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Reflux oesophagitis
OESOPHAGUS AND STOMACH
Reflux oesophagitis
Los Angeles classification of reflux oesophagitis
David Gotley FRACS
Grade A B C D
Symptomatic gastro-oesophageal reflux is one of the commonest presentations to GPs, with 15–20% of the adult population experiencing heartburn at least once per week. Surgery for gastrooesophageal reflux disease is increasing in ‘developed’ countries due to the limitations of the long-term effectiveness of proton pump inhibitor therapy in controlling severe reflux, and the more widespread use of laparoscopic fundoplication, which is more attractive than open surgery. This contribution focuses on the presentations, indications, procedures and complications of surgery of this common condition, and should be read with ‘Investigation of dysphagia’, page 89.
1
hernia is permissive i.e. an hiatal hernia does not cause reflux, but enhances an existing tendency to reflux via lower oesophageal sphincter hypotension by various mechanical factors (e.g. sequestering of gastric contents in the herniated stomach immediately beneath a lax lower oesophageal sphincter). A hiatal hernia does not imply gastro-oesophageal reflux disease. Factors that increase the propensity to reflux include obesity, ingestion of alcohol, fat or caffeine, smoking, and diseases such as scleroderma, chronic respiratory disease (including post-lung transplantation). It can be seen in institutionalized or intellectually handicapped individuals and patients nursed supine for prolonged periods. Delayed gastric emptying can enhance gastro-oesophageal reflux disease. In most people, the natural history of gastro-oesophageal reflux disease is chronic reflux with a tendency for symptoms to worsen over time, but with periods of stability, and exacerbations due to stress and dietary factors. Gastro-oesophageal reflux disease therefore requires long-term management.
Definition Gastro-oesophageal reflux is the retrograde movement of gastric contents into the oesophagus. It is a normal physiological event that occurs particularly after eating and during belching. Gastrooesophageal reflux disease is an abnormal degree of gastrooesophageal reflux that exposes the patient to the risk of complications (ulcerative oesophagitis, Barrett’s oesophagus (see below), carcinoma, peptic stricture) or symptoms that impair wellbeing or quality of life. There are several systems of grading reflux oesophagitis when it is seen endoscopically. A commonly used system is the Los Angeles classification (Figure 1).
Presentation Symptoms can be grouped according to those caused by reflux and those occurring as a result of the complications of the reflux. The common symptoms of gastro-oesophageal reflux disease are heartburn and regurgitation, but about 50% of patients with severe gastro-oesophageal reflux disease requiring surgery also have intermittent dysphagia. Excessive salivation due to exposure of the oesophagus to acid (‘waterbrash’) is also a common symptom. Particularly troublesome symptoms of gastro-oesophageal reflux disease are those that wake the patient at night, when regurgitation may result in nocturnal aspiration and chest infection. About 10% of patients present with atypical symptoms, including chest pain that may even radiate to the neck and left shoulder or arm, mimicking ischaemic heart pain. Such patients need investigation, which may include cardiac studies (e.g. ECG, stress echocardiography) and 24-hour monitoring of oesophageal pH (see below). Another group of patients with atypical symptoms of gastrooesophageal reflux disease are those with chronic cough and other laryngeal symptoms (e.g. dysphonia, repeated clearing of throat). The commonest causes of chronic cough (after eliminating smoking and medications) are asthma, post-nasal drip, post-bronchial infection and gastro-oesophageal reflux disease. The diagnosis in
Aetiology In health, the gastric mucosa comprises mucus-producing columnar cells and is resistant to digestion by acid or pepsin. The oesophagus is lined by a squamous mucosa that is sensitive to acid and may be digested by the prolonged presence of acid or pepsin. The lower oesophageal sphincter (together with the diaphragmatic crura) is crucial to the control of excessive gastro-oesophageal reflux and the symptomatic and mucosal consequences of exposure to oesophageal acid. Most gastro-oesophageal reflux is due to transient relaxations of the lower oesophageal sphincter, but most patients with severe gastro-oesophageal reflux have resting basal lower oesophageal sphincter hypotension as the principal cause of excessive reflux. The contribution of a coexistent hiatal
David Gotley is a Mayne Professor of Surgery at Queensland University, Queensland, Australia.
