Who, What, and When:

Who are the Patients that Need Surgery and When Should We Intervene?

Andrew S. Wright MD

University of Washington

Center for Videoendoscopic surgery

@andrewswright

Nothing to disclose

SAGES 2015 Disclosure Slide

GERD

• Spectrum of disease

Typical Symptoms

Atypical Symptoms

GERD

• Spectrum of disease

Typical Symptoms

Atypical Symptoms

Esophageal Injury

PEH Pulmonary Disease

GERD

Montreal Definition

“A condition which develops when the reflux

of stomach contents causes troublesome

symptoms and/or complications”

GERD

Montreal Definition

“A condition which develops when the reflux

of stomach contents causes troublesome

symptoms and/or complications”

Definition of Troublesome?

Causes of GERD

Gut. 2014 Jul; 63(7): 1185–1193

Causes of GERD

Gut. 2014 Jul; 63(7): 1185–1193

Note: No mention of abnormal or increased gastric acid secretion

Medical Therapy

Failure of Medical Therapy

• Inadequate Acid Suppression

• Non-acid reflux/regurgitation

• Poor compliance

Failure of Medical Therapy

• Inadequate Acid Suppression

• Non-acid reflux/regurgitation

• Poor compliance

• Incorrect Diagnosis

– Up to 50% of patients with GERD symptoms have no pathologic reflux

Diagnosis

• Upper GI

• 24hr pH monitoring

– 48hr Bravo may be more sensitive

– Role of impedance still unclear

• Manometry

• EGD

Indications for Surgery - 2015

• Failed Medical Management

Indications for Surgery - 2015

• Failed Medical Management

• Desire surgery despite successful management

Indications for Surgery - 2015

• Failed Medical Management

• Desire surgery despite successful management

• Complications of GERD

Indications for Surgery - 2015

• Failed Medical Management

• Desire surgery despite successful management

• Complications of GERD

• Extra-esophageal manifestations

Long-term Surgical Outcomes

92 month FU (6-175)

400 patients

Long-term Surgical Outcomes

Long-term Surgical Outcomes

Long-term Surgical Outcomes• 41% on PPI

• 15/400 reoperations

– 9 recurrent reflux

– 6 side effect of primary operations

Special Case: Barrett’s

82 patientsMedian 8 year FU (1-16)

Special Case: Hiatal Hernia

• Repair of asymptomatic type I (sliding) HH not indicated (+++, strong)

Special Case: Hiatal Hernia

• Repair of asymptomatic type I (sliding) HH not indicated (+++, strong)

• All symptomatic PEH (types II-IV) should be repaired (+++, strong)

Special Case: Hiatal Hernia

• Repair of asymptomatic type I (sliding) HH not indicated (+++, strong)

• All symptomatic PEH (types II-IV) should be repaired (+++, strong)

• Asymptomatic PEH may not be indicated. Consider age and co-morbidities (+++, weak)

– Risk of needing emergent surgery 2%/year

Special Case: Idiopathic Pulmonary Fibrosis

Special Case: Recurrent Disease

Recommendations

• Take a careful history

• Make the correct diagnosis

Recommendations

• Take a careful history

• Make the correct diagnosis

• Be realistic with your patients

– 80% improved at 8 years

– 40% back on PPIs

– 25% side effects (dysphagia, bloat, diarrhea)

– 3% re-operation rate

Recommendations

• Take a careful history

• Make the correct diagnosis

• Be realistic with your patients

– 80% improved at 8 years

– 40% back on PPIs

– 25% side effects (dysphagia, bloat, diarrhea)

– 3% re-operation rate

• Do a Good Operation

“Either partial or complete fundoplication is

acceptable as long as the surgeon constructs the

fundoplication well, and this is the important point:

We, as surgeons or other medical professionals,

have a tendency to blame the operation when we

should blame how the operation was done. A good

operation done badly will lead to poor results.”

- Vic Velanovich

Surgical Technique

SAGES Foregut Group

https://www.facebook.com/groups/SAGESforegut/