patients after laparoscopic and 88% after open repair Hernia recurrence: Significantly higher in laparoscopic group (42%, 9 of 21) compared to open group (15%, 3 of 20) Use of mesh reduces paraesophageal hernia recurrence significantly

Work-up
2) EGD
Presence of esophagitis Presence and the type of hiatal hernia Esophageal length Presence of Barretts, dysplasia or cancer Presence of stricture

Laparoscopic Nissen For Barretts

Long-Term Outcome of Antireflux Surgery in Patients With Barrett's Esophagus

At 5-years median follow-up: Reflux symptoms absent in 79% Recurrent symptoms in 20%. Most common in patients undergoing Collis-Belsey (33%) 24-hour pH monitoring results normal in 81% 77% patients considered themselves cured, 22% considered themselves improved, and 97% were satisfied
Hofstetter WL et.al. Annals of Surgery, 234(4), Oct.2001

Long-Term Outcome of Antireflux Surgery in Patients With Barrett's Esophagus

44% regression of low-grade dysplasia to nondysplastic Barretts 14% regression of intestinal metaplasia to cardiac mucosa Low-grade dysplasia developed in 6% patients No patient developed high-grade dysplasia or cancer in median 5-year follow-up
Hofstetter WL et.al. Annals of Surgery, 234(4), Oct.2001

Dysplasia and Adenocarcinoma After Classic Antireflux Surgery in Patients With Barrett's Esophagus
161 patients had antireflux surgery between 1978 and 1992. Prospective follow-up ended Dec.1999 17 (10.5%) who developed dysplasia and 4 (2.5%) who developed adenocarcinoma were compared to 126 patients with long-segment Barretts in whom dysplasia did not develop Patients were evaluated with clinical questionnaire, multiple EGD and biopsy, and 24hour pH and bilirubin monitoring
Csendes A et.al. Annals of Surgery,235(2),p.178-185,Feb.2002

Results
Visick I-II (n=52) Visick III-IV (n=74) Dysplasia (n=17) Adenoca. (n=4)

Symptoms
Length of Barretts (mm) Incompetent LES Pathologic acid reflux % time with bilirubin

0%
65 21% 12.5% 5.3+1.6%

95%
68 61% 96% 30.9+19%

82%
77 70% 93% 86%

100%
65 100% 100% -

Csendes A et.al. Annals of Surgery,235(2),p.178-185,Feb.2002

Conclusions
Patients with failed antireflux surgery are a high-risk group for development of dysplasia and carcinoma Metaplastic changes from fundic to cardiac mucosa and then intestinal metaplasia, dysplasia and adenocarcinoma can clearly be documented Patients with Barretts who undergo antireflux surgery require long-term subjective and objective follow-up
Csendes A et.al. Annals of Surgery,235(2),p.178-185,Feb.2002

Barretts Esophagus Can and Does Regress after Antireflux Surgery

91 patients with symptomatic Barretts esophagus: 77 treated with surgery and 14 with proton pump inhibitors 28 of 77 (36.4%) after surgery had histologic regression of Barretts 1 of 14 patients (7.1%) had regression with medical therapy Patients with Barretts less than 3 cm. had greater likelihood of regression
Gurski R, Peters J, Hagen J, et al Journal of the Amer Coll Surg 2003 196 (5): 706-713

Work-up
3) Manometry
Not diagnostic Esophageal body motility LES function LES position

Normal LES Parameters

Basal resting pressure of <37 mmHg Single peak 40-180 mmHg Duration of 2-5 seconds Velocity of 3-4 cm./sec.

Work-up
4) 24 h pH
Perform on all patients without erosive esophagitis (grade I and II) Remains the gold standard Stop proton pump inhibitor 2 weeks before Presence of abnormal reflux Correlate between symptoms and reflux

DeMeester Score
Based on six variables: a) percent total time pH<4 b) percent upright time pH<4 c) percent supine time pH<4 d) number of episodes pH<4 lasting >5 min. e) longest episode pH<4 (min.) f) total number episodes pH<4 Normal score <14.7

Workup
5) Radionuclide gastric emptying study
when symptoms of delay gastric emptying, diabetes, peptic ulcer disease when severe reflux on the 24h pH with normal LES on the manometry

Simultaneous 24-hour pH and intraesophageal impedance may be useful in evaluating the role of non-acid reflux in symptoms that persist despite adequate acid suppression

Surgical Management - Approaches

A) Surgical approaches include (Open or Laparoscopic) 1) Total fundoplication (Nissen procedure) 2) Partial fundoplication (Belsey, Toupet, or Dor procedure) B) Endoluminal techniques such as the Stretta procedure

Proper diagnostic workup is essential. It may alter the algorithm of management

Paradigm Shift in the Management of Gastroesophageal Reflux Disease

75 patients underwent laparoscopic fundoplication and 65 patients underwent the Stretta procedure Only patients who did not have a hiatal hernia larger than 2 cm., LES pressure less than 8 mmHg, or Barretts esophagus were offered the Stretta procedure They concluded that the patients in both groups had comparable improvement in GERD symptoms and quality of life even though the more severe symptomatic patients underwent surgery
Richards W, Houston H, Torquati A et al Ann Surg 2003; 237(5): 638-649

Proper preoperative workup will help manage recurrent postoperative symptoms

Symptoms are a poor indicator of reflux status after fundoplication for GERD: the role of esophageal function tests
124 patients who developed GERD symptoms after laparoscopic fundoplication underwent esophageal manometry and pH monitoring 76 (61%) patients had normal esophageal acid exposure Symptoms, except for regurgitation, are an unreliable index of the presence of reflux
Galvani C, Fisichella P, Gorodner M, et al. Arch Surg 2003; 138: 514-519

Take home message: In order to achieve good postoperative results, there must be a thorough preoperative workup