The Role of Surgery in Gastroesophageal Reflux Disease
Abstract & Commentary
By Malcolm Robinson, MD, FACP, FACG, Emeritus Clinical Professor of Medicine, University of Oklahoma College of Medicine, Oklahoma City. Dr. Robinson reports no financial relationship to this field of study.
Synopsis: Although anti-reflux surgery seems to be declining in the United States, there are still many such operations undertaken. However, new data make it clear that very few patients are candidates for fundoplication.
Source: Vakil N. Aliment Pharmacol Ther. 2007;25:1365-1372.
Many surgeons and some gastroenterologists enthusiastically promote fundoplication (now mostly done using a laparoscopic approach) as an effective treatment for gastroesophageal reflux disease (GERD). Success rates ("cures") have been claimed in as many as 85-93% of all cases. Indications for surgery have included failed medical therapy, patient choice despite successful medical therapy, large hiatal hernias, and complications of reflux disease including Barrett's esophagus and extra-esophageal reflux symptoms (chronic cough, asthma, and recurrent aspiration). Some surgical departments have initiated direct to consumer promotion of surgery as the ultimately effective therapy for heartburn. Despite such enthusiasm, rates of anti-reflux surgery have declined as much as 30% from their peak in 1999 (much lower rates in younger patients and in most teaching hospitals). Almost half of all patients who do opt for fundoplication do so due to recommendations by their primary physicians. Oddly enough, there has been no evidence-based data to support physician enthusiasm for surgical therapy as superior to or even equal to medical management. Indeed, large numbers of surgical patients are known to require chronic resumption of acid antisecretory treatment at some point following anti-reflux surgery. Although many have assumed that fundoplication will lessen or eliminate the subsequent development of esophageal adenocarcinoma in GERD patients, actual data show that cancer rates are identical between medically and surgically treated patients. If GERD signs and symptoms are well controlled on medical therapy, surgery does not eliminate or even lessen the ultimate requirement for medical therapy (eg, 62% of surgically treated patients were using medications for reflux more than 10 years post-fundoplication). A number of studies have demonstrated that overall medical costs are lower than those of surgery. There is appreciable morbidity and even mortality associated with surgery.
For example, a large Finnish study demonstrated almost 2 deaths per 1,000 patients operated. Complications of fundoplication include dysphagia that may require repeated dilation and a variety of unpleasant post-operative symptoms that may be quite difficult to control. Unfortunately, patients who fail to respond to medical therapy are usually nonresponders to surgery. At the least, prior to the contemplation of surgical therapy, such patients need additional sophisticated evaluation to rule out such non-surgical causes of their symptoms as eosinophilic esophagitis and a number of potentially confounding esophageal motor abnormalities.
If careful pH and/or impedance studies do demonstrate reflux despite medical treatment, and if patients have signs and symptoms such as recurrent aspiration or regurgitation, anti-reflux surgery may be reasonably contemplated. Suspected reflux-related laryngitis that does not respond to adequate proton pump inhibitor (PPI) therapy has been shown also not to respond to anti-reflux surgery. There is some consensus that patients with demonstrated reflux who also have large hiatal hernias or para-esophageal hernias may be candidates for fundoplication since medical therapy may not eliminate volumetric reflux in such cases. There are a few patients with severe symptoms and documented acidic or weakly acidic reflux despite full dose PPIs who might respond favorably to surgery. Surgical trials have often not been performed with scientific rigor and there is always the problem of inter-surgeon variability to consider. On the other hand, PPIs work regardless of who prescribes them. Overall, most existing data reinforce the concept that most GERD patients are best managed with expert medical therapy and that anti-reflux surgery has few valid indications in 2007.
As most readers of Internal Medicine Alert already know, this series usually does not involve selection of review articles like the one outlined above. However, there are some occasions that seem to merit a departure from this approach. As noted above, there continues to be a large number of primary care physicians who recommend anti-reflux surgery to their GERD patients. Since we are all charged with trying to practice medicine using the most reliable available scientific evidence, we sometimes need to be reminded that many of our habits were developed prior to modern evidence-based medicine. When our behavior is no longer consistent with the best available data, our practices need to change. There seems to be little or no current support for the wide application of fundoplication in the management of GERD.
Although a few selected patients may be candidates for anti-reflux surgery, such patients should be very thoroughly evaluated before any such intervention. Likewise, the sometimes touted endoscopic procedures for the treatment of GERD have even weaker scientific underpinnings. As stated before in this series, such procedures should remain investigational until adequate long-term supportive data are published.