gastroesophageal reflux disease pathophysiology and treatment
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Gastroesophageal Reflux DiseasePathophysiology and Treatment
George Ferzli, M.D., FACSProfessor of Surgery, SUNY Health
Science Center at Brooklyn
Department of Laparoscopic Surgery, Staten Island University Hospital
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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.
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Incidence of presenting symptoms experiencedas a percent of all patients in study (n=198)
Heartburn 80%Regurgitation 68%Dysphagia 38%Resp. symptoms 27%Chest pain 10%Abdominal pain 10%Nausea or vomiting 7%Belching 6% Bleeding 5%
Hinder, RA, et al: Laparoscopic Nissen Fundoplication is an effective treatment for GERD. Annals of Surgery 220, No. 4
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Definition
It is increased exposure of the esophagus to gastric and / or duodenal secretions
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Etiology
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Protective Mechanisms
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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
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Goals of Treatment
Eliminate symptomsHeal esophagitisManage or prevent complicationsMaintain remission
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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
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Medical Management
• Esophagitis will heal in 90% of cases
• Doesn’t address etiology of GERD
• 80% recur within one year of stopping therapy
• Alkaline injury may continue to occur
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Lifestyle modification non-compliance
Antacids poor long-term control
Prokinetic agents no esophageal healing
H2 Blockers short-term good resultslong-term 50% recur
Proton pump inhibitors good healing, ?safetyrapid relapse
Pitfalls of Medical Management
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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
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What is the next step???
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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) Barrett’s esophageal metaplasiae) Lifestyle choice (avoid long-term use of
medicines)
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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
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Surgery vs. Medical TherapyStudy 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
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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
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Work-up
• 1) Barium swallow– Not diagnostic– Presence and size of hiatal hernia– Presence of stricture– Length of esophagus
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Laparoscopic Paraesophageal Hernia Repair
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Paraesophageal Hernia RepairSymptomatic Outcomes
0
20
40
60
80
100
Excellent/Good Fair/Poor Satisfied
% p
atie
nts
Laparoscopic (n=26) Open (n=25)
Hashemi et al, J Am Coll Surg 2000;190:553-561
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Paraesophageal Hernia RepairTechnique and Recurrence
0
5
10
15
20
% R
ecur
renc
e
PTFE mesh (n=17) No mesh (n=18)
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
•Follow-up for 6 months
Frantzides CT et al, Surg Endosc (1999) 13: 906-908
16%
0%
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Paraesophageal Hernia RepairSummary
• 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
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Work-up
• 2) EGD– Presence of esophagitis– Presence and the type of hiatal hernia– Esophageal length– Presence of Barrett’s, dysplasia or cancer– Presence of stricture
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Laparoscopic Nissen For Barrett’s
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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
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Long-Term Outcome of Antireflux Surgery in Patients With Barrett's Esophagus
• 44% regression of low-grade dysplasia to nondysplastic Barrett’s
• 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
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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 Barrett’s in whom dysplasia did not develop
• Patients were evaluated with clinical questionnaire, multiple EGD and biopsy, and 24-hour pH and bilirubin monitoring
Csendes A et.al. Annals of Surgery,235(2),p.178-185,Feb.2002
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Results Visick Visick I-II (n=52) III-IV (n=74)
Dysplasia (n=17)
Adenoca. (n=4)
Symptoms 0% 95% 82% 100%
Length of Barrett’s (mm)
65 68 77 65
Incompetent LES
21% 61% 70% 100%
Pathologic acid reflux
12.5% 96% 93% 100%
% time with bilirubin
5.3+1.6% 30.9+19% 86% -
Csendes A et.al. Annals of Surgery,235(2),p.178-185,Feb.2002
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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 Barrett’s 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
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Barrett’s Esophagus Can and Does Regress after Antireflux Surgery
• 91 patients with symptomatic Barrett’s esophagus: 77 treated with surgery and 14 with proton pump inhibitors
• 28 of 77 (36.4%) after surgery had histologic regression of Barrett’s
• 1 of 14 patients (7.1%) had regression with medical therapy
• Patients with Barrett’s 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
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Work-up
• 3) Manometry– Not diagnostic– Esophageal body motility– LES function– LES position
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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.
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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
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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
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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
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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
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Proper diagnostic workup is essential. It may alter the algorithm of management
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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 Barrett’s 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
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Proper preoperative workup will help manage recurrent postoperative symptoms
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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
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Take home message: In order to achieve good postoperative results, there must be a thorough preoperative workup