The role of surgery in the
modern management of
dyspepsia
Mr Paras Jethwa Bsc MD FRCS
Surrey & Sussex NHS Trust
and 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
➡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
R CRUS
L CRUS
OESOPHAGUS
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
Dose
Cost (£, 28 days)
Annual(£)
Omeprazole
20mg
28.56
571.2
Lansoprazole
30mg
£23.75
712.5
Pantoprazole
40mg
£23.65
946
Rabeprazole
20mg
£22.75
455
Esomeprazole
20mg
£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”.
•
•
•
But - need to add cost of testing (OGD/pH/manometry) & loss of work etc.
Significant QOL improvement at 12 months+ (SF36)
•
•
Mean cost of Surgery: £2000 - £4000
(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
•
•
Significant improved QOL in surgical group
•
•
Four trials elligible n=1232
% 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 considerations
BMI <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
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 FRCS
Surrey & Sussex NHS Trust
and Spire Gatwick Hospital