Gastroesophageal Reflux: Medical and Surgical Treatment Options
Am Fam Physician. 2003 Oct 1;68(7):1271-1277.
Symptoms consistent with gastroesophageal reflux disease (GERD) are extraordinarily common, and treatment of GERD is an important aspect of primary care medicine. Therapeutic options range from patient-driven lifestyle changes and as-needed use of over-the-counter (OTC) agents, through therapy with powerful prescription drugs, up to new endoscopic and surgical treatments. In this issue of American Family Physician, Heidelbaugh and associates1 provide a well-written, comprehensive review of the treatment of GERD. However, a few additional comments are appropriate.
By the time of the initial visit, most patients with GERD symptoms have tried antacids, and many have used OTC histamine-H2 receptor antagonists (H2RAs). Sophisticated patients also may have researched the subject of GERD and attempted lifestyle changes. The family physician is then left to make two major decisions: (1) Should the patient have endoscopy to rule out complications of GERD? (2) Which prescription medication should the patient receive? Heidelbaugh and colleagues1 appropriately reserve endoscopy for patients who have “warning” symptoms or who are at risk for Barrett's esophagus.
If cost were not a factor, once-daily proton pump inhibitor (PPI) therapy would be the initial treatment of choice, because it is clearly superior to twice-daily H2RA therapy.2 Reasons for using H2RAs are related primarily to lower cost and, occasionally, intolerance of PPIs (most often because of headache or diarrhea). With the introduction of generic and OTC PPIs, initial PPI therapy would seem to be an even stronger preferred treatment choice.
PPI therapy should control symptoms and mucosal damage in more than 80 percent of patients with GERD. This leaves two groups of patients in whom consideration of alternative therapies would seem reasonable: those whose symptoms are not well controlled by medical therapy and those who would rather not remain on medical therapy because of side effects, cost, or personal preference.
Antireflux surgery now is being offered to more patients, primarily because recovery is quicker with the newer, laparoscopic approach. Yet, patient selection for surgery remains problematic. Some data suggest that the best surgical outcome is in patients whose symptoms responded completely to PPI therapy.3 Patients with atypical and refractory symptoms are less likely to have a favorable surgical outcome than are those with heartburn and regurgitation, which are well controlled by medical therapy.4
An important, obvious, but often overlooked aspect of patient selection for surgery is to be absolutely sure that the patient has GERD. Acceptable evidence includes endoscopically documented esophagitis (mucosal breaks, not redness) or an abnormal ambulatory pH test. The presence of typical symptoms and a response to medical therapy are not sufficient to support the use of surgery. In this situation, patients should undergo endoscopy and, if the examination is normal, have ambulatory pH testing performed while they are off medications to make sure that they have pathologic amounts of acid exposure.
Contraindications to surgery are related primarily to intolerance of anesthesia. However, antireflux surgery may not be possible in some patients who have had previous upper abdominal surgery and may be less effective in extremely obese patients.5
Well-selected patients should have symptoms and esophagitis that are at least as well controlled with surgery as with medications.6 However, surgical therapy does have some downsides. Increasing information suggests that many, if not most, surgically treated patients end up taking reflux medications at some point. For example, long-term follow-up in a group of patients randomized to receive medication or surgery found that after 10 years, 92 percent of the patients randomized to medical therapy were still taking medication, and 62 percent of the patients initially treated with surgery were again taking antireflux medications.7
Furthermore, postoperative symptoms are common and include dysphagia,8 difficulty with belching, increased flatulence, and diarrhea.9 Although mortality from antireflux surgery is low, death can occur in approximately one of 1,000 patients.10,11 Safety and efficacy appear to be greater when antireflux surgery is performed by a surgeon who has done the procedure 50 or more times.10 When counseling patients, I tell them that even when antireflux surgery is performed by an experienced surgeon, new, annoying symptoms may occur in 10 to 20 percent of patients, significant, life-altering symptoms may develop in 1 to 2 percent of patients, and death may occur in 0.1 percent of patients.6–9
The introduction of endoscopic techniques for controlling reflux generated a great deal of excitement. Radiofrequency application (Stretta procedure) is designed to increase the reflux barrier of the lower esophageal sphincter. At one-year follow-up, most patients in the first cohort treated with this technique reported improvement of symptoms, but 34 percent were again taking PPIs, and an additional 38 percent were regularly taking antacids.12
Results on one13 of the two approved endoscopic sewing techniques (endocinch) also have been reported. Six months after treatment, 62 percent of the 64 patients in the initial report were no longer taking PPIs, although few patients had normalization of esophageal acid exposure.13 Finally, early data14 on a new endoscopic technique suggest an improvement in symptoms and medication usage after injection of a biopolymer into the lower esophageal sphincter; however, only 38 percent of patients had normalization of esophageal acid exposure on follow-up testing.
