Surgery of the Foregut

From the 9th Annual Surgery of the Foregut Symposium, presented by Cleveland Clinic Florida

Educational Objectives

The goal of this program is to improve surgical management of epiphrenic diverticula, gastroesophageal reflux disease, and obesity. After hearing and assimilating this program, the clinician will be better able to:

1.   Diagnose epiphrenic diverticula.

2.   Manage reflux symptoms that recur after antireflux surgery.

3.   Identify patients requiring reoperation after antireflux surgery.

4.   Recognize patient characteristics that contraindicate bariatric surgery.

5.   Cite research on surgical management of metabolic syndrome.

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. Ponsky is a consultant for U.S. Endoscopy. Dr. Shikora is a consultant for Betastim, EnteroMedics, and GI Dynamics. Dr. Rice and the planning committee reported nothing to disclose. In his lectures, Dr. Shikora presents information that is related to the off-label or investigational use of a therapy, product, or device.

Epiphrenic Diverticula: Etiology and Surgical Treatment Options

Thomas W. Rice, MD, Professor of Surgery, Cleveland Clinic Lerner College of Medicine, and Section Head, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH

Description: acquired abnormality; presumed to arise from obstruction of distal esophagus; false “pulsion” (pushed out) diverticulum produced at site of weakness (thought to be entry of artery or venous channel into esophageal wall); commonly associated with motility disorders; classic presentation on right side; frequently associated with achalasia

Categorization of patients: speaker and colleagues reviewed findings on 40 patients; tests included barium esopha­gography, esophagogastroduodenoscopy (EGD), and biopsy of muscle distal to diverticulum (to evaluate gan­glion cell number and evidence of neurologic inflammation and fibrosis)

Findings: >80% of patients had abnormality of myenteric plexus; >40% had diminished ganglion cell number and nerve cell damage (suggestive of achalasia); nearly 75% had motility disorder detectable on standard manome­try; most patients had achalasia, ineffective esophageal motility, diffuse esophageal spasm, nutcracker esopha­gus, and hypertensive lower esophageal sphincter (LES); >50% had associated hiatal hernia

Cases unrelated to hiatal hernia: 100% of patients with diffuse esophageal spasm (including 3 with ganglion cell loss or neural findings); similar findings in patients with achalasia (however, not all had classic findings; suggests etiology other than myenteric damage alone)

Cases related to hiatal hernia: of 3 patients with nutcracker esophagus, 2 had myenteric plexus abnormalities; my­enteric plexus abnormalities also seen in patients with ineffective esophageal motility; of patients with no motil­ity disorder, most had myenteric plexus abnormalities; of 3 patients with hypertensive LES, 2 had inflammatory abnormalities of nerves

Conclusions: myenteric plexus abnormalities common among patients with epiphrenic diverticula; may be sole finding in patients with no motility disorder or hiatal hernia; isolated epiphrenic diverticulum uncommon (may reflect inability to investigate patients; muscle biopsy at myotomy site recommended); consider high-resolution manometry for all patients

Operative management: patients presented with solid and liquid dysphagia, regurgitation, chest pain, and heartburn; of 44 patients operated on by speaker and colleagues, only 15% had unrestricted diet; achalasia and hiatal hernia common; 73% of patients underwent diverticulectomy, myotomy, and partial fundoplication; hiatal hernia not re­paired in 3; 9 required esophagectomy; procedure  —  speaker prefers access through left chest (ie, “minithoracot­omy”); twist esophagus 180^o to bring diverticulum into field; diverticulum sits like mushroom cap on top of esophagus; dissect off to find muscle defect from which submucosa protrudes; speaker prefers open surgery (per­mits use of pin stapler to encompass entire diverticulum and avoid leaks; more difficult to ensure with laparo­scopic approach from below); then perform myotomy

Complications: 33 in 17 patients; pleural effusions, atelectasis, and pneumonia most common; 15% of patients had surgical problems; one patient had leak requiring immediate esophagectomy (leaks disastrous and require imme­diate management; usually involve obstructed amotile esophagus)

Results: 97% improvement in dysphagia; average improvement in symptom score 2.9; reflux main problem associ­ated with surgery (warn patients that operation should improve symptoms but may induce reflux requiring medi­cation); 67% of patients had unrestricted diet postoperatively  

Recurrent Symptoms After Antireflux Surgery: What to Do?

