antireflux surgery
TRANSCRIPT
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Antireflux Antireflux SurgerySurgery
Parissa Tabrizian M.D.Parissa Tabrizian M.D.
Team IV 11/10/06Team IV 11/10/06
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AnatomyAnatomy
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Esophageal PhysiologyEsophageal Physiology
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Lower Esophageal Lower Esophageal SphincterSphincter
Intrinsic distal esophageal muscles – tonically Intrinsic distal esophageal muscles – tonically contractedcontracted
Muscular Sling fibers of the gastric cardiaMuscular Sling fibers of the gastric cardia Diaphragmatic cruraDiaphragmatic crura Transmitted pressure of the abdominal cavityTransmitted pressure of the abdominal cavity
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IntroductionIntroduction
Increased rate during the 90’s.Increased rate during the 90’s. 4.4 to 12 procedures per 100 000 4.4 to 12 procedures per 100 000
adultsadults Popularity of minimally invasive Popularity of minimally invasive
surgerysurgery 65% 65%
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Historical AspectHistorical Aspect
Rudolf Nissen ( 1896-1981)Rudolf Nissen ( 1896-1981) Thoracic surgery- lobectomy and pneumonectomyThoracic surgery- lobectomy and pneumonectomy Professor of Surgery in Istanbul, Turkey 1933Professor of Surgery in Istanbul, Turkey 1933 Mid 1930s: began work that would lead to his 1Mid 1930s: began work that would lead to his 1stst performed performed
fundoplication in 1955fundoplication in 1955 1956 Swiss journal, 1956 Swiss journal, Schweizerische Medizinische WochenschriftSchweizerische Medizinische Wochenschrift Brooklyn Jewish Hospital and Maimonides Hospital 1941Brooklyn Jewish Hospital and Maimonides Hospital 1941 Chairman of Surgery at the University of Basel, Switzerland 1951Chairman of Surgery at the University of Basel, Switzerland 1951
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Gastroesophageal reflux Gastroesophageal reflux diseasedisease
MC GI disorder of the western world. MC GI disorder of the western world.
44% adults in US have abnormal reflux of 44% adults in US have abnormal reflux of acidic gastric juices into the esophagus on a acidic gastric juices into the esophagus on a montly basis.montly basis.
10% of patients require daily acid 10% of patients require daily acid suppression medicationsuppression medication
Over 1.0 million out patients visit per yearOver 1.0 million out patients visit per year
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GERDGERD
Pathophysiology:Pathophysiology:Defective lower esophageal sphincter (LES) functionDefective lower esophageal sphincter (LES) function
transient LES relaxations ( TLESRs)transient LES relaxations ( TLESRs)
hypotonic LES ** ( e.g. sleroderma)hypotonic LES ** ( e.g. sleroderma)
disruption of LES ** ( e.g. resection, balloon rupture)disruption of LES ** ( e.g. resection, balloon rupture)
Hiatal hernia ** ( mal alignment of LES and crural Hiatal hernia ** ( mal alignment of LES and crural diaphragm)diaphragm)
Poor esophageal clearance **Poor esophageal clearance **
Decreased salivary protectionDecreased salivary protection
decreased volume ( e.g. sicca syndrome)decreased volume ( e.g. sicca syndrome)
deficient production of epidermal growth factordeficient production of epidermal growth factor
Poor gastric emptyingPoor gastric emptying
Increased intra-abdominal pressure ( e.g. straining, Increased intra-abdominal pressure ( e.g. straining, obesity, pregnancy)obesity, pregnancy)
Duodenogastric reflux (bile)Duodenogastric reflux (bile)
** predisposes to severe GERD** predisposes to severe GERD
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Hiatal HerniasHiatal Hernias
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Clinical presentationClinical presentationPrevalence of Symptoms in 1000 Patients Evaluated for Prevalence of Symptoms in 1000 Patients Evaluated for
Gastroesophageal Reflux Disease *Gastroesophageal Reflux Disease *
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Extraesophageal Manifestations Extraesophageal Manifestations of GERDof GERD
PulmonaryPulmonary
AsthmaAsthma
Aspiration pneumoniaAspiration pneumonia
Chronic bronchitisChronic bronchitis
Pulmonary fibrosisPulmonary fibrosis
OtherOther
Chest painChest pain
Dental erosionDental erosion
