The role of surgery in the treatment of gastroesophageal reflux disease
More than 20% of adults of all ages suffer from daily heartburn, a symptom of gastroesophageal reflux disease (GERD). GERD is caused by dysfunction of the lower esophageal sphincter, a valve mechanism that normally allows food into the stomach but prevents reflux of stomach contents up into the esophagus. Reflux of stomach acid and undigested food into the esophagus causes heartburn and regurgitation, the commonest (“typical”) symptoms of GERD.
“Lower esophageal sphincter dysfunction can be caused by diseases such as obesity and hiatal hernia and dietary or lifestyle factors such as smoking, caffeine and alcohol consumption. GERD is also common during pregnancy, but this is typically temporary and resolves after delivery”, says Dr. Ballian, general surgeon who specializes in esophageal disorders (www.nballian.gr).
Despite heartburn and regurgitation being the most frequent GERD symptoms, some patients present with atypical complaints such as chronic hoarseness, asthma, frequent episodes of aspiration pneumonia, chronic cough, laryngitis and pharyngitis.
Patients with typical and mild symptoms can be treated empirically, at least initially, without the need for diagnostic testing. If, however, symptoms are severe, atypical or not responsive to empiric therapy, patients should undergo diagnostic testing including endoscopy (esophagoscopy and gastroscopy).
In some patients with GERD, surgery is the treatment of choice in order to create a new valve mechanism at the lower end of the esophagus.
“The main indication for surgery is failure of medical therapy, due to persistent symptoms or persistent endoscopic signs of esophageal injury such as esophagitis (inflammation), stricture or Barrett’s disease, a change in the characteristics of cells lining the esophagus”, explains Dr. Ballian. “Further indications for surgical treatment include intolerance of medical therapy and young patient age, when patients do not desire life-long drug therapy”. Contraindications to surgery, for example some types of previous esophageal or stomach surgery, are relatively rare.
Surgical treatment (“fundoplication”) aims to create a new valve mechanism to replace the failing lower esophageal sphincter in order to completely and permanently prevent gastroesophageal reflux. This is achieved by wrapping the uppermost part of the stomach (“fundus”) around the junction between esophagus and stomach. If the patient has a hiatal hernia, this is also corrected at the same operation. In morbidly obese patients with GERD, gastric bypass surgery instead of fundoplication is recommended, as it treats obesity and GERD at the same time.
The success rate of anti-reflux surgery in patients with typical symptoms is over 95%, while in those with atypical complaints it is lower owing to non-GERD conditions also playing a role.
“The majority of patients undergoing anti-reflux surgery remain in hospital for 1-2 days postoperatively. Clear liquids only are allowed for the first 2-3 days, while a soft diet is recommended for a few more days until swelling of the new valve mechanism resolves”, Dr. Ballian adds. There are no long-term dietary restrictions. “Pain after surgery usually responds to over the counter medications. For the first 6 weeks, patients should avoid lifting objects weighing more than 5 kg”.
Studies have shown that anti-reflux surgery is an effective treatment, as 5 years after fundoplication almost 85% of patients report no GERD symptoms and remain off medications. An additional 10% require medications to remain asymptomatic and only 5% report partial or, more rarely, complete recurrence.
For all GERD patients, however, “lifestyle and dietary modifications are recommended, such as avoidance of large meals, smoking cessation, reduction of alcohol and caffeine use, as well as not eating at least 3 hours before bedtime”, Dr. Ballian concludes.
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