the non-medical treatments of the gastroesophageal reflux disease (gerd)
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The Non-Medical Treatments of the Gastroesophageal Reflux Disease (GERD). Joint Hospital Grand Round 25.1.2014 Prepared by Siu Yin Yu, Eva North District Hospital. Definition. - PowerPoint PPT PresentationTRANSCRIPT
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The Non-Medical Treatments of the Gastroesophageal Reflux Disease (GERD)Joint Hospital Grand Round 25.1.2014Prepared by Siu Yin Yu, EvaNorth District Hospital
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DefinitionAGA: There can be no criterion standard definition of GERD because the threshold distinction between physiologic reflux and reflux disease is ultimately arbitrary
Montreal consensus 1
Reflux of stomach contents
Troublesome symptoms and/or
Complications
1.Am J Gastroenterol 2006;101:1900-20
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BackgroundPrevalence:
10-20% in Western world, even up to 42%2
2.5-6.7% in east/east-southern Asia3
Symptoms : Esophageal Vs Extraesophageal
Investigations: OGD
24Hr pH monitoring
Manometry
Mutichannel Intraluminal Impedence study
2. Gut 2005;54:710-73. Clin Gastroenterol Hepatol. 2006 Apr;4(4):398-407.
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TreatmentLife style modification
Acid-suppressive drugs
Antireflux Surgery
Endoscopic Therapy
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When do we consider antireflux surgery?
Which approach? Open? Laparoscopic ? Robotic-assisted?
Total Vs Partial?
Does short gastric vessel division improve the outcomes?
Recent development of endoscopic therapy ? Effectivenss ? Safety?
Questions…
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When do we consider antireflux surgery?
Which approach? Open Vs Laparoscopic Vs Robotic-assisted
Total Vs Partial?
Does short gastric vessel division improve the outcomes?
Recent development of endoscopic therapy ? Effectiveness ? Safety?
Questions…
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Antireflux SurgeryIndications
Patients with esophageal symptoms intolerant of PPIs
For atypical symptoms, no conclusive evidence to support
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When do we consider antireflux surgery?
Which approach? Open Vs Laparoscopic Vs Robotic-assisted
Total Vs Partial?
Does short gastric vessel division improve the outcomes?
Recent development of endoscopic therapy ? Effectiveness ? Safety?
Questions…
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Antireflux SurgeryVariety of fundoplications
ApproachesOpen
Laparoscopic
Robotic-assisted
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Open Vs LaparoscopicA meta-analysis, the American Journal of Gastroenterology 2009 6
12 RCTs, 503 Vs 533 pt (Open Vs Lap)
Results: Favors Laparoscopic approach significantly
Shorter hospital stay (2.68 days)
Faster return to work (7.75 days)
Lower Cx rate (relative odds reduction in 65%)
But…
Comparable Tx failure rate though further surgery rate higher in the Lap group (odd ratio 1.79)
Longer operating time in Lap group (39 mins )6. Am J Gastroenterol. 2009;104(6):1548.
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Laparoscopic Vs Robotic-assisted
RCT Italy, 50 patients, Nissen, Da Vinci system7
ResultsComparable outcomes/ conversion rate/ Cx rate
But in Robotic group…
Significantly longer operating time
Higher cost
7. J Am Coll Surg. 2012;215(1):61.
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Meta-analysis 2010, 11 trials (3 RCTs)
Slightly lower post-operative Cx rate in robotic group
Longer operation time and higher costs
Laparoscopic Vs Robotic-assisted
8. Surg Endosc (2010) 24:1803–1814
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Approach
Laparoscopic fundoplication > Open
Robotic-assisted fundoplication was found to achieve comparable outcome and might be a slightly lower post-operative Cx rate compared to the laparoscopic approach
BUT…The Significant higher cost and longer operative time of the robotic-assisted fundoplication make it LESS cost-effective than laparoscopic approach
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When do we consider antireflux surgery?
Which approach? Open Vs Laparoscopic Vs Robotic-assisted
Total Vs Partial?
Does short gastric vessel division improve the outcomes?
