UPPER GI SURGERY
| CURRENT SURGICAL THERAPY FOR GERD—Jeffrey H. Peters, MD, Seymour I. Schwartz Professor and Chair, Department
of Surgery, University of Rochester School of Medicine and Dentistry, and Surgeon-in-Chief, Strong Memorial
Hospital, Rochester, NY
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| Introduction: most patients referred for surgery for gastroesophageal reflux disease (GERD) have had trial of proton
pump inhibitor (PPI) and wish to try another form of treatment; patients fall into 3 categories (acid symptoms; nonacid or
volume symptoms; no symptoms related to GERD)
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| Predictors of success after laparoscopic Nissen fundoplication: 1999 study found most significant predictor of
success in relieving symptoms positive 24-hr pH test score (3 greatest predictors pH score, typical symptoms, and good response
to medical therapy); shown that certain factors (eg, presence or absence of defective lower esophageal sphincter
[LES]) not as important in patient selection and outcome as originally thought
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| Total Nissen fundoplication: gold standard; most other options (eg, partial fundoplication, Collis gastroplasty) not as effective;
as shown in studies (Pellegrini et al), procedure does not need to be modified for individual patients as much as originally
thought
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| Role of symptoms: understand cause and type of symptoms before taking patient to operating room (OR); characterization
of symptoms vital to outcome; most patients with GERD present with multiple symptoms of gastrointestinal (GI)
disease, some of which are not caused by reflux and will remain after surgery
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| Patients with complex scenarios: more difficult to manage surgically (and perhaps not good candidates) than typical
reflux patient; include patients with stricture or shortened esophagus, severe motility disorders that can be named or absent
motility, intrathoracic stomach, severe gastric abnormalities, or patients undergoing reoperation for failed repair
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| Technical components of Nissen fundoplication: becoming more standardized over time (eg, mobilization of fundus);
technical issues still cause failure (study by Swanstrom et al found 22 of 145 patients who underwent reoperation had
technical reason for failure of initial procedure); think of fundoplication as hernia operation (majority, if not all, antireflux surgery
patients have hernias; correcting hernia important part of technique and may be important component of side effects that
occur with procedure)
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| Keys to success: near certainty that reflux source of symptoms for which surgery being performed; differentiate symptoms
based on likelihood of being secondary to GERD; explain to patient which symptoms can be resolved with surgery
and which cannot; consider possibility of severe disease and complex physiology and anatomy (exercise extra caution under
such circumstances); carefully perform standardized technique; if patient returns with recurrent symptoms, important
to document (through endoscopy and pH probe) presence or absence of reflux and that symptoms unrelated to reflux
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| Physiology of Nissen fundoplication: operation stops reflux (as measured by pH score or impedance study) in almost
100% of cases; fundoplication has been shown to restore distensive characteristics of gastroesophageal junction (GEJ) opening
(too loose to transfer fluid from stomach to esophagus in patient with GERD) and flow rates through GEJ to normal;
however, study from Europe found fundoplication can also cause impairment and delay in transit time of liquids and solids
across GEJ; in most patients with reflux (compared to normal patients), gastric fundus distends more after eating and resolves
less; fundoplication restores this function to “more than normal”
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| Long-term outcomes after Nissen fundoplication: at 5 yr (Australian study)—87% of patients had no or minimal
heartburn; 10% back on acid suppressing medications; at 10 yr (Dallemagne et al)—92% free of reflux symptoms
(results with partial fundoplication less satisfactory)
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| Utilization of fundoplication: prevalence of severe GERD in United States, 3%; however, annual rate of antireflux surgery,
0.00012% (12 of every 100,000 patients); study (Liu and Birkmeyer) on appropriate threshold for surgery for GERD
concluded that in 50% of cases of relatively severe GERD, antireflux surgery should be seriously considered
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| REASONS FOR FAILURE OF ANTIREFLUX SURGERY —Lee Swanstrom, MD, Clinical Professor, Department of
Surgery, Oregon Health Sciences University; Director, Division of Minimally Invasive Surgery, Legacy Health System; and
Director, Legacy/OHSU Surgical Endoscopy and Laparoscopy Postgraduate Fellowship Program, Portland, OR
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| Introduction: substantial number of fundoplications reoperative; typical case scenario (sorting out which symptoms
treatable and untreatable, helping patient adjust to untreatable symptoms, and identifying those that can be resolved)
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| Indicators of failed fundoplication: residual or recurrent symptoms; signs of wrap herniation or disruption; abnormal
postoperative 24-hr pH test; dysphagia worse or unimproved after surgery; not indicators of failure—side effects of surgery;
