Treatment Options for Gastroesophageal Reflux Disease (GERD)

Role of Endoscopic and Surgical Therapy in Gastroesophageal Reflux Disease (GERD)

Although lifestyle modifications and drug therapy can effectively control symptoms of gastroesophageal reflux disease (GERD) in many patients, a vast majority of patients will experience a relapse of GERD systems when drug therapy is discontinued. These patients will require long-term "maintenance" drug therapy to control their symptoms. Patients who are relatively young who do not want long-term medical therapy or patients who have failed to respond to medical therapy may be considered as candidates for more invasive treatments such as endoscopic antireflux therapy or gastrointestinal reflux surgery.

Endoscopic Antireflux Therapy

Endoscopic antireflux therapy represents a potentiall effective treatment option for patients with moderate to severe GERD. Currently, there are two major types of endoscopic antireflux therapy that are used clinically:

• Suturing of the gastroesophageal junction - Using an endoscopic suturing device (e.g., EndoCinch), the surgeon inserts three stiches at the gastroesophageal junction to strenghten the lower esophageal sphincter (LES) muscle and, thereby, prevent the backflow of stomach acid into the esophagus.

• Endoscopic radiofrequency ablation - Using a radiofrequency ablation device (e.g., Stretta catheter), the surgeon applies radio-frequency energy to the lower esophagus in order to reduce the frequency of LES muscle relaxations and prevent the backflow of stomach acid into the esophagus.

Studies have shown that endoscopic antireflux therapy is effective in about 60% to 65% of patients and can also reduce the use of long-term medications for controlling symptoms of the disease. As such, it offers a reasonable non-surgical treatment option for many patients with moderate to severe GERD.

Gastroesophageal Reflux Surgery

Surgery for gastroesophageal reflux disease (GERD), technically known as fundoplication surgery, was originally developed in the 1950s. The goal of this type of surgery is to strengthen the lower esophageal sphincter (LES) muscle to prevent the backflow of stomach acid into the esophagus. This is achieved by surgically wrapping and then sewing the upper curve of the stomach around the esophagus so that the distal segment of the esophagus passes through a small opening of the stomach muscle.

The most commonly performed type of fundoplication surgery is "Nissen" fundoplication, although other variations of this procedure (e.g, Toupet; Hill; Belsy) have also been recently developed. Fundoplication surgery may be performed as a "open" procedure (through the abdomen or chest) or as a "laparoscopic" procedure (minimally-invasive surgery using a series of small incisions or "ports" usually through the navel).

Fundoplication surgery (open or laparoscopic) is estimated to be effective for the treatment of GERD in about 85% of patients. Studies that have followed patients for 10 years or longer after sugery indicate, however, that about 60% of these patients eventually require drug therapy to control their GERD symptoms.

Postoperative complications of fundoplication surgery, which occur in about 5% to 20% of patients, may include:

• Difficulty in swallowing
• Chest pain
• Bloating from the accumulation of gas
• Injury to the vagal nerves which causes delayed gastric emptying with symptoms such as nausea, vomiting, and diarrhea