Surgery for GERD:not always a definitive cure for a common problemNormally, this valve shuts tight after eating, keeping the acidic digestive juices safely in the stomach. If the valve is weak, however, stomach contents may wash back up the esophagus, giving rise to the typical symptoms of heartburn and regurgitation.
GERD can affect sufferers in a variety of ways. Heartburn may cause significant pain and distress, interfere with sleep and general wellbeing, and necessitate changes in diet and eating habits. More seriously, recurrent and longstanding exposure to stomach acid can damage the inner lining of the esophagus, giving rise to a condition called esophagitis. Initially characterised by demage of the inner lining of esophagus, as esophagitis becomes more severe ulceration and bleeding may develop and later the lower part of the gullet may become constricted, causing difficulty in swallowing.This can also lead to changes in the cells that line the esophagus – a condition known as Barrett’s esophagus. People with Barrett’s esophagus may have an increased risk of developing adenocarcinomaa of the esophagus, a type of malignancy that is becoming increasingly common.
The treatment of GERD has two primary aims: To relieve symptoms of heartburn and regurgitation, thereby improving patients’ everyday lives; and to prevent the development of more serious complications, which include esophagitis, narrowing, Barrett’s esophagus, and esophageal adenocarcinoma. There are some simple steps that all patients with GERD should take to help reduce their symptoms. Examples of such lifestyle changes include stopping smoking; losing weight if overweight; not eating too close to bedtime; eating slowly and eating small, regular meals; elevating the head of the bed; avoiding tight clothing that puts pressure on the stomach; and cutting back on caffeine, alcohol, citrus juices, peppermint, and spicy and fatty foods.
While these changes may improve symptoms, the majority of patients with GERD will also require medication. The drugs most commonly prescribed are antisecretory agents, which reduce the amount of acid produced in the stomach, and antacids, which neutralise the remaining acid. These drugs need to be taken every day. As well as offering rapid relief of heartburn, certain drugs such as proton pump inhibitors are effective in healing damage to the esophagus, thereby helping to prevent more serious complications.
Because GERD is generally a lifelong disease, and therefore requires long-term treatment, there is a lot of interest in approaches that might offer a permanent cure. The main alternative to drugs is surgery, using a procedure known as ’fundoplication‘. This operation was originally done as open surgery, which involved making an incision into the abdomen under general anaesthesia. However, fundoplication has become much more popular since the development of laparoscopic techniques (also known as minimally invasive or keyhole surgery), which offer faster recovery and fewer complications. While the vast majority of patients will be deemed suitable for laparoscopic surgery, a few will not, such as those who have had previous abdominal surgery, or individuals with certain other medical conditions.
Whether fundoplication is done as open or keyhole surgery, the surgeon creates a new ’valve’ between the esophagus and the stomach by wrapping the upper portion of the stomach around the lowest portion of the esophagus. As the stomach becomes distended after eating, the wrap compresses the esophagus, preventing stomach acid from escaping. If the patient has other problems – for instance, a hiatal hernia, a swallowing disorder, or a shortened esophagus – these may also be corrected during surgery. Fundoplication is a relatively safe operation: The most common complication is perforation of the stomach or esophagus, which occurs in around 1 in 100 patients. Rarely, perforation or bleeding will be missed during the procedure and the patient will have to undergo a second operation. In addition, around 5% of patients will start off being treated laparoscopically but will then be converted to open surgery.
In recent years, fundoplication has become an increasingly popular treatment for GERD, with more than 30,000 such operations being performed in the United States alone each year. Exponents of surgery believe that it obviates the need for drug therapy and reduces the risk of esophageal cancer. Indeed, a study conducted in the late 1980s initially appeared to confirm the superiority of surgery over drug therapy for controlling the signs and symptoms of GERD. However, 10 years on, the researchers revisited the study participants and were surprised to discover that almost two-thirds of the surgery patients still needed medication to control their symptoms. In addition, patients who had undergone surgery a decade previously were just as likely to have developed esophageal cancer as those who only received medication.
On the basis of their findings, and from weighing up the relative risks, benefits, and financial costs of surgery and drug therapy, the researchers concluded: “Long-term medical therapy with proton pump inhibitors is the preferred strategy for patients with GERD and severe esophagitis.” To date, this remains the only large, long-term study to compare surgery with drugs for GERD, and the debate continues. Most experts agree that there are some patients in whom surgery may be preferable to drugs – for instance, individuals who are unable to tolerate proton pump inhibitors due to side effects, patients who develop additional symptoms such as cough, chest pain, or hoarseness, or those who completely respond to drug therapy but relapse with symptoms when medication is withdrawn. But, with the advent of more effective and better-tolerated drugs, the advantages of surgery appear to be less clear-cut for the majority of patients with GERD.
In summary, patients with GERD should discuss their treatment options carefully with their doctor, and be aware that drugs and surgery each have advantages and disadvantages. As Dr. Stuart Spechler, who undertook the study described above, advised: “Patients who are going to have an operation should consider very carefully their reasons for having the surgery. If they believe that surgery will allow them to never again take medicine for the treatment of reflux disease, or that they are preventing a cancer of the esophagus, this study does not support either of these contentions.”
National Heartburn Alliance
http://www.heartburnalliance.org/
American Gastroenterological Association
http://www.gastro.org/
American College of Gastroenterology
http://www.acg.gi.org/
GERD Information Resource Centre
http://www.gerd.com/
Digestive Disorders Foundation
http://www.bdf.org.uk/
UK Digestive Disorders Foundation
http://www.bdf.org.uk/
DeVault KR, Castell DO. Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease. The Practice Parameters Committee of the American College of Gastroenterology. Am J Gastroenterol 1999; 94: 1434–1442.
Kahrilas PJ. Surgical therapy for reflux disease. JAMA 2001; 285: 2376–2378.
Spechler SJ, Lee E, Ahnen D, et al. Long-term outcome of medical and surgical therapies for gastroesophageal reflux disease: Follow-up of a randomized controlled trial. JAMA 2001; 285: 2331–2338.
Spechler SJ. Comparison of medical and surgical therapy for complicated gastroesophageal reflux disease in veterans. The Department of Veterans Affairs Gastroesophageal Reflux Disease Study Group. N Engl J Med 1992; 326: 786–792.
Lundell L. Laparoscopic fundoplication is the treatment of choice for gastro-oesophageal reflux disease. Protagonist. Gut 2002; 51: 468–471.
Galmiche JP, Zerbib F. Laparoscopic fundoplication is the treatment of choice for gastro-oesophageal reflux disease. Antagonist. Gut 2002; 51: 472–474.
Madan A, Minocha A. Gastroesophageal reflux disease: the ongoing saga of pill versus knife. Am J Gastroenterol 2001; 96: 3199–3200.
Arguedas MR, Heudebert GR, Klapow JC, et al. Re-examination of the cost-effectiveness of surgical versus medical therapy in patients with gastroesophageal reflux disease: the value of long-term data collection. Am J Gastroenterol 2004; 99: 1023–1028.
Spechler SJ. Medical or invasive therapy for GERD: an acidulous analysis. Clin Gastroenterol Hepatol 2003; 1: 81–88. |
