Related Experiment Videos
Surgical and endoscopic treatment of gastroesophageal reflux disease
1Digestive Healthcare of Georgia, 95 Collier Road, Suite 4075, Atlanta, GA 30309, USA.
Insights
For gastroesophageal reflux disease (GERD), neither medical nor surgical therapy is definitively best. Individualized assessment is crucial for treatment decisions, including considering antireflux surgery for specific patient groups.
Area of Science:
- Gastroenterology
- Surgical Gastroenterology
Background:
- Gastroesophageal reflux disease (GERD) management requires careful consideration of long-term medical therapy versus surgical intervention.
- Proton pump inhibitor (PPI) therapy is a cornerstone of medical management, but challenges like intolerance and poor response exist.
Purpose of the Study:
- To evaluate the current evidence for medical and surgical therapies in GERD management.
- To define specific circumstances where antireflux surgery, such as fundoplication, should be considered.
- To inform patient counseling regarding the risks and benefits of both long-term medication and surgical options.
Main Methods:
- Review of existing evidence on medical and surgical treatments for GERD.
- Analysis of indications for considering fundoplication surgery.
- Discussion of patient selection criteria and preoperative evaluation for antireflux surgery.
Main Results:
- No definitive evidence supports medical or surgical therapy as universally superior for GERD.
- Fundoplication may be considered for patients intolerant to PPIs, poorly responsive to PPIs (especially with atypical GERD), or seeking a permanent solution.
- Patients considering surgery must be counseled on potential suboptimal outcomes, including the possibility of needing medication post-surgery or experiencing worsening symptoms.
Conclusions:
- Individualized treatment decisions are paramount in GERD management.
- Antireflux surgery offers an alternative for select patients, but requires thorough evaluation and informed consent regarding risks.
- Endoscopic therapies for GERD are promising but not yet widely established or standardized.
Abstract:
There is no evidence to advocate medical or surgical therapy as the best therapy for GERD. The decision to have antireflux surgery must be individualized. All patients taking long-term medications for GERD should receive advice on the safety and wisdom of staying on that therapy and information on antireflux surgery. Fundoplication should be considered in three circumstances [4]: 1. Patients who are intolerant of PPI therapy because of side effects should be considered for surgery. This situation will be less common now with five PPIs, however. 2. Patients who are poorly responsive to PPI therapy should be considered for surgery. This situation is probably not common, given the effectiveness of the currently available PPIs. It is more common in patients with atypical GERD. The gastroenterologist should be as certain as possible that the patient not only has GERD, but also that the patient's symptoms are reflux related. 3. Surgery should be considered when patients desire a permanent solution to free them of the need to take medications. These patients must be warned about the potential suboptimal results, including the frequent need for medication within a few years of having the procedure and the small but real possibility of becoming worse after the operation. Even in experienced hands, 1% to 2% of patients are worse after the procedure. A careful preoperative evaluation to ensure that the patient's symptoms are reflux related and that the right operative procedure is performed offers the patient the best opportunity for success. Widespread use of endoscopic therapy for GERD is probably still several years away. The best endoscopic therapy is yet to be determined, but it will need to be safe, effective, and easy to use.