Prof. Sandro Mattioli
in qualità di docente dell’evento sopra indicato,
ai sensi dell’art. 3.3 sul Conflitto di Interessi, pag. 17
del Reg. Applicativo dell’Accordo Stato-Regioni del
5/11/09, per conto del provider I&C srl
dichiara
che negli ultimi due anni
non ha avuto rapporti con soggetti portatori
di interessi commerciali in campo sanitario
The “point” on GERD Surgery
Sandro Mattioli
Division of Thoracic Surgery
Center for the Study and Therapy of Diseases of the Esophagus
Alma Mater Studiorum - University of Bologna
GVM Care and Research
Cotignola
Italy
Medical versus surgical management for gastrooesophageal reflux disease (GORD) in adults
Wileman SM et al. Cochrane Database Syst Rev. 2010 Mar 17;(3):CD003243
• A total of 173 titles and/or abstracts were read independently by the authors.
• Of these, 12 potential papers for full critical appraisal were obtained. The papers
reported data at multiple timepoints from four clinical trials:
One study in 11 European
countries (LOTUS Trial 2008)
Two multicentric studies in
the UK (Mahon 2005;
REFLUX Trial 2008)
The remaining study in a single centre in Canada (Anvari 2006)
• Sample sizes ranged from 104 to 554 participants, with a total of 1232 randomised
participants.
Medical vs laparoscopic
surgical
management,
outcome:
Health-related
quality of life (SF-36).
Medical vs laparoscopic surgical
management, outcome: Healthrelated quality of life (EQ-5D).
Surg Endosc 2010; 24:2647–2669
Methodology
• A total of 293 graded articles relevant to this guideline were
reviewed.
• Randomized
controlled trials, metaanalyses, and systematic
reviews were selected for further review, along withprospective
and retrospective studies that included at least 50 patients.
• Studies with smaller samples were considered when additional
evidence was lacking. The most recent reviews were also
included.
• All
case reports, older reviews, and smaller studies were
excluded.
Surg Endosc 2010; 24:2647–2669
INDICATIONS FOR SURGERY
Surgical therapy should be considered in
individuals who:
• Have failed medical management (inadequate symptom control,
severe regurgitation not controlled with acid suppression, or
medication side-effects)
OR
•Opt for surgery despite successful medical management (due to
quality-of-life considerations, lifelong need for medication intake,
expense of medications, etc.)
OR
• Have complications of GERD (e.g., Barrett’s esophagus,peptic
stricture)
OR
• Have extra-esophageal manifestations (asthma, hoarseness,
cough, chest pain, aspiration) .
Indications and Techniques for the Surgical Treatment of GERD
Indications for Surgical Therapy in GERD
• Pts non responders to medical therapy.
• Pts not compliant with long term medical therapy.
• Pts requiring high dosages of drugs.
• Pts too young for a lifetime medical treatment.
Spechler SJ et al. JAMA 2001; 285:2331-2338
Watson DI et al. GUT 1999; 45: 791-792
Baldi F et al. Ital J Gastroenterol Hepatol. 1998; 30(1):107-12
Galmiche JP et al. BMJ 1998; 316: 1720-1723
Galmiche JP et al. Acta Gastroenterol Belg 1998;61(4):438-49
• Pts with the axial intrathoracic migration of the GE
junction and severe GERD.
L’Esofago Corto nella MRGE
Cause della controversia
• La
posizione intratoracica della GEG nello studio
preoperatorio (Radiologia – Endoscopia) ha significato
fisiopatologico e predittivo , ma non sempre
corrisponde ad un vero esofago corto.
• Può essere difficile individuare intraoperatoriamente
la GEG e la sua posizione rispetto allo hiatus
diaframmatico.
The Intrinsic and Extrinsic Components of
the LES
RK Mittal, DH Balaban.
N Engl J Med 1997,336;13:924-32.
Radiologic Classification of Hiatus Hernia
a
b
Normal
GEJ
Sliding
Hiatus
Hernia
Hiatal
Insufficiency
Concentric
Hiatus
Hernia
Short
Esophagus
Incarcerated
Hiatus Hernia
Radiologic Classification of Hiatus Hernia
T
E
angle of
HIS
P
HH
A
D
EGJ
EGJ
HH
EGJ
SS
Z-line
EGJ
Normal
EGJ
Hiatal
Insufficiency
Wolf BS 1960
Rex JC, Andersen HA, Bartholomew LG,
Cain JC 1961
Concentric
Short
Hiatus Hernia Esophagus
Zaino C, Poppel MH, et al. 1963
Pringot J, Ponette E 1974.
