Hiatal Hernia Repair, Vagotomy, Gastrectomy for GERD <?xml version="1.0"?><Settings><answerBulletFormat>Numeric</answerBulletFormat><answerNowAutoInsert>No</answerNowAutoInsert><answerNowStyle>Explosion</answerNowStyle><answerNowText>Answer Now</answerNowText><chartColors>Use PowerPoint Color Scheme</chartColors><chartType>Horizontal</chartType><correctAnswerIndicator>Checkmark</correctAnswerIndicator><countdownAutoInsert>No</countdownAutoInsert><countdownSeconds>10</countdownSeconds><countdownSound>TicToc.wav</countdownSound><countdownStyle>Box</countdownStyle><gridAutoInsert>No</gridAutoInsert><gridFillStyle>Answered</gridFillStyle><gridFillColor>0,0,0</gridFillColor><gridOpacity>100%</gridOpacity><gridTextStyle>Keypad #</gridTextStyle><inputSource>Response Devices</inputSource><multipleResponseDivisor># of Responses</multipleResponseDivisor><participantsLeaderBoard>5</participantsLeaderBoard><percentageDecimalPlaces>0</percentageDecimalPlaces><responseCounterAutoInsert>No</responseCounterAutoInsert><responseCounterStyle>Oval</responseCounterStyle><responseCounterDisplayValue># of Votes Received</responseCounterDisplayValue><insertObjectUsingColor>Blue</insertObjectUsingColor><showResults>Yes</showResults><teamColors>User Defined</teamColors><teamIdentificationType>None</teamIdentificationType><teamScoringType>Voting pads only</teamScoringType><teamScoringDecimalPlaces>1</teamScoringDecimalPlaces><teamIdentificationItem></teamIdentificationItem><teamsLeaderBoard>5</teamsLeaderBoard><teamName1></teamName1><teamName2></teamName2><teamName3></teamName3><teamName4></teamName4><teamName5></teamName5><teamName6></teamName6><teamName7></teamName7><teamName8></teamName8><teamName9></teamName9><teamName10></teamName10><showControlBar>Slides with Get Feedback Objects</showControlBar><defaultCorrectPointValue>100</defaultCorrectPointValue><defaultIncorrectPointValue>0</defaultIncorrectPointValue><chartColor1>187,224,227</chartColor1><chartColor2>51,51,153</chartColor2><chartColor3>0,153,153</chartColor3><chartColor4>153,204,0</chartColor4><chartColor5>128,128,128</chartColor5><chartColor6>0,0,0</chartColor6><chartColor7>0,102,204</chartColor7><chartColor8>204,204,255</chartColor8><chartColor9>255,0,0</chartColor9><chartColor10>255,255,0</chartColor10><teamColor1>187,224,227</teamColor1><teamColor2>51,51,153</teamColor2><teamColor3>0,153,153</teamColor3><teamColor4>153,204,0</teamColor4><teamColor5>128,128,128</teamColor5><teamColor6>0,0,0</teamColor6><teamColor7>0,102,204</teamColor7><teamColor8>204,204,255</teamColor8><teamColor9>255,0,0</teamColor9><teamColor10>255,255,0</teamColor10><displayAnswerImagesDuringVote>Yes</displayAnswerImagesDuringVote><displayAnswerImagesWithResponses>Yes</displayAnswerImagesWithResponses><displayAnswerTextDuringVote>Yes</displayAnswerTextDuringVote><displayAnswerTextWithResponses>Yes</displayAnswerTextWithResponses><questionSlideID></questionSlideID><controlBarState>Expanded</controlBarState><isGridColorKnownColor>True</isGridColorKnownColor><gridColorName>Yellow</gridColorName><AutoRec></AutoRec><AutoRecTimeIntrvl></AutoRecTimeIntrvl><chartVotesView>Percentage</chartVotesView><chartLabelsColor>0,0,0</chartLabelsColor><isChartLabelColorKnownColor>True</isChartLabelColorKnownColor><chartLabelColorName>Black</chartLabelColorName><chartXAxisLabelType>Full Text</chartXAxisLabelType></Settings> <?xml version="1.0"?><AllQuestions /> <?xml version="1.0"?><AllAnswers /> Hiatal Hernia Repair, Vagotomy, Gastrectomy for GERD Bill Richards, MD FACS Professor and Chair Surgery University of South Alabama College of Medicine