SURGERY 24:3
Feature One (or more) mucosal breaks, no longer than 5 mm, not-confluent One (or more) mucosal breaks >5 mm long, not confluent One (or more) mucosal breaks continuous between mucosal folds, <75% of circumference One (or more) mucosal breaks that involves at least 75% of circumference
93
© 2006 Elsevier Ltd
OESOPHAGUS AND STOMACH
this instance is initially made by elimination, followed by investigation for gastro-oesophageal reflux disease with 24-hour monitoring of oesophageal pH. Alarm symptoms demand early investigation (Figure 2).
record acid reflux events over 24 hours, while the patient presses an event marker for symptoms and notes them in a diary. The test gives rise to two items of information, the: • correlation (or otherwise) between symptoms and acid reflux events • number and duration of acid reflux events, including the total degree of acid exposure. This test is used in patients in whom the diagnosis is unclear after a trial of therapy and endoscopy. It is particularly helpful in patients with atypical symptoms and a negative endoscopy. Monitoring of bile components and oesophageal impedance may be used to detect ‘non-acid’ reflux (e.g. bile) into the oesophagus, but these methods are used largely as research tools. Oesophageal manometry is used if an oesophageal motility disorder is suspected (e.g. dysphagia in a patient with a negative endoscopy, or odynophagia) and to exclude achalasia, diffuse oesophageal spasm or ‘nutcracker oesophagus’. Its routine use in preoperative assessment is not appropriate given that, in patients without dysphagia, it has little influence on the outcome of fundoplication (whichever fundoplication technique is used). Cardiac investigations – ECG and stress echocardiography may be appropriate in patients with atypical pain in the chest.
Diagnosis Diagnosis can usually be made on symptoms alone. There may be overlap of symptoms of gastro-oesophageal reflux disease with other conditions such as gallstone disease, peptic ulcer and irritable bowel syndrome and, because these conditions are not uncommon, the patient may have more than one of them. The severity or chronicity of symptoms are poor indicators of ulcerative oesophagitis or Barrett’s oesophagus. A symptom-based diagnosis can be supported by a therapeutic trial of a high-dose proton pump inhibitor for 2–4 weeks (or >6 weeks in the case of chronic cough). This approach is more reliable than endoscopy because only 30% of patients with chronic gastro-oesophageal reflux disease symptoms have reflux oesophagitis.
Investigations The key issue is when to investigate. In general, a trial of therapy is appropriate initially, without investigation, in patients with mild typical symptoms (no alarm symptoms). Investigation is warranted if the diagnosis is unclear (e.g. atypical symptoms, ‘mixed’ symptom complexes), symptoms persist or are refractory to therapy, complications are suspected or alarm symptoms are present. Endoscopy is the first-line investigation because it: • is readily available • is the most sensitive detection method of reflux oesophagitis and Barrett’s oesophagus • can diagnose other mucosal lesions (e.g. cancer, peptic ulcer, infective oesophagitis) • can accurately grade oesophagitis • can be used to manage strictures. Endoscopy is negative in 50% of patients with gastro-oesophageal reflux disease. Barium studies are not useful in most patients with gastro-oesophageal reflux disease. It is useful in the assessment of some strictures, large hiatal hernias and in patients with gastro-oesophageal reflux disease symptoms who have had previous anti-reflux surgery. Twenty-four-hour monitoring of ambulatory pH – a pH electrode is tethered 5 cm above the lower oesophageal sphincter to
Management The principal aims of treatment are to control symptoms and improve quality of life, heal oesophagitis, and reduce the risk of complications. General management Lifestyle modifications, together with antacid preparations as required, may improve milder symptoms, but rarely control severe gastro-oesophageal reflux disease in the long term. By the time many patients are referred for consultant review, they are at least aware of and may have adopted such measures as: • avoidance of spicy, acidic and fatty foods • avoidance of large meals late at night • elevation of the head of the bed • reduced intake of alcohol and cigarettes. Obesity is an important risk factor for reflux and some effort in reducing weight is important in the long-term control of reflux and in consideration of anti-reflux surgery. Consideration should be given to bariatric surgery (rather than anti-reflux surgery) in the morbidly obese. Medical management For mild symptoms, drug therapy with H2-receptor antagonists as required is appropriate; proton pump inhibitors are the first-line treatment for more severe or persistent symptoms. The aims are to confirm the diagnosis of reflux through the relief of symptoms and healing of oesophagitis. In patients with daily symptoms and impairment of quality of life, initial high-dose proton pump inhibitor therapy can be argued on the grounds of outcomes and speed of response. Longer-term therapy involves titration of the dose downward according to symptom control. A significant minority of patients need only intermittent therapy. Prokinetic therapy has a role in a minority of patients with delayed gastric emptying, but must be given with a proton pump inhibitor. Medical therapy should not be withdrawn in patients with
Symptoms of gastro-oesophageal reflux Typical
Atypical
Alarm
Heartburn
Chest pain (cardiac type)
Dysphagia
Regurgitation
Nausea, dyspepsia
Waterbrash
Bloating, belching, flatulence Cough, throat clearing Dysphonia Sore throat
Odynophagia (painful swallowing) Haematemesis Nocturnal choking Weight loss
2
SURGERY 24:3
94
© 2006 Elsevier Ltd
OESOPHAGUS AND STOMACH
known severe oesophagitis because it will recur, and there is a good case for repeat endoscopy in these patients (e.g. after six weeks) to confirm healing.