Recent development of endoscopic therapy ? Effectiveness ? Safety?
Questions…
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Total Vs Partial Fundoplication
Variety of fundoplications
Total Vs PartialNissen (total posterior 360)
Toupet (Posterior 270)
Dor (Anterior 180-200)
Belsey (anterior 270)
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Laparoscopic Nissen fundoplication is a popular anti-reflux surgery
Successful rate ~ 90%
Recommended by the European Study Group for Antireflux Surgery in 1997
But…Dysphagia (8-12% ), may require dilation Gas-related symptoms (19%) Especially in those with a pre-operative esophageal dysmotility
Laparoscopic Toupet procedure (posterior 270 deg) as an alternative
Less common x ? Less satisfactory reflux control
Total Vs Partial Fundoplication
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Total Vs Partial Fundoplication
A systematic review and meta-analysis, British Journal of Surgery 20109
Laparoscopic Nissen Vs Toupet
7 RCTs from 1997-2000, at least 12 months FU (up to 60months)
Results:NO sig difference in effectiveness and recurrence (eg. post operative esophagitis, abnormal acid exposure durations or subjective recurrence/ satisfaction )
Significantly HIGHER prevalence of dysphagia (requiring dilatation / surgical intervention) and gas-related symptoms (inability to belch/ gas bloating) in the laparoscopic Nissen group
9. British Journal of Surgery 2010; 97: 1318–1330
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British Journal of Surgery 2010; 97: 1318–1330
Dysphagia
• Post op dilatation and reoperation is also higher in the Nissen group RR : 2.45 and 2.19
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Lap Posterior Vs Anterior Fundoplication
? Laparoscopic anterior fundoplication has an even lower dyphagia rate
Higher recurrence of reflux?
A meta-analysis and systematic review, Annuals of Surgery 10 2011
7 RCTs, 1999-2010
Laparoscopic posterior Vs anterior10. Ann Surg 2011;254:39–47
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Long-term dysphagia scores, inability to belch, gas bloating and satisfaction showed NO significant differentAnn Surg 2011;254:39–47
Lap Posterior Vs Anterior Fundoplication
Result: Lap Posterior> Lap Anterior
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Laparoscopic Toupet > NissenComparable effectiveness and recurrence
But Laparoscopic Nissen was associated with more dyphagia that required intervention (dilatation/ reoperation) and gas-related symptoms
Laparoscopic posterior fundoplication > anteriorBetter heartburn/ acid exposure/ reoperation rate in Lap posterior fundoplication
The short-term benefit of lower dysphagia rate in the Lap anterior fundoplication group disappeared in long term FU (after 12m)
Total Vs Partial Fundoplication
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When do we consider antireflux surgery?
Which approach? Open Vs Laparoscopic Vs Robotic-assisted
Total Vs Partial?
Does short gastric vessel division improve the outcomes?
Recent development of endoscopic therapy ? Effectiveness ? Safety?
Questions…
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Short Gastric Vessel Division
Complication of fundoplication: dysphagia/ gas-related symptoms
Modification of surgery -> Short Gastric Vessel Division (SGVD) in laparoscopic Nissen fundoplication
11. Surg Endosc (2012) 26:970–978
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A meta-analysis, Surgical Endoscopy 201211
5 RCTs, 194 Vs 194 (SGVD Vs No-SGVD)
3 trials FU 1 yr, 2 trials FU 10 yrs
Results:No-SGVD > SGVDNo significant difference in dysphagia/gas-related syms/ effectiveness / conversion rate in both 1yr & 10yrs FUNo-SGVD has a significant SHORTER operative time and length of stay
Short Gastric Vessel Division
11. Surg Endosc (2012) 26:970–978
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When do we consider antireflux surgery?
Which approach? Open Vs Laparoscopic Vs Robotic-assisted
Total Vs Partial?
Does short gastric vessel division improve the outcomes?
Recent development of endoscopic therapy ? Effectiveness ? Safety?
Questions…
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Endoscopic Therapy
Principles:To improve the LOS length and pressure
To remodel the smooth muscles of the GEJ
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Endoscopic Therapy
Endoscopic Radiofrequency (Stretta procedure)
Reduce the postprandial LOS relaxation and GEJ compliance? ?
