the role of surgery in the modern management of dyspepsia
DESCRIPTION
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) - PowerPoint PPT PresentationTRANSCRIPT
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The role of surgery in the modern management of
dyspepsia
Mr Paras Jethwa Bsc MD FRCSSurrey & Sussex NHS Trustand Spire Gatwick Hospital
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GORDVery significant modern diseaseHigh prevalence and incidenceSubstantial drug budgetVariable prescribing rationale (everyone in hospital)Correlation with obesity, diet, alcohol, coffee etc....
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Mechanics of reflux
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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
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➡What about the guidelines?
➡significant number were mis-referred
➡(i.e should have been urgent)
➡2% incidence of OG cancer
➡98% sensitive
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Barrett’s
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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
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Current treatment• Treatment dose of a PPI• Consider NSAIDs/ Aspirin
• Surveillance• Duration• Interval• Aneuploidy/tetraploidy
• Anti reflux surgery• Oesophagectomy for HGD or Cancer
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Surveillance limitations
• Surveillance probably doesn't work
• Time consuming, inaccurate, distressing for patients, expensive
• Lack of an easily identifiable high risk group?
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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
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Long term effects of GORD
PEPTIC STRICTURE
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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
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Surgical correction
OESOPHAGUS
R CRUS
L CRUS
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Effect of operation
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Who should you consider referring?
Clear indication:Poorly controlled symptomsHiatus hernia causing dysphagia +/- refluxYoung patients with IM/marked oesophagitisIntolerant of conventional therapyMass reflux Respiratory compromise
Probably not for:Reasonable control with occasional flare-ups
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Cost of therapy Drug Dose Cost (£, 28
days) Annual(£)Omeprazole 20mg 28.56 571.2Lansoprazol
e 30mg £23.75 712.5Pantoprazol
e 40mg £23.65 946Rabeprazole 20mg £22.75 455Esomeprazo
le 20mg £18.50 370Esomeprazo
le 40mg £28.56 1142.4
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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”.
• Mean cost of Surgery: £2000 - £4000• But - need to add cost of testing (OGD/pH/manometry) & loss of work
etc.• Significant QOL improvement at 12 months+ (SF36)
• (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
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• (3) Fundoplication vs medical management in adults for GORD -
Cochrane review 2010• Four trials elligible n=1232
• Significant improved QOL in surgical group• % 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
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Surgical considerationsBMI <35 (men store fat at GOJ) woman up to 40
(Similar area to LAGB placement)Reasonable health/respiratory compromiseNo major motility issues (HRM/Ba swallow)Hiatus hernia/OGD proven reflux without pH studiesPsychological onlay/effect of dietary changePhysiological studies
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pH StudiesOnly method of objectively proving refluxIn cases of odd symptoms/symptom correlationPre/Post operative comparisonMedico legal aspectsBravo or conventional systems
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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
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Complications & SE• Dysphagia - acute revision
• Gas bloating
• GI dysmotility (non vagal)
• Recurrent symptoms
• Injury (GOJ/vagus/spleen/other)
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Advanced technique - presented in Europe and UKLargest series of mesh reinforced hiatal closuresCommon practice at ESH/Spire
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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
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SASH4 dedicated Laparoscopic specialists - laparoscopic surgery has become a speciality in itself.
Very latest laparoscopic facilities and optics.
SASH recognised as a high quality training centre amongst KSS trainees
Links to Imperial College
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The role of surgery in the modern management of
dyspepsia
Mr Paras Jethwa Bsc MD FRCSSurrey & Sussex NHS Trustand Spire Gatwick Hospital