Jeffrey L. Ponsky, MD, Oliver H. Payne Professor and Chair, Department of Surgery, and Surgeon-in-Chief, University Hospitals, Case Western Reserve University School of Medicine, Cleveland

Thorough history: determine possible causes (eg, tissue may have stretched in ensuing years, patient may have sus­tained trauma); get detailed description of timing and nature of symptoms (history more important with recurrent symptoms than with initial surgery); ask about new medications; perform complete physical examination; deter­mine if lungs clear; check for recent changes in weight

Work-up: not necessary if symptoms mild (start patient on medication); barium swallow recommended for postoper­ative patients; perform pH testing and manometry before reoperating (manometry helps evaluate Nissen wrap); en­doscopy

Medications: warn patient that intermittent use of antacids may be necessary after ³10 yr (proton pump inhibitors recommended)

Endoscopic therapy: radiofrequency procedure (Stretta) — balloon with metal prongs; muscle of esophagus “burned” (presumably destroys vagal afferent fibers that cause transient esophageal relaxation); effective, but not currently available (may be reintroduced); transoral incisionless fundoplication (EsophyX)  —  pushes down esopha­gogastric (EG) junction and creates nipple valve; only endoscopic procedure presently available for reflux

Repeat surgery: consider if all else fails; may require takedown and redo of previous wrap; tight wrap  —  converts re­flux into achalasia; patients report inability to swallow; Nissen wrap should resemble “floppy turtleneck sweater;” endoscopic dilation ineffective (reoperation only option); may lead to pseudoachalasia (symptoms of achalasia with high pressure on manometry); esophagus becomes stretched and loses motility (barium swallow shows delayed emptying); requires taking down wrap (Heller myotomy recommended); misplaced wrap  —  also known as “slipped Nissen”; generally responds only to reoperation (can try medical therapy if symptoms mild); esophageal lengthening (Collis gastroplasty)  —recommended only for patients with short esophagus

Patient Selection for Bariatric Surgery

Scott Shikora, MD, Professor of Surgery, Tufts University School of Medicine, and Chief, General and Bariat­ric Surgery, Tufts Medical Center, Boston, MA

Patient selection criteria: differ according to setting (large academic center provides more support than small private practice; influences decision to operate on higher-risk patients)

Behavioral issues: most credentialing organizations require multidisciplinary patient selection process; £60% of patients have psychiatric disorder (usually depression or bipolar disorder); certain behaviors may affect suc­cess of surgery (eg, eating disorders, poor coping or compliance skills, low intelligence); concerns or relative contraindications include major depressive disorder, severe mental retardation, personality disorders, and self-destructive lifestyle (eg, active bulimia, drug use); literature sparse on elements of appropriate behavioral eval­uation; unclear whether poor candidate can undergo successful behavioral rehabilitation

Behavioral red flags: patient abusive to staff; misses ³3 appointments with support staff (eg, dietitian, behavioral therapist); unduly impatient to undergo surgery; abuses alcohol or smokes; gains weight during preoperative period; withholds important health-related information

Miscellaneous considerations: loss of job; death of loved one just before surgery; divorce, separation, or other family problems; pregnancy; recent psychiatric hospitalization for treatment of major depressive disorder; in­stinctive negative feeling about patient

Medical considerations: absolute or relative contraindications include incurable cancer, AIDS, end-stage hepatic cirrhosis with portal hypertension, or any condition that would prevent surgery from significantly improving quality of life

Surgical considerations: obtain as much information as possible about patient before operation

