Gut Check: Antireflux Surgery With Dr Rena Yadlapati

Host Brian Lacy, MD, talks with Dr Rena Yadlapati about determining which patients may need antireflux surgery, types of surgical approaches, and possible complications.

Brian Lacy, MD, is a professor of medicine at Mayo Clinic-Florida in Jacksonville, Florida. Rena Yadlapati, MD, is medical director of the Center for Esophageal Diseases at UC San Diego Health, professor in the Department of Medicine and program director of the advanced fellowship in esophageal diseases at University of California San Diego School of Medicine.

TRANSCRIPT:

Welcome to Gut Check, a podcast from the Gastroenterology Learning Network. My name is Brian Lacy. I'm a professor of medicine at the Mayo Clinic in Jacksonville, Florida. I am absolutely delighted to be speaking today with Dr. Rena Yadlapati, professor of medicine in the Division of Gastroenterology at UCSD—University of California San Diego. Dr. Yadlapati is a nationally recognized expert in disorders of the esophagus. She has authored many key articles and guidelines on the evaluation, diagnosis, and treatment of esophageal motility disorders. She is a sought-after lecturer nationally on all topics related to the esophagus, including gastroesophageal reflux disease.

Today, we’re going to focus on the topic of complications after antireflux surgery. Dr Yadlapati, welcome. What a delight to have you here. To help set the stage for our listeners, we know that acid reflux is a common disorder, but what percentage of patients with acid reflux fail medical therapy, and thus might be potential candidates for antireflux surgery?

Dr Yadlapati: Well, first of all, I'm delighted to be here, Dr. Lacy. Thank you for having me. Now, your question all depends on the definition of the patient that's failing medical therapy. So first of all, we know that about 50% of patients that have acid reflux symptoms, and this includes things such as heartburn, regurgitation—they will not respond to therapy. But many of these patients don't actually have pathologic reflux disease to begin with. So first of all, key to ensure that the patient actually has pathologic disease.

Next, these reflux-type symptoms are not only due to acid. There are various other mechanisms of symptoms, whether it's mechanical reflux, nerve hypersensitivity, and so on. And so it's really critical that these other mechanisms of reflux disease are addressed and personalized to the patient's scenario before we determine if someone has failed.

But getting back to your question, once we have a patient that has pathologic GERD, they're optimized on their lifestyle and pharmacologic therapy, the percentage that will continue to not respond is around 10 to 30%. And these are the patients that may be candidates for antireflux surgery.

Dr Lacy: Wonderful. For our listeners who may not be quite as familiar with that type of surgery as you are, can you describe how anti-reflux surgery is performed? The concept is to anatomically restore the anti-reflux barrier and thus reduce reflux. But how is that actually accomplished?

Dr Yadlapati: To understand this, I think it would be a value to just briefly review what the antireflux barrier actually is. So this barrier is a high-pressure zone that separates our chest cavity from the abdominal cavity. It is comprised of 3 major factors that keep the competence of the antireflux barrier.

So first of all, the crural diaphragm, and this is thought to serve as an external sphincter. And then there's the lower esophageal sphincter, what separates the esophagus from the stomach, and this is the intrinsic esophageal sphincter. And then finally, the gastroosophageal flap valve. So this is where the intra-abdominal portion of the lower esophageal sphincter, it enters into the stomach at an oblique angle, what we refer to as the angle of His. So in reflux disease, any and all of these can be compromised. And the tenets of antireflux surgery are to address these dysfunctions.

Now, while there are different forms of antireflux surgery, we'll focus on fundoplication because this is the most common approach. It's the one that probably has the greatest outcome data available. And so in fundoplication, the integrity of the antireflux barrier is restored. First of all the surgeon will repair a hiatal hernia, if it’s present, and then reposition that lower esophageal sphincter into the abdomen; repair any defect at the crural diaphragm; and wrap the stomach around the sphincter, and this recreating that flap valve.

Now, there are different techniques to performing a fundoplication. A Nissen, or also known as a complete fundoplication, is where that stomach is wrapped 360 degrees around. But there's also partial approaches to fundoplication. This is where the stomach's wrapped less than 360 degrees. And some of the ones that we're more familiar with are the Toupet, which is a 270-degree wrap or the Dor, which is 180 degrees.

