Gastro-oesophageal reflux disease: medical or surgical treatment? Report of an interactive workshop

Gastroesophageal reflux disease (GERD) is the most common disease of the upper gastrointestinal tract. With the introduction of proton pump inhibitors medical treatment of GERD has been significantly improved. However, the development of laparoscopic antireflux surgery resulted in an increasing interest of surgeons in this disease. An interactive meeting was organized in order to develop an agreement between gastoenterologists and surgeons regarding therapeutic decisions and this is the main topic of this paper.

[PPI or laparoscopic surgery in the treatment of reflux esophagitis?]

Proton pump inhibitor (PPI) is very effective in the initial treatment of reflux esophagitis. However, the recurrence ratio is high during maintenance therapy. Ten to 20% patients did not remained healed or the symptom were relapsed in spite of one year maintenance treatment with half or routine dose of PPI. Therefore, prolonged maintenance therapy with PPI is needed for many patients with symptomatic reflux esophagitis. On the other hand, surgical treatment is to repair functional disorder in defensive mechanism at esophagogastric junction which is main pathophysiology of reflux esophagitis. Surgical treatment is radical treatment for reflux esophagitis in this point of view. Nissen fundoplication has become the most commonly used antireflux procedure. Following fundoplication, 90% of the patients become symptom free in the long run. Laparoscopic Nissen fundoplication is as effective as open Nissen fundoplication in the short-term results. The average operation time is 2.5 hours, most of patients were discharged within two days after operation and lead to faster recovery from surgery than open procedure. Satisfaction rates ranged from 87 to 100%. Laparoscopic fundoplication can be performed with less morbidity than open procedure. Therefore, laparoscopic Nissen fundoplication is considered to be radical antireflux procedure. Compared to medical treatment, the life time costs of treatment are less with initial surgical management for men age 48 or below and women age 55 or below. The answer for "PPI or laparoscopic surgery in the treatment of reflux esophagitis" is laparoscopic surgery definitely.

Contingent valuation with an open-ended follow-up question: a test of scope effects

It has been suggested that an open-ended follow-up question should be added to the binary contingent valuation question. Before this is generally recommended, it is important to evaluate the properties of such follow-up questions. Using a split sample approach, we test whether the open-ended follow-up is sensitive to the scope of the commodity being valued. No significant scope effects were detected. It is concluded that the results obtained do not support the use of an open-ended follow-up in contingent valuation applications.

An objective end point for dilation improves outcome of peptic esophageal strictures: a prospective randomized trial

BACKGROUND

The usual end point for defining success of dilation is subjective (relief of dysphagia). In most patents thus managed strictures recur. We asked whether an objective end point would improve outcome.

METHODS

After dilation to 15 mm, patients were randomized into subjective and objective groups. In subjective group patients, end point for dilation was alleviation of dysphagia; in objective group patients, passing the 12 mm barium pill test. Objective group patients who failed underwent redilation until they passed the pill or failed three times. During Part 1 of the study, patients received ranitidine, during Part 2 they received omeprazole.

RESULTS

In part 1, dysphagia was alleviated in 7 of 8 subjective group patients. Only 2 of 10 objective group patients passed the pill test and no additional patients passed after 3 sessions, although most had no dysphagia. In Part 2, 19 subjective groups and 15 objective group patients were studied. End point was not achieved in 3 objective group patients. Over long-term follow-up, objective group patients had less recurrent dysphagia (p = 0.02) and required fewer redilation sessions (p < 0.05). Overall, the pill test correlated with the presence or absence of dysphagia (P < 0.001). Predictive value of passing the pill 1 week after dilation for the absence of dysphagia was 100%, but of failing the pill test and the presence of dysphagia was only 18%.

CONCLUSIONS

Achieving an objective end point reduces stricture recurrence and the need for subsequent dilation. Initial subjective improvement does not predict long-term success.

Long-term comparison of antireflux surgery versus conservative therapy for reflux esophagitis

OBJECTIVE

The purpose of the study was to evaluate the long-term symptomatic and endoscopic outcome in gastroesophageal reflux disease with erosive esophagitis, comparing conservative with operative management.