Sequelae of laparoscopic Nissen fundoplication (n = 2,300) at one year
Surgical management: anti-reflux surgery Indications: the principal indications for anti-reflux surgery are: • failure to respond adequately to appropriate doses of medical therapy • intolerable side effects of, or non-compliance with, medical therapy • a desire to be free of long-term medication for gastro-oesophageal reflux disease
Symptom Dysphagia Early satiety Bloat Colic Inability to vomit Difficulty belching Diarrhoea Nausea Flatulence
Risks and benefits: randomized controlled clinical trials have shown that laparoscopic fundoplication has the advantages of less postoperative pain, shorter stay in hospital, and quicker return to work compared with open fundoplication. The morbidity is <5% and mortality is <0.2%. The results of laparoscopic fundoplication are related to the experience of the surgeon, with regard to longterm control of reflux and the prevention of long-term sequelae. Long-term reflux control rates of 88–95% have been reported, and reoperation rates for failed anti-reflux surgery are <3%, with results similar to primary operation being achieved. In a recent randomized controlled clinical trial comparing long-term proton pump inhibitor therapy with laparoscopic Nissen fundoplication, fundoplication provided better symptomatic and quality-of-life outcomes, and resulted in cost savings after eight years. These results confirm that laparoscopic fundoplication for the long-term management of gastro-oesophageal reflux disease is valid irrespective of whether symptoms are well controlled by the proton pump inhibitor. The range of postoperative side effects of fundoplication is influenced by the type of wrap done (see below) and is outlined in Figure 3. Side effects tend to improve during the first year after surgery, but tend to remain static thereafter. In cases of chronic dysphagia and gas bloat (seen most commonly after the Nissen fundoplication), good results can be achieved by laparoscopic reoperation and conversion to a lesser fundoplication (e.g. posterior 270o or anterior 180o wrap).
Source: Database of the Princess Alexandra and Royal Brisbane Hospital, Queensland, Australia.
3
Procedure: in general, a 5-port technique is used, with the initial trocar inserted under direct vision. The division of the short gastric vessels is not necessary; it does not make a difference to long-term control of reflux or side effects according to a recent randomized controlled clinical study. These vessels may be divided according to how the wrap ‘sits’ when it is around the oesophagus, a tension-free wrap being desirable. The cardia and lower oesophagus are mobilized with great care to prevent damage to the vagus nerves, which may result in chronic diarrhoea or gastroparesis. Hiatal hernias are reduced, and a length of abdominal oesophagus of 5–6 cm must be achieved. The posterior hiatal crura should be apposed posteriorly with one or two sutures of non-absorbable material, but should not be tight. An intra-oesophageal bougie of 54 FG (18 mm) should allow the oesophagus to meet the hiatal margins. The desired wrap is then sutured in place with nonabsorbable sutures. ‘Crown sutures’ (sutures between the wrap, oesophagus and hiatal margin) may be added to stabilize the wrap. Because the most common site for recurrent herniation (and failure of reflux control) is left posterolateral to the oesophagus, similar sutures may also be placed in this area to close off access of the stomach to the mediastinum.
Assessment: patients undergoing anti-reflux surgery should have proven abnormal reflux by oesophagitis or Barrett’s oesophagus on endoscopy (at some stage during their disease) or by 24-hour monitoring of oesophageal pH. This is particularly important in patients with atypical symptoms, where symptom correlation with acid reflux events on pH monitoring can be determined. An endoscopy should be done if one has not been done within six months of surgery to exclude new or unexpected disease. Oesophageal manometry is indicated in cases of endoscopically negative dysphagia, to exclude achalasia.