Dr Lacy: Wonderful. I think everybody now has a really great vision of how these things are done. So how common is antirefluxsurgery performed? For a while, it seemed as if there was really a growing trend to perform more of these operations, but then it seemed to level off. Where are we at right now?

Dr Y: Yeah, that's correct, Brian. The volume of antireflux surgeries rose tremendously in the 1990s, and this was largely attributed to the great transition from moving from open surgical approach to laparoscopic. And so according to databases, such as the nationwide inpatient sample, for example, the rates went from 5 to 16 per 100,000 adults.

However, in the early thousands, there was a decline, almost a third decline, largely attributed to concerns about safety and durability of the surgery. And at the same time, there was increasing availability of proton pump inhibitors or medical antisuppressants for acid. So thereafter, the databases suggests that the volume of surgery has plateaued around 5 to 6 cases per 100 ,000 adults.  And nowadays, you know, some patients are really in favor and seeking surgery because there are more and more concerns about long-term PPI therapy. And at the same time, many patients really prefer staying on medical and lifestyle approaches, which are becoming increasingly more effective. And so it really has plateaued around that level. It'll certainly be interesting to see how things change with some of those other interventions and some new medications.

Dr Lacy: It will certainly be interesting to see how things change, with some of those other inventions and new medications. So kind of a tricky question, because maybe it depends on how we define success, but how successful is antireflux surgery, Rena? What percentage of patients are able to stop their acid suppressants after that type of surgery?

Dr. Yadlapati: Yes, tricky because, well, let's assume that the patient we're talking about underwent the correct preoperative evaluation and that the surgeon performing the surgery had adequate competency to do so. And I say that because as we've just reviewed, this is a complex surgery.

But under those assumptions, in the immediate postoperative phase, fundoplication is extremely effective as an antireflux approach. In terms of complications, less than 5% of patients will have a complication. And in terms of treatment success, probably the best data that we have or the most recent data comes from New England Journal of Medicine. There was this great study from Stu Speckler and the VA cooperative. And these included patients that had refractory GERD was proven. And 67% of patients had treatment success.

Now, in terms of your question about being able to stop acid-suppressing therapy, studies show that around 5 years, 30 to 40% of patients may resume their acid-suppressing therapy, meaning that the remainder remain off of it. And I always tell patients that our goal is not to define surgical success by being off of PPI therapy, but rather If quality of life is better and symptom burden is better by achieving that mechanical improvement with surgery and then requiring a little bit of acid suppressant, we're still better off than we were to start off with.

Dr Lacy: Boy, I like the way you phrase that. And certainly for everybody listening in today, that's a really nice phrase to remind patients that it's not maybe just stopping medications or reducing the dose, but kind of quality of life and kind of the burden of these symptoms. And so just fleshing that out a little bit—this is a nice segue—you know, for patients where the operation is successful, again, depending on how we define success, what do you usually tell them? Is it 5 years, 10 years, 20 years? What do you think is a reasonable estimate for these patients?

Dr Yadlapati:  Even with a technically superb surgery, it's important to keep in mind that that fundoplication is really vulnerable to laxity from just day-to-day occurrences. You always want to talk to patients about this. The durability of a fundoplication is expected to weaken over time, particularly when there is stress to the abdomen. So abdominal exercises, heavy lifting, gaining weight— especially obesity around the belly—or abdominal strain from coughing, nausea, vomiting, these stressors increase the susceptibility of that wrap to disrupt, develop a hernia.

Now in the absence of routine mechanical stressors, we typically anticipate a wrap to be durable at least 10 years out.

Dr Lacy: Okay, Rena, that’s great. Let’s shift gears now and think about when antireflux surgery unfortunately doesn’t go quite as planned. And that’s not to fault anybody; but this is, as you point out, this is a technically difficult surgery. What are some of the problems that can develop immediately after antireflux surgery? Let’s say in the first week to the first month.

