PeriOperative Concerns for Anti Reflux Procedure Patients Kevin Gillian, M.D., F.A.C.S. VHC Heartburn Center Director GERD word association Heartburn Chest pain Spicy food Tums Purple pills How big a problem is it? GERD stats Medical management PPI s H2 Blockers Promotility agents OTC 80% of pts relapse in 6 8 months following cessation of medical therapy 1
GERD stats 0.7% of adults are in the severe medically refractory group Equivalent to 39k in the D.C. DC Metro What other options do they have? Surgery (4 decades of experience) Endoscopic Therapy GERD stats Only 1/50 of the chronic GERD pts who fail medical therapy are treated surgically Why? Only 1% of pts under Rx for GERD are aware of a surgical option Only 50% of the primary care providers are aware of the surgical option Surgery and GERD Long term results in experienced hands show elimination of typical symptoms (> 90%) Results have improved with ih better patient selection EGD, UGI/BS, 24hr ph testing, manommetry Impedance technology is revolutionizing the work up 2
Acquired esophageal dysmotility Sllbufferny acid Lower Esophageal Sphincter (LES) dysfunction Poorly functioning sphincter muscle Gastroesophageal junction (GEJ) incompetent Delayed emptying of stomach Hiatal hernia Why do we reflux? Causes GERD? Deteriorated valve between stomach and esophagus allows acid to wash up into esophagus Hiatal Hernia and Elongation of PEM Hiatal Hernia Acid chamber Elongation of phrenoesophageal membrane Gastric tissue up into chest above diaphragm Small pouch Confirmed with CXR, barium series, EGD 65 80% of patients with chronic severe GERD have hh 2cm Symptoms Heartburn Burning or tightness behind sternum or top stomach (confused with angina heart attack like symptoms) 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 swallowing or painful swallowing 3
Progression of disorder Become a resource for the patient s with GERD and their primary care and subspecialty MDs Streamline and standardize the evaluation process Educate the patients and primary care MDs about ALL Options for GERD treatment available. Heartburn Treatment Center Staff 4
Nurse Coordinator Performs the Studies Manometry, 24hr ph, Impedence, New technologies Capsule endoscopy Coordinates outpatient events UGI, EGD, Subspecialty evaluations Documentation of studies/outcome Liaison for patients and referring doctors Diagnosis of patients with persistent symptoms on PPI Study patient On or Off PPI Correlate acid & nonacid GER to symptoms Evaluation of postprandial GER Correlate acid & nonacid GER episodes to symptoms Dysphagia evaluations Achalasia, DES, Nutcracker, Spasm, Globus, Aspiration 5
17 cm 15 cm Impedance ph Catheter 9 cm 7 cm 5 cm 3 cm 6 impedance channels ph - 5 cm 1 ph channel Adult Standard Model ZAN-S61C01E Impedance Range Low Conductivity = High Impedance Air I m p e d a n c e Esophageal Lining Saliva Food Refluxate High Conductivity = Low Impedance Multichannel Intraluminal Impedance (MII) Antegrade Bolus Movement (swallow) 6
Retrograde Bolus Movement (reflux) Multichannel Intraluminal Impedance 17 cm Acid Rereflux Episode 15 cm 9 cm 7 cm 5 cm 3 cm 4.0 S98 9526 1, Rev. 1.0 5 cm ph shows one long reflux episode. Impedance shows two distinct reflux episodes 20 Clinical Application Overview Diagnosis of patients with persistent symptoms on PPI Study patient On or Off PPI Correlate acid & nonacid GER to symptoms Evaluation of postprandial GER Correlate acid & nonacid GER episodes to symptoms 7
Anatomy of Reflux Normal Anatomy Physiologic valve prevents reflux Dysfunctional Valve Deteriorated valve, no anatomical reflux barrier Large Hiatus Hernia R Crus L Crus Hiatus Large Hernia Reduced Stomach esophagus RR Crus L Crus 8
Surgical Goals Reduce Hiatal Hernia get distal esophagus below the diaphragm Increase Pressure on GE Junction Prevent Recurrence of the defect Surgical Options Open Nissen Fundoplication ( RARE) Laparoscopic Nissen Fundoplication Robotic Nissen Fundoplicatin Trans Oral Incisionless Fundoplication TIF Constructing a Nissen Fundoplication Laparoscopic Technique 9
Reestablish High Pressure Zone Hiatal Hernia dissected Hiatal Hernia Hiatal Closure Mobilize esophagus Close hiatus with nonabsorbable suture 10
Prepare Wrap/Fundoplication Hiatus is closed Fundus is brought through tunnel NO tension present Vagus inside wrap Fundus pulled posterior to GE junction Fundoplication Completed Wrap over bougie dilator 3 sutures 1cm apart 2cm of esophagus below hiatus Lap Nissen Video 11
