LAPAROSCOPIC TREATMENT FOR REFLUX DISEASE (GERD)
(Excerpted from National Institutes of Health Information Clearinghouse, November 2001)
Gastroesophageal
reflux is the most common gastrointestinal disorder
of the western world. Gallup poles have elucidated
that approximately 44 % of the adult population
in the U.S. has some abnormal reflux of acidic gastric
juices into the esophagus on a monthly basis. Roughly
10% of patients require daily acid suppression medication
for relief of symptoms. GERD accounts for over 1.0
million out patient visits to physicians every
year! Gastroesophageal reflux disease, or GERD,
occurs when the lower esophageal sphincter (LES)
does not close properly, and stomach contents splash
back, or reflux, into the esophagus. The LES is
a ring of muscle located at the far end of the esophagus
as it leads into the stomach. It's normal function
is to act as a physical barrier between the esophagus
and the stomach, protecting the esophagus from 
harmful
gastric acid, and preventing food from being regurgitated.
It does this by involuntary tonic contraction. When
one eats, food is propelled into the esophagus toward
the stomach. It is during swallowing that the LES
relaxes and allows passage of food and liquids into
the stomach.
When refluxed stomach acid touches the lining of the esophagus, it causes
a burning sensation in the chest or throat called heartburn. The fluid may
even be tasted in the back of the mouth, and this is called acid indigestion.
Occasional heartburn is common but does not necessarily mean one has GERD.
Heartburn that occurs more than twice a week may be considered GERD, which
can eventually lead to more serious health problems.
The main symptoms of GERD can be divided into typical and atypical symptoms.
Typical symptoms include a burning sensation in the chest, and
regurgitation of food. These symptoms are general, and not necessarily specific
for reflux disease. For instance, patients may experience chest pain
or burning as a result of a primary cardiac problem, or they may be a manifestation
of another primary esophageal disorder. It is imperative that the cause of
the symptoms be clearly delineated by your physician so the proper therapy
may be instituted. Regurgitation is also a relatively common complaint.
Atypical symptoms of GERD include:
- asthma;
- chronic sinusitis;
- chronic hoarseness;
- difficulty swallowing (dysphagia);
- vomiting;
- choking sensation at night time;
- pneumonias;
- excessive salivation.;
The
basic problem in patients with reflux disease is
a defective lower esophageal sphincter (LES). If
the LES is loose, then the barrier between the stomach
and esophagus is compromised and gastric juice and
food are allowed to flow freely back into the esophagus.
Hiatal hernias (see figure) are sometimes
contributing factors. This is an entity in which
the normally intra-abdominal portion of the esophagus
"slides" or "slips" up into
the chest. In doing so, the pressure in that portion
of the esophagus now becomes low enough so the intra-abdominal
pressure of the stomach is high enough to overcome
the natural barrier of the LES, causing reflux.
Certain medical conditions, foods and medications
may also exacerbate GERD by their ability to lower
the resting pressure of the LES. These include:
MEDICAL CONDITIONS
Obesity
Pregnancy
PERSONAL HABITS
Alcohol use
Smoking
|
AGGRAVATING FOODS
Chocolate
Caffeine (+, -)
Spearmint
Peppermint
Fatty foods
Cola
Milk
Citrus juices
|
MEDICATIONS
|
.. CAN DECREASE LES PRESSURE
oral contraceptives
nitrates
theophllyine
narcotics
calcium channel blockers
ß-adrenergic agonists
a-adrenergic agonists
diazepam
dopamine
nicotine patch
|
.. CAN DIRECTLY INJURE ESOPHAGEAL LINING
aspirin
NSAIDS (i.e.: ibuprofen)
quinidine
tetracycline
potassium
iron
|
If you have had persistent heartburn or other persistent symptoms, you should
consult with a physician. You may decide to visit an internist, a doctor who
specializes in internal medicine, or a gastroenterologist, a doctor who treats
diseases of the digestive tract. Treatment for GERD may involve one or more
of the following lifestyle changes, medications, or surgery. The goals of
therapy for GERD include: a) Symptomatic relief; b) Resolution of esophagitis
(inflammatory changes of the esophagus as a result of abnormal acid exposure);
and c) Prevention of complications.
Lifestyle Changes
The first step in treating GERD includes lifestyle and diet modifications:
And these are usually very effective.
- Elevate the head the head of your bed. You must place blocks under the
bed post. Pillows will not help. Patients with GERD tend to have more frequent
and longer episodes of reflux in the supine position than normal individuals.
