this presentation describes the pathophysiology and presentaion of gastroesophageal reflux disease. It also discusses the medical and surgical management of gastroesophageal reflux disease. What makes this presentaion unique is that it also explains the short and long term effects of antireflux surgery and patient's satisfaction with surgery with references.

1. Gastroesophageal Reflux Disease
and Antireflux Surgery
Dr Hasan Muhammad Saeed
PGR Surgical Unit-1
Services Hospital, Lahore

2. Learning Objectives
 Understand the natural history of reflux disease
 Understand how to identify candidates for antireflux surgery
 Understand the complications of antireflux surgery and
patient’s satisfaction with surgery

3.  10% of US adults report heartburn daily and 40% monthly
 More than 40,000 antireflux operations performed yearly in the US
 GERD is a strong risk factor for adenocarcinoma of the esophagus
 $ 6-13 billion annual sales for PPIs (up to 6 times the yearly sales of
McDonald’s, Burger King, Taco Bell, Pizza Hut and Kentucky Fried Chicken)
 Frequency and severity does not predict esophagitis, stricture or cancer
development
Why Care?

5. Definition of GERD
 Montreal consensus panel (44 experts):
“a condition which develops when reflux of stomach contents
causes troublesome symptoms and/or complications”
 Troublesome- Patient gets to decide when reflux interferes
with lifestyle.

6. Clinical Presentation
 Heartburn
1-2 hours after eating, often at night, antacid relief
 Regurgitation
Spontaneous return of gastric contents proximal to GEJ; less
well relieved with antacid
 Dysphagia- difficulty in swallowing should prompt search for
pathological condition

7. Clinical Presentation
 Atypical Symptoms (20-25%)
Cough
Hoarseness
Asthma
Non-cardiac chest pain

8. Diagnosis
 Diagnosis based on symptoms alone is correct only
in 2/3rd of the patients
 Differential (ALL CAN KILL YOU)
Achalasia
Diffuse esophageal spasm
Other esophageal motility disorders
Ulcer disease
Cancer
Coronary artery disease

9. Norerosive disease
Erosive disease
Barrett’s esophagus
Esophageal Adenocarcinoma
Spectrum of disease theory

10. Pathophysiology of GERD
 Normally, gastric contents don’t back up into the esophagus because
LES creates enough pressure around the lower end of the esophagus to
close it
 Reflux occurs when LES pressure is deficient or pressure in the stomach
exceeds LES pressure
 When this happens, the LES relaxes, allowing gastric contents to
regurgitate into the esophagus

11.  The acidity of gastric content and amount of time in contact with the
esophageal mucosa are related to the degree of mucosal damage
 Extension of inflammation into muscularis propria causes progressive
loss in length and pressure of LES-- esophageal shortening
 Loss of LES leads to regurgitation, heartburn and subsequent severe
esophagitis
Pathophysiology of GERD

12. Predisposing factors
 Pylorus surgery (alteration or removal of the pylorus), which
allows reflux of bile and pancreatic juice
 Nasogastric intubation for more than 4 days
 Hiatal hernia with incompetent sphincter
 Any condition or position that increase intraabdominal pressure

13. complications
 Esophagitis (mucosal injury) with or without heartburn
 Reflux chest pain syndrome
 Respiratiory complications
 Metaplastic and neoplastic complications

14. Reflux chest pain syndrome
 Heartburn without esophagitis
 Bile salts inhibit pepsin
 Acidic pH inactivates trypsin
 Pain comes from acidic gastric juice breaking mucosal barrier and
irritating nerve endings

15. Respiratory Complications
 Reflux and aspiration of gastric contents induces asthma
 Correlation between hiatal hernia and pulmonary fibrosis
 Pathologic acid exposure often seen in proximal esophagus in
patients with asthma
 Simultaneous esophageal and tracheal pH shows acidification of
trachea in concert with esophagus

16. Metaplastic and Neoplastic Complications
 Norman Barrett (1950) first described the process whereby the
esophageal squamous epithelium changes to columnar epithelium
 Occurs in 7-10% of patients with GERD
 Factors predisposing to Barrett’s
Early onset GERD
Abnormal LES or motility disorder
Mixed reflux of gastric and duodenal contents
 Barrett’s metaplasia harbors dysplasia in 15-25% patients
 High grade dysplasia in 5-10% of the patients

17. Mangement

18. Lifestyle Modifications
Educate about lifestyle modifications that may alleviate symptoms
Smoking, alcohol and caffeine cessation
Avoid meals before bedtime
Elevate head of bed
Weight loss if patient obese
Start treatment with Proton Pump Inhibitors
Arrange for follow-up visit