METHODS

The study comprised 105 of 120 patients consecutively referred for severe reflux symptoms to the gastroenterologic outpatient department of a teaching hospital, where erosive esophagitis was confirmed endoscopically. If conservative management (modified lifestyle and medication) failed to relieve symptoms and heal the esophagitis, antireflux surgery (Nissen fundoplication) was undertaken. Follow-up (median, 10.9 years) evaluation of all patients included comprehensive, standardized interviews; self-scoring of symptoms at the time of referral and currently; and observations at endoscopy.

RESULTS

Nissen fundoplication was performed on 37 of the 105 patients. At follow-up of these 37 patients, (31) 84% had no or only occasional mild heartburn, (33) 89% were free from erosive esophagitis, and (2) 5% were taking H2 antagonists or omeprazole. The corresponding figures in the 68 patients with only conservative treatment were (36) 53%, (31) 45%, and (14) 21%. The mean change in symptom score between referral time and follow-up was 5.7 in the surgically treated group and 1.7 in the nonsurgically treated group. Fifteen new cases of Barrett's metaplasia were found at follow-up.

CONCLUSIONS

In gastroesophageal reflux disease with erosive esophagitis, surgical treatment gave results subjectively and objectively superior to those from conservative management.

Influence of pathophysiology, severity, and cost on the medical management of gastroesophageal reflux disease

This article summarizes the pathophysiology of gastroesophageal reflux disease (GERD) and the wide spectrum in disease and symptom severity as they influence the selection of cost-effective treatment strategies. The vast majority of patients with GERD have mild symptoms, no gross endoscopic evidence of esophagitis, and little risk of developing complications. More than 85% of patients with GERD symptoms have uncomplicated disease. Diffuse ulcerations or complications (grade III or IV esophagitis) occur in only 3.5% of patients < 65 years of age. However, some patients with GERD can develop severe complications, including esophageal obstruction, significant blood loss, and, in rare circumstances, perforation. Furthermore, adenocarcinoma of the esophagus, which is increasing in incidence faster than any other cancer, is caused by GERD. Although severe ulcerations are uncommon in young patients, they occur in 20-30% of patients over age 65. Patients with ulcerative esophagitis are not only more prone to develop complications, they are also more resistant to treatment. Cost-effective medical management of GERD must take into account the wide spectrum of symptom and disease severity. Therapy consists of both nonpharmacologic treatment and the appropriate use of medications from several classes of drugs, either alone or in combination. Traditionally, prokinetic agents or histamine receptor antagonists have been used as primary therapy; proton-pump inhibitors are reserved for more resistant cases. The rationale for this and for alternative approaches is discussed.

Gastroesophageal reflux--how to mend it?

Gastroesophageal reflux (GER) is a common condition affecting children. The clinical presentation varies widely from innocuous spitting up to life threatening apnea. Various diagnostic tests are available to document the etiology, presence or complications of GER. In most cases, conservative approach is sufficient. In complicated cases, pharmacotherapy is indicated while surgical therapy is reserved for resistant cases with complications.

Atrophic gastritis and Helicobacter pylori infection in patients with reflux esophagitis treated with omeprazole or fundoplication

BACKGROUND

Helicobacter pylori infection plays an important part in the development of atrophic gastritis and intestinal metaplasia, conditions that predispose patients gastric cancer. Profound suppression of gastric acid is associated with increased severity of gastritis caused by H. pylori, but it is not known whether acid suppression increases the risk of atrophic gastritis.

METHODS

We studied patients from two separate cohorts who were being treated for reflux esophagitis: 72 patients treated with fundoplication in Sweden and 105 treated with omeprazole (20 to 40 mg once daily) in the Netherlands. In both cohorts, the patients were followed for an average of five years (range, three to eight). After fundoplication, the patients did not receive acid-suppressive therapy. The presence of H. pylori was assessed at the first visit by histologic evaluation in the fundoplication group and by histologic and serologic evaluation in the omeprazole group. The patients were not treated for H. pylori infection. Before treatment and during follow-up, the patients underwent repeated gastroscopy, with biopsy sampling for histologic evaluation.