continued use of peptic medications; symptoms alone (recent study found 66% of patients who complain of GERD
symptoms after surgery have normal 24-hr pH test; 9% of patients with no symptoms have positive 24-hr pH test); if patient
returns with residual or recurrent symptoms, physician’s first step to get 24-hr pH test (to establish whether surgery has
failed)
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| Why fundoplications fail: cause of failure typically multifactorial; reasons include wrong surgeon, wrong procedure,
choosing wrong patient, and technical errors
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| Risk for recurrence: when presenting for first-time antireflux surgery, all patients should be warned of possibility of recurrence;
some patients at high risk for recurrence (eg, substantial failure rate seen in surgery for large paraesophageal hernia);
patient with recurrent symptoms who comes in for repeat surgery at high risk for further recurrences and must be
warned that second or third operations not as successful as initial surgeries
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| Mechanical problems (modes of failure): malpositioning of wrap; residual reflux through intact wrap (eg, in patients
who have had partial fundoplication); wrap disruption or herniation (resulting from repair under tension); most
common finding in cases of recurrence, herniation (either slippage or wrap herniating up into mediastinum)
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| Reasons for failure (repairs under tension): torsion of wrap (prevented by division of short gastric vessels during
fundoplication); fundoplication made too loose; axial shortening (short esophagus rare, but possible)
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| Indications for repeat antireflux surgery: daily symptoms requiring long-term medical treatment (patients with
minor symptoms not candidates for reoperation, which is more complicated procedure with possibility of exacerbating,
rather than improving, symptoms); recurrence of complications of GERD; objective confirmation of failure necessary;
avoid surgery in patients with underlying psychologic problems
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| Preoperative evaluation: thorough medical evaluation critical; comprehensive evaluation of esophageal
physiology—upper GI series; endoscopy; 24-hr pH test; motility testing; gastric emptying study; if tests normal, do not
hesitate to forgo surgery (“if there’s nothing mechanically wrong, then there’s no sense operating”); other options available
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| Short esophagus: uncommon; risk factors include long-standing severe disease, strictures, GEJ >5 cm above hiatus,
Barrett’s syndrome, and recurrence; most patients can be treated laparoscopically (transhiatal dissection achieves esophageal
mobilization in majority of cases); in cases of reoperation, especially, surgeon should be prepared and able to do
Collis gastroplasty
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| Recurrence of paraesophageal hernia (PEH): PEH different disease (disease of diaphragm; familial/genetic; high
recurrence rates); patients at risk of needing Collis gastroplasty; mesh important component of repair (use of biologic
mesh shown to dramatically reduce recurrence of PEHs; plastic mesh not recommended); when reoperating for PEH, relaxing
incision needed; early on, speaker tried wrapping esophagus circumferentially; however, he quickly found that
whichever mesh used caused stricturing and problems with esophagus (thus wrap should not be circumferential); more
common now to use U-shaped piece of mesh to cover repair
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| Endoluminal treatments: in patients who have breakthrough reflux after laparoscopic antireflux surgery, endoluminal
treatment effective (works well, success rate high, and good way to salvage these patients)
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| Results of reoperative antireflux surgery: of all antireflux surgeries, reoperative cases have worst outcomes (outcome
excellent after first procedure, but patients who need repeat operations have much worse objective outcomes, ie, higher
failure rates); outcome continues to worsen as recurrences continue, so by third or fourth surgery, failure rate 50% to 60%;
such patients end up needing radical surgery (eg, esophagectomy, gastrectomy), which is associated with greater morbidity;
once patients require third or fourth surgery, discomfort and GI problems greatly increase as well (even when results after
surgery good, patients tend to have more gas, more diarrhea, and more dyspepsia than after initial procedure)
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| SURGICAL MANAGEMENT OF UPPER GI EMERGENCIES —Charles E. Lucas, MD, Professor of Surgery, Wayne
State University School of Medicine, Detroit, MI
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| Introduction: definitions—minor GI bleeding (stable vital signs, hemoglobin, and hematocrit); moderate bleeding (tachycardia
with 10% decrease in hematocrit); massive bleeding (hypotension or visible active bleeding during endoscopy);
natural history that most bleeding stops; however, some situations in which bleeding will not stop or rebleeding
expected after initial stoppage; widespread administration of warfarin (eg, Coumadin) and clopidogrel (Plavix) has led to
higher incidence of coagulopathy in patients presenting with acute upper and lower GI bleeding; patients with continued
bleeding require urgent endoscopic assessment or urgent operative intervention with hemostasis