Lap Nissen Durability Long term results of surgery for control of GERD are variable Symptom control often greater than 90% at 10 years in experienced hands Failures are often emphasized by gastroenterologist Disruption of the hiatal closure appears to be a major weak point in the repair Surgical Failure Rates Breakdown of Crural Repair Leading to Nissen Wrap Herniation Watson (1995)Brit J Surg 253 6.6 % Cadiere(1996)Surg Endo 209 11 Munro(1996)Surg Lap Endo 100 7 Stein(1996)Am J Surg 105 5.7 Perdikis(1997)Ann Surg 65 15 Basso(2000) Surg Endo 65 13.8 Champion(2001)Surg Endo 144 10.6 Kamolz (2002) Surg Endo 100 14 Frantzides(2002)Arch Surg 38 defects>8cm 22 Orringer(1973)J Thora Surg* 892 open surgery 14.5 Polypropylene Patch Basso Surgical Endoscopy 2000 First 67 pts 14.5 % Next 65 pt 0 % at 2yrs Sequential Study 12
Results of Mesh Repair CruraSoft Mesh Permanent Mesh Repair 13
Allograft biologic Mesh Repair Lap Nissen with Mesh experience 109 Nissen Fundoplications by a Single Surgeon 20.9 mos follow up (12/03 12/07) Utilized Crurasoft onlay technique 11 had paraesophageal hernias Insertion / fixation time approximately 3 5 minutes Gillian, G.K. American Hernia Society presentation 2008 Nissen with Mesh results No recurrent hernias in 109 pts No reflux symptoms after surgery No significant dysphagia No revisions or balloon dilatation No infections No chronic pain issues Gillian, G.K. American Hernia Society presentation 2008 14
Summary of Mesh Utilization Historical Data Suggest that the failure rate of Nissen Fundoplication is largely due to hiatal disruption with secondary wrap migration Placement of a prosthetic mesh to reinforce the hiatal closure appears to improve recurrence rates just as it does in other types of hernia repair Summary of Mesh Utilization Evaluation of proactive mesh utilization in Nissen Fundoplication includes the mesh being used as well as fixation technique The placement of permanent/biologic mesh with the onlay technique is easily performed, safe and should impact the rate of hiatal hernia and symptom recurrence as time progresses Robotic Nissen Fundoplication DaVinci Platform Technically same steps and same risks Significant investment in staff training and resources 15
Robotic NissenVideo The EsophyX Approach Trans oral Surgery for GERD No incisions No scarring No incisional herniation Less potential for infection Does it work? Can you do it for everybody? GERD Treatment Options Benefits of EsophyX GEJ reconstructed PPIs reduced Can correct Esophagitis Hiatal Hernia fixed < 2cm Benefit Med/High Significant ph Normalization Improved Quality of Life Reduce/Eliminate reflux Adjustment possible Risk Low Challenges Large Hiatal Hernias Limitations of Rx Treat the symptoms not the anatomical cause Do not stop reflux Do not treat atypical symptoms 20 40% of patients are not happy with PPI medication* *Gallup Poll 2000 for AGA N=1000 American Journal of Gastroenterology 2003; vol. 98 Shaker et al 16
Reconstructs the primary EsophyX barrier Experience to reflux by creating a robust valve emulating natural anatomy 45 60 minute procedure 8 14 fasteners SerosaFuse fasteners (3.0 propylene sutures) Overnight stay (general anesthesia) Rapid Recovery Unique Surgical Approach Native Flap Valve Anatomy Lesser curvature Posterior Valve Anterior Valve Lip Fundus Tightness around scope TIF Reduction of GE junction below diaphragm 17
EsophyX Animation EsophyX Animation Multicenter Trial (1 year) N=79 85% of Patients OFF daily PPIs Comparable efficacy & better tolerated then LNF No significant ifi dysphagia, diarrhea, gas bloat Excellent QOL improvement 73% Elimination of PPI use 85% Esophagitis resolution 59% Hiatal hernia reduction 71% ph normalization 49% (Hill grade one) 18
Effectiveness Conclusions EsophyX TIF was shown to be effective in treating chronic GERD as indicated by the significantly improved quality of life and reduced dependency on daily PPIs. The significant reduction in esophageal acid exposure, hiatal hernia and esophagitis as well as the significant increase in LES resting pressure supported the ability of EsophyX TIF to increase the antireflux competency of the gastroesophageal junction. The results at 12 and 24 mo supported a long term maintenance of the anatomical integrity of TIF valves. PACU considerations Minimally invasive surgery but Working in the mediastinum Dissection of Spleen Pleural tears possible with big hiatal hernias Esophageal perforation possible (TIF) Crepitus PACU Physical Exam Warning Signs Decreased Breath Sounds Tachycardia Chest Pain Dysphagia 19
Typical Surgical Recovery Overnight stay Clears on evening of surgery PPIs stopped on day of surgery Minimal narcotic usage after discharge Splat Diet for 10 14 days Gradual Progression to regular diet in first month Summary Surgical repair of the structural defects that allow GERD to occur is effective. Full understanding di of the physiology involved and skill with all possible techniques available is necessary for complete patient care Thank you! 20