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Gastroesophageal Reflux Disease (GORD)

Guérin Eric MDGuérin Eric MD

CHUBGES

Castell «iceberg» for GORD

• Hospital Refluxer

• Office Refluxer

• Anonym Refluxer

15%

40%

• Anonym Refluxer

45%

Kitchin & Castell, Arc.Intern.Med.1991

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Definition

« a condition which develops when the reflux of stomach contents causes troublesome symptoms

and/or complications »

eal consensus, Kahrilas PJ et al. American GastroenterologicalAssociation Medical Position Statement on the management of gastroesophageal reflux disease. Gastroenterology 2008, 135: 1383

From a surgical persperctive

Defective Lower Oesophageal Sphincter

(LOS)

Failed oesophageal

peristaltis

GORD

Gastric emptying disorder

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Diagnosis of GORD

a mucosal break on endoscopy with typical symptomsBarrett’s oesophagus on biopsy

a peptic stricture in the absence of malignancypositive pH-metry

Stefanidis D et al. Guidelines for surgical treatment of gastroesophageal reflux disease. Surg Endosc 2010 24:2647-2669.

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Indications for surgery

• Failure of medical treatment OR

• despite successful medical treatment (QoL, lifelong medication, expensive) OR

• complications of GORD (Barrett’s, stricture) OR

• extra-oesophageal symptoms (asthma, cough, hoarseness, chest pain, ...)

Preoperative workup

• Oesogastroduodenoscopy (OGD)

• pH-metry

• Oesophageal manometry

• Barium swallow

• isotopic gastric emptying

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Medical vs Surgical treatment of GORD

Surgery is an effective alternativeSurgery is an effective alternative

for patients with good control on medical therapy

for patients who achieve only partial symptomatic relief from PPIs

Fundoplication has comparable QoL and associated with a high patient satisfaction rate

Lundell Eur J Gastroenterol Hepatol (2000); Spechler JAMA (2001); Mahon Br J Surg (2005); Anvari Surg Innov (2006); Mehta J Gastrointest (2006); Lundell Br J Surg (2007); Lundell Gut (2008)

Medical vs Surgical therapy of GORD

Reducing PPIsReducing PPIsused in 62 % of cases after fundoplication in one study (1)

9 - 21 % up to 8 years after surgery in the majority of the literature (2,3,4,5,6,7)

Cost

(1) Spechler SJ et al. Long-term outcome of medical and surgical therapiesfor gastroesophagealreflux disease: follow-up of a randomized controlled trial. JAMA 2001, 285:2331-2338 (2) Mehta S et al. Prospective trial of laparoscopic Nissen fundoplication vs proton PPI therapy for GERD: seven year follow-up. J Gastrointest Surg 2006, 10:1312-1316

(3) Dassinger MS et al. Laparosocpic fundoplication: 5-yearfollow-up. Am Surg 2004 70: 691_694(4) Kamolz T et al. Laparoscopic Nissen fundoplication in patients with non erosive reflux disease. Long-term QoL assessment and surgical outcome. Surg Endosc 2005 19:494-500

(5) Rosenthal R et al. Laparoscopic antireflux surgery: long-term outcomes and quality of life J Laparoendosc Adv Surg Tech A 2006 16:557-561(6) Zaninotto G et al. Long-term results (6-10 years) of laparoscopic fundoplication. J Gastrointest Surg 2007 11:1138-1145

(7) Pessaux P et al. Laparoscopic antireflux surgery: five-year results and beyond in 1340 patients. Arch Surg 2005 140:946-951.(8) Myrvold HE et al. The cost of long-term therapy for GORD: a randomised trial comparing omeprazole and open antireflux surgery. Gut 2001, 49:488-494

Surgery > Omeprazole over 5 years (8)

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Surgical Techniques > 1990

• Geagea-1991 (Laparoscopic Nissen’s fundoplication:preliminary report on ten cases. Surg Endosc; 5: 170-173)

• Dallemagne-1991 (Laparoscopic Nissen fundoplication: preliminary report. Surg Endosc; 1: 138-143)

• Nissen

• Floppy Nissen

• Nissen Rossetti

• Toupet

Nissen’s procedure: Standardization

• Complete mobilization of the gastro-oesophageal junction and lower oesophagus (3 cm)

• Systemic section of the upper short gastric vessels

• Crura closure posteriorly

• Creation 1,5-2 cm wrap with bougie placement

Attwood SE et al. Standardization of surgical technique in antireflux surgery: the LOTUS trial experience. World J Surg 2008, 32:995-998

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Post-operative morbidity

• 2 % conversion rate

• 3 % postop complication rate (dysphagia, gasbloating, hyperflatulence, difficult belching,...)

• median postoperative lenght of stay of 2 days Nissen

Attwood SE et al. Standardization of surgical technique in antireflux surgery: the LOTUS trial experience. World J Surg 2008, 32:995-998

Lap antireflux surgery compare to open

12 RCT have compared open to lap Nissen

lower morbidityshorter hospital stay

faster return to normal activitiesNo difference in late outcomes

Lap fundoplication:

BUT

Stefanidis D et al. Guidelines for surgical treatment of gastroesophageal reflux disease. Surg Endosc 2010 24:2647-2669.

longer to performhigher incidence of reoperations

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Total vs Partial fundoplication

• dysphagia

• bloating

• flatulence

• reoperation rate Nissen

Varin O et al. Total vvs partial fundoplication in the treatment of gastroesophageal reflux disease: a meta-analysis. Arch Surg 2009 144:273-278

Total vs Partial Fundoplication

No difference in incidence of postop:

Heartburnpersisting acid reflux

patients experiencing good outcome

Varin O et al. Total vvs partial fundoplication in the treatment of gastroesophageal reflux disease: a meta-analysis. Arch Surg 2009 144:273-278

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Tailored approach

• Wetscher World J. Surg 1997

• Watson Dig.Surg. 1998

• Gadenstätter Surgery 1999

• Pessaux Surg.Endosc 2000

Tailored Approach in Anti-Reflux Surgery

Tailored approach• Lundell Br J Surg 1996

• Lundell World J Surg 1999

• Bessell Br J Surg 2000

• Fibbe Gastroenterology 2001

• Zornig Surg Endosc 2002

• Yang J Gastrointest Surg 2007

• Booth Br J Surg 2008

• Tailored Approach is Unnecessary

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QuickTime™ et undécompresseur

sont requis pour visionner cette image.

Nissen Rossetti

Conclusions

• There still is a place for surgery in the treatment of GORD in selected patients

• To compete with medical treatment, surgery has to be associated with minimal morbidity and costy

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Thank you