Reported complications of the new endoscopic techniques include chest pain, fever, infection, dysphagia, perforation, bleeding, and at least two deaths (after radiofrequency application). The available data indicate that additional study and improvement are needed before these techniques can be advocated fully.
Choosing patients for endoscopic or surgical treatment remains something of a paradox. Patients who respond fully to PPIs appear to be the best candidates, but one wonders how advisable it is to subject well-controlled patients to the morbidity and potential mortality of these more invasive treatments. Some patients who are refractory to medical therapy (especially those with nocturnal regurgitation) will benefit from surgery, but there are no clear data to help predetermine which patients will benefit most.
The bottom line is that medications can control the symptoms of GERD in most patients. The decision to use other treatments should be made in consultation with a sub-specialist who understands the successes and limitations of each treatment option. Even if medications do not provide perfect reflux control, the principle of “first do(ing) no harm” supports a conservative approach to recommending surgical or endoscopic treatment of GERD.
1. Heidelbaugh JJ, Nostrant TT, Kim C, Van Harrison R. Management of gastroesophageal reflux disease. Am Fam Physician. 2003;68:1311–8,1321–2.
2. 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;94:1434–42.
3. Jackson PG, Gleiber MA, Askari R, Evans SR. Predictors of outcome in 100 consecutive laparoscopic antireflux procedures. Am J Surg. 2001;181:231–5.
4. So JB, Zeitels SM, Rattner DW. Outcomes of atypical symptoms attributed to gastroesophageal reflux treated by laparoscopic fundoplication. Surgery. 1998;124:28–32.
5. Perez AR, Moncure AC, Rattner DW. Obesity adversely affects the outcome of antireflux operations. Surg Endosc. 2001;15:986–9.
6. Lundell L, Miettinen P, Myrvold HE, Pedersen SA, Liedman B, Hatlebakk JG, et al. Continued (5-year) followup of a randomized clinical study comparing antireflux surgery and omeprazole in gastroesophageal reflux disease. J Am Coll Surg. 2001;192:172–9.
7. Spechler SJ, Lee E, Ahnen D, Goyal RK, Hirano I, Ramirez F, et al. Long-term outcome of medical and surgical therapies for gastroesophageal reflux disease. Follow-up of a randomized controlled trial. JAMA. 2001;285:2331–8.
8. Malhi-Chowla N, Gorecki P, Bammer T, Hinder RA, DeVault KR. Dilation after fundoplication: timing, frequency, indications and success. Gastrointest Endosc. 2002;55:219–23.
9. Klaus A, Hinder RA, DeVault KR, Achem SR. Bowel dysfunction after laparoscopic anti-reflux surgery: incidence, magnitude and clinical course. Am J Med. 2003;114:6–9.
10. Flum DR, Koepsell T, Heagerty P, Pellegrini CA. The nationwide frequency of major adverse outcomes in antireflux surgery and the role of surgeon experience, 1992–1997. J Am Coll Surg. 2002;195:611–8.
11. Pessaux P, Arnaud JP, Ghavami B, Flament JB, Trebuchet G, Meyer C, et al. Morbidity of laparoscopic fundoplication for gastroesophageal reflux: a retrospective study about 1,470 patients. Hepatogastroenterology. 2002;49:447–50.
12. Triadafilopoulous G, DiBaise JK, Nostrant TT, Stollman NH, Anderson PK, Wolfe MM, et al. The stretta procedure for the treatment of GERD: 6 and 12 month follow-up of the U.S. open label trial. Gastrointest Endosc. 2002;55:149–56.
13. Filipi CJ, Lehman GA, Rothstein RI, et al. Transoral, flexible endoscopic suturing for treatment of GERD: a multicenter trial. Gastrointest Endsoc. 2001;53:416–22.
14. Johnson DA, Ganz R, Aisenberg J, et al. Endoscopic, deep mural implantation of enteryx for the treatment of GERD: 6-month follow-up of a multicenter trial. Am J Gastroenterol. 2003;98:250–8.
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