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| Managing patients who present with acute bleeding: go through all steps of resuscitation; important to identify
coagulopathy and correct with fresh frozen plasma (FFP); initial resuscitation should include interference with acid secretion
(mostly done with histamine type 2 [H2 ] blockers, but use of PPIs increasing); in cases of serious bleeding, prepare
patients for early endoscopy (data show that early assessment reduces length of stay, time in intensive care unit [ICU],
and mortality); need for surgical hemostasis mostly eliminated; in cases of refractory bleeding, in which patient requires
immediate surgery, bring endoscopist into OR
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| Comments: at Detroit Medical Center, most common category of bleeding “the itises”; usually caused by alcohol abuse (in
other hospitals, NSAIDs implicated as well); important area of advancement in last 30 yr prevention of so-called stress bleeding
with H2 blockade or PPIs; current “leap-frog criteria” for managing critical care include gastric prophylaxis with H2
blocker; these criteria do not include monitoring of gastric pH, which speaker considers mistake; speaker recommends that, in
critical care unit, medical student or resident be appointed to measure pH each morning in all patients with nasogastric (NG)
tubes to determine whether they are outside range of pepsinogen conversion to pepsin (very important; in time, will become
standard in ICUs)
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| Mallory-Weiss syndrome: typically, patient has had too much to drink, vomited, and then had problems related to hematemesis
30 min after initial vomiting; when patient resuscitated, blood still seen in NG aspirate; longitudinal tear along
lesser curvature of stomach visible via endoscopy; tear can be made hemostatic by using heater probe (important to utilize
endoscopist in these cases; eliminates need for surgery in majority of patients)
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| Bleeding from gastroesophageal varices: usually associated with alcohol abuse, hepatitis C, or combination; patients
almost always present in coagulopathic state; initiate FFP, then transfer patient to endoscopy suite for band ligation
or injection therapy; transjugular intrahepatic portosystemic shunt (TIPS) procedure popular in 1980s, but associated
with high incidence of encephalopathy; if surgery necessary, speaker prefers EndoSite 3Di Digital Vision System portacaval
shunt; devascularization (accomplished by doing splenectomy, ligation of right and left gastroepiploic vessels and
right gastric vessels, and omentectomy) has excellent rate of stopping bleeding without causing problems of portal encephalopathy
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| Portal gastrorrhaphy: sometimes seen in patients with severe cirrhosis who continue drinking alcohol; causes refractory
bleeding from stomach (patients continue to bleed as long as they continue to drink); treatment portosystemic shunt
by TIPS procedure, or in rare cases, total gastrectomy
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| Varices along greater curvature of stomach: extremely unusual cause of upper GI bleeding; usually misdiagnosed
and mistreated when first seen; typically associated with pancreatitis with or without pseudocysts and often associated
with additional splenic venous thrombosis; also seen (rarely) in patients who have had arteriovenous fistula; treatment
splenectomy and devascularization of greater curvature of stomach (by taking down right and left gastroepiploic vessels
and inverting greater curvature)
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| Bleeding duodenal ulcer: common source of GI bleeding that may require surgery; typical approach to make upper midline
incision, then do gastroduodenotomy, pyloroplasty, and truncal vagotomy; 1- or 2-layer closure acceptable (but important
that it be brought together without tension and be secure)
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| Patient rebleeding from duodenal ulcer: surgeon must do distal resection (incorporating ulcer); procedure can be
difficult (requires carefully dissecting ulcer off pancreas); be “a bit paranoid” when doing gastrectomy for deep bleeding
duodenal ulcer; if stump “very bad,” also do tube duodenostomy; speaker has had 2 cases in which third operation (Whipple
procedure) necessary to control bleeding
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| Bleeding prepyloric ulcer: approach similar to duodenal ulcer, except surgery consists of antrectomy and Billroth I reconstruction;
since ulcer also acid-stimulated (by way of vagus nerve), also perform vagotomy; antrum represents only
≈20% of surface area of stomach, therefore large gastrectomy not necessary for true antrectomy
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Suggested Reading
Abraldes JG, Bosch J: The treatment of acute variceal bleeding. J Clin Gastroenterol 41:S312, 2007; Blom D et al:
Physiologic mechanism and preoperative prediction of new-onset dysphagia after laparoscopic Nissen fundoplication. J
Gastrointest Surg 6:22, 2002; Byrne JP et al: Symptomatic and functional outcome after laparoscopic reoperation for
failed antireflux surgery. Br J Surg 92:996, 2005; Dallemagne B et al: Clinical results of laparoscopic fundoplication at
ten years after surgery. Surg Endosc 20:159, 2006; Donkervoort SC et al: Impact of anatomical wrap position on the
outcome of Nissen fundoplication. Br J Surg 90:854, 2003; Finlayson SR et al: Trends in surgery for gastroesophageal
reflux disease: the effect of laparoscopic surgery on utilization. Surgery 133:147, 2003; Hatch KF et al: Failed fundoplications.