19. Medical Therapy
 Acid suppression is the mainstay of GERD treatment today
 70-90% of patients will experience relapse within 12
months of healing of acute disease without prophylactic
medical treatment
 Agents used
 Proton Pump Inhibitors
 Histamine blockers
 Prokinetic agents

20. Histamine blockers
 Reversible competitive blockade of H2 receptors of the parietal
cell
 Acid suppression by 70%
 Esophagitis healing rates up to 70%
 Healing rates dependent on dosage, treatment duration and
severity of disease
 Ranitidine, cimetidine, famotidine, nizatidine

21. Proton Pump Inhibitors (PPI)
 Most effective available pharmacologic agent for GERD
 Acid suppression by 99%
 Esophagitis healing rates 80-100%
 Inhibit H+
/K+
ATPase enzyme system on parietal cells
 Omeprazole, lansoprazole, rabeprazole, pantoprazole, esomeprazole

22. Indications for surgery
 Patients with incomplete symptom control or disease progression on
PPI therapy
 Patients with well-controlled disease who do not want to be on life-
long antisecretory treatment
 Patients with proven extra-esophageal manifestations of GERD like
cough, wheezing, aspiration, hoarseness, sore throat, otitis media, or
enamel erosion.
 The presence of Barrett esophagus is a controversial indication for
surgery

23. Predictors of Successful Outcome
• Typical symptoms
• Clinical response to acid suppression therapy
• Abnormal 24-hour pH score
Campos et al. J Gastrointest Surg 1999;3:292-300.
Factors Present “Excellent” Outcome
3 97%
2 75% - 85%
1 50%

24. Preoperative Investigations
 Edoscopy
 24 Hour ambulatory pH monitoring
 Radiograph
 Esophageal and gastric body function

25. Preoperative Evaluation:
Endoscopy
 Amount to the physical examination
 Strictures and large hiatal hernia may indicate shortened
esophagus
 High-grade dysplasia or a mass in the esophagus, gastric or
duodenal lumen will change management

27. 24 Hour pH Monitoring
 Rationale: gold standard for diagnosis of GERD
 Quantifies actual time the esophageal mucosa is exposed to gastric juice
 Measures the ability of esophagus to clear refluxed acid
 Correlates esophageal acid exposure with patients’ symptoms
 Without abnormal pH study, surgery is unlikely to benefit

28. Swallow Study
 Only 40% of patients with classic symptoms of GERD will have
reflux observed on radiography
 Assess for
Esophageal shortening
Hiatal hernia (80%)
Paraesophageal hernia
Stricture or obstructing lesion
Beading or corkscrewing (motility disorders)

29. Sliding hiatal hernia with
narrowed sphincter and crural
opening
Sliding hiatal hernia with lax
sphincter and diaphragm is wide
open

31. Manometry
 Measure the length and pressure of the LOS and
assess motility in the body of the oesophagus during
swallowing
 Rules out esophageal motility disorders
 Esophageal body dysfunction (achalasia or aperistalsis)
should change management

32. Surgery
 Works by restoring the barrier function of the LES
 Careful selection of patients with well documented GERD is imperative
 Laparoscopic fundoplication is considered the gold standard in antireflux
surgery
 Number of cases risen exponentially

33. Goals of Surgery
 Prevent significant reflux
 Improve quality of life
 Minimize complications
(dysphagia)

34. Fundoplication
 The most common antireflux operation is the laparoscopic fundoplication
 Crural dissection, identification and preservation of both vagi
 25% have left hepatic artey coming from left gastric artery in the
gastrohepatic ligament
 Circumferential dissection of esophagus
 Restoration of 2-3 cm of intraabdominal esophageal length

35. Fundoplication
 Elements of laparoscopic Nissen
 Crural closure
 Fundic mobilization by division of short gastrics
 Creation of short, loose fundoplication by enveloping
anterior and posterior wall around lower esophagus

38. Patient Satisfaction
 Patient satisfaction is high (86-97%)
 Long term symptom (heartburn and regurgitation) relief in 84-97%
 Symptomatic failure rates (3-13%)
Heartburn and regurgitation
Does not correlate with acidic reflux exposure
 Operation did nothing for 3-13%!
Surgeon, August 2009:224.

39. Complications
 Review of 10,489 laparoscopic antireflux procedures
 Bloating and increased flatulence (9-53%)
Most common side effect
 Dysphagia 20%
 Wrap herniation (early) 1.3%
 Pneumothorax 1%
 All others <1% (perforation, hemorrhage, pneumonia, abscess, splenic
injury, trocar hernia, effusion, pulmonary embolism, ulcer, atelectasis,
wound infection, MI, splenectomy)
JACS 2001: 193(4);428-39
Surgeon, August 2009:224.