RESULTS

Among the patients treated with fundoplication, atrophic gastritis did not develop in any of the 31 who were infected with H. pylori at base line or the 41 who were not infected; 1 patient infected with H. pylori had atrophic gastritis before treatment that persisted after treatment. Among the patients treated with omeprazole, none of whom had atrophic gastritis at base line, atrophic gastritis developed in 18 of the 59 infected with H. pylori(P<0.001) and 2 of the 46 who were not infected (P=0.62).

CONCLUSIONS

Patients with reflux esophagitis and H. pylori infection who are treated with omeprazole are at increased risk of atrophic gastritis.

Current management of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a chronic condition that is very common, and may result in considerable morbidity as well as mortality (from complications). I present data on the therapy of patients with GERD and offer a practical approach to their management. The goals of management of GERD are relief of symptoms, healing of esophagitis, prevention of complications, and maintenance of remission. Simple lifestyle changes may control GERD in up to 20% of patients. Promotility therapy addresses the pathophysiology of this disorder, but the best results are only 50 to 60% control using cisapride, whereas the older agents (metoclopramide and bethanechol) are limited by side effects. Acid suppression using histamine receptor antagonists controls GERD in 50 to 60% of patients, whereas proton pump inhibitors offer the most effective control (80-100%). A surgical approach (especially using newer laparoscopic techniques) will provide effective therapy of GERD in a high percentage of patients, but further careful comparisons are needed to define the long-term efficacy and cost issues associated with both surgical and chronic medical therapy of GERD. Despite this lack of long-term data, we know that GERD is a chronic, often lifelong illness, and maintenance therapy should be offered to most patients. This therapy may include aggressive medical therapy (up to and including chronic proton pump inhibitor therapy) or antireflux surgery in selected patients.

Intraesophageal Polytef injection for the treatment of reflux esophagitis

BACKGROUND

In view of the unsatisfactory results of medical and surgical treatment of reflux esophagitis, a treatment modality with polytetrafluoro-ethylene injection in the lower esophagus is presented.

METHODS

Twenty-one patients (13 men, 8 women; mean age 47.7 years) presented with a lower esophageal sphincter (LES) pressure which was significantly lower than normal (mean 5.3 +/- 1.1 SD cm H2O) (P < 0.001). Four to 6 ml Polytef was injected submucosally into the lower esophagus at 3 and 9 o'clock. Patients were followed up for 18-24 months.

RESULTS

No complications were encountered. In the first 3 postinjection months, symptoms disappeared and LES pressure was elevated (mean 24.2 +/- 6.6 SD cm H2O) (P < 0.001). At the 6th month, LES pressure dropped in nine patients (P < 0.05), of whom three had become symptomatic again and were reinjected. Endoscopically, esophageal hyperemia and erosion disappeared in 16 patients. At the 12th month, LES pressure was normal in 10 patients; the remaining 11 showed a significant LES pressure drop (P < 0.01) with reflux manifestations and were reinjected. At the 18th month, LES pressure was normal in all patients; endoscopically, there was mild lower esophageal hyperemia in five patients. The nine patients who were followed for 24 months had normal LES pressure and endoscopic findings and were symptom-free.

CONCLUSIONS

Polytef injection achieved LES competence through elevation of LES pressure and restoration of lower esophageal rosette. Pressure drop could be due to implant egress. The technique is simple and easy, has no complications, and is performed on an outpatient basis.

Management of refractory and complicated reflux esophagitis

Simple intermittent heartburn with minor or no esophagitis can be treated with simple measures including lifestyle changes and antacids as needed, or H2 receptor antagonists (H2RA), and has a good outcome. Problematic reflux includes resistance to therapy, stricture, Barrett's esophagus and aspiration. Severe reflux esophagitis, often resistant to H2RA therapy, requires more potent treatment with potent acid suppression using proton pump inhibitors, often indefinitely. When complicated by stricture, dilatations with potent acid suppression are needed. Barrett's esophagus is subject to esophagitis, which is no more difficult to treat than other cases of esophagitis. Reflux in Barrett's esophagus should be treated on its own merits without regard to the presence of Barrett's epithelium. Dysplasia leading to adenocarcinoma is a different problem, apparently not influenced by reduced exposure to acid. Indications for antireflux surgery are quite limited and should be carefully analyzed as a cost/risk/benefit problem.

