QUESTIONS & ANSWERS
GERD, ACID REFLUX,
SURGICAL TREATMENT OF GERD
INDICATIONS FOR SURGERY
LAPAROSCOPIC TREATMENT OF GERD
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QUESTIONS & ANSWERS
|GERD, ACID REFLUX,|
Gastroesophageal reflux disease (GERD) has long been recognized as a significant public health concern. GERD occurs in many Americans, with nearly 44% experiencing monthly "heartburn" and 18% of these individuals using nonprescription medication for this problem (1,2). GERD is a chronic progressive disorder, often prompting patients to seek medical advice for further treatment.
Surgical treatment of GERD is well established and provides well recognized benefits (3-10). This document outlines the indications for and appropriate surgical treatment of GERD. This document is not intended to debate the issues of diagnosis and medical management of GERD, which are dealt with elsewhere (11).
GERD is defined as the failure of the antireflux barrier, allowing abnormal reflux of gastric contents into the esophagus (12). It is a mechanical disorder which is caused by a defective lower esophageal sphincter, a gastric emptying disorder or failed esophageal peristalsis. These abnormalities result in a spectrum of disease ranging from "heartburn" to esophageal tissue damage with subsequent complications. While the exact nature of the antireflux barrier is incompletely understood, the current view is that the lower esophageal sphincter (LES), the diaphragmatic crura, and the phrenoesophageal ligament are key components (8,13).
In the appropriate clinical setting, the diagnosis of GERD relies on the demonstration of ONE of the following:
1 . the presence of documented (photographic or histologic) esophageal mucosal injury (esophagitis)
2. excessive reflux during 24-hour intraesophageal pH monitoring.
Additional studies may be used for confirmation in difficult cases (e.g., contrast radiographic studies, symptom mapping with provocative tests, gastric emptying studies).
Medical therapy is the first line of management for GERD. Esophagitis will heal in approximately 90% of cases with intensive medical therapy. However, medical management does not address the condition's mechanical etiology; thus symptoms recur in more than 80% of cases within one year of drug withdrawals. In addition, while medical therapy may effectively treat the acid-induced symptoms of GERD, esophageal mucosal injury may continue due to ongoing alkaline reflux (14). Since GERD is a chronic condition, medical therapy involving acid suppression and/or promotility agents may be required for the rest of a patient's life. The expense and psychological burden of a life time of medication dependence, undesirable life style changes, uncertainty as to the long term effects of some newer medications, and the potential for persistent mucosal changes despite symptomatic control, all make surgical treatment of GERD an attractive option. Surgical therapy, which addresses the mechanical nature of this condition, is curative in 85-93% of patients (6,7,9,10). Chronic medical management may be most appropriate for patients with limited life expectancy or comorbid conditions which would prohibit safe surgical intervention.
Two controlled trials which compared medical and surgical therapy of GERD favored surgical therapy (5,16). In the most recent prospective randomized comparison, surgical treatment was significantly more effective than medical therapy (ranitidine and metoclopromide) in improving symptoms and endoscopic signs of esophagitis for periods of up to two yearsl6. Other longitudinal studies report good to excellent long term results in 80-93% of surgically treated patients (6,7,9,10,17-26).
- Before considering surgical treatment of G-ERD, it is recommended that patients undergo,-
1 . esophagogastroduodenoscopy (with biopsy, where appropriate - see below)
2. esophageal manometric evaluation*.
In selected cases, the following investigations may prove helpful:
1 . 24-hour intraesophageal pH monitoring*(l), and
2. barium cineradiography.
While not always available, these investigations should not only confirm the diagnosis, but also lead to appropriate selection of patients for surgical repair. In particular, biopsies from areas of suspected Barrett's epithelium may document the presence of severe dysplasia or carcinoma. In such settings, an antireflux procedure alone would be inappropriate and other interventions such as resection or close endoscopic surveillance might be indicated (27,28). Upper gastrointestinal endoscopy may also identify other esophagogastric mucosal abnormalities, suggesting symptomatic etiologies other than GERD. Additionally, a normal 24hour intraesophageal pH study should strongly suggest an alternate diagnosis and lead to additional diagnostic investigations. Finally, abnormal peristalsis on esophageal manometric study may suggest a significant risk of dysphagia following fundoplication.
Surgical therapy should be considered in those individuals with documented GERD (see above who:
1 . have failed medical management
2. opt for surgery despite successful medical management (due to life style considerations including age, time or expense of medications, etc.)
