The Non-Medical Treatments of the Gastroesophageal Reflux Disease (GERD)

The Non-Medical Treatments of the Gastroesophageal Reflux Disease (GERD)Joint Hospital Grand Round 25.1.2014Prepared by Siu Yin Yu, EvaNorth District Hospital

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

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.

TreatmentLife style modification

Acid-suppressive drugs

Antireflux Surgery

Endoscopic Therapy

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…


Which approach? Open Vs Laparoscopic Vs Robotic-assisted

Total Vs Partial?


Recent development of endoscopic therapy ? Effectiveness ? Safety?

Questions…

Antireflux SurgeryIndications

Patients with esophageal symptoms intolerant of PPIs

For atypical symptoms, no conclusive evidence to support



Total Vs Partial?



Questions…

Antireflux SurgeryVariety of fundoplications

ApproachesOpen

Laparoscopic

Robotic-assisted

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.

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.

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

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



Total Vs Partial?



Questions…

Total Vs Partial Fundoplication

Variety of fundoplications

Total Vs PartialNissen (total posterior 360)

Toupet (Posterior 270)

Dor (Anterior 180-200)

Belsey (anterior 270)

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



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

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

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

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

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?



Questions…

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

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



Total Vs Partial?



Questions…

Endoscopic Therapy

Principles:To improve the LOS length and pressure

To remodel the smooth muscles of the GEJ

Endoscopic Therapy

Endoscopic Radiofrequency (Stretta procedure)

Reduce the postprandial LOS relaxation and GEJ compliance? ?

Fibrosis ?

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

Endoscopic TherapyEndoscopic sewing and full-thickness

plication

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

Endoscopic Therapy

Transoral Incisionless Fundoplication (TIF), EsophyX

Full-thickness plication to produce a neogastroesophageal valve

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

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

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

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

Diagnosis

HistoryAny hx of typical syms of GERD relieved with PPI is suspicious

InvestigationsOGD

Esophagitis

Grade A

Grade D

Grade B

Grade C

Los Angeles (LA) Classification

24Hr pH monitoring

Manometry

Standard

High Resolution

Multichannel Intraluminal Impedance

• Resistance of current

• Bolus of food decreases the impedance

• Direction and velocity of food bolus

• With pH monitor / manometry

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

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

http://www.ncbi.nlm.nih.gov/pubmed/19515186

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The Non-Medical Treatments of the Gastroesophageal Reflux Disease (GERD)