- Try to limit or avoid foods that can exacerbate GERD (see above). This includes decreasing alcohol intake. Eat small meals.
- DO NOT SMOKE. Aside from it's effect on LES and GERD, it can cause you a multitude of serious life and limb threatening problems. But you already knew that. Right?!
- If possible, lose weight. Excess weight can increase intra-abdominal pressure sufficient enough to overcome the resting pressure of the LES.
- Avoid tight fitting clothes.
- Avoid lying down for several hours after eating.
Medical Therapy
- If at all possible, try to avoid medications that act to lower
the LES pressure. (see above)
- Antacids, such as ALKA-SELTZER, MAALOX,
MYLANTA, PEPTO-BISMOL, ROLAIDS, and RIOPAN,
are usually the first drugs recommended to relieve heartburn and other mild
GERD symptoms. Many brands on the market use different combinations of three
basic salts--magnesium, calcium, and aluminum--with hydroxide or bicarbonate
ions to neutralize the acid in your stomach. Antacids, however, have side
effects. Magnesium salt can lead to diarrhea, and aluminum salts can cause
constipation. Aluminum and magnesium salts are often combined in a single
product to balance these effects. Calcium carbonate antacids, such as TUMS,
TITRALAC, and ALKA-2, can also be a supplemental source of
calcium. These medications frequently cause constipation. In general antacids
are good for occasional relief of symptoms in patients with mild disease.
However for patients with more frequent symptoms and esophagitis, further
therapy is usually required.
- Foaming agents, such as GAVISCON, work by covering
your stomach contents with foam to prevent reflux. These drugs may help
those who have no damage to the esophagus.
- H2 blockers, such as
cimetidine (TAGAMET HB), famotidine (PEPCID AC),
nizatidine (AXID AR), and ranitidine (ZANTAC 75),
impede acid production. They are available in prescription strength and
over the counter. These drugs provide short-term relief, but over-the-counter
H2 blockers should not be used
for more than a few weeks at a time. They are effective for about half of
those who have GERD symptoms. Many people benefit from taking H2
blockers at bedtime in combination with a proton pump inhibitor. These medications
act by significantly reducing the acid output of the stomach (60%-70%),
and are very effective in relieving symptoms and healing esophagitis. However,
some are better than others. Consult your doctor for specifics. H2
blockers are relatively safe drug. They can potentiate or decrease the
efficacy of certain other medications (particularly cimetidine).
It is therefore important to consult your doctor prior to using these medication
if you are taking other drugs. Furthermore, on occasion H2
blockers may cause central nervous system toxicity.
- Proton pump inhibitors or PPI are the latest class of
drug created to treat GERD. These drugs are extremely effective at decreasing
the 24 hour acid output by the stomach, and reduce it almost completely.
Proton pump inhibitors include omeprazole (PRILOSEC),
lansoprazole (PREVACID), pantoprazole (PROTONIX),
rabeprazole (ACIPHEX), and esomeprazole (NEXIUM),
which are all available by prescription. Proton pump inhibitors are more
effective than H2 blockers and
can relieve symptoms in almost everyone who has GERD. The long lasting effect
of PPI is probably the reason they are more effective than H2
blockers in healing esophagitis. In many instances, the majority of
patients with esophagitis refractory to H2
blockers are healed with eight months of therapy. However, following
withdrawal of PPI, there is a significant relapse rate in both symptoms
and esophagitis after approximately six months in patients with rather severe
disease. Therefore, some patients may require long term or even life long
maintenance of acid suppression with PPI for control of their disease.
- Another group of drugs, prokinetics, helps strengthen
the sphincter and makes the stomach empty faster. This group includes bethanechol
(Urecholine) and metoclopramide (Reglan). Metoclopramide also improves muscle
action in the digestive tract, but these drugs have frequent side effects
that limit their usefulness. Erythromycin, an antibiotic, can also help
your stomach empty faster.
SAFETY OF MEDICAL THERAPY
Side Effects of Medications:
Antacids containing magnesium and aluminum can lead to hypermagsemia,
and dementia in patients with preexisting kidney failure. H2Blockers
are very safe medications, and have extremely low rates of toxicity even after
many years of therapy. Results of long term PPI therapy are not clear yet,
however. Early animal studies suggest an increased risk for cancer formation.
