1. The role of surgery in the modern management of dyspepsia
Mr Paras Jethwa Bsc MD FRCS
Surrey & Sussex NHS Trust
and Spire Gatwick Hospital

3. GORD Very significant modern disease High prevalence and incidence
Substantial drug budget
Variable prescribing rationale (everyone in hospital)
Correlation with obesity, diet, alcohol, coffee etc....

4. Mechanics of reflux

5. Treatment Options Lifestyle (smoking.red wine, obesity) PRN Antacids
PRN PPI
Regular PPI (?BD ?Nexium)
OGD (or sooner if red flag)
Addition of antacid for breakthrough (Gaviscon Advanced)
Addition of ranitidine for nocturnal symptoms
? Surgery - refer for pH/manometry

6. What about the guidelines?
significant number were mis-referred
(i.e should have been urgent)
2% incidence of OG cancer
98% sensitive

7. Barrett’s

8. Intestinal Metaplasia
Both endoscopic and histological diagnosis
Caused principally by uncontrolled acid reflux
Confers an increased risk of oesophageal cancer of x
Rapidly rising incidence
Oesophageal Cancer 5th commonest cause of cancer mortality in the UK

9. Current treatment Treatment dose of a PPI Consider NSAIDs/ Aspirin
Surveillance
Duration
Interval
Aneuploidy/tetraploidy
Anti reflux surgery
Oesophagectomy for HGD or Cancer

10. Surveillance limitations
Surveillance probably doesn't work
Time consuming, inaccurate, distressing for patients, expensive
Lack of an easily identifiable high risk group?

11. Current risk markers High Grade Dysplasia:
Patchy and easily missed
On average HGD occupies only
1.3cm2/ 32cm2 of Barrett’s
Variable Future Cancer risk:
13-59% develop Cancer within 5 years
40% of cancer patients not found to have prior HGD
Aneuploidy:
If no HGD or aneuploidy tiny risk (approaching 0%) of developing cancer in next 5 yrs (87% of patients)
If aneuploidy risk of 38%
If aneuploidy and HGD risk is 66%
Panel of biomarkers:
Ultimately this will be the answer
Still in research setting

13. Long term effects of GORD
PEPTIC STRICTURE

14. Anti reflux procedures
UK lags behind Australia and South Africa
Determined by healthcare funding(?)
Poorly accepted by some gastroenterologists
Perception of a high risk/limited procedure
May be underused in high risk groups and in younger patients
Can offer a significant improvement in QoL

15. Surgical correction
R CRUS
OESOPHAGUS
L CRUS

16. Effect of operation

18. Who should you consider referring?
Clear indication:
Poorly controlled symptoms
Hiatus hernia causing dysphagia +/- reflux
Young patients with IM/marked oesophagitis
Intolerant of conventional therapy
Mass reflux
Respiratory compromise
Probably not for:
Reasonable control with occasional flare-ups

19. Cost of therapy Drug Dose Cost (£, 28 days) Annual(£) Omeprazole 20mg
28.56
571.2
Lansoprazole
30mg
£23.75
712.5
Pantoprazole
40mg
£23.65
946
Rabeprazole
£22.75
455
Esomeprazole
£18.50
370
£28.56
1142.4

20. Is it cost effective?
(1) The REFLUX Trial (first reported in BMJ 2009)
“The effectiveness and cost-effectiveness of minimal access surgery amongst people with gastro-oesophageal reflux disease - a UK collaborative study”.
Mean cost of Surgery: £ £4000
But - need to add cost of testing (OGD/pH/manometry) & loss of work etc.
Significant QOL improvement at 12 months+ (SF36)
(2) Systemic review 2011 Surg endoscopy Thijssen et al.
Four publications were suitable, Jan 1990 to 2010
Surgery more expensive in n=3;
Better QALY in n-=2, fewer symptoms n=1
C.E. - inconclusive - slight improvement in QALY

21. (3) Fundoplication vs medical management in adults for GORD - Cochrane review 2010
Four trials elligible n=1232
Significant improved QOL in surgical group
% of patients have post op dysphagia
Surgery risk uncommon but not without it’s risk
Cost greater - based on 1st year of treatment only.
Need to consider the long term effect of GORD
Summary
Improved QOL/QALY
but ££ at one year

22. Surgical considerations
BMI <35 (men store fat at GOJ) woman up to 40
(Similar area to LAGB placement)
Reasonable health/respiratory compromise
No major motility issues (HRM/Ba swallow)
Hiatus hernia/OGD proven reflux without pH studies
Psychological onlay/effect of dietary change
Physiological studies

23. pH Studies Only method of objectively proving reflux
In cases of odd symptoms/symptom correlation
Pre/Post operative comparison
Medico legal aspects
Bravo or conventional systems

24. Results of surgery Three types of wrap commonly performed:
180< 270 < 360
Progressively better but increase risk of dysphagia & gas bloating
Tension free wrap with good crural closure
>85% report major improvement at 5 years
pH retesting - no one with abnormal profile
Not uncommon to return to some medication

25. Complications & SE Dysphagia - acute revision Gas bloating
GI dysmotility (non vagal)
Recurrent symptoms
Injury (GOJ/vagus/spleen/other)

26. Advanced technique - presented in Europe and UK
Largest series of mesh reinforced hiatal closures
Common practice at ESH/Spire

27. Advances Improved training & simulation
Emphasis on dedicated laparoscopic service
Improvement in HD systems/integrated theatre
Anaesthesia and pain control
Improved instrumentation
Enhanced recovery protocols
3D laparoscopy/robots/NOTES/SILS

28. SASH 4 dedicated Laparoscopic specialists - laparoscopic surgery has become a speciality in itself. Very latest laparoscopic facilities and optics. SASH recognised as a high quality training centre amongst KSS trainees Links to Imperial College

29. The role of surgery in the modern management of dyspepsia
Mr Paras Jethwa Bsc MD FRCS
Surrey & Sussex NHS Trust
and Spire Gatwick Hospital