The Surgical Option in the Treatment of Gastroesophageal Reflux Disease: Rationale and Indications

Carlos A. Pellegrini, MD

In This Article

A Change in Indications for Antireflux Surgery

As knowledge regarding the complications of reflux and its treatment developed, and as operations became safer, more efficient, and less painful, the indications for surgery started to evolve. In the past, operations were indicated only when the patient had failed medical therapy or had developed serious complications of reflux disease, or both. I will review and contrast this concept with the principles that guide our own approach to patients with reflux.

Successful therapy (medical or surgical) for GERD is one that abolishes all esophageal and extraesophageal symptoms and keeps the mucosa of the esophagus free of inflammation. Because PPIs are so effective in the control of heartburn and in the healing of esophagitis, medical therapy is successful in most patients with abnormal reflux; surgery has nothing to offer these patients. On the other hand, in some patients, particularly those with a mechanically defective cardia (lower esophageal sphincter [LES] pressure < 6 mm Hg, short sphincter length, large hiatal hernias), recurrence (of symptoms or esophagitis) is the rule, and treatment must be lifelong to prevent it. Some patients find it difficult to adhere to this form of treatment for life. If they are fit for an operation, especially if they are young, have had the disease since early age or for more than 3 years, we believe surgery becomes an alternative to medical management. Thus, in a way, failure is defined by the patient. The results of surgery are best in individuals who have had a history of response to PPIs. Paradoxically, many of our patients tell us after the operation that the greatest relief they have is with respect to regurgitation. While heartburn was taken care of by PPIs preoperatively, they realize after an operation the improved quality of life associated with the ability to lie down immediately after they eat, if they so wish, without the fear of regurgitation. Therefore, the physician must exercise good judgement and take into consideration all elements before deciding on the best therapeutic alternative. Life-long medical therapy may be perfectly appropriate for example in the case of elderly patients or those who are obese or have other factors that may increase the chance of complications with surgery. By contrast, surgery may be a better alternative for patients who are found to have a mechanically deficient cardia and who are fit for operation. It is indeed this group -- patients with good initial response to medical therapy but with severe functional and anatomical abnormalities of the gastroesophageal junction -- that today constitutes the largest group of individuals treated by surgeons for GERD.

The next group of patients for whom we believe surgery should be considered is referred to as the "aspirators." These patients present with laryngeal (laryngitis, hoarseness, continued need to clear their throat), pulmonary (repeated pneumonia, asthma, wheezing, chronic cough, pulmonary fibrosis), or other symptoms (recurrent otitis, loss of enamel of teeth, etc.) related to high regurgitation of gastric contents and/or aspiration into the airway. In some of these individuals, PPIs provide good control of both esophageal and extraesophageal manifestations. One may choose to keep them under medical therapy, but they deserve closer observation: their response to medical therapy tends to decrease with time and the complications of aspiration can be devastating. On the other hand, mechanical correction of the anatomical defect is usually followed by long-term relief or significant improvement of their condition.[9] The key to a successful surgical outcome in these patients is to be able to diagnose preoperatively a causal relationship between their reflux and the symptom(s) that one is trying to correct. Of course, even with current diagnostic tools this may not be easy. We recommend paying special attention to such factors as the results of 24-hr pH monitoring (relationship of episodes of reflux to laryngeal/pulmonary symptoms, abnormal amounts of proximal reflux, ratio of proximal to distal reflux greater than 1 in 3, etc.) and results of direct laryngeal examination under stroboscopy. In patients with clinical and objective evidence suggestive of aspiration, we are very liberal in the indication for surgical correction unless associated conditions jeopardize the outcome.

A rather small group of patients remain whose esophageal symptoms simply do not respond to medical therapy. Although they represent the very small minority of patients with reflux, they are the true failures of medical therapy. This would be, indeed, the group for whom operation was recommended in the past. Today, however, we approach this group of patients with suspicion. Knowing how effective PPIs are in controlling heartburn, we should think that for an individual whose heartburn has not responded to medical therapy, reflux may not be causing the symptom. Thus, we test these patients on and off therapy. We measure esophageal and gastric acid secretion over a 24-hr period to determine whether or not they are affected by treatment. Only when we have shown that gastric acid secretion (and abnormal reflux) continue while on medical therapy are they offered an operation. Today, they represent the minority of patients for whom surgical intervention is offered.

Patients who have developed Barrett's esophagus represent a true challenge. There is no clear objective evidence that surgical (or for that matter medical) therapy affects the evolution of Barrett's. Several studies in the past have shown that regression of Barrett's epithelium is the exception rather than the rule with either form of therapy.[10,11] Emerging evidence, however, suggests that complete restoration of gastroesophageal competence (only possible with an operation) may have an effect on the evolution of the columnar epithelium to dysplasia.[7,12] Thus, when a patient is symptomatic, when a patient has a long segment of Barrett's, and in particular when the individual is younger than 50 years of age, we recommend the operation, with the proviso that the patient must continue endoscopic surveillance.

Thus, as a direct consequence of the progress experienced in the last decades of the 20th century, a significant change in indications for antireflux surgery has occurred. Operative treatment for many patients has become an alternative rather than a method of last resort to treat abnormal reflux and prevent the development of its complications.