®
Understanding and
Treating Chronic Acid Reflux
Including Incisionless Surgery
120308
Peter Krone M.D., F.A.C.S.
®
Overview
• Understanding GERD
• Medical Management
• Surgical Options
®
Is this YOU?
®
Typical Symptoms of GERD
• Heartburn
• Acid regurgitation
– Sour or bitter taste in throat or
mouth
– Esp. after large, late meals
• Water brash
– Hot sensation in stomach
– Excess salivation
• Dysphagia and Odynophagia
– Difficulty or painful swallowing
®
Other Symptoms of GERD
Pulmonary
Asthma
Aspiration pneumonia
Chronic bronchitis
Other
Regurgitation
Chest pain
Dental erosion
ENT
Hoarseness
Laryngitis
Sore throat
Chronic cough
Frequent swallowing
Burning in the throat or
mouth
Atypical symptoms
®
Lower
Esophageal
Sphincter (LES)
Stomach (Fundus)
Gastroesophageal
Flap Valve (GEV)
Esophagus
Diaphragm
Gray’s Anatomy, 1997
Anatomy 101
®
What Causes GERD?
Normal Anatomy Fully Functional Valve Prevents Reflux
Extrinsic Factors: Deterioration of natural barrier to reflux; the Antireflux Valve
Normal Anatomy Antireflux Valve Tight to the Scope
®
What Causes GERD?
Extrinsic Factors: Deterioration of natural barrier to reflux; the Antireflux Valve
Dysfunctional Valve Can’t close to prevent reflux of
stomach contents
This requires surgical management
Dysfunctional Valve Can’t close. Loose to the scope.
®
65-80% of patients with chronic severe GERD have hh≤2cm
What Causes GERD?
Hiatal Hernia
®
• 10 - 15% of adult population suffers from daily GERD (~
15 million)
• Incidence of GERD rises rapidly after 40 years of age
• Most GERD gets worse over time.
– Early correction can prevent further deterioration of the natural
barrier to reflux.
• Esophageal cancer is 8X more likely to occur in patients
with weekly heartburn or regurgitation
GERD Facts
®
Clinical Progression of GERD
Physiological
Reflux
Symptomatic
GERD Esophagitis
Complicated
Esophagitis
Typical • Heartburn
• Regurgitation
Atypical •Chest pain
•Swallowingdifficulties
•Cough
•Asthma
•Laryngitis
Complications •Ulceration
•Hemorrhage
•Strictures
•Barrett’s
•Adeno-Ca
®
Overview
• Understanding GERD
• Medical Management
• Surgical Options
®
Lifestyle/Behavior Modification
LOSE WEIGHT
WATCH WHAT YOU EAT
DON’T EAT LATE
AVOID STRESS
®
• Antacids
– Neutralize or buffer stomach acid
– Tums, Mylanta, Alka-Seltzer
• H2 blockers (ranitidine, cimetidine)
– Blocks the body’s signal to the
stomach to produce acid
– Zantac, Tagamet
• Proton Pump Inhibitors (PPIs)
– Blocks the secretion of acid into the
stomach
– Nexium, Prilosec, Zegerid, Protonix
Types of Medications
May be satisfactory for some patients
®
PPI Complications
FDA Warnings
Vitamin B12 Deficiency
Increased
Pneumonia Risk
Reduced Gallbladder
Motility
Osteoporosis Related
Fractures
Drug Interaction
Plavix
Fundic Gland
Polyps
Magnesium
Deficiency
Bacterial
Gastroenteritis
Small Intestinal
Bacterial
Overgrowth
®
Continued Reflux Symptoms on Medications
Gallup Poll Reflux* 72% on Medication
79% Nighttime symptoms
50% Nighttime reflux worse than daytime reflux
63% Ability to sleep affected
40% Daytime function affected
70% Nighttime discomfort moderate to severe
75% Can not fall asleep or wakes them up
45% Medication does not relieve all symptoms
*Gallup Poll 2000 for AGA N = 1000
American Journal of Gastroenterology 2003; vol. 98 Shaker et al
20-40% of patients dissatisfied with medication
WHY???
®
Medication is not the solution for
severe or chronic reflux
IT DOES NOT STOP
• Reflux
• Non Erosive Reflux Disease
(NERD)
• Regurgitation
ANATOMICAL CHANGES
NEED ANATOMICAL
REPAIRS
Symptoms vs. Solutions
Normal
Chronic GERD
®
Overview
• Understanding GERD
• Medical Management
• Surgical Options
®
What Indications for Surgery
• Esophagitis
• PPIs required for control
• Persistent symptoms despite medications
• Presence of Barrett’s esophagus
• Non-acid symptoms of reflux (asthma,
chronic cough, laryngitis…)
ANY OF THESE CONDITIONS CAN EXIST
TO BE A SURGICAL CANDIDATE
®
Surgery Workup
CONSULT
EGD (SCOPE)
BARIUM SWALLOW**
pH TESTING**
MANOMETRY**
** MAY BE REQUIRED ON INDIVIDUAL BASIS
®
Anti-Reflux Surgery
®
Anti-Reflux Surgery
®
Evolution of Reflux Surgery
20cm Incision
OPEN SURGERY
NATURAL
ORIFICE SURGERY
No Incision 0.5-1cm Incision
LAPARASCOPIC
SURGERY
FUNDOPLICATIONS
1955
Dr. Rudolph Nissen
“Gastroplication”
1990s
Laparoscopic Nissen
Laparoscopic Toupet
2008
Transoral
Fundoplication (TIF)
®
Lap Nissen Fundoplication
• 3-5 small incisions on abdomen
• Surgery performed in abdominal cavity
• Average hospital stay 1.2 days
• Resolution of symptoms at 1 year: 94%
• Off Daily Medication: 79-100%
• Major surgical complications: 2%
• Long term complications: 2-62%
– Gas bloat/Flatulence
– Difficulty swallowing
– Difficulty vomiting
1. Hunter JG, et al. Surgical Endoscopy 2001 N=1000
Gold Standard of Lap Anti-Reflux Surgery
®
Transoral Fundoplication (TIF)
• No Incisions
• Surgery performed within the stomach
• Average hospital stay 1.2 days
• Resolution of symptoms at 1 year: 85%
• Off Daily Medication: 65-94%
• Major surgical complications: 0.1%
• Long term complications: 0%
Over 6,500 TIFs performed in the US since 2008
®
Degraded Valve Allows Reflux of
Stomach Acids into Esophagus
6-months Post-Op
Retightened Valve
Pre-TIF Procedure Post-TIF Procedure
Before and After TIF
®
Syndrome Disease
Mild GERD
Severe
GERD
(~1%)
Pharmaceutical
Symptom Control
Lap Nissen
Treatment of root cause
Hill Grade I II III IV
Pills or Surgery???
TIF
Treatment of root cause
®
Are You:
• On a PPI longer than 6 months
• On double dose PPIs
• Having nighttime symptoms even on medication
• Having non-heartburn symptoms of reflux that
can’t be treated with medications
• Dissatisfied with the current treatment
Please call our office to schedule a consult.
®
Questions?