Perioperative care: a nasogastric tube is not necessary in the postoperative period. Prevention of retching or vomiting is essential to avoid the serious complication of early acute herniation of the wrap, which can strangulate at the diaphragmatic hiatus and perforate; giving a potent antiemetic (e.g. ondansetron 4 mg i.v.) during induction of anaesthesia, and timely administration of antiemetics in the postoperative period for nausea, are important preventative measures. Early oral intake of fluids progressing to a soft-texture food diet (in the absence of nausea) permits early discharge from hospital (within 24–36 hours of surgery) in most cases. The soft-food diet should be pursued for four weeks after hospital discharge to minimize dysphagia or bolus obstruction. Avoidance of chunky meat and bread should be highlighted. Patients have a degree of dysphagia during the first four weeks (which resolves in most cases) and difficulty in belching for up
Choice of surgery: the most common procedure for reflux is the laparoscopic Nissen (360o) fundoplication. Lesser degrees of fundoplication (e.g. posterior 270o Toupet, anterior 180o Watson, anterior 90o) exist. In general, as the wrap decreases in extent to 90o, postoperative wind-related side effects and dysphagia are decreased, but so is the long-term efficacy of control of reflux (Figure 3).
SURGERY 24:3
Sequelae (%) 8 64 24 9 23 33 12 10 56
95
© 2006 Elsevier Ltd
OESOPHAGUS AND STOMACH
to ten weeks (with resulting increase in bloating, abdominal borborygmi and flatulence). Early satiety is also common due to some loss of receptive relaxation of the fundus. Patients can lose 4–6 kg in weight during the first month postoperatively and must be warned of these side effects.
invasive cancer within four years. The recommendation for confirmed high-grade dysplasia is oesophagectomy if the patient is fit, or endoscopic mucosal resection if localized and unfit for surgery.
Complications Intraoperative complications include perforation (stomach, oesophagus, bowel) and bleeding. Perforation is most common while attempting to form a window for the wrap behind the oesophagus. This can be primarily closed and the fundoplication completed. Postoperative complications specific to fundoplication include haemorrhage, missed perforation, vomiting and gastric herniation, and an overtight hiatus or wrap producing acute dysphagia. Early reoperation is indicated for these complications. Recurrent reflux: about 5–7% of patients report clinically significant symptoms of reflux within five years of laparoscopic fundoplication. Reflux is well controlled with proton pump inhibitors in some of these patients, but revision surgery must be considered in others. These patients need objective evaluation for recurrent reflux by endoscopy and 24-hour monitoring of pH if gastroscopy is normal. The most common reason for recurrent reflux is posterior herniation of stomach through the hiatus, with distortion and eventual disruption of the wrap. At endoscopy, an intact fundoplication, without laxity, and absence of hiatal herniation without laxity of the diaphragmatic crura indicates that recurrent reflux is very unlikely. Most cases of recurrent reflux can be successfully dealt with laparoscopically, and the principles include complete takedown of the original wrap, reduction of the hernia, repair of the hiatus, and fashioning of a new fundoplication. Great care must be taken to identify the vagus nerves and not damage them. Results similar to first-time operations can be achieved using this approach. New procedures: a number of new endoscopic anti-reflux procedures are under evaluation, including endoscopic suturing (plication) of the mucosa at the cardia, radioablation of the cardial tissues producing scarring (Stretta procedure), and intra-sphincteric injection of polymers. These techniques are experimental and should not be offered outside of a clinical trial.
Barrett’s oesophagus In the context of anti-reflux surgery, the indication for surgery is principally on symptomatic grounds, rather than to ameliorate the cancer risk. Long-term studies are in progress to assess the effects of anti-reflux surgery on cancer risk in Barrett’s oesophagus, but there is little evidence in support of this notion at present. Surveillance after fundoplication is important, and, in the absence of dysplasia, two-yearly endoscopic review with four-quadrant biopsies at 2-cm intervals is standard practice, with specific targeting of nodular or suspicious areas. Repeat endoscopy and biopsy should be done within six months if low-grade dysplasia is found. The sections should be reviewed by two independent pathologists if high-grade dysplasia is found, and biopsies repeated if doubt persists. About one-third of patients with high-grade dysplasia have invasive carcinoma, and up to 60% develop a macroscopic
SURGERY 24:3
96
© 2006 Elsevier Ltd
Reflux oesophagitis
Los Angeles classification of reflux oesophagitis
David Gotley FRACS
Grade A B C D
Symptomatic gastro-oesophageal reflux is one of the commonest presentations to GPs, with 15–20% of the adult population experiencing heartburn at least once per week. Surgery for gastrooesophageal reflux disease is increasing in ‘developed’ countries due to the limitations of the long-term effectiveness of proton pump inhibitor therapy in controlling severe reflux, and the more widespread use of laparoscopic fundoplication, which is more attractive than open surgery. This contribution focuses on the presentations, indications, procedures and complications of surgery of this common condition, and should be read with ‘Investigation of dysphagia’, page 89.