ENTENTHoarsenessHoarsenessLaryngitisLaryngitisPharyngitisPharyngitisChronic coughChronic coughGlobus sensationGlobus sensationSinusitisSinusitisSubglottic stenosisSubglottic stenosisLaryngeal cancerLaryngeal cancer
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Diagnostic Tests for Diagnostic Tests for GERDGERD
Barium swallowBarium swallow
EndoscopyEndoscopy
Ambulatory pH Ambulatory pH monitoringmonitoring
Esophageal manometryEsophageal manometry
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Barium SwallowBarium Swallow
Useful first diagnostic test for patients Useful first diagnostic test for patients with dysphagiawith dysphagia Stricture (location, length)Stricture (location, length) Mass (location, length)Mass (location, length) Bird’s beakBird’s beak Hiatal hernia (size, type)Hiatal hernia (size, type)
LimitationsLimitations Detailed mucosal exam for erosive Detailed mucosal exam for erosive
esophagitis, Barrett’s esophagusesophagitis, Barrett’s esophagus
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EndoscopyEndoscopy
IndicationsIndications Alarm symptomsAlarm symptoms Empiric therapy failureEmpiric therapy failure Preoperative Preoperative
evaluationevaluation Detection of Barrett’s Detection of Barrett’s
esophagusesophagus
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Ambulatory 24 hr. pH Ambulatory 24 hr. pH MonitoringMonitoring
Physiologic studyPhysiologic study
Quantify reflux in Quantify reflux in proximal/distal proximal/distal esophagusesophagus
--% time pH < 4--% time pH < 4
Prox esophagus: <1%Prox esophagus: <1%
Distal esophagus <4%Distal esophagus <4%
--DeMeester score --DeMeester score
( < 14.7 nl)( < 14.7 nl)
Symptom correlationSymptom correlation
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Ambulatory 24 hr. pH MonitoringAmbulatory 24 hr. pH Monitoring
NormalNormal
GERDGERD
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Wireless, Catheter-Free Esophageal pH Wireless, Catheter-Free Esophageal pH MonitoringMonitoring
• Improved patient comfort Improved patient comfort and acceptanceand acceptance
• Continued normal work, Continued normal work, activities and diet studyactivities and diet study
• Longer reporting periods Longer reporting periods possible (48 hours)possible (48 hours)
• Maintain constant probe Maintain constant probe position relative to SCJposition relative to SCJ
Potential AdvantagesPotential Advantages
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Esophageal ManometryEsophageal Manometry
Assess LES pressure, Assess LES pressure, location and relaxationlocation and relaxation Assist placement of Assist placement of
24 hr. pH catheter24 hr. pH catheter Assess peristalsisAssess peristalsis
Prior to antireflux Prior to antireflux surgery surgery
Limited role in GERDLimited role in GERD
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Treatment Goals for Treatment Goals for GERDGERD
Eliminate symptomsEliminate symptoms
Heal esophagitisHeal esophagitis
Manage or prevent complicationsManage or prevent complications
Maintain remissionMaintain remission
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Lifestyle ModificationsLifestyle Modifications
Elevate head of bed 4-6 inches Elevate head of bed 4-6 inches Avoid eating within 2-3 hours of bedtimeAvoid eating within 2-3 hours of bedtime Lose weight if overweightLose weight if overweight Stop smokingStop smoking Modify dietModify diet
Eat more frequent but smaller mealsEat more frequent but smaller meals Avoid fatty/fried food, peppermint, Avoid fatty/fried food, peppermint,
chocolate, alcohol, carbonated chocolate, alcohol, carbonated beverages, coffee and teabeverages, coffee and tea
OTC medications prnOTC medications prn
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Acid Suppression Therapy for Acid Suppression Therapy for GERDGERD
HH22-Receptor Antagonists-Receptor Antagonists
(H(H22RAs)RAs)
Cimetidine Cimetidine (Tagamet(Tagamet®®))
Ranitidine (ZantacRanitidine (Zantac®®))
Famotidine (PepcidFamotidine (Pepcid®®))
NizatidineNizatidine (Axid (Axid®®))
Proton Pump InhibitorsProton Pump Inhibitors (PPIs)(PPIs)
Omeprazole (PrilosecOmeprazole (Prilosec®®))Lansoprazole Lansoprazole (Prevacid(Prevacid®®))Rabeprazole (AciphexRabeprazole (Aciphex®®))Pantoprazole Pantoprazole (Protonix(Protonix®®))Esomeprazole (Nexium Esomeprazole (Nexium ®®) )
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Effectiveness of Medical Therapies for Effectiveness of Medical Therapies for GERDGERD
