1. Minimally Invasive Techniques for GERD
Joseph P. Regan, M.D.

2. GERD: Definitions Reflux of gastric contents above GE junction
Associated with incompetent valve, hiatal hernia
Chronic disease involving symptoms at least twice per week
Heartburn is most common symptom
Chest pain, regurgitation, cough, asthma symptoms, dysphagia also common

3. GERD: Anatomy

4. GERD: Definitions
Associated with obesity, pregnancy, smoking, consumption of chocolate, caffeine, alcohol, and peppermint
Complications can include esophagitis, esophageal stricture, respiratory issues, Barrett’s esophagus, adenocarcinoma of esophagus

5. GERD: Definitions 60 million adults have symptoms once per month
15 million adults have daily symptoms
15% of adults have chronic symptoms
20 million adults take PPI regularly
50% increase in double dose PPI scripts in last 7 years
42% PPI users supplement their scripts
30% PPI users dissatisfied with therapy
$15 billion in direct healthcare costs for GERD

6. GERD: Definitions Lifestyle changes Medications Decrease meal size
Eliminate late eating
Weight control
Quit smoking
Elevate bed from below
Medications
Antacids
H2 blockers
PPIs

7. GERD: Definitions Patient concerns regarding GERD
Quality of life issues
Use of internet
Increasing rates of Barrett’s and adenocarcinoma at GE junction – 2.5-fold increase in incidence since 1970
Long term and inappropriate use of PPIs
Recent reports on osteoporosis, chronic renal failure, dementia

8. GERD: Diagnosis
Abnormal EGD
Typical symptoms
Abnormal pH study

9. Hiatal Hernia

10. Hiatal Hernia and Hill Grade

11. GERD: Anatomical Considerations

12. GERD: Montreal Definition/Classification

13. GERD: Historical Perspective
1800s - confusion regarding reflux disease
Examples include heartburn, cardia portion of stomach, cardiospasm, biliousness, dyspepsia
Early 1900s - recognized relationship of acid and esophagitis
Winkelstein s - gastroenterologist at Mount Sinai in NYC - first detailed description of esophagitis
Barrett s in London - first description of peptic esophagitis and ectopic gastric mucosa

14. GERD: Historical Perspective
Development of diagnostic and treatment stategies
Early 1900s – barium studies and rigid endoscopy
1960s – flexible endosocopy
1970s – manometry and pH probes, use of H2 blockers
1980s – use of PPIs
1950s – first Nissen fundoplication in Germany
1991 – first laparoscopic Nissen in Canada and Belgium

15. GERD Procedures Laparoscopic Nissen fundoplication
TIF procedure – transoral incisionless fundoplication
LINX procedure – laparoscopic magnetic augmentation of GE junction

16. Nissen Fundoplication

17. Toupet Fundoplication

18. Nissen Fundoplication
National Inpatient Sample
9,173 procedures in 1993
32,980 procedures in 2000
19,668 procedures in 2006
Concern for postop complications and durability, increase in bariatric surgery, new endoscopic techniques, PPIs available over the counter
Patients undergoing Nissen fundoplication are older, have longer LOS, and higher morbidity and mortality
Dis Esophagus 2011;24:

19. TIF Procedure
Endoscopic device (EsophyX2) used to create 2-3cm 270 degree fundoplication
EndoGastric Solutions based in Redmond, WA
Uses deployment of polypropylene H-shaped fasteners
Under direct vision using endoscope

20. TIF Procedure First developed in Belgium – Prof. Cadiere
FDA approved in September 2007
17,000 cases world-wide
AMA granted level 1 CPT code as of January 1, 2016
Requires general anesthesia with less than 1 hour length of procedure
Discharge same day versus overnight stay

21. TIF Procedure

22. TIF Procedure

23. TIF Procedure

24. TIF Procedure

25. TIF Procedure Candidates for TIF Failure of medical management
Fear of long term PPI use
Breakthrough symptoms
Hiatal hernia <2cm
BMI <38
Classic symptoms including regurgitation, response to PPI
Atypical symptoms

26. TIF Procedure Confirmation of GERD EGD pH study – Bravo/impedance
Lack of motility disorder
Manometry
Barium study

27. TIF Procedure Two-year outcomes from 127 patients at 14 centers
No serious adverse events
Quality of life and regurgitation scores improved by 50% or greater in 66% of patients
Reflux symptom index score improved in 65% of patients
Daily PPI use decreased from 91% to 29%
2/3 patients had symptom control
75% (12/16) had resolution of esophagitis and 57% (8/14) had normal esophageal acid exposure
Am Surg 2014;80:

28. LINX Procedure
Laparoscopically placed magnetic augmentation of the lower esophageal sphincter
Torax Medical based in Shoreview, MN
5 different sizes of linked magnets

29. LINX Procedure Company founded in 2002 FDA approved in 2012
Over 4000 cases in 6 countries
AMA granted level 1 CPT code to take effect January 1, 2017
Requires general anesthesia with less than 1 hour length of procedure
Discharge same day versus overnight stay

30. LINX Procedure

31. LINX Procedure

32. LINX Procedure

33. LINX Procedure Candidates for LINX Failure of medical management
Fear of long term PPI use
Breakthrough symptoms
Hiatal hernia repair at same time
BMI <38
Classic symptoms including regurgitation, response to PPI
Atypical symptoms

34. LINX Procedure Confirmation of GERD EGD pH study – Bravo/impedance
Lack of motility disorder
Manometry
Barium study

35. LINX Procedure Easily explanted
Device is MR Conditional with static magnetic field up to 1.5-Tesla
Goal is to improve the barrier function of the esophageal sphincter without altering gastric or hiatal anatomy or interfering with swallowing, belching, or vomiting

36. LINX Procedure Five-year results from 100 patients No adverse events
Significant improvement in quality of life scores
85% off PPI
Moderate to severe regurgitation rates decreased from 57% at baseline to 1.2% at 5 years
Dysphagia present in 6% at 5 years
Gas bloat decreased from 52% at baseline to 8% at 5 years
Clinical Gastroenterology and Hepatology 2015;15:763-6.

37. Sleeve Gastrectomy

38. Roux-en-Y Gastric Bypass

39. Development of Sleeve Gastrectomy
2008 U.S. bariatric surgery
67% gastric bypass
24% Lap-Band
1% sleeve gastrectomy
2012 U.S. bariatric surgery
56% gastric bypass
36% sleeve gastrectomy
4% Lap-Band

40. Sleeve Gastrectomy and GERD
919 patients underwent sleeve gastrectomy
4% diagnosed with postop GERD
3% with de novo GERD
1% with pre-existing GERD
96% with de novo GERD responded to meds
77% with pre-existing GERD responded to meds
4 total patients converted to gastric bypass secondary to GERD
Surg Obes Relat Dis 2015 (Epub).

41. Summary GERD is increasing in incidence
Dramatic increase in PPI use, but with concerns for long term use
Minimally invasive options for GERD to improve barrier function at the esophageal sphincter include Nissen/Toupet fundoplication, TIF, and LINX
TIF and LINX have both been shown to be safe and provide durable symptom relief over short term
Appropriate patient selection and work-up are critical
Obese patient with GERD may require bariatric surgery

42. Development of CSM Reflux Center
Centralized phone number – (414)
Website development
Nurse coordinator
Preoperative GI conference
Coordinated insurance preauthorization
Informational seminars
Dietitian support
Plan for marketing and promotion