1
hernia is permissive i.e. an hiatal hernia does not cause reflux, but enhances an existing tendency to reflux via lower oesophageal sphincter hypotension by various mechanical factors (e.g. sequestering of gastric contents in the herniated stomach immediately beneath a lax lower oesophageal sphincter). A hiatal hernia does not imply gastro-oesophageal reflux disease. Factors that increase the propensity to reflux include obesity, ingestion of alcohol, fat or caffeine, smoking, and diseases such as scleroderma, chronic respiratory disease (including post-lung transplantation). It can be seen in institutionalized or intellectually handicapped individuals and patients nursed supine for prolonged periods. Delayed gastric emptying can enhance gastro-oesophageal reflux disease. In most people, the natural history of gastro-oesophageal reflux disease is chronic reflux with a tendency for symptoms to worsen over time, but with periods of stability, and exacerbations due to stress and dietary factors. Gastro-oesophageal reflux disease therefore requires long-term management.
Definition Gastro-oesophageal reflux is the retrograde movement of gastric contents into the oesophagus. It is a normal physiological event that occurs particularly after eating and during belching. Gastrooesophageal reflux disease is an abnormal degree of gastrooesophageal reflux that exposes the patient to the risk of complications (ulcerative oesophagitis, Barrett’s oesophagus (see below), carcinoma, peptic stricture) or symptoms that impair wellbeing or quality of life. There are several systems of grading reflux oesophagitis when it is seen endoscopically. A commonly used system is the Los Angeles classification (Figure 1).
Presentation Symptoms can be grouped according to those caused by reflux and those occurring as a result of the complications of the reflux. The common symptoms of gastro-oesophageal reflux disease are heartburn and regurgitation, but about 50% of patients with severe gastro-oesophageal reflux disease requiring surgery also have intermittent dysphagia. Excessive salivation due to exposure of the oesophagus to acid (‘waterbrash’) is also a common symptom. Particularly troublesome symptoms of gastro-oesophageal reflux disease are those that wake the patient at night, when regurgitation may result in nocturnal aspiration and chest infection. About 10% of patients present with atypical symptoms, including chest pain that may even radiate to the neck and left shoulder or arm, mimicking ischaemic heart pain. Such patients need investigation, which may include cardiac studies (e.g. ECG, stress echocardiography) and 24-hour monitoring of oesophageal pH (see below). Another group of patients with atypical symptoms of gastrooesophageal reflux disease are those with chronic cough and other laryngeal symptoms (e.g. dysphonia, repeated clearing of throat). The commonest causes of chronic cough (after eliminating smoking and medications) are asthma, post-nasal drip, post-bronchial infection and gastro-oesophageal reflux disease. The diagnosis in
Aetiology In health, the gastric mucosa comprises mucus-producing columnar cells and is resistant to digestion by acid or pepsin. The oesophagus is lined by a squamous mucosa that is sensitive to acid and may be digested by the prolonged presence of acid or pepsin. The lower oesophageal sphincter (together with the diaphragmatic crura) is crucial to the control of excessive gastro-oesophageal reflux and the symptomatic and mucosal consequences of exposure to oesophageal acid. Most gastro-oesophageal reflux is due to transient relaxations of the lower oesophageal sphincter, but most patients with severe gastro-oesophageal reflux have resting basal lower oesophageal sphincter hypotension as the principal cause of excessive reflux. The contribution of a coexistent hiatal
David Gotley is a Mayne Professor of Surgery at Queensland University, Queensland, Australia.
