1. Joint Hospital Surgical Grand Round Surgical Management of GERD Department of Surgery The Prince of Wales Hospital YF Yeung

2. GERD  Exposed to the risk of physical complications from gastroesophageal reflux  Experience clinically significant impairment of health-related well-being as a result of reflux-related symptoms Genval conference 1999

3. Epidemiology Dent et al GUT 2005 Hong Kong, APT 2003 Beijing & Shanghai, Chi J Dig Dis 2000 Hong Kong, APT 2002 Houston, US, Gastro 2004

4. Treatment Options Antacids H2-receptor antagonists Sucralfate Prokinetics Proton pump inhibitors Surgical Medical

5. Types of Fundoplication  Complete  Nissen 360 o  Partial Posterior  Toupet 270 o  Lind 300 o Anterior  Belsey Mark IV  Dor hemifundoplication Toupet fundoplication

6. Physiological mechanisms  LES pressure enhanced with the wrap of fundus After meal, gastric distension (1) pressure transmitted from stomach to fundus (2) Fundal pressure pressed on the esophagus (3)

7. Effect of Fundoplication

8. Surgery or Medication?  Lundell et al. European Journal of Gastroenterology and Hepatology 2000  Long-term management of gastro- oesophageal reflux disease with omeprazole or open antireflex surgery: results of a prospective, randomized clinical trial

9. Surgery or Medication?  298 patients included Omeprazole (20mg daily) group: 154 patients Open Antireflux surgery group: 144 patients  3-year follow-up  Outcome measures Symptoms 24-h pH monitoring Endoscopy QoL assessment

10. Surgery or Medication?  Results  No significant difference in symptoms relapse, oesophagitis and QoL if dose of omeprazole adjusted to 40mg or 60mg accordingly Surgery (129)Omeprazole (139) Symptoms relapse 17 (13.1%)50 (35.9%) Oesophagitis14 (10.8%)18 (12.9%) Remission97 (75.1%)77 (55.3%)

11. Surgery or Medication?  Conclusion Omeprazole is as effective as antireflux surgery in controlling GERD

12. Indications of surgery  Patients do not accept long term medical therapy  Patients who do not respond or only partially respond to medical therapy  Antireflux surgery considered as equivalent alternative SSAT guidelines

13.  Open or laparoscopic approach?

14. Open Vs Laparoscopic AuthorYearGroupsNo. of patients Hiatal plasty DSGV Laine1997Open Lap 55 1414 5555 Bais2000Open Lap 46 57 Yes Chrysos2002Open Lap 50 56 Yes No Ackroyd2004Open Lap 47 52 Yes No

15. Open Vs Laparoscopic AuthorGroupConver- sion (%) Morbidity (%) Average Length (min) Average Hospital Stay (days) Average Sick Leave (days) LaineOpen Lap9.1 12.7 5.5 57 88 6.4 3.2 37.2 15.3 BaisOpen Lap8.8 17.4 8.9 NR ChrysosOpen Lap-- 76.0 21.4 83 77 5.9 2.4 -- AckroydOpen Lap-- NR 46 82 5353 49 28

16. Open Vs Laparoscopic AuthorFollow-up (mth) GroupsA/V at FU Recurrence (%)Dysphagia (%) Bloating (%) Laine12Open Lap 30 18 10.0 -- 13.3 -- 6.7 16.7 Bais3Open Lap 46 57 2.2 3.5 -- 12.3 NR Chrysos12Open Lap 50 56 2.0 3.6 4.0 3.6 6.0 -- Ackroyd12Open Lap 39 42 NR 23.0 26.1 17.9 26.1

17. Open Vs Laparoscopic  Conclusion Perioperative recovery of laparoscopic fundoplication is better than that of open fundoplication Short-term FU show no differences concerning recurrence, dysphagia and bloating

18.  Division of short gastric vessels or not?

19. Division (DSGV) Vs No Division of SGV (NDSGV) DSGV  Advantages Better fundus mobilization  Disadvantage Longer operative time ? Higher risk of intra- operative bleeding NDSGV  Advantage Shorter operation Lower risk of bleeding  Disadvantage Development of tension

20. Division Vs No Division of SGV AuthorYearTypeHiatal repairDSGV (no. of patients) NDSGV (no. of patients) Luostarinen1995-99OpenSelective2623 Watson1997-2002LapRoutine5250 Blomqvist2000LapRoutine5247 Chrysos2001LapRoutine2432

21. Division Vs No Division of SGV AuthorDSGVNDDSGVNDDSGVNDDSGVND LuostarinenNR 5/628/231/261/23 Watson7/526/50957115/5217/503/525/50 Blomqvist15/525/4712010411/3915/411/521/47 Chrysos2/243/32100604/245/321/240/32 MorbidityLength (min)DysphagiaRecurrence

22. Division Vs No Division of SGV  Conclusion No significant differences regarding morbidity, dysphagia and recurrence Shorter operation time for the non-division group

23.  Complete or partial fundoplication?

24. Complete or Partial AuthorYearTypeFollow-upProceduresNo. of patients DSGV Lundell1991-2002Open>3 yrsNissen Toupet 65 72 Yes Csendes2000Open8 yrsNissen Hill 76 88 Yes Watson1999Lap6 mthsNissen Anterior 53 No Fibbe2001-2002Lap4 mthsNissen Toupet 100 Yes

25. Complete Vs Partial AuthorProcedureMorbidityAverage length (min) DysphagiaRecurrenceRe-operation LundellNissen Toupet 0/65 3/72 NR 6/62 12/71 3/62 4/71 5/65 2/72 CsendesNissen Hill 3/76 5/88 NR 29/76 33/88 NR WatsonNissen Anterior 8/53 10/53 58 60 21/53 8/53 1/20 3/22 1/53 FibbeNissen Toupet NR 45 60 18/100 6/100 18/93 10/95 13/100 1/100

26. Complete Vs Partial  Conclusion Similar operative time, morbidity and recurrence rate for both groups Partial fundoplication had significantly reduced post-operative dysphagia

27. PWH experience  2001 to 2006  28 cases – antireflux surgery 19 Laparoscopic Nissen Fundoplication 9 Lap Toupet Fundoplication

28. NissenToupetp Age41.150.20.07 Smoker320.53 No. of co-morbid000.21 Heartburn16 (84.2%)7 (77.8%)0.53 Acid reflux19 (100%)8 (88.9%)0.32 % time pH < 44.972.300.06 DeMeester score31.423.90.65

29. NissenToupetp OT duration1301700.04 † Conversion00 Hospital Stay4.13.30.40 Redo fundoplication 1 (5.3%)1 (11.1%)0.55 Recurrence2 (10.5%)4 (44.4%)0.04 †

30. Summary  Long term outcome of surgery versus medical treatment to GERD is equivalent  Laparoscopic surgery is a better approach  ?Complete or partial fundoplication Further evaluation is required