Computer-generated screening tool: BaroScreen  —  developed for research on implantable gastric stimulator; uses classification and regression tree (CART) analysis (makes predictions based on past trends) to aid in patient se­lection; in prospective trial of 51 cases, patients selected by screen did significantly better than rejected patients; when subsequently tested in Screened Health Assessment and Pacer Evaluation (SHAPE) trial, no difference in weight loss between patients using implantable gastric stimulator (“on” group) and control group (gastric stimu­lator implanted but turned off); both groups approved by screening tool; conclusion  —  screen added little benefit

Matching patient to procedure: factors to consider include patient or surgeon preference and/or expertise, patient’s body mass index, comorbid conditions, history of previous abdominal disease, surgeries, or irradiation, behavior and eating habits, and safety and efficacy of procedure; some procedures better suited to particular comorbidities (eg, gastric bypass and biliopancreatic diversion [BPD] associated with higher rates of resolution of diabetes than gastric band; patients with Crohn disease or history of gastric irradiation may be better candidates for purely gas­tric procedures; consider BPD for patients with history of antireflux surgery)

Patient characteristics: little scientific research upon which to rely; studies on factors predictive of success with gastric banding procedures show conflicting results

Conclusions: not all patients good surgical candidates; no procedure succeeds every time; currently, no formal means of identifying good or bad candidates; multidisciplinary evaluation as good as any screening tool available; must balance risks and benefits of surgery to patient’s lifestyle, personality, and comorbidities

Effects of Endosleeves and Neuromodulation in Metabolic Syndrome

Dr. Shikora

Components of metabolic syndrome: diabetes, hypertension, and hypertriglyceridemia; obesity  —  associated with numerous comorbidities, including metabolic syndrome; affects almost every organ system; bariatric surgery con­sidered metabolic surgery (improves or resolves many comorbid conditions)

Endosleeve: permeable or semipermeable; placed in duodenum to segregate ingested food from digestive fluids; pro­motes weight loss and improves diabetes; does not cause diarrhea (suggests mechanism of action other than mal­absorption)

Procedure: sleeve 60 cm in length; deployed endoscopically; positioned in duodenum, then extended into jejunum; essentially creates duodenal-jejunal bypass; requires passage of guide wire into duodenum, opening of capsule containing device, deployment and passage of device into jejunum, and fixation of device with nitinol barbs; con­sistently associated with weight loss of 20% to 30% and improved levels of hemoglobin (Hb) A_1c and blood glu­cose, compared to patients who underwent sham surgery

Neuromodulation: use of electrical pulse stimulator (pacemaker device) to apply pattern of nerve impulses to target organ; goal is to enhance or inhibit normal physiologic responses; effect may be exerted directly on target organ or may be transmitted distally to other organ (eg, brain)

Implantable gastric stimulator (IGS): 2 bipolar leads implanted in lesser curvature of stomach; activated to provide constant, patterned stimulatory current; tested in 800 patients worldwide; overall success limited (did not achieve primary end points in major trials); worked well in small number of patients at speaker’s institution; patients re­porting regain of weight found to have depleted batteries in device

Tantalus system: electrodes placed in gastric fundus sense presence of food and activate device to provide patterned electrical stimulatory current in gastric antrum; modest weight loss (9 kg) seen in single small trial; diabetic pa­tients on oral medication experienced »1% drop in HbA_1c levels as well as weight reduction; no significant bene­fit seen in diabetic patients on insulin

Vagal Blocking for Obesity Control (VBLOC): electrical leads implanted on vagus nerve; goal is to block all vagal input to brain; 80% of vagal fibers afferent (carry messages to brain from gastrointestinal tract); assumes “de­fault” position of brain with no input from digestive tract is satiety; associated with 14% weight loss at 6 mo in small study by Camilleri et al; later substudy of Australian patients showed continued weight loss and propor­tional reduction in protein, carbohydrate, and fat intake (ie, patients ate what they wished, but in smaller quanti­ties); HbA_1c levels dropped from 8.7% to 7% at 6 mo; hypertensive patients experienced decrease in blood pressure