SURGERY 24:3
Feature One (or more) mucosal breaks, no longer than 5 mm, not-confluent One (or more) mucosal breaks >5 mm long, not confluent One (or more) mucosal breaks continuous between mucosal folds, <75% of circumference One (or more) mucosal breaks that involves at least 75% of circumference
93
© 2006 Elsevier Ltd
OESOPHAGUS AND STOMACH
this instance is initially made by elimination, followed by investigation for gastro-oesophageal reflux disease with 24-hour monitoring of oesophageal pH. Alarm symptoms demand early investigation (Figure 2).
record acid reflux events over 24 hours, while the patient presses an event marker for symptoms and notes them in a diary. The test gives rise to two items of information, the: • correlation (or otherwise) between symptoms and acid reflux events • number and duration of acid reflux events, including the total degree of acid exposure. This test is used in patients in whom the diagnosis is unclear after a trial of therapy and endoscopy. It is particularly helpful in patients with atypical symptoms and a negative endoscopy. Monitoring of bile components and oesophageal impedance may be used to detect ‘non-acid’ reflux (e.g. bile) into the oesophagus, but these methods are used largely as research tools. Oesophageal manometry is used if an oesophageal motility disorder is suspected (e.g. dysphagia in a patient with a negative endoscopy, or odynophagia) and to exclude achalasia, diffuse oesophageal spasm or ‘nutcracker oesophagus’. Its routine use in preoperative assessment is not appropriate given that, in patients without dysphagia, it has little influence on the outcome of fundoplication (whichever fundoplication technique is used). Cardiac investigations – ECG and stress echocardiography may be appropriate in patients with atypical pain in the chest.
Diagnosis Diagnosis can usually be made on symptoms alone. There may be overlap of symptoms of gastro-oesophageal reflux disease with other conditions such as gallstone disease, peptic ulcer and irritable bowel syndrome and, because these conditions are not uncommon, the patient may have more than one of them. The severity or chronicity of symptoms are poor indicators of ulcerative oesophagitis or Barrett’s oesophagus. A symptom-based diagnosis can be supported by a therapeutic trial of a high-dose proton pump inhibitor for 2–4 weeks (or >6 weeks in the case of chronic cough). This approach is more reliable than endoscopy because only 30% of patients with chronic gastro-oesophageal reflux disease symptoms have reflux oesophagitis.
Investigations The key issue is when to investigate. In general, a trial of therapy is appropriate initially, without investigation, in patients with mild typical symptoms (no alarm symptoms). Investigation is warranted if the diagnosis is unclear (e.g. atypical symptoms, ‘mixed’ symptom complexes), symptoms persist or are refractory to therapy, complications are suspected or alarm symptoms are present. Endoscopy is the first-line investigation because it: • is readily available • is the most sensitive detection method of reflux oesophagitis and Barrett’s oesophagus • can diagnose other mucosal lesions (e.g. cancer, peptic ulcer, infective oesophagitis) • can accurately grade oesophagitis • can be used to manage strictures. Endoscopy is negative in 50% of patients with gastro-oesophageal reflux disease. Barium studies are not useful in most patients with gastro-oesophageal reflux disease. It is useful in the assessment of some strictures, large hiatal hernias and in patients with gastro-oesophageal reflux disease symptoms who have had previous anti-reflux surgery. Twenty-four-hour monitoring of ambulatory pH – a pH electrode is tethered 5 cm above the lower oesophageal sphincter to
Management The principal aims of treatment are to control symptoms and improve quality of life, heal oesophagitis, and reduce the risk of complications. General management Lifestyle modifications, together with antacid preparations as required, may improve milder symptoms, but rarely control severe gastro-oesophageal reflux disease in the long term. By the time many patients are referred for consultant review, they are at least aware of and may have adopted such measures as: • avoidance of spicy, acidic and fatty foods • avoidance of large meals late at night • elevation of the head of the bed • reduced intake of alcohol and cigarettes. Obesity is an important risk factor for reflux and some effort in reducing weight is important in the long-term control of reflux and in consideration of anti-reflux surgery. Consideration should be given to bariatric surgery (rather than anti-reflux surgery) in the morbidly obese. Medical management For mild symptoms, drug therapy with H2-receptor antagonists as required is appropriate; proton pump inhibitors are the first-line treatment for more severe or persistent symptoms. The aims are to confirm the diagnosis of reflux through the relief of symptoms and healing of oesophagitis. In patients with daily symptoms and impairment of quality of life, initial high-dose proton pump inhibitor therapy can be argued on the grounds of outcomes and speed of response. Longer-term therapy involves titration of the dose downward according to symptom control. A significant minority of patients need only intermittent therapy. Prokinetic therapy has a role in a minority of patients with delayed gastric emptying, but must be given with a proton pump inhibitor. Medical therapy should not be withdrawn in patients with
Symptoms of gastro-oesophageal reflux Typical
Atypical
Alarm
Heartburn
Chest pain (cardiac type)
Dysphagia
Regurgitation
Nausea, dyspepsia
Waterbrash
Bloating, belching, flatulence Cough, throat clearing Dysphonia Sore throat
Odynophagia (painful swallowing) Haematemesis Nocturnal choking Weight loss
2
SURGERY 24:3
94
© 2006 Elsevier Ltd
OESOPHAGUS AND STOMACH
known severe oesophagitis because it will recur, and there is a good case for repeat endoscopy in these patients (e.g. after six weeks) to confirm healing.