This has NOT been shown to be the case in humans, and there is no evidence
to suggest that this is clinically relevant inpatients being treated with
PPI.
Effects of long term acid suppression:
With decreased gastric acid output there is a tendency for an overgrowth of
bacteria in the stomach. There is also an increase in the gut hormone gastrin,
which is released into the blood stream when gastric acid levels are low leading
to gastrin mediated stimulation of stomach acid producing cells. This in turn
causes what is known as hyperplasia of the acid secreting cells of the stomach.
In rats, this phenomenon has been suggested to cause the growth of a certain
type of tumor called a carcinoid. Again however, this has not been borne out
in human studies and PPI are approved by the FDA for long term therapy of
GERD.
Surgical Treatment for GERD
What are the indications for surgical therapy and are you candidate?
Surgical therapy for GERD has made a sort of resurgence over the last several years, as a result of the introduction of minimally invasive surgery. There is increasing patient and doctor satisfaction with surgical therapy and many more patients and there physicians entertain surgery as an excellent therapeutic option for GERD.
The goals of surgical therapy are identical to those of medical therapy. Patients are considered for surgical therapy of GERD if:
- Medical therapy fails to control their symptoms despite large doses
of PPI, or prevent complications of GERD such as Barret's esophagus
(thought to be a precancerous lesion), esophageal stricture (leading to
obstruction and inability to eat), ulcer formation, and bleeding.
- Atypical symptoms persist (asthma, sinusitis, cough, hoarseness, etc...)
- A patient cannot take mediation because of undesirable side effects,
poor compliance, or unwilling or unable to pay for long-term medical
treatment. (Annual cost of PPI can be $1200.00 . On average hospital
charges for Nissen fundoplication are from 10,000-25,000 with surgical fee
approximately $3000.00. This may prove cost effective to patients, considering
presently many insurance companies do not include medication coverage in
their policies, but do provide for surgery and hospitalization if indicated.
- A patient prefers surgery rather than life long medical therapy.
Preoperative patient evaluation
Proper patient selection is essential in order to achieve successful surgical results.
As mentioned earlier, symptoms suggestive of GERD are nonspecific and can be caused by a variety of ailments. It is therefore necessary to obtain objective information regarding the nature and severity of the reflux, esophageal motility and complications of GERD.
These studies include a 24 hour monitoring of the pH (acidity) in the esophagus.
The test is administered by a gastroenterologist or surgeon who has expertise
in this area. A probe is placed into the esophagus at very specific points,
and the number of acid exposures as well as the quantity of acid exposure
is recorded. The patient also records episodes of symptomatic reflux, and
this is compared to the record of the esophageal probe by the physician. Patients
then receive a score, which quantifies the degree of gastroesophageal reflux.
This study has been deemed the gold standard for diagnosing GERD, and a normal
study eliminates GERD as the cause of a patient's symptoms.
Another objective study to determine a patient's appropriateness for surgical
therapy is called esophageal manometry. This test documents the muscular coordination
and function of the esophagus as food and liquids are swallowed. If a patient
has an esophagus that does not propel food and liquids adequately, the patient
may not be a candidate for Nissen Fundoplication. Also, prior to surgery patients
should undergo endoscopy to visually inspect the lining of the esophagus for
unusual pathology. This is done as a base line study to document healing of
esophagitis following surgery and also to identify any cancerous or precancerous
lesions that my preclude fundoplication And finally, some surgeons prefer
to obtain video x-ray of the esophagus (video esophagram). This defines esophageal
anatomy of an individual, and my also uncover other causes than GERD for the
patients symptoms.
If after the above studies are performed and demonstrate significant GERD, patients are then counseled on the surgical procedure, its risks and benefits.
Laparoscopic
(minimally-invasive) Surgery for GERD
The most common surgical procedure performed for
treatment of GERD is a Nissen fundoplication.
Fundoplication refers to wrapping the distal esophagus
with the uppermost part of the stomach. (see illustration).
Recognizing the relationship between a dysfunctional
lower esophageal sphincter and GERD, Dr. Nissen
developed this procedure in the early twentieth
century. However, it carried with it a significant
morbidity rate. With the success of laparoscopy
used to remove the gallbladder in the late 1980's,
surgeons began applying this technology to other
surgical diseases. With some modifications, the
Nissen fundoplication is now performed using
minimally
invasive techniques. Patients have small incisions,
have less pain, leave the hospital sooner, and return
to normal activity sooner. And the success rate
of this operation has been excellent. Furthermore,
surveys following laparoscopic Nissen fundoplication
have demonstrated immense patient satisfaction with
the procedure.