3. have complications of GERD (e.g. Barrett's/stricture; grade 3 or 4 esophagitiS) (27)
4. have "atypical" symptoms (asthma, hoarseness, cough, chest pain, aspiration) and reflux documented on 24 hour pH monitoring.
In patients with Barrett's changes and severe dysplasia, the risk of underlying malignancy may suggest consideration of esophagectomy, rather than antireflux surgery (27,28).
The primary goal of surgical intervention for GERD is to re-establish the antireflux barrier without creation of undue side effects. In addition, most surgeons feel it is necessary to: 1 . position the LES within the abdomen where the sphincter is under positive (intraabdominal) pressure
2. close any associated hiatal defect.
Various safe and effective surgical techniques have been developed to realize the above goals (6,7,9). The choice of technique has typically been based upon anatomic considerations, as well as the surgeon's preference and expertise. Many of these techniques have been extensively tested and proven to be effective in controlling reflux with minimal side effects. The Nissen fundoplication has emerged as the most widely accepted procedure for patients with normal esophageal motility (ll,12,17,19,24). For patients with compromised esophageal motility, one of the various partial fundoplications (e.g., Toupet fundoplication) is recommended to decrease the possibility of postoperative dysphagia. The success of an antireflux procedure depends upon the surgeon's familiarity and training with the specific technique and his/her ongoing involvement in the pre- and post-operative care. The choice of procedure and methods of access (open or laparoscopic) should be determined by the surgeon's experience and training more than by the technique itself. Special mention of the laparoscopic approaches for the treatment of GERD follows.
Laparoscopic antireflux procedures rely on videoscopic technologies to allow surgeons to reproduce the accepted "open" procedures in a minimally invasive fashion (30-33). The benefits of a laparoscopic approach are analogous to those realized with laparoscopic cholecystectomy and include a shorter and more comfortable recovery with an earlier return to normal activities (33). Several reports in the literature document the feasibility, safety, and favorable results of laparoscopic antireflux procedures (32,33,35-37).
The indications for laparoscopic treatment of GERD are the same as those outlined earlier in this document. Laparoscopic antireflux surgery should only be offered by surgeons skilled and privileged in the equivalent open antireflux procedure. Safe and effective laparoscopic treatment of GERD requires advanced laparoscopic skills such as intracorporeal knot tying, the use of angled scopes to achieve multiple viewing angles, and two-handed organ and tissue manipulation. Therefore, appropriate training in advanced laparoscopic techniques is mandatory. These skills are most appropriately acquired through a residency, fellowship, or course which details the specific laparoscopic antireflux technique and teaches the appropriate advanced skills. Such a course should provide documentation of attendance and skills taught. Before attempting such a procedure independently, the surgeon should be preceptored by a surgeon experienced in the procedure38. Finally, laparoscopic antireflux surgery requires a well trained operating team familiar with the equipment, instruments and techniques of antireflux surgery.
Gastroesophageal reflux disease (GERD) is a significant health concern. Medical management is expensive and may be necessary lifelong. Effective surgical therapy is available and, if performed by experienced surgeons, is successful in greater than 90% of patients. Laparoscopic techniques which reproduce their "open" counterpart are also available. When performed by appropriately trained surgeons, these laparoscopic approaches appear to hasten the patient's recovery and return to normal function.
1 Klingman RR, Stein HJ, DeMeester TR. The current management of gastroesophageal reflux. Adv Surg 1991; 24:259-91.
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9. Luostarinen M. Nissen fundoplication for reflux esophagitis. Long-term clinical and endoscopic results in 109 of 127 consecutive patients. Ann Surg 1993; 217:329-37.
10. Shirazi SS, Schulze K, Soper RT Long-term follow-up for treatment of complicated chronic reflux esophagitis. Arch Surg 1987; 122:548-552.
11. Devault KR, Castell DO, Guidelines for the diagnosis and treatment of gastroesophageal reflux disease, in Guidelines Statement of ACG, AGA, ASGE. 1994,
12. Wetscher GJ, Redmond EJ, Vititi LMH. Pathophysiology of gastroesophageal reflux disease. In: Hinder RA, ed. Gastroesophageal Reflux Disease. ed. Austin: R. G. Landes Company l 993: 7-29.
13. Ireland AC, Holloway RH, Toouli J, Dent J. Mechanisms underlying the antireflux action of fundoplication. Gut 1993; 34:303-8.
14. Vaezi MF, Richter JE. Synergism of acid and duodenogastroesophageal reflux in complicated Barrett's esophagus. Surgery 1995; 117:699-704.