Sequelae of laparoscopic Nissen fundoplication (n = 2,300) at one year
Surgical management: anti-reflux surgery Indications: the principal indications for anti-reflux surgery are: • failure to respond adequately to appropriate doses of medical therapy • intolerable side effects of, or non-compliance with, medical therapy • a desire to be free of long-term medication for gastro-oesophageal reflux disease
Symptom Dysphagia Early satiety Bloat Colic Inability to vomit Difficulty belching Diarrhoea Nausea Flatulence
Risks and benefits: randomized controlled clinical trials have shown that laparoscopic fundoplication has the advantages of less postoperative pain, shorter stay in hospital, and quicker return to work compared with open fundoplication. The morbidity is <5% and mortality is <0.2%. The results of laparoscopic fundoplication are related to the experience of the surgeon, with regard to longterm control of reflux and the prevention of long-term sequelae. Long-term reflux control rates of 88–95% have been reported, and reoperation rates for failed anti-reflux surgery are <3%, with results similar to primary operation being achieved. In a recent randomized controlled clinical trial comparing long-term proton pump inhibitor therapy with laparoscopic Nissen fundoplication, fundoplication provided better symptomatic and quality-of-life outcomes, and resulted in cost savings after eight years. These results confirm that laparoscopic fundoplication for the long-term management of gastro-oesophageal reflux disease is valid irrespective of whether symptoms are well controlled by the proton pump inhibitor. The range of postoperative side effects of fundoplication is influenced by the type of wrap done (see below) and is outlined in Figure 3. Side effects tend to improve during the first year after surgery, but tend to remain static thereafter. In cases of chronic dysphagia and gas bloat (seen most commonly after the Nissen fundoplication), good results can be achieved by laparoscopic reoperation and conversion to a lesser fundoplication (e.g. posterior 270o or anterior 180o wrap).
Source: Database of the Princess Alexandra and Royal Brisbane Hospital, Queensland, Australia.
3
Procedure: in general, a 5-port technique is used, with the initial trocar inserted under direct vision. The division of the short gastric vessels is not necessary; it does not make a difference to long-term control of reflux or side effects according to a recent randomized controlled clinical study. These vessels may be divided according to how the wrap ‘sits’ when it is around the oesophagus, a tension-free wrap being desirable. The cardia and lower oesophagus are mobilized with great care to prevent damage to the vagus nerves, which may result in chronic diarrhoea or gastroparesis. Hiatal hernias are reduced, and a length of abdominal oesophagus of 5–6 cm must be achieved. The posterior hiatal crura should be apposed posteriorly with one or two sutures of non-absorbable material, but should not be tight. An intra-oesophageal bougie of 54 FG (18 mm) should allow the oesophagus to meet the hiatal margins. The desired wrap is then sutured in place with nonabsorbable sutures. ‘Crown sutures’ (sutures between the wrap, oesophagus and hiatal margin) may be added to stabilize the wrap. Because the most common site for recurrent herniation (and failure of reflux control) is left posterolateral to the oesophagus, similar sutures may also be placed in this area to close off access of the stomach to the mediastinum.
Assessment: patients undergoing anti-reflux surgery should have proven abnormal reflux by oesophagitis or Barrett’s oesophagus on endoscopy (at some stage during their disease) or by 24-hour monitoring of oesophageal pH. This is particularly important in patients with atypical symptoms, where symptom correlation with acid reflux events on pH monitoring can be determined. An endoscopy should be done if one has not been done within six months of surgery to exclude new or unexpected disease. Oesophageal manometry is indicated in cases of endoscopically negative dysphagia, to exclude achalasia.