Dr Yadlapati: For a first-time fundoplication, the mortality rate is low, always start off with that. The 30-day mortality rate is around 0.1 to 0.2%. Some of the complications that might be more common are the ones that we typically expect with surgery, which include infection, bleeding, esophageal perforation. These all comprise less than 5% of potential complication rate. And then these numbers, however, do increase for revisions or redos of a fundoplication. And so we take this very seriously if a patient's ever considering a surgical revision.

Probably the most common problem that we encounter in the acute phase is dysphagia, and this can affect about half of patients. And it’s an expected consequence to a certain degree because there is edema and inflammation following surgery, that is expected to resolve within 3 months. And this acute dysphagia is usually managed with dietary modification and reassurance.

Dr Lacy: That’s great, Rena, thank you. What about long-term complications from acid reflux surgery? Do you have a process where you break this down into structural and anatomic issues, such as an overly tight Nissen or a wrap that might slip, or do you think about it like potential nerve injury issues, and subsequent issues of esophageal dysmotility and prolonged dysphasia?

Dr Yadlapati: Yes, and as gastroenterologists, this is a key question because we are often the first point of contact for patients when they develop symptoms following surgery. So up to 30% of patients can experience a structural complication of fundoplication. And it's really critical to understand where this issue may lie, just as you were saying. Characterizing a patient’s symptoms can be a helpful start, so for instance, is the patient presenting with obstructive types of symptoms, and this includes things such as food impaction, regurgitation that’s bland, or dysphasia. If so they might have a mechanical obstruction, such as a tight fundoplication, or the fundoplication being too long, or angulation at where that flap valve was recreated, or perhaps they may have reflux and developed a stricture or esophagitis.

Now, on the other hand, if the patient has predominantly acid reflux types of symptoms— heartburn, acidic regurgitation—perhaps they have an anatomical issue where their wrap is disrupted or there's a hiatal hernia.

But in real life, patients often present with a mixed bag of symptoms. And so the first step in evaluation always is to get a barium esophagram with a tablet and then to proceed with the upper GI endoscopy. And if you have impedance planimetry available, such as FLIP, this can be really helpful. Because these two examinations help to evaluate the anatomy, hernia, wrap disruption, and then also for reflux esophagitis and for that obstruction at the level of the surgery. So during the endoscopy, if you do encounter an obstructive physiology, dilation can be considered in real time. This is why I really like having the esophagram first, because it can provide that corroboratory data and then really support real-time intervention if it is indicated.

Now, if the findings are relatively normal, then we move on to more the nerve injury question and dysmotility. So if you're suspecting that the patient may have refractory GERD, then performing ambulatory reflux testing is an option. If you're suspecting esophageal dysmotility, then considering perhaps a high-resolution manometry. And as you mentioned, vagal nerve injury is a possibility, and this is where gastric emptying study can be helpful.

Dr Lacy: Rena, I love what you said about the barium swallow. I think with all these emerging technologies, we've somewhat lost track of the fact that a really carefully performed barium swallow can yield a huge amount of information. And your PCP or internist or NP in the office can easily order that and gives us a lot of information, doesn't it?

Dr Yadlapati: Absolutely.

Dr Lacy: Rena, you've probably seen this a lot. Some patients after antireflux surgery come to the clinic and now their reflux symptoms are great, but now they're talking about horrible diarrhea all the time. How do patients develop symptoms of diarrhea after antireflux surgery? What's the mechanism here? And do you have any tricks on how to treat that?

Dr Yadlapati: This is very tough and can be quite challenging for patients. And 1 in every 3 to 5 patients after fundoplication can develop diarrhea. This multifactorial, and I really like to try to understand the mechanism. So first of all, is it even related or unrelated to the surgery? We have to remember that irritable bowel syndrome, other sources of diarrhea, are common. But also other things to consider in patients that have had surgery, if the patient also had a cholecystectomy, could this be bile acid diarrhea, and should we consider a bile acid sequestrant? Speaking to vagal nerve injury, could this patient have accelerated gastric emptying and should we consider pharmacologics that augment fundic accommodation, dietary and lifestyle modifications? There’s not great data to support necessarily a framework, but this is how I like to approach it for my patients.