Position of the Lower Esophageal Sphincter with respect to
the Diaphragmatic Dome
p= .0002
10
cm
5
Diaphragmatic
dome
0
cm
5
p= .02
p= .02
p= .0002
Normal
Hiatal Concentric
Short
GEJ Insufficiency Hiatus Esophagus
Hernia
S.Mattioli et al. J Thorac Cardiovasc Surg 1998; 116: 267-75.
LES resting tone
mmHg
30
25
20
15
10
5
0
p=.00003
p=.00002
p=.0001
p=.0001
p=.008
p=.0002
HV SHH HI CHH SE
Acid GER 24-hr Ph recording
Time %
pH <4
30
25
20
15
10
5
0
p=.00003
p=.00002
p=.0001
p=.01
p=.001 p=.01
HV SHH HI CHH SE
S Mattioli et al. J Thorac Cardiovasc Surg 1998; 116: 267-75
GERD Surgery and Short Esophagus
• Not the Sliding Hiatus Hernia but the Permanent Axial Orad
Migration of the gastroesophageal junction above the hiatus is
correlated with severity of GERD.
• In 80% of cases the intrathoracic migration of the
gastroesophageal junction is associated with esophagitis ≥ Los
Angeles A.
•The existence of a common cavity correlated with an
irreversible anatomic abnormality is preface to surgical therapy
.
•Mattioli S. JCTVS.1998 ; 116 .267-275 - Dig Dis Scienc .
2003;48(9):1823-31.
GERD Surgery and Short Esophagus
S
H
O
R
T
E
S
O
P
H
A
G
U
S
Is it an elective indication for
surgical therapy ?
Intraoperative
localization of the GEJ
Surgical
therapy
Choice of the
surgical technique
Surg Endosc 2010; 24:2647–2669
Recommendations
• Surgical therapy for GERD is an equally effective alternative to medical
therapy and should be offered to appropriately selected patients by
appropriately skilled surgeons (grade A).
• Surgical therapy effectively addresses the mechanical issues associated
with the disease and results in long-term patient satisfaction (grade A).
• Based
on the available evidence that is of high quality (level I),
laparoscopic fundoplication should be preferred over its open
alternative as it is associated with superior early outcomes (shorter hospital
stay and return to normal activities, and fewer complications) and no
significant differences in late outcomes (failure rates) (grade A).
Surgical approach for severe complications of GERD
Short Esophagus does require dedicated surgical procedures .
20-33% of failures of antireflux surgery are caused by
misdiagnosing a condition of foreshortened esophagus (Siewert
1989, Jobe 1998).
Manchonnage sur cône gastrique acc. to Maillet
(Lyon. Chir. 1970)
Author
Windsor J.A. et al.
Basso N. et al.
Farrell T.M. et al.
Kamolz T. et al.
Leggett P.L. et al.
O'Boyle C.J. et al.
Pessaux P. et al.
Ross S. et al.
Windsor J.A. et al.
Yau P. et al.
Eubanks T.R. et al.
Zaninotto G. et al.
Luketich J.D. et al.
Kleimann E.et al.
Terry M. et al.
Awad Z.T. et al.
Urbach D.R. et al.
O’Rourke R.W. et al.
Lin E. et al.
Terry M. et al.
Mattioli S. et al.
Year
No Patients
Surgery
2000
2000
2000
2000
2000
2000
2000
2000
2000
2000
2000
2000
2000
2001
2001
2001
2001
2003
2004
2004
2004*
474
135
669
175
239
511
1470
200
1218
757
228
621
100
255
1000
260
153
487
1579
143
170
open
mini-invasive
mini-invasive
mini-invasive
mini-invasive
mini-invasive
mini-invasive
mini-invasive
mini-invasive
mini-invasive
mini-invasive
mini-invasive
mini-invasive
mini-invasive
mini-invasive
mini-invasive
mini-invasive
mini-invasive
mini-invasive
mini-invasive
open, mini-invasive
Short Esophagus (%)
0
0
0
0
0
0
0
0
0
0
0.8%
0.9%
27%
2%
1.5%
5%
13%
19%
4.3%
11.2%
23%
Mattioli S. In: Ferguson MK. Difficult Decisions in Thoracic Surgery. Springer-Verlag 2007: 305-317.