15. Kauer WK, Peters JH, DeMeester TR, et al. Mixed reflux of gastric and duodenal juices is more harmful to the esophagus than gastric juice alone. The need for surgical therapy re-emphasized. Ann Surg 1995; 222:525-31.
16. Spechler SJ. Comparison of medical surgical therapy for complicated gastroesophageal reflux disease in veterans. N Engl J Med 1992; 326:786-792.
17. Donohue PE, samelson S, Nyhus LM, Bombeck CT. The Nissen fundoplication. Effective long-term control of pathologic reflux. Arch Surg 1985; 120:663-667.
18. Ellis FH. The Nissen fundoplication. Ann Thorac Surg 1992; 54:1231-1235.
19. Grande L, Toledo-Pimentel V, Manterola C, et al. Value of Nissen fundoplication in patients with gastrooesophageal reflux judged by long-term symptom control. Br J Surg 1994; 81:548-50.
20. Johansson J, Johnsson F, Joelsson B, Floren CH, Walther B. Outcome 5 years after 360 degree fundoplacation for gastro-oesophageal reflux disease. Br J Surg 1993; 80:46-9.
21. Luostarinen M, Isolauri J, Laitinen J, et al. Fate of Nissen fundoplication after 20 years. A clinical, endoscopical, and functional analysis. Gut 1993; 34:1015-20.
22. Macintyre IM, Goulbourne IA. Long-term results after Nissen fundoplication: a 5-15-year review. J R Coll Surg Edinb 1990; 35:159-62.
23. Martin CJ, Cox MR, Cade RJ. Collis-Nissen gastroplasty fundoplication for complicated gastrooesophageal reflux disease. Aust N Z J Surg 1992; 62:126-9.
24. Mira-Navarro J, Bayle-Bastos F, Frieyro-Segui M, Garramone N, Gambarini A. Long-term follow-up of Nissen fundoplication. Eur J Pediatr Surg 1994; 4:7-1 0.
25. Pope C. The quality of life following antireflux surgery. World J Surg 1992; 16:355-8.
26. Thor KBA, Silander T. A long-term randomized prospective trial of the Nissen procedure versus a modified Toupet technique. Ann Surg 1989; 210:719-724.
27. Spechler SJ, Goyal RK. The columnar-lined esophagus, intestinal metaplasia, and Norman Barrett. Gastroenterology 1996; 110:614-621.
28. Ortiz A, Martinez-deHard LF, Parilla P, et al. Conservative treatment versus antireflux surgery in Barrett's oesophagus: long-term results of a prospective study. Br J Surg 1996; 83:274-8.
29. Waring JP, Hunter JG, Oddsdottir M, Wo J, Katz E. The preoperative evaluation of patients considered for laparoscopic antireflux surgery. Am J Gastroenterol 1995; 90:35-8.
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32. Collard JM, de Gheldere CA, De Kock M, Otte JB, Kestens PJ. Laparoscopic antireflux surgery. What is real progress? Ann Surg 1994; 220:146-54.
33. Cuschieri A, Hunter J, Wolfe B, Swanstrom LL, Hutson W. Multicenter prospective evaluation of laparoscopic antireflux surgery. Preliminary report. Surg Endosc 1993; 7:505-1 0.
34. Gallstones and laparoscopic cholecystectomy. NIH Concensus Statement Year; 10 (3):1-26.
35. Weerts JM, Dallemagne B, Hamoir E, et al. Laparoscopic Nissen fundoplication: detailed analysis of 132 patients. Surg Laparosc Endosc 1993; 3:359-364.
36. Peters JH, Heimbucher J, Kauer WK, et al. Clinical and physiologic comparison of laparoscopic and open Nissen fundoplication. J Am Coll Surg 1995; 180(4):385-93.
37. Hunter JG, Trus TL, Branum GD, et al. A physiologic approach to laparoscopic fundoplication for gastroesophageal disease. Ann Surg 1996; 223(6):673-685.
38. SAGES publication #14, Granting of privileges for laparoscopic (peritoneoscopic) general surgery; May, 1990, originally publication #5 [published in American Journal of Surgery 161: 324-325] January 1990, revised October, 1992; [Surgical Endoscopy 7:1 (Jan, Feb/93) p.67-8]
This statement was reviewed and approved by the Board of Govemors of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), October, 1996. It was prepared by SAGES Committee on Standards of Practice.
Request for reprints should be sent to:
SOCIETY OF AMERICAN GASTROINTESTINAL ENDOSCOPIC SURGEONS (SAGES)
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