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Antireflux surgery in the proton pump inhibitor era

Cleveland Clinic Journal of Medicine. 2012 April;79(4):273-281 | 10.3949/ccjm.79a.11097
April 1, 2012|Cleveland Clinic Journal of Medicine
William J. Bulsiewicz, MD, MSc;Ryan D. Madanick, MD
Author and Disclosure Information

William J. Bulsiewicz, MD, MSc
Center for Esophageal Diseases and Swallowing, Department of Medicine, Division of Gastroenterology, University of North Carolina School of Medicine, Chapel Hill

Ryan D. Madanick, MD
Center for Esophageal Diseases and Swallowing, Department of Medicine, Division of Gastroenterology, University of North Carolina School of Medicine, Chapel Hill

Address: William J. Bulsiewicz, MD, MSc, Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, CB#7080, Chapel Hill, NC 27599-7080; e-mail wbulsiewicz@gmail.com

Dr. Madanick has disclosed teaching and speaking for AstraZeneca corporation, makers of Nexium.

ABSTRACTAlthough proton pump inhibitors (PPIs) are now the first-line treatment for gastroesophageal reflux disease (GERD), surgery still has several specific indications. We review the current treatment of GERD and discuss how antireflux surgery fits into the overall scheme.

KEY POINTS

  • If a PPI in twice-daily doses fails to relieve GERD symptoms, a pH study combined with multichannel intraluminal impedance testing can help in deciding whether to try surgery.
  • Antireflux surgery can be considered for erosive esophagitis that does not resolve with drug therapy, for volume regurgitation (particularly if it occurs at night or if there is a risk of aspiration), and for patients who need lifelong treatment for reflux but have had a serious adverse event related to PPI therapy.
  • Studies are needed to directly compare medical and surgical therapy in patients with extraesophageal manifestations of GERD and refractory symptoms, a difficult group of patients.
  • Drugs that inhibit transient relaxation of the lower esophageal sphincter are under investigation, as are minimally invasive procedures to manipulate the physical barrier to reflux.

For most patients with gastroesophageal reflux disease (GERD), a proton pump inhibitor (PPI) is the first choice for treatment.1 But some patients have symptoms that persist despite PPI therapy, some desire surgery despite successful PPI therapy, and some have persistent extraesophageal symptoms or other complications of reflux. For these patients, surgery is an option.2

In this article, we review the management of GERD and clarify the indications for antireflux surgery based on evidence of safety and efficacy.

GERD DEFINED: SYMPTOMS OR COMPLICATIONS

Defining the role of antireflux surgery is difficult, given the variety of presentations and the absence of a gold standard for diagnosing GERD. Most adults experience several episodes of physiologic reflux daily without symptoms.3 But a broad array of symptoms have been attributed to GERD, including chest pain, cough, and sore throat, and some conditions caused by acid reflux (eg, Barrett esophagus) can be asymptomatic.4,5

Given these challenges, in 2006 the Montreal Consensus Group defined GERD as “a condition which develops when the reflux of stomach contents causes troublesome symptoms or complications.” 4 Critical to the Montreal definition is the distinction between “troublesome symptoms” and “complications” or bodily injury (Table 1).

HEARTBURN ISN’T ALWAYS GERD

Typical GERD presents with the classic symptoms of pyrosis (heartburn) or acid regurgitation, or both.

Although these symptoms are often thought to be specific for GERD, other causes of esophageal injury— eg, eosinophilic esophagitis, infection (Candida, cytomegalovirus, herpes simplex virus), pill-induced esophagitis, or radiation therapy—can produce similar symptoms. Other causes, including coronary artery disease, biliary colic, foregut malignancy, or peptic ulcer disease, should also be considered in patients with supposedly typical GERD. Life-threatening mimics of GERD, such as unstable angina, should be excluded if they are likely, before proceeding with evaluating for possible GERD. Therefore, the initial history and examination should focus on appropriate diagnosis, with careful delineation of symptom quality.

Alarm features for advanced pathology6–8 include involuntary weight loss, dysphagia, vomiting, evidence of gastrointestinal blood loss, anemia, chest pain, and an epigastric mass.7 Admittedly, these features are only mediocre for detecting or excluding gastric or esophageal cancer, with a sensitivity of 67% and a specificity 66%.9 Nevertheless, they should prompt an endoscopic examination. In patients who have alarm features but have not yet been treated for GERD, upper endoscopy can identify an abnormality in about 60% of patients.10–12

PPIs HAVE REPLACED ANTACIDS AND HISTAMINE-2 RECEPTOR ANTAGONISTS

When the symptoms suggest GERD and no alarm features are present, an initial trial of the following lifestyle changes is reasonable:

  • Avoiding acidic or refluxogenic foods (coffee, alcohol, chocolate, peppermint, fatty foods, citrus foods)
  • Avoiding certain medications (anticholinergics, estrogens, calcium-channel blockers, nitroglycerine, benzodiazepines)
  • Losing weight
  • Quitting smoking
  • Raising the head of the bed
  • Staying upright for 2 to 3 hours after meals.

For someone with mild symptoms, these changes pose minimal risk. Unfortunately, they are unlikely to provide adequate symptom control for most patients.13–17

Before PPIs were invented, drug therapy for GERD symptoms that did not resolve with lifestyle changes consisted of antacids and, later, histamine-2 receptor antagonists. When maximal therapy failed to control symptoms, fundoplication surgery was considered an appropriate next step.

PPIs substantially changed the management of GERD, suppressing acid secretion much better than histamine-2 receptor antagonists. Taken 30 minutes before breakfast, a single daily dose of a PPI normalizes esophageal acid exposure in 67% of patients.18 Adding a second dose 30 minutes before dinner raises the number to more than 90%.19

PPIs have consistently outperformed histamine-2 blockers in the healing of esophagitis and in improving heartburn symptoms and are now the first-line medical therapy for uncomplicated GERD.6,8,20–25

WHEN PPIs WORK, SURGERY OFFERS NO ADVANTAGE

Patients may not want to take a PPI for the rest of their life, for a number of reasons: cost, the need to take one or more pills daily, and potential adverse effects.26 In these cases, the physician can counsel the patient on the relative merits of long-term medical therapy vs surgery (Table 2).2,26

The LOTUS trial (Long-Term Usage of Esomeprazole vs Surgery for Treatment of Chronic GERD) compared long-term drug therapy with surgery to maintain remission of symptoms in GERD.27 In this trial, 554 patients whose symptoms initially responded to the PPI esomeprazole (Nexium) were randomized to continue to receive esomeprazole (n = 266) or to undergo laparoscopic antireflux surgery (288 were randomly assigned, and 248 had the operation). Dose adjustment of the esomeprazole was allowed (20–40 mg/day). A total of 372 patients completed 5 years of follow-up (192 esomeprazole, 180 surgery).

Symptoms stayed in remission in 92% of the esomeprazole group and 85% of the surgery group (P = .048). However, the difference was no longer statistically significant after modeling the effects of study dropout. The rate of severe adverse events was similar in both groups: 24.1% with esomeprazole and 28.6% with surgery.

These findings indicate that if symptoms fully abate with medical therapy, surgery offers no advantage. In addition, patients who desire surgery in the hope of avoiding lifelong drug therapy should be made aware that drug therapy and reoperation are often necessary after surgery.28 In most cases, antireflux surgery is unnecessary for patients whose GERD fully responds to PPI therapy.

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