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Understanding and

Treating Chronic Acid Reflux

Including Incisionless Surgery

120308

Peter Krone M.D., F.A.C.S.

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Overview

• Understanding GERD

• Medical Management

• Surgical Options

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Is this YOU?

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Typical Symptoms of GERD

• Heartburn

• Acid regurgitation

– Sour or bitter taste in throat or

mouth

– Esp. after large, late meals

• Water brash

– Hot sensation in stomach

– Excess salivation

• Dysphagia and Odynophagia

– Difficulty or painful swallowing

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Other Symptoms of GERD

Pulmonary

Asthma

Aspiration pneumonia

Chronic bronchitis

Other

Regurgitation

Chest pain

Dental erosion

ENT

Hoarseness

Laryngitis

Sore throat

Chronic cough

Frequent swallowing

Burning in the throat or

mouth

Atypical symptoms

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Lower

Esophageal

Sphincter (LES)

Stomach (Fundus)

Gastroesophageal

Flap Valve (GEV)

Esophagus

Diaphragm

Gray’s Anatomy, 1997

Anatomy 101

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What Causes GERD?

Normal Anatomy Fully Functional Valve Prevents Reflux

Extrinsic Factors: Deterioration of natural barrier to reflux; the Antireflux Valve

Normal Anatomy Antireflux Valve Tight to the Scope

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What Causes GERD?

Extrinsic Factors: Deterioration of natural barrier to reflux; the Antireflux Valve

Dysfunctional Valve Can’t close to prevent reflux of

stomach contents

This requires surgical management

Dysfunctional Valve Can’t close. Loose to the scope.

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65-80% of patients with chronic severe GERD have hh≤2cm

What Causes GERD?

Hiatal Hernia

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• 10 - 15% of adult population suffers from daily GERD (~

15 million)

• Incidence of GERD rises rapidly after 40 years of age

• Most GERD gets worse over time.

– Early correction can prevent further deterioration of the natural

barrier to reflux.

• Esophageal cancer is 8X more likely to occur in patients

with weekly heartburn or regurgitation

GERD Facts

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Clinical Progression of GERD

Physiological

Reflux

Symptomatic

GERD Esophagitis

Complicated

Esophagitis

Typical • Heartburn

• Regurgitation

Atypical •Chest pain

•Swallowingdifficulties

•Cough

•Asthma

•Laryngitis

Complications •Ulceration

•Hemorrhage

•Strictures

•Barrett’s

•Adeno-Ca

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Overview

• Understanding GERD

• Medical Management

• Surgical Options

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Lifestyle/Behavior Modification

LOSE WEIGHT

WATCH WHAT YOU EAT

DON’T EAT LATE

AVOID STRESS

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• Antacids

– Neutralize or buffer stomach acid

– Tums, Mylanta, Alka-Seltzer

• H2 blockers (ranitidine, cimetidine)

– Blocks the body’s signal to the

stomach to produce acid

– Zantac, Tagamet

• Proton Pump Inhibitors (PPIs)

– Blocks the secretion of acid into the

stomach

– Nexium, Prilosec, Zegerid, Protonix

Types of Medications

May be satisfactory for some patients

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PPI Complications

FDA Warnings

Vitamin B12 Deficiency

Increased

Pneumonia Risk

Reduced Gallbladder

Motility

Osteoporosis Related

Fractures

Drug Interaction

Plavix

Fundic Gland

Polyps

Magnesium

Deficiency

Bacterial

Gastroenteritis

Small Intestinal

Bacterial

Overgrowth

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Continued Reflux Symptoms on Medications

Gallup Poll Reflux* 72% on Medication

79% Nighttime symptoms

50% Nighttime reflux worse than daytime reflux

63% Ability to sleep affected

40% Daytime function affected

70% Nighttime discomfort moderate to severe

75% Can not fall asleep or wakes them up

45% Medication does not relieve all symptoms

*Gallup Poll 2000 for AGA N = 1000

American Journal of Gastroenterology 2003; vol. 98 Shaker et al

20-40% of patients dissatisfied with medication

WHY???

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Medication is not the solution for

severe or chronic reflux

IT DOES NOT STOP

• Reflux

• Non Erosive Reflux Disease

(NERD)

• Regurgitation

ANATOMICAL CHANGES

NEED ANATOMICAL

REPAIRS

Symptoms vs. Solutions

Normal

Chronic GERD

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Overview

• Understanding GERD

• Medical Management

• Surgical Options

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What Indications for Surgery

• Esophagitis

• PPIs required for control

• Persistent symptoms despite medications

• Presence of Barrett’s esophagus

• Non-acid symptoms of reflux (asthma,

chronic cough, laryngitis…)

ANY OF THESE CONDITIONS CAN EXIST

TO BE A SURGICAL CANDIDATE

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Surgery Workup

CONSULT

EGD (SCOPE)

BARIUM SWALLOW**

pH TESTING**

MANOMETRY**

** MAY BE REQUIRED ON INDIVIDUAL BASIS

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Anti-Reflux Surgery

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Anti-Reflux Surgery

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Evolution of Reflux Surgery

20cm Incision

OPEN SURGERY

NATURAL

ORIFICE SURGERY

No Incision 0.5-1cm Incision

LAPARASCOPIC

SURGERY

FUNDOPLICATIONS

1955

Dr. Rudolph Nissen

“Gastroplication”

1990s

Laparoscopic Nissen

Laparoscopic Toupet

2008

Transoral

Fundoplication (TIF)

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Lap Nissen Fundoplication

• 3-5 small incisions on abdomen

• Surgery performed in abdominal cavity

• Average hospital stay 1.2 days

• Resolution of symptoms at 1 year: 94%

• Off Daily Medication: 79-100%

• Major surgical complications: 2%

• Long term complications: 2-62%

– Gas bloat/Flatulence

– Difficulty swallowing

– Difficulty vomiting

1. Hunter JG, et al. Surgical Endoscopy 2001 N=1000

Gold Standard of Lap Anti-Reflux Surgery

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Transoral Fundoplication (TIF)

• No Incisions

• Surgery performed within the stomach

• Average hospital stay 1.2 days

• Resolution of symptoms at 1 year: 85%

• Off Daily Medication: 65-94%

• Major surgical complications: 0.1%

• Long term complications: 0%

Over 6,500 TIFs performed in the US since 2008

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Degraded Valve Allows Reflux of

Stomach Acids into Esophagus

6-months Post-Op

Retightened Valve

Pre-TIF Procedure Post-TIF Procedure

Before and After TIF

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Syndrome Disease

Mild GERD

Severe

GERD

(~1%)

Pharmaceutical

Symptom Control

Lap Nissen

Treatment of root cause

Hill Grade I II III IV

Pills or Surgery???

TIF

Treatment of root cause

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Are You:

• On a PPI longer than 6 months

• On double dose PPIs

• Having nighttime symptoms even on medication

• Having non-heartburn symptoms of reflux that

can’t be treated with medications

• Dissatisfied with the current treatment

Please call our office to schedule a consult.

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Questions?