Fibrosis ?
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Stretta ProcedureSeveral RCTs with Sham-controlled/ cohorts showed ~ 55 to 83 % of patients
Satisfactory symptom control or
Cessation of PPI
Acid exposure/ LES pressure
Durable - Average follow-up of 12 to 33 months (even up to 48m)
Safe, minimal invasive & lower cost
But…Patients selection
Not enough evidence to be comparable with laparoscopic fundoplication
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Endoscopic TherapyEndoscopic sewing and full-thickness
plication
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Endoscopic Sewing
Sham study : symptoms improvement in short-term (3m in EndoCinch 6-9m in plication), but lacking durability
No change in esophageal pH monitoring
Complications: Perforation
Pharyngitis/ chest pain
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Endoscopic Therapy
Transoral Incisionless Fundoplication (TIF), EsophyX
Full-thickness plication to produce a neogastroesophageal valve
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TIFObjective measurement:
Decrease in esophageal acid exposureIncrease in LOS pressure
Subjective measurements:> 50% improvement in QOLs and Heartburn scores in 68% and 75% of patients respectively 12
But…More perforationLacking RCTsLacking long-term evidenceNot much information in the learning curve of the method
1.World J Surg (2008) 32:1676–1688
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ConclusionLaparoscopic fundoplication is more preferable than open and robotic-assisted approach
Laparoscopic Toupet fundoplication has more potential benefits than Nissen
Laparoscopic posterior fundoplication is more effective than anterior fundoplication
SGVD is not suggested to be performed as a routine procedure
Novel endoscopic therapy might be of some benefits but lacking evidence ground
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References1.Am J Gastroenterol 2006;101:1900-202.Gut 2005;54:710-73.Clin Gastroenterol Hepatol. 2006 Apr;4(4):398-407.4.Gastroenterology 2010;138:896-9045.Am J Gastroenterol. 2009;104(3):7526.Am J Gastroenterol. 2009;104(6):1548. 7.J Am Coll Surg. 2012;215(1):61.8.Surg Endosc (2010) 24:1803–18149.British Journal of Surgery 2010; 97: 1318–133010.Ann Surg 2011;254:39–4711.Surg Endosc (2012) 26:970–97812.World J Surg (2008) 32:1676–1688
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Pathophysiology
Hiatus hernia
- Short length of LOS
- Low basal tone
- Transient LOS relaxation
- Sling fibre of cardia
Failed clearance of acid reflux
IGP: obesity, delayed gastric emptying
Diaphragmatic crura
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Diagnosis
HistoryAny hx of typical syms of GERD relieved with PPI is suspicious
InvestigationsOGD
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Esophagitis
Grade A
Grade D
Grade B
Grade C
Los Angeles (LA) Classification
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24Hr pH monitoring
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Manometry
Standard
High Resolution
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Multichannel Intraluminal Impedance
• Resistance of current
• Bolus of food decreases the impedance
• Direction and velocity of food bolus
• With pH monitor / manometry
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Treatment
PPIs > H2R blockers
PPI once-daily dose ? Twice-daily dose?
Symptoms relief and esophagitis healing
SEs of Esomeprazole 1yr:Headache (10% ) Abd pain & diarrhoea (9%) Nausea (6%)
Failure of PPIInadequate response of heartburn on 2x daily PPI
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Predictors of post op outcomes
Factors predictive of dysphagia after laparoscopic Nissen fundoplication.
~ 150 patients, prospective cohorts
Analyse pre op dysphagia/ DeMeester score/ manometry for LOS pressure and length etc
Only the presence of pre operative dysphagia increases the risk of post-operative dysphagia
Surg Endosc. 1999;13(12):1180.
Dis Esophagus. 2009;22(8):656-63.
Does combined multichannel intraluminal esophageal impedance and manometry predict postoperative dysphagia after laparoscopic Nissen fundoplication?
Even with the development of pre op MII with manometry, result doesn’t showed sig predictor of post op dysphagia except pre op dysphagia