Benefits of Surgery
About 90% of patients are free of heartburn after the operation. It also
cures GERD-induced asthmatic or respiratory symptoms in up to 85% of patients.
The procedure may enhance stomach emptying, and it improves peristalsis in
about half of patients. It may actually cause abnormal peristalsis in about
14% of patients. This complication, however, does not appear to cause many
problems. Although fundoplication is not thought to be very effective for
Barrett's esophagus, it is the only treatment that suppresses both bile and
acid reflux. Bile reflux is thought to play a role in the development of early
cancer in Barrett's esophagus. It is recommended for patients whose condition
includes one or more of the following: esophagitis (inflamed esophagus); recurrent
or persistent symptoms in spite of drug treatment; strictures; evidence of
severe asthmatic symptoms caused by GERD; or in children, failure to gain
or maintain weight. Surgery has, until recently, been the primary treatment
for children with severe complications from GERD, because drugs had severe
side effects, were ineffective, or had not been optimized for children. With
the introduction of omeprazole, some children may be able to avoid surgery.
The procedure has little benefit for patients with impaired stomach motility
(an inability of the stomach muscles to move normally).
Many
experts now believe that because of advances in techniques, particularly the
use of laparoscopy, surgery should be considered as primary treatment in patients
who are now candidates for long-term maintenance drug therapy. They argue
that medications cannot cure GERD. Moreover, only surgery improves regurgitation,
and it is far more effective in improving asthmatic symptoms than drug treatment.
One study reported that the lifetime costs of surgical treatment are less
than treatment using proton pump inhibitors, assuming a patient took the medication
for one-third of a normal life-span. Complications, although uncommon, can
still occur even with minimally invasive surgeries, and patients should always
consider any elective surgery very carefully.
In 2000, the U.S. Food and Drug Administration (FDA) approved two endoscopic
devices to treat chronic heartburn. The Bard EndoCinch system puts stitches
in the LES to create little pleats that help strengthen the muscle. The Stretta
system uses electrodes to create tiny cuts on the LES. When the cuts heal,
the scar tissue helps toughen the muscle. The long-term effects of these two
procedures are unknown.
Potential Complications of Surgery
After surgery, there may be a delay in intestinal recovery that causes bloating,
gagging, and vomiting, which resolves in a few weeks. If symptoms persist
or if they start weeks or months after surgery, particularly if vomiting is
present, then surgical complications are likely. Complications are uncommon,
but include bowel obstruction, wound infection, and injury to nearby organs.
Respiratory complications can occur but are uncommon, particularly with laparoscopic
fundoplication. If the fundus is wrapped too tightly, patients may have difficulty
swallowing or be unable to burp. In rare cases following surgery, muscles
spasms after swallowing food can cause intense pain, and patients may require
a liquid diet, sometimes for weeks. The surgery may need to be repeated under
certain circumstances: if the wrap has slipped or is too loose; or if the
patient has persistent difficulty in swallowing, hernia, or recurrent ulcers.
Even with repeat surgery, results are excellent.
Sometimes GERD can cause serious complications. Inflammation of the esophagus
from stomach acid causes bleeding or ulcers. In addition, scars from tissue
damage can narrow the esophagus and make swallowing difficult. Some people
develop Barrett's esophagus, where cells in the esophageal lining take on
an abnormal shape and color, which over time can lead to cancer.
Also, studies have shown that asthma, chronic cough, and pulmonary fibrosis
may be aggravated or even caused by GERD.
- Heartburn, also called acid indigestion, is the most common symptom of
GERD. Anyone experiencing heartburn twice a week or more may have GERD.
- You can have GERD without having heartburn. Your symptoms could be excessive
clearing of the throat, problems swallowing, the feeling that food is stuck
in your throat, burning in the mouth, or pain in the chest.
- In infants and children, GERD may cause repeated vomiting, coughing, and
other respiratory problems. Most babies grow out of GERD by their first
birthday.
- If you have been using antacids for more than 2 weeks, it is time to see
a doctor. Most doctors can treat GERD. Or you may want to visit an internist--a
doctor who specializes in internal medicine--or a gastroenterologist--a
doctor who treats diseases of the stomach and intestines.
- Doctors usually recommend lifestyle and dietary changes to relieve heartburn.
Many people with GERD also need medication or surgery.