Mixed Reflux of Gastric and Duodenal Juices is more Harmful to the Esophagus than Gastric Juice Alone Kauer WK et al Ann Surg 222: 525-533 Prevalence of esophageal bilirubin exposure

Antireflux Surgery 1976 Donahue and Bombeck defined a technique of "floppy" Nissen fundoplication (FNF) that prevented experimental pathologic reflux without preventing gaseous eructations or vomiting (normal reflux) when appropriate

LES Pressure Returns to Normal After Laparoscopic Fundoplication Peters JH et al. Ann Surg 1998;228:40-50.

24 Hour pH Studies after Laparoscopic Fundoplication Author # patients pH Negative Follow-up (months) Hinder (87%) 3-12 Hunter (91%) 12 Watson 3 Peters (93%) 21

Does Nissen reduce NonAcid Reflux? 8 patients with Barrett’s 24 hour pH and nonacid relfux - before (on omeprazole 20 mg BID) - after laparoscopic Nissen fundoplication

Acid Episodes Data are shown as median (horizontal line), interquartile range (box), and 5th to 95th percentile (vertical line)

P=0.001 Non-Acid Episodes Data are shown as median (horizontal line), interquartile range (box), and 5th to 95th percentile (vertical line)

Conclusions: Patients with Barrett’s esophagus Nissen eliminates acid and non-acid reflux PPI’s fail to eliminate acid reflux in 33-50% PPI’s do not reduce non-acid reflux

W/u persistent GERD after Nissen Barium swallow Esophageal pH studies On or off PPI Endoscopy Tc 99 scrambled egg gastric emptying study

Obese patient GERD after Nissen Subtotal gastrectomy and Roux-en-Y reconstruction Diverts acid and bile Weight loss reduces IA pressure Improves gastric emptying Improves blood glucose control

Recurrent GERD +Hiatal Hernia after Nissen Never redo same operation Ask yourself why did they fail? Esophageal lengthening Reinforcement of esophageal hiatus

The enemy of Good is BETTER

Selective vagotomy Hemigastrectomy 360 Nissen 60 cm Roux Early and Late Results of the Acid Suppression and Duodenal Diversion Operation in Patients with Barrett's Esophagus: Analysis of 210 Cases Attila Csendes, M.D., et al Selective vagotomy Hemigastrectomy 360 Nissen 60 cm Roux World J. Surg. 26. 566-576, 2002

Nissen V+A Roux Reduces Acid production Pre-OP Post-OP % reduction Basal Acid Volume 40 16 60% Basal acid output mM/hr 4.7 0.2 96% Stimulated Acid Volume 120 47 Stimulated Acid output mM/hr 18 3 84%

Nissen V+A Roux Reduces Bile reflux PREOP N= 56 POSTOP N=22 Normal study 18% 91% Pathologic bile reflux 82% 9% World J. Surg. 26. 566-576, 2002

Nissen V+A Roux Good symptom scores and NO progression of Barrett’s Parameter Primary op N=92 Reop N=54 Total N=146 Visick I 90% 80% 86% Visick II 7% 2% 5% Visick III 3 % 16% 8% Visick IV 1% Dysplasia Adenocarcinoma World J. Surg. 26. 566-576, 2002

Endoscopy after Nissen, V+A, Roux Reconstruction Pre-OP POST-OP Hiatal hernia 72% 2% Erosive esophagitis 81% Esophageal ulcer 86% Esophageal Stricture 26% 3% Length of Barrett’s 73 mm 70 mm World J. Surg. 26. 566-576, 2002

Summary Barrett’s associated with Non Acid and Acid Reflux Non acid and acid reflux can cause esophageal cancer in experimental animals

Summary Nissen significantly reduces acid and non acid reflux PPI’s reduce acid reflux only and normalize 50-80% of patients Nissen V+A with Roux reconstruction Reduces Acid Reduces bile reflux Improves endoscopic findings of stricture, ulcers and esophagitis

Summary There is no proof that Nissen fundoplication can prevent progression to cancer. But Nissen fundoplication is the only modality that can reduce both acid and non acid reflux and has been shown to reverse Short Segment Barrett’s Nissen V +A with Roux reconstruction may prevent progression of dysplasia in Barrett’s