An Evidence Based Approach to the Treatment of GERD
I read with great interest this elegant review on acid reflux disease by Dr. Marco Patti from the University of North Carolina in Chapel Hill. The study was recently published in JAMA Surgery, previously known as Archives of Surgery. Dr. Patti conducted a PubMed review of English written articles from 1985 till 2015 including terms like heartburn, regurgitation, dysphagia, cough, aspiration, laryngitis, GERD, manometry, pH monitoring, proton pump inhibitors and fundoplication. His review is thorough, accurate, and straight to the point. The analysis is objective and reflects the latest advances in our understanding of GERD and its treatment.
Dr. Patti starts by examining the pathophysiology of GERD. GERD pathophysiology is multifactorial. The lower esophageal sphincter is only part of the problem. 40% of patients with GERD have a normal lower esophageal sphincter muscle length and pressure. In these patients, transient lower esophageal sphincter relaxation, TLESR, contributes to acid reflux and is partly due to gastric fundus compliance and motility abnormalities. Other factors contributing to GERD include esophageal peristalsis, hiatal hernia and trans diaphragmatic pressure gradient. He rightly points to the fact that GERD and hiatal hernia can exist independently and that GERD in obese patients has a different pathophysiology compared to lean patients.
The author then discusses the tools we use to evaluate and work up GERD patients. He nicely shows that the “PPI trial” technique adopted by most primary care physicians and gastroenterologists, is not a reliable diagnostic approach. 30% of patients on PPI treatment for GERD have normal reflux scores on pH monitoring. Therefore, these patients are committed to long-term therapy and subjected to many side effects for no reason. Ambulatory pH monitoring allows for confirmation of the disease and allows for correlation between symptoms and episodes of reflux. Upper endoscopy helps rule out other pathologies like eosinophilic esophagitis, gastritis, peptic ulcers, Barrett esophagus and other malignancies. Endoscopy also allows for hiatal hernia evaluation. Both esophageal manometry and Barium swallows are of limited use in GERD diagnosis. However, they are valuable tools in preparing the patient for fundoplication surgery.
At the end, Dr. Patti discusses GERD treatment. Lifestyle changes like weight loss and smoking cessation are always recommended to help alleviate GERD related symptoms. He doesn’t offer however any evidence based data on the effectiveness of these changes except for weight loss. Weight loss is crucial to control GERD especially in the morbidly obese patient. Medications in the form of PPIs are effective in controlling erosive esophagitis and alleviating heartburn. All 7 different available PPIs are equally effective with no difference in symptom control. PPIs are associated with serious side effects and do not eliminate reflux but mask symptoms. Endoscopic therapies like Stretta (radiofrequency ablation) and TIF (Transoral incisionless fundoplication) are ineffective and in my personal opinion should be banned. Surgery in the form of fundoplication is the most reliable treatment with excellent symptom control in 90% of the patients in ten-year follow up studies. I fully agree with the author on the importance of proper preoperative workup and meticulous execution of surgical technique to ensure a durable, reliable and effective outcome following fundoplication surgery.
Lastly, the author briefly touches on LINX device as a new surgical modality for treatment of GERD. He mentions that some patients with severe GERD symptoms are reluctant to undergo a laparoscopic fundoplication. LINX may be a less invasive approach though less effective than fundoplication. I think by the time this article was published the author did not have access to the 5 year LINX FDA trial results showing around 25% complication rate.
Overall, I enjoyed reading this excellent high quality review by a renowned esophageal surgeon. Our understanding of acid reflux disease has greatly evolved. Our surgical technique has been perfected over the past 70 years. It is time to put this knowledge and expertise in centers of excellence dedicated to the treatment of GERD. A complex disease that affect more than 20% of the population cannot be limited to “PPI trials” and ineffective endoscopic therapies. If you suffer from heartburn, food regurgitation, chronic cough… you ought to seek the opinion of a GERD expert to stop the symptoms and improve your life.