VBLOC-EMPOWER trial: 1-yr double-blind placebo-controlled 2 to 1 randomization study; primary end point was to demonstrate significant difference between active and control groups; end point not attained (no differ­ence in weight loss between groups); post-hoc analysis revealed that in control condition (device implanted but kept in “off” position), small amount of current generated by device caused degradation of action potential in va­gus nerve (ie, control group actually received treatment); weight loss  —  found to be dose-related; among compli­ant patients (wore device 12 hr/day), >20% in both groups; among noncompliant patients (wore device <6 hr/day), 5% in both groups; weight loss in compliant patients 31% in standard therapy group, 22% in low-level therapy group; hypertension  —  improved in both groups within 1 wk of surgery (effect independent of weight loss)

Implantation of electrodes into duodenal wall: goal is to manage diabetes; now in early pilot studies in Europe; in animals, delays gastric emptying, increases duodenal flow (duodenum empties more rapidly into jejunum), causes some malabsorption of sugars and fats, and decreases blood glucose and insulin levels

Conclusions: bariatric surgery is metabolic surgery; endosleeves, neuromodulation, and other technologies offer novel opportunities to make procedures safer and more palatable to patients; more studies needed to identify full potential

Acknowledgements

Drs. Rice, Ponsky, and Shikora were recorded at 9th Annual Surgery of the Foregut Symposium, held February 14-17, 2010, in Coral Gables, FL, and sponsored by Cleveland Clinic Florida. To register for the 2011 Symposium, please visit www.ClevelandClinicMedEd.com. The Audio-Digest Foundation thanks the speakers and Cleveland Clinic Florida for their cooperation in the production of this program.

Suggested Reading

Abeles D, Shikora SA: Bariatric surgery: current concepts and future directions. Aesthet Surg J 2008 Jan-Feb;28(1):79-84; Blackstone RP et al: Psychological classification as a communication and management tool in obese patients undergoing bar­iatric surgery. Surg Obes Relat Dis 2010 May-Jun;6(3):274-81; Camilleri M et al: Intra-abdominal vagal blocking (VBLOC therapy): clinical results with a new implantable medical device. Surgery 2008 Jun;143(6):723-31; Chukwumah CV, Ponsky JL: Revisional surgery for failed antireflux surgery. Surg Laparosc Endosc Percutan Tech 2010 Oct;20(5):326-31; Deveney CW, Martindale RG: Factors in selecting the optimal bariatric procedure for a specific patient and parameters by which to measure appropriate response to surgery. Curr Gastroenterol Rep 2010 Aug;12(4):296-303; Gracia-Solanas JA et al: Meta­bolic Syndrome after Bariatric Surgery: Results Depending on the Technique Performed. Obes Surg 2010 Nov 16 [Epub ahead of print]; Hoppo T et al: Transoral incisionless fundoplication 2.0 procedure using EsophXTM for gastroesophageal reflux dis­ease. J Gastrointest Surg 2010 Dec;14(12):1895-901; Kueper MA et al: Laparoscopic sleeve gastrectomy: standardized tech­nique of a potential stand-along bariatric procedure in morbidly obese patients. World J Surg 2008 Jul;32(7):1462-5; Reznik SI et al: Assessment of a pathophysiology-directed treatment for symptomatic epiphrenic diverticulum. Dis Esophagus 2007;20(4):320-7; Rice TW et al: Myenteric plexus abnormalities association with epiphrenic diverticula. Eur J Cardiothorac Surg 2009 Jan;35(1):22-7; Shikora SA et al: Implantable gastric stimulation for the treatment of clinically severe obesity: re­sults of the SHAPE trial. Surg Obes Relat Dis 2009 Jan-Feb;5(1):31-7; Ziomber A et al: Magnetically induced vagus nerve stimulation and feeding behavior in rats. J Physiol Pharmacol 2009 Sep;60(3):71-7.