Reflux oesophagitis

This article summarises the current position concerning the pathogenesis, clinical picture, diagnosis and management of reflux oesophagitis. It is aimed at the practising clinician who forms part of the team including primary care and specialist-based diagnostic services.

[Therapeutic principles in gastroesophageal reflux]

Gastroesophageal reflux is a common disease. Its chronic course, even if mild, is sometimes complicated by erosive oesophagitis. Drug therapy acts against gastric acidity and motility disorders. Treatment of gastroesophageal reflux disease has three aims: improvement of symptoms and quality of life, healing erosive lesions and prevention of symptomatic and endoscopic relapses. Non-drug measures are always useful, even if their efficacy is not well established. Initial therapy of a symptomatic reflux or mild oesophagitis is most of the time effective (antacids, prokinetics, H2 receptor antagonists). Proton-pump inhibitors are also effective in healing and preventing severe oesophagitis. Questions about long-term treatment adverse events with powerful acid inhibitors, such as hypergastrinemia and the risk of gastric carcinoid tumours seem to be resolved. Studies are requested to define the optimal long-term maintenance treatment with cisapride, H2 receptor antagonists or proton-pump inhibitors at low doses in prevention of symptomatic and mild oesophagitis relapses.

The rationale for continuous maintenance treatment of reflux esophagitis

Reflux esophagitis is a chronic process associated with frequent episodes of relapse in many patients. In addition, the disease may be progressive in at least some patients. Erosion of the esophageal mucosa precedes the development of some of the complications of the condition. There is accumulating evidence that continuous treatment of patients with erosive esophagitis effectively maintains symptomatic remission and absence of esophageal erosions. Whether such treatment will prevent the development of complications has not yet been demonstrated. We investigated a number of questions concerning the natural history and complications of erosive esophagitis and the need for maintenance treatment for patients with severe manifestations of disease as well as the impact of continuous maintenance treatment on the natural history of reflux esophagitis and its complications.

[Effects of gastric resection by the Billroth II technic on reflux esophagitis associated with duodenal or pyloric ulcer]

Although duodenal ulcer and reflux esophagitis may frequently co-exist, it is not clear whether surgery for duodenal ulcer associated with reflux esophagitis should not be associated with anti-reflux plastic surgery. The authors make a retrospective evaluation of the prevalence of reflux esophagitis (endoscopic diagnosis) in a consecutive series of 633 patients undergoing elective gastric resection according to Billroth II for duodenal or pyloric ulcer during the period 1974-1992 and assess the effects of surgery on co-existent esophagitis. The prevalence of reflux esophagitis associated with duodenal or pyloric ulcer was 12.3%. In patients in whom stenosis represented the indication for ulcer surgery, the prevalence of esophagitis was 20%, whereas it was 5% in those operated because of failure to respond to medical therapy of hemorrhage (p = 0.000001). In 95% of patients, controlled endoscopically 6 months after surgery, Billroth II gastric resection led to the resolution or improvement of associated esophagitis. The authors conclude that by eliminating the main pathological factors of reflux esophagitis associated with duodenal ulcer (hypersecretion of gastric acid, impeded gastric emptying) gastric resection is sufficient to achieve the resolution of esophagitis.