Treatment ResponseResponse
Lifestyle modifications/antacidsLifestyle modifications/antacids 20 %20 %
HH22-receptor antagonists-receptor antagonists 50 %50 %
Single-dose PPI Single-dose PPI 80 %80 %
Increased-dose PPIIncreased-dose PPI up to 100 %up to 100 %
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Complications of GERDComplications of GERD
Erosive/ulcerative esophagitisErosive/ulcerative esophagitis
Esophageal (peptic) strictureEsophageal (peptic) stricture
Barrett’s esophagusBarrett’s esophagus
AdenocarcinomaAdenocarcinoma
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Indications for SurgeryIndications for Surgery
Intractable GERD – rareIntractable GERD – rare Difficult to manage stricturesDifficult to manage strictures Severe bleeding from esophagitis ( grade III-IV)Severe bleeding from esophagitis ( grade III-IV) Non-healing ulcers Non-healing ulcers
GERD requiring long-term PPI-BID in a healthy young GERD requiring long-term PPI-BID in a healthy young patient patient
LES < 10LES < 10 Large hiatal herniaLarge hiatal hernia Persistent regurgitation/aspiration symptomsPersistent regurgitation/aspiration symptoms Not Barrett’s esophagus aloneNot Barrett’s esophagus alone NoncomplianceNoncompliance Patient’s preference ( cost, life style…)Patient’s preference ( cost, life style…)
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Mechanism of Antireflux Mechanism of Antireflux OperationsOperations
Creation of a floppy valve by maintaining close apposition Creation of a floppy valve by maintaining close apposition b/w the abdominal esophagus and the gastric fundusb/w the abdominal esophagus and the gastric fundus
Exaggeration of the flap valve at the angle of HisExaggeration of the flap valve at the angle of His
Increase in the basal pressure generated by the lower Increase in the basal pressure generated by the lower esophageal sphincteresophageal sphincter
Reduction in the triggering of TLES relaxationsReduction in the triggering of TLES relaxations
Reduction in the capacity of the gastric fundusReduction in the capacity of the gastric fundus speeding speeding prox. and a total gastric emptyingprox. and a total gastric emptying
Prevention of effacement of the lower esophagus Prevention of effacement of the lower esophagus
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* Restrospective analysis* Restrospective analysis* Medical or surgical treatment for > 1 yr* Medical or surgical treatment for > 1 yr* 120 pts undergoing surgery* 120 pts undergoing surgery* 51 pts nonoperative mgt* 51 pts nonoperative mgt* QOL: surgery > medical* QOL: surgery > medical
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Nissen FundoplicationNissen Fundoplication
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Postoperative Postoperative ComplicationsComplications
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* 171 patients, mean f/u 6.4 yrs* 171 patients, mean f/u 6.4 yrs* computerized log / questionnaire* computerized log / questionnaire
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•Overall: 96.5 % satisfied vs 3.5 %Overall: 96.5 % satisfied vs 3.5 %
* Persistent Sx: abd bloating ( 20%), diarrhea ( 12%), * Persistent Sx: abd bloating ( 20%), diarrhea ( 12%), regurgitation ( 6.4%), heartburn ( 5.8%)regurgitation ( 6.4%), heartburn ( 5.8%)
27 % dysphagia27 % dysphagia 7% dilatation 7% dilatation
14% postop PPI ( 79% vague abd symptoms)14% postop PPI ( 79% vague abd symptoms)
* Excellent long term treatment* Excellent long term treatment
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Complete vs. partial Complete vs. partial fundoplicationfundoplication
Ant. partial Ant. partial fundoplicationfundoplication
Thal/Dor procedureThal/Dor procedure
Post. partial Post. partial fundoplicationfundoplication
Toupet procedureToupet procedure
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Endoscopic Therapy Endoscopic Therapy
Endoscopic antireflux therapiesEndoscopic antireflux therapies Radiofrequency energy delivered to the Radiofrequency energy delivered to the
LESLES Stretta procedureStretta procedure
Suture ligation of the cardiaSuture ligation of the cardia Endoscopic plicationEndoscopic plication
Submucosal implantation of inert material Submucosal implantation of inert material in the region of the lower esophageal in the region of the lower esophageal sphinctersphincter
EnteryxEnteryx