The treatment of GERD has two primary aims: To relieve the 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 lifestyle changes that all patients with GERD should take to help reduce their symptoms including: 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. Antisecretory drugs are most commonly prescribed, which reduce the amount of acid produced in the stomach, and antacids which neutralise the remaining acid. These drugs need to be taken daily and will offer relief from GERD symptoms and help in healing damage to the esophagus
Because GERD is generally a lifelong disease requiring long-term treatment, there is much 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. Today 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.
In fundoplication 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 about 1% of all patients, requiring a second operation to rectify. Also, around 5% of patients will start off being treated laparoscopically but will then be converted to open surgery.
Fundoplication has become an increasingly popular treatment for GERD, with more than 30,000 such operations being performed in the U.S. alone each year. Proponents of surgery believe that it eliminates the need for drugs and reduces the risk of esophageal cancer. A 1980's study initially appeared to confirm the superiority of surgery over drug therapy for controlling the signs and symptoms of GERD. However, after 10 years, when the researchers followed up on the study participants, they 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. 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.”
GERD Surgery- Not Necessarily a Definitive Cure - References
By Mortin - Copyright 2010
Last modification 05/02/2010