Perioperative care: a nasogastric tube is not necessary in the postoperative period. Prevention of retching or vomiting is essential to avoid the serious complication of early acute herniation of the wrap, which can strangulate at the diaphragmatic hiatus and perforate; giving a potent antiemetic (e.g. ondansetron 4 mg i.v.) during induction of anaesthesia, and timely administration of antiemetics in the postoperative period for nausea, are important preventative measures. Early oral intake of fluids progressing to a soft-texture food diet (in the absence of nausea) permits early discharge from hospital (within 24–36 hours of surgery) in most cases. The soft-food diet should be pursued for four weeks after hospital discharge to minimize dysphagia or bolus obstruction. Avoidance of chunky meat and bread should be highlighted. Patients have a degree of dysphagia during the first four weeks (which resolves in most cases) and difficulty in belching for up
Choice of surgery: the most common procedure for reflux is the laparoscopic Nissen (360o) fundoplication. Lesser degrees of fundoplication (e.g. posterior 270o Toupet, anterior 180o Watson, anterior 90o) exist. In general, as the wrap decreases in extent to 90o, postoperative wind-related side effects and dysphagia are decreased, but so is the long-term efficacy of control of reflux (Figure 3).
SURGERY 24:3
Sequelae (%) 8 64 24 9 23 33 12 10 56
95
© 2006 Elsevier Ltd
OESOPHAGUS AND STOMACH
to ten weeks (with resulting increase in bloating, abdominal borborygmi and flatulence). Early satiety is also common due to some loss of receptive relaxation of the fundus. Patients can lose 4–6 kg in weight during the first month postoperatively and must be warned of these side effects.
invasive cancer within four years. The recommendation for confirmed high-grade dysplasia is oesophagectomy if the patient is fit, or endoscopic mucosal resection if localized and unfit for surgery.
Complications Intraoperative complications include perforation (stomach, oesophagus, bowel) and bleeding. Perforation is most common while attempting to form a window for the wrap behind the oesophagus. This can be primarily closed and the fundoplication completed. Postoperative complications specific to fundoplication include haemorrhage, missed perforation, vomiting and gastric herniation, and an overtight hiatus or wrap producing acute dysphagia. Early reoperation is indicated for these complications. Recurrent reflux: about 5–7% of patients report clinically significant symptoms of reflux within five years of laparoscopic fundoplication. Reflux is well controlled with proton pump inhibitors in some of these patients, but revision surgery must be considered in others. These patients need objective evaluation for recurrent reflux by endoscopy and 24-hour monitoring of pH if gastroscopy is normal. The most common reason for recurrent reflux is posterior herniation of stomach through the hiatus, with distortion and eventual disruption of the wrap. At endoscopy, an intact fundoplication, without laxity, and absence of hiatal herniation without laxity of the diaphragmatic crura indicates that recurrent reflux is very unlikely. Most cases of recurrent reflux can be successfully dealt with laparoscopically, and the principles include complete takedown of the original wrap, reduction of the hernia, repair of the hiatus, and fashioning of a new fundoplication. Great care must be taken to identify the vagus nerves and not damage them. Results similar to first-time operations can be achieved using this approach. New procedures: a number of new endoscopic anti-reflux procedures are under evaluation, including endoscopic suturing (plication) of the mucosa at the cardia, radioablation of the cardial tissues producing scarring (Stretta procedure), and intra-sphincteric injection of polymers. These techniques are experimental and should not be offered outside of a clinical trial.
Barrett’s oesophagus In the context of anti-reflux surgery, the indication for surgery is principally on symptomatic grounds, rather than to ameliorate the cancer risk. Long-term studies are in progress to assess the effects of anti-reflux surgery on cancer risk in Barrett’s oesophagus, but there is little evidence in support of this notion at present. Surveillance after fundoplication is important, and, in the absence of dysplasia, two-yearly endoscopic review with four-quadrant biopsies at 2-cm intervals is standard practice, with specific targeting of nodular or suspicious areas. Repeat endoscopy and biopsy should be done within six months if low-grade dysplasia is found. The sections should be reviewed by two independent pathologists if high-grade dysplasia is found, and biopsies repeated if doubt persists. About one-third of patients with high-grade dysplasia have invasive carcinoma, and up to 60% develop a macroscopic
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© 2006 Elsevier Ltd