The role of surgery in the modern management of dyspepsia Mr Paras Jethwa Bsc MD FRCS Surrey &...
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Transcript of The role of surgery in the modern management of dyspepsia Mr Paras Jethwa Bsc MD FRCS Surrey &...
The role of surgery in the modern management of
dyspepsia
Mr Paras Jethwa Bsc MD FRCSSurrey & Sussex NHS Trustand Spire Gatwick Hospital
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....
Mechanics of reflux
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
➡What about the guidelines?
➡significant number were mis-referred
➡(i.e should have been urgent)
➡2% incidence of OG cancer
➡98% sensitive
Barrett’s
Intestinal Metaplasia
• Both endoscopic and histological diagnosis
• Caused principally by uncontrolled acid reflux
• Confers an increased risk of oesophageal cancer of 30-120x
• Rapidly rising incidence
• Oesophageal Cancer 5th commonest cause of cancer mortality in the UK
Current treatment
• Treatment dose of a PPI• Consider NSAIDs/ Aspirin
• Surveillance• Duration• Interval• Aneuploidy/tetraploidy
• Anti reflux surgery• Oesophagectomy for HGD or Cancer
Surveillance limitations
• Surveillance probably doesn't work
• Time consuming, inaccurate, distressing for patients, expensive
• Lack of an easily identifiable high risk group?
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
Long term effects of GORD
PEPTIC STRICTURE
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
Surgical correction
OESOPHAGUS
R CRUS
L CRUS
Effect of operation
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
Cost of therapy
Drug DoseCost (£, 28
days)Annual(£)
Omeprazole 20mg 28.56 571.2Lansoprazol
e30mg £23.75 712.5
Pantoprazole
40mg £23.65 946
Rabeprazole 20mg £22.75 455Esomeprazo
le20mg £18.50 370
Esomeprazole
40mg £28.56 1142.4
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: £2000 - £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
• (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
Surgical considerationsBMI <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
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
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
Complications & SE
• Dysphagia - acute revision
• Gas bloating
• GI dysmotility (non vagal)
• Recurrent symptoms
• Injury (GOJ/vagus/spleen/other)
Advanced technique - presented in Europe and UK
Largest series of mesh reinforced hiatal closures
Common practice at ESH/Spire
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
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
The role of surgery in the modern management of
dyspepsia
Mr Paras Jethwa Bsc MD FRCSSurrey & Sussex NHS Trustand Spire Gatwick Hospital