Short and long-term outcome of medically treated reflux esophagitis

The purpose of this retrospective study was to characterize the clinical course of medically-treated reflux esophagitis and to identify factors related to acute healing and relapse of the disease. We investigated 77 patients (56 males, 21 females, mean age 46.9 years) suffering from esophagitis (grade I-IV according to Savary and Miller), who were referred to our Unit during the period between January 1984 and December 1988. Typical GER symptoms were present in 63 patients, 51 of whom had esophageal 24-hour pH-monitoring suggestive of pathological GER, defined as total time with pH < 4 equal to or greater than 7%. All patients received 3 to 6 months of treatment (H2-antagonists = 68, antacids = 6, prokinetic drugs = 1, omeprazole = 2). After 3 months of therapy 39/88 patients (50.7%) had healed, and this figure increased to 56/77 patients (72.7%) after 6 months. The majority of these patients (N = 49) subsequently underwent a 24-week course of treatment, mostly with low-dose H2-antagonists (N = 44). At the end of treatment, 34/49 patients (69.3%) remained healed, while 15/49 (30.7%) relapsed, 40% asymptomatically. 14/21 patients (66.7%) who were not healed after 6 months' therapy, healed when the same treatment was prolonged up to 18 months (median: 11 months). The only factor found to influence acute healing significantly was the type of therapy, while none of the variables analyzed were seen to correlate with disease relapse.

Gastroesophageal reflux in children. Clinical manifestations, diagnosis, and therapy

Gastroesophageal reflux (GER) is a common occurrence during infancy. Most children have physiologic reflux that is of little consequence and requires minimal intervention. Pathologic GER, characterized by irritability, apnea, poor weight gain, or respiratory compromise, often requires diagnostic evaluation and aggressive treatment. A framework to help the clinician to understand the pathogenesis, natural history, diagnostic testing, and therapy of this disorder is presented in this article.

Prospective randomized comparison of polyvinyl bougies and through-the-scope balloons for dilation of peptic strictures of the esophagus

We prospectively compared the efficacy of polyvinyl bougies (Savary type) passed over a guide wire and through-the-scope balloons for the dilation of peptic esophageal strictures in a randomized study. Thirty-four patients, 17 in each treatment arm, were studied. At entry, dysphagia was assessed according to a six-point scale (0, unable to swallow; 5, normal). The end-point for dilation was to size 45F or 15 mm. Discomfort during the procedure was graded on a four-point scale (0, no discomfort; 1, mild; 2, moderate; 3, severe discomfort). Follow-up visits were at 1 week, 1 month, 3 months, and every 3 months thereafter for 2 years. At the 1-week visit, the size of esophageal lumen was measured by 8-, 10-, and 12-mm pills. Both devices effectively relieved dysphagia. By life-table analysis, stricture recurrence during the first year of follow-up was similar in both groups, but during the second year, the risk of recurrence was significantly lower in patients whose strictures were dilated with balloons. Other advantages of balloons included the need for fewer treatment sessions to achieve the defined end-diameter for dilation (1.1 + 0.1 versus 1.7 + 0.2, p < .05), and less procedural discomfort (p < .05). The differences in luminal size after dilation, measured by the barium pill test, were not significant. Ability to pass the 12-mm pill and absence of dysphagia were correlated. Our results indicate that both devices are effective in relieving dysphagia, but balloons may have a long-term advantage.

[Treatment of gastroesophageal reflux]

Several therapeutic means are available for the treatment of pathological gastroesophageal reflux (GOR): positional therapy, thickening the feedings, dietetic modifications, antacids, mucosa-protecting agents, gastrokinetic drugs, antisecretory drugs, and surgery. In uncomplicated GOR, simple measures must be used first, associating positional therapy, thickening the feedings and a mucosa-protecting agent or an antacid; a gastrokinetic drug will be added if these measures are insufficient after 2 or 3 weeks. Peptic esophagitis requires a more drastic treatment, using antacid, prekinetic and antisecretory drugs; in addition, its cure should be assessed by esophagoscopy. When GOR is associated with life-threatening events, treatment may be completed with an atropine derivative in case of vagal hypertonia, and its efficiency must be verified by monitoring of oesophageal pH under treatment. In infants, the medical treatment should be maintained until complete cure, which usually occurs when walking is achieved. Surgery is indicated in complicated GOR (esophagitis, life-threatening event, pulmonary complication) with failure of the medical treatment, or as first-line treatment in the case of severe esophagitis in children with severe psychomotor impairment.