1. Gastro-esophageal Reflux Surgical Management Fahad Y. Bamehriz, MBBS, SBIS

2. Introduction GERD is a chronic disease of upper GI tract as a cause of complex mechanisms defects, resulting in back flow of gastric contents to the esophagus, that presents with GI and extra-GI manifestation. affecting up to 40% of people in the Western world.

3. Mechanisms for GERD By Orlando R, 1- TLESR 2- Hypotensive or incompetent LES 3- Anatomic disruption of EGJ. Refluxate material: - Acid - Bile - Gas

4. Aim of treatment –Control acute GERD symptoms –Maintain the control –Prevent long-term complications

5. Mechanism of action of fundoplication

6. Surgical options

7. Nissen’s fundoplication

8. X-ray picture

9. Partial Toupet (posterior)fundoplication

10. Partial Anterior (Dor) fundoplication

11. Nissen Fundoplication

12. Step 1

13. Step 2

14. Step 3

15. Step 4

16. Step 5

17. Step 6

18. Step 7

19. Step 8

20. Picture of a partial ‘Toupet’ fundoplication

21. Partial Anterior (Dor) fundoplication

22. Peri-operative information OR time is 1houre Less pain medication Hospital stay is 1 day Back to regular activity within 5-7 days

23. Cosmetic appearance open Laparoscopic

24. Complications Complications, during or the after the operation in 5- 15% of cases Serious problems is around 2-8% of patients, with around 2% requiring a new operation Difficulties swallowing persist for longer than 3 months in only 10%. After 1 year, it’s around 2% Diffuse abdominal complaints Thee is about a 10% risk of reflux disease reoccurring Despite all the risks to be taken into consideration, the fact remains that in around 90% of reflux cases a long- lasting cure of reflux disease can be achieved. Difficulties swallowing

25. Clinical data 1 Dallemagne B et al (Surg Endosc. 2005 Dec 5):Dallemagne B 100 consecutive patients who underwent LAS by a single surgeon in 1993 Evaluations of the outcome were made 5 and 10 years after surgery At 5 years, 93% of the patients were free of significant reflux symptoms. At 10 years, 89.5% of the patients still were free of significant reflux (93.3% after Nissen, 81.8% after Toupet). The GIQLI scores at 10 years were significantly better than the preoperative scores of the patients under medical therapy with proton pump inhibitors. Four patients underwent revision surgery: one patient for persistent dysphagia and three patients for recurrent reflux symptoms

26. Clinical data satisfRECDyspF/UPt 93%10%5.1%>5y13402005Pessaux 91%12% 5 y1412005Dan S 95%2%5%5y892005Pointner R 94%21%2%4y932005Tucker L 89%12%5 %5y10232004Anvari/b amehriz 96%3pt1 pt10y1002005Dallema gne B

27. Clinical data 2 Beher and colleagues (NEJM-1975), surgery is superior to antacid therapy. Spechler and coworkers (NEJM-1992), surgery is superior to H² blockers. Lundell (J Am Coll Surg-1999), surgery is superior to PPI therapy

28. Clinical data 2 Mahon D (Br J Surg-2005), surgery is superior to PPI therapy. Olberg P (Scand J Gast-2005), surgery is more effective than medical care. Cookson R( Br J Surg-2005), surgery maybe cost saving after 8 years compared to PPI maintenance therapy

29. GERD& Barrett’s esophagus Surgical therapy: –Controls symptoms of GERD –Controls acid & bile reflux –May prevent or slow progression –May cause regression

30. Clinical data Pope et al (N Eng J Med-1980), complete regression of IM in 4/10 patients. Low et al (Am J Gastr-1999), Complete regression in 2/14 pt partial regression in 10/14 pt Disappearance of dysplasia in 4/14 pt De Meester (Ann Surg-1998), Complete regression and loss of IM in 4.4%

31. Clinical data Ortiz and colleagues (Br J Surg-1996), Randomized 27 pt (M) + 32 pt (S) Follow-up 5 years Regression of IM: 2/27 pt of medical arm 8/32 pt of surgical arm. Mc Callum et al (Gast-1991). Katz et al (Am J Gas-1998)

32. GERD & Pregnancy Two thirds of pregnant pt develop HB ? Progesterone, ? High intra A pressure Al-Amri SM (Eur J Obstet Gynecol Reprod Biol. 2002 ),Al-Amri SM Pregnancy is associated with decreased LES pressure, more frequent episodes of reflux and upright reflux.

33. Clinical data Bamehriz (Surg End-2005), of 146 child-bearing age women, 25 pt became pregnant after LNF 5of 25 patients (20 %) developed dyspepsia during their pregnancy 1 patient (4%) developed acute intra-thoracic herniation of the stomach However, for majority laparoscpic Nissen fundoplication provides effective control of their reflux symptom during and after pregnacy

34. GERD &TLESR TLESR cause 70-100% of reflux episodes in normal person. 63-74% in GERD pt. PPI has no effect on TLESR Bamehriz et al (Surg Endo-2004), 73 pt with GERD +TLESR TLESR is significantly reduced to a mean number of 0.19 per pt from 2.4 per pt Only 8/73 pt had TLESR post LNF

35. LNF & NERD Kamolz,Pointner et al (Surg End-2005), - 89/500 pt had NERD who underwent LNF -Compared with EGD-positive GERD pt -Follow-up was 5 years -GIQLI was significantly better in NERD pt

36. GERD & Cough Anvari et al (Surg Endo-2005), - 209 pt had GERD+ cough, underwent LNF -60% has 5 years follow-up -Cough improved in 71% of pt at 5 years -LNF is successful in the long-term control of GERD-related Cough.

37. Redo fundoplication MORTAL ITY CONVE RSION FOLLO WUP Pt number 0.4%10%3 Y225Pointner R 020%2Y10Richard son WS 07%2 Y28Bamehri z F

38. Factors contributing to success of LNF

39. factors 1- typical GERD symptoms 2- well-respond to PPI therapy 3- abnormal 24 pH study All 3 factors = 95-98% success of LNF Only 2 factors= 70-80% Only 1 factor = < 50%

40. Summary PPI is still the first line of GERD therapy Laparoscopic Nissen fundoplication remains an effective anti-reflux measure at 10 yearsLaparoscopic Nissen fundoplication remains an effective anti-reflux measure at 10 years Resumption of anti-secretory Rx not a measure of surgical failureResumption of anti-secretory Rx not a measure of surgical failure Recurrence can be treated effectively with laparoscopic revisionRecurrence can be treated effectively with laparoscopic revision Severe GERD symptoms and response to PPI are good indicators of symptom outcomeSevere GERD symptoms and response to PPI are good indicators of symptom outcome

41. Final word Let the GERD patient decide about the treatment option What about YOUNG PREGNANCY POOR PATIENTS BILE REFLUX ……………….ECT