University of Bologna
Prof. Mattioli
University of Milan
Prof. Rosati
University of Naples
Prof. Del Genio
University of Naples
Prof. Di Martino
University of Naples
Prof. Fei
University of Padua
Prof. Ancona
Prof. Zaninotto
University of Pisa
University of Turin
Prof. Rossi
Prof. Morino
Proximal
margin of the
gastric folds
Intraoperative laparoscopic
measurement of the distance
between GEJ-hiatus*
* Mattioli S et al. J Thorac Cardiovasc Surg. 2008;
136(4):834-41.
Results
180 patients
84 Men
96 Women
(46.6%)
(53.4%)
Mean age 49.3 ± 15.3 years
Range 17- 79 years
cm
4
3
2
1
Second
0
Measure
-1
-2
-3
-4
-5
-6
-2
0
2
4
6
8
10
12
14
cm
Length of dissection
Second Measure = -3,285 + ,137 * Length of dissection; R^2 = ,068
p = 0.0041
Surgical approach for severe complicated GERD
To inform the patient
GEJ
D
GEJ
D.Hiatus
To choose the surgeon
To plan the procedure
GERD Surgery and Short Esophagus
Collis–Nissen
Fundusplication
3.5 cm
Alma Mater Studiorum - University of Bologna
2nd Surgical Clinic
Division of Thoracic Surgery
Center for the Study and Therapy of Diseases of
the Esophagus
GVM Care and Research
1980 - 2010
Surgical Therapy for GERD
541 pts
Open
277 (51.2%)
Minimally-Invasive
264 (48.8%)
Alma Mater Studiorum - University of Bologna
2nd Surgical Clinic - Division of Thoracic Surgery
Center for the Study and Therapy of Diseases of the Esophagus
GVM Care and Research
Surgical Therapy for GERD 1980-2010
Minimally-Invasive 264 (48.8%)
Nissen
Collis-Nissen
Collis-Dor
206
(78%)
57
(21.6%)
1
(0.4%)
Mortality 0.8%
Morbidity 7.5%
Alma Mater Studiorum - University of Bologna
2nd Surgical Clinic - Division of Thoracic Surgery
Center for the Study and Therapy of Diseases of the Esophagus
GVM Care and Research
Terapia Chirurgica per MRGE 1980-2010
Laparoscopic Nissen 206 (78.2%)
Mortality 0.5%
Morbility 7%
Mean Follow up 72.7 months
(range 12-180 months)
Excellent/
Good
Fair
Poor
87.5%
11.7%
0.8%
Laparoscopic left-thoracoscopic COLLIS-NISSEN
57 (21.6%) procedures
• Conversion 4
(7%)
• Mortality
(1,7%)
1
• Morbidity
(10.5%)
6
3 Split of the endosuture
1 Angle of His perforation
Intrathoracic Migration of the antireflux
fundoplication
1
Pulmonary embolism
1
Emyema
1 (no fistula)
Hemorrhagic Colitis
1
Acute Pancreatitis
1
Severe Dysphagia
1 (Candida Alb.)
Laparoscopic left-thoracoscopic COLLIS-NISSEN
Criteria of assessement
Excellent
Good
Fair
RS0/D0/E0
RS1/D1/E0
RS1-2/D2/E1
Poor
RS2-3/D2-3/E2-3 or Anatomical Recurrence
Mean follow-up 58.1 ± 24.8 months (range 12-108)
Excellent
Good
Fair
Poor *
13 (24%)
36 (66.6%)
2 (3.7%)
3 (5.5%)
* *Severe Esophagitis 2 (3.7%), Anatomical Recurrence 1 (1.8%)
Surg Endosc 2010; 24:2647–2669
Recommendations
• While atypical symptoms improve in a majority of patients after antireflux
surgery, symptom persistence is higher compared with patients with typical
symptoms and surgeons should therefore carefully select and counsel these
patients preoperatively (grade B).
• Patients undergoing laparoscopic antireflux surgery should be counseled
preoperatively about the reported rates of symptom relapse and resumption
of acid-reducing medications (grade A).
Alma Mater Studiorum - University of Bologna
2nd Surgical Clinic
Division of Thoracic Surgery
Center for the Study and Therapy of Diseases of the Esophagus
GVM Care and Research
GERD Surgery
1995-2010
Mean Follow up 61 months
Range 3-180 months
83 pts
Typical Symptoms (A)
70%
68 pts
Typical Symptoms +
Chronic Cough (B)
p > 0,05
60%
50%
A
40%
B
30%
20%
10%
0%
Excellent
Good
Fair
Insufficient