Dr Lacy: Nice. I like that comment about impaired gastric accommodation in the fundus and how that might accelerate gastric emptying. Great teaching point.

So as we start to wind down here a little bit, what about that dreaded gas bloat syndrome after antireflux surgery? Is that something we should just tell patients to expect? Do you think there are some patients who are more prone to it in others? And how do you like to treat that?

Dr Yadlapati: Yes. Dreaded gas bloat is precisely correct. You know, it is similarly reported in about 10 to 32% of patients. So it's not something that everyone should expect, but it is common. And particularly, again, for us gastroenterologists, patients will present with dyspeptic types of symptoms, bloating, postprandial fullness, nausea, sometimes abdominal pain. Now, gas bloat is more commonly seen with that complete Nissen fundoplication as opposed to a partial fundoplication. And the mechanism here is thought to arise from the inability of the stomach to vent gas into the esophagus, perhaps related to that tight barrier or impaired relaxation at the gastroesophageal flap valve when the stomach is distended.

Also, patients can often develop aerophagia or air swallowing and supragastric belching when they try to attempt to palliate these uncomfortable symptoms in their foregut region. So generally the treatment recommended is lifestyle changes, such as avoiding gas-producing foods or carbonated beverages; eating slowly, to prevent aerophagia; stop smoking, if that’s present. You can try gas-reducing agents such as simethicone. For really refractory cases we have discussed with our surgeons converting a complete Nissen fundoplication to a partial fundoplication, and so this is certainly something that can be considered, but as we’ve discussed, every revision is more complex with increased morbidity and mortality— so something very important to keep in mind.

It’s also critical to differentiate whether this patient actually truly has gas bloat from another source of dyspeptic symptoms—a small bowel obstruction, delayed gastric emptying—all of which can be seen in patients after fundoplication.

Dr Lacy: Rena, thank you. That was absolutely wonderful and a lot of great clinical pearls there for our listeners. So any last thoughts for our listeners?

Dr Yadlapati: Yeah, this has been a really great discussion. I want to mention that we are primarily focusing on surgical fundoplication today. But remember, there are a multitude of other antireflux interventions that we haven't talked about, but this includes magnetic sphincter augmentation, also commercially referred to as Linx; the Roux en Y gastric bypass for your patients with obesity and reflux disease; and then endoscopic interventions, such as transoral incisionless fundoplication. So, you know, we're at a point now where we can personalize management starting from lifestyle to pharmacologics to more invasive therapies for our patients with GERD and always to remember all that's available to us.

And then, you know, one last note that I really would like to end with is that as a gastroenterologist, we are often the gatekeepers for patients, either initially the patients that present with GERD, and again, the patients that have symptoms following surgery. And so it is critical for us to understand how to manage postsurgical complications like we've talked about today. But perhaps it’s even more critical that we’re selecting the right patients for surgery. Again, we really need to make sure that our patient has GERD; that we’ve addressed those mechanisms beyond just the acid; and then it’s really important to develop strong partnerships with our surgical colleagues. Because when antireflux surgery is selected in the right scenario with the right surgeon, it is highly effective. It can tremendously improve patient quality of life, and in some cases, can be life-saving.

I think that’s all I have for today. I’m really so grateful to have had this opportunity and thank you for thinking of me.

Dr Lacy: I really like that last set of comments a lot, and I like the idea of a gatekeeper. We want to protect our patients, and of course, we want to protect our surgeons, and that collaborative effort is critical.

So Rena, again, thank you so much. I learned an awful lot today. I know our listeners on Apple and Spotify and other streaming networks learned an awful lot, too.

I'm Brian Lacy, professor of medicine at the Mayo Clinic in Jacksonville, Florida. You have been listening to Gut Check, a podcast from the Gastroenterology Learning Network, and our guest today was Dr. Rena Yadlapati, professor of medicine in the Division of Gastroenterology at UC San Diego.

I know you found this just as enjoyable as I did, and I look forward to having you join us again for future gut check podcasts. Stay well. All right.