40. Persistent side effects (>1 month)
Bloating 9%
Reflux 4%
Dysphagia 3%
JACS 2001: 193(4);428-39
Surgeon, August 2009:224.
Complications

41. After a Decade
 10 Year follow up of 250 patients
 83% highly satisfied with outcome
 84% had good or excellent control of heartburn
 17% revision operation (usually 3-7%)
Recurrent hiatal hernia, dysphagia, reflux, bleeding (early takeback protocol
for dysphagia)
 21% used acid-suppressive medication
JACS 2007;205:570

42.  Use of acid-suppressive medication after antireflux
surgery varies (21-62%)
 But only 20-30% with “reflux like” symptoms after surgery
have positive pH studies
JACS 2007;205:570

43. Randomized Trial
 Randomized trial comparing treatment of GERD with omeprazole and
antireflux surgery
 Treatment success- no symptoms or esophagitis
 67% surgical
 47% medical
 Dysphagia, bloating, rectal flatulence common in surgical group
British J Surg 2007;94:198.

44. Cancer Risk
 Cancer risk in patients with reflux symptoms is <1 in 10,000 patients
per year
 No benefit to avoidance of Barrett’s or adenocarcinoma with
surgery compared to PPI therapy
 Low morbidity and mortality risks associated with laparoscopic
antireflux surgery dwarf potential benefit of avoiding cancer
Gastroent 2008;135:1392.

45. What does all of this mean, should I have surgery or
not?
 Surgery wins over PPI’s if you don’t mind trading heartburn and
regurgitation for bloating, inability to belch, and excessive
flatulence
 Not in everybody, BUT IT COULD BE YOU!
 Nevertheless, 86-97% of patients are satisfied with surgery.
Gastroent 2008;135:1392.

46. Complete vs. Partial Wrap
 Complete fundoplication offers superior protection to reflux
 Increased incidence of dysphagia, inability to belch, and excessive
flatulence
 Partial wrap offers lesser protection against reflux, but also lesser
symptoms
 Up to 51% may have pathologic esophageal acid exposure on 24 hour pH
monitoring
Surg Endos 1997;11:1080

47. Complete vs. Partial Wrap
 Complete now considered superior to partial even in patients with
weak esophageal peristalsis
 Exceptions:
 Achalasia- anterior wrap utilized with myotomy
 Aperistalsis (i.e, Scleroderma)

48. Antireflux Surgery in Reflux
Induced Asthma
 Once reflux induced asthma is established, PPI therapy is
instituted
 25-50% patients have relief of respiratory symptoms
 <15% have improvement in pulmonary function
 Antireflux surgery
90% have improvement in pulmonary function
33% of children and 70% of adults have relief
Am J Gastroenterol 2003;98:987

49. Barrett’s esophagus can and does regress after
antireflux surgery: a study of prevalence and predictive
factors
Gurski RR et al. J Am Coll Surg 2003; 196(5):706-712.
 Retrospective review
 91 patients with symptomatic Barrett’s
 77 had surgery, 14 on PPI
 Histopathologic regression occurred in 36% (surgery) vs. 7% (PPI; p<0.03)
 On multivariate analysis short segment BE and type of treatment were
significantly associated with regression
 Median time to regression 18.5 months

50. Does a surgical antireflux procedure decrease the
incidence of esophageal adenocarcinoma in
Barrett’s esophagus?
 Meta-analysis: 1247 abstracts reviewed published 1966-2001, 34
included
 4678 (surgical) vs. 4906 (medical) patient-years follow-up
 Cancer incidence 3.8/ 1000 patient-years (surgical) vs. 5.3/ 1000
(medical; p=0.29)
 Also no significant difference in last 5 years
 Antireflux surgery in the setting of BE should not be recommended as
an antineoplastic measure
Corey KE. Am J Gastroenterol 2003; 98(11):2390-2394.

51. Summary
 PPI’s work to control symptoms and esophagitis, but require life long
treatment
 Successful antireflux surgery is based on abnormal 24 hour pH score,
typical GERD symptoms, and symptomatic improvement in response to
acid-suppression therapy
 Surgery is a very effective treatment of GERD with symptom resolution in
over 90% of patients and excellent quality of life

52.  Randomized studies document superior efficacy of surgery compared to
PPI in controlling the disease in the short-term but there are concerns
that in the long-term some patients may need to go back on PPI therapy
 Having antireflux surgery is patient-centered decision with a benefit:risk
ratio that can only be weighed by the patient
Summary