Am J Surg 188:786, 2004; Higuchi N et al: Endoscopic band ligation therapy for upper gastrointestinal bleeding
related to Mallory-Weiss syndrome. Surg Endosc 20:1431, 2006; Khajanchee YS et al: Laparoscopic reintervention for
failed antireflux surgery: subjective and objective outcomes in 176 consecutive patients. Arch Surg 142:785, 2007;
Khajanchee YS et al: Postoperative symptoms and failure after antireflux surgery. Arch Surg 137:1008, 2002; Lafullarde
T et al: Laparoscopic Nissen fundoplication: five-year results and beyond. Arch Surg 136:180, 2001; Leontiadis
GI et al: Systematic reviews of the clinical effectiveness and cost-effectiveness of proton pump inhibitors in acute upper
gastrointestinal bleeding. Health Technol Assess 11:1, 2007; Lin HJ: Pre-endoscopic PPI therapy reduces recurrent adverse
outcomes in acute non-variceal upper gastrointestinal bleeding. Aliment Pharmacol Ther 25:343, 2007; Lord RV et
al: Absence of gastroesophageal reflux disease in a majority of patients taking acid suppression medications after Nissen
fundoplication. J Gastrointest Surg 6:3, 2002; Oleynikov D et al: Total fundoplication is the operation of choice for patients
with gastroesophageal reflux and defective peristalsis. Surg Endosc 16:909, 2002; Palmer K: Acute upper gastrointestinal
haemorrhage. Br Med Bull 83:307, 2007; Pandolfino JE et al: Restoration of normal distensive
characteristics of the esophagogastric junction after fundoplication. Ann Surg 242:43, 2005; Pohl D et al: Management
and outcome of complications after laparoscopic antireflux operations. Arch Surg 136:399, 2001; Portale G et al: A current
assessment of endoluminal approaches to the treatment of gastroesophageal reflux disease. Surg Innov 11:225, 2004;
Power C et al: Factors contributing to failure of laparoscopic Nissen fundoplication and the predictive value of preoperative
assessment. Am J Surg 187:457, 2004; Rosemurgy AS et al: Reoperative fundoplications are effective treatment
for dysphagia and recurrent gastroesophageal reflux. Am Surg 70:1061, 2004; Soper NJ: Fundoplication and the short
gastric vessels: divide and conquer. Ann Surg 235:171, 2002; Safranek PM et al: Results of laparoscopic reoperation
for failed antireflux surgery: does the indication for redo surgery affect the outcome? Dis Esophagus 20:341, 2007; Targownik
LE et al: The role of rapid endoscopy for high-risk patients with acute nonvariceal upper gastrointestinal bleeding.
Can J Gastroenterol 21:425, 2007; Targownik LE, Nabalamba A: Trends in management and outcomes of
acute nonvariceal upper gastrointestinal bleeding: 1993-2003. Clin Gastroenterol Hepatol 4:1459, 2006; Theodorou
DA, Peters JH: Causes of failure of antireflux surgery. Semin Laparosc Surg 8:272, 2001; van Lanschot JJ: Management
of bleeding gastroduodenal ulcers. Dig Surg 19:99, 2002; Williams VA et al: Gastrectomy as a remedial operation
for failed fundoplication. J Gastrointest Surg 11:29, 2007.
Educational Objectives
| The goal of this program is to improve surgical management of gastroesophageal reflux disease (GERD), as well as the
management of emergent upper gastrointestinal (GI) bleeding. After hearing and assimilating this program, the clinician
will be better able to:
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 | 1. Identify the surgical procedure of choice for GERD and the factors predictive of a successful outcome.
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| 2. Examine technical components of antireflux surgery and outline the keys to successful treatment.
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| 3. Recognize and explain what constitutes the failure of antireflux surgery.
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| 4. Discuss the reasons for failure and the outcomes associated with reoperative antireflux surgery.
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| 5. Describe the recommended treatment of acute upper GI bleeding.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning
committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts
of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health
care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Swanstrom
has received educational grants from Ethicon Endo-Surgery, research support from USGI Medical and Olympus America, and
research support and royalties from Richard Wolf Medical Instruments. Additionally, he has been a consultant for NDO
Surgical. Drs. Peters and Lucas and the planning committee reported nothing to disclose.
Acknowledgements
Drs. Peters and Swanstrom spoke at the Esophageal Conference, held September 6-7, 2007, in Omaha, NE, and sponsored
by the Creighton University Medical Center and School of Medicine. Dr. Lucas was recorded at the Detroit
Trauma Symposium, held November 8-9, 2007, in Detroit, MI, and sponsored by the Detroit Medical Center (DMC),
Detroit Receiving Hospital, and Wayne State University School of Medicine. The Audio-Digest Foundation thanks
the speakers and the sponsors for their cooperation in the production of this program.
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