Surgery Is An Option For Individuals With Intractable Heartburn

A young man suffering from chest pain. (Hemera/Thinkstock)
A young man suffering from chest pain. (Hemera/Thinkstock)

Heartburn afflicts nearly two thirds of adults at some point in their lives, and accounts for millions of physician office visits every year. That adds up to a lot of tax dollars.

Last week we discussed the various aspects of medical treatment for heartburn, also known as gastroesophageal reflux disease (GERD).

There is a small group of patients with GERD who do not respond to medical treatment and they wonder if there is another option to relieve the symptoms and complications. Surgery, of course, is an option. Surgery is also an option for those who do respond to pills but cannot afford to buy them or do not want to be on the pills for the rest of their lives.

In GERD, there is failure of the antireflux barrier, allowing abnormal reflux of stomach contents into the esophagus. It is a mechanical disorder, which is caused by a defective lower esophageal sphincter (valve) at the junction of the esophagus and stomach, a gastric emptying disorder, or failed esophageal peristalsis. But the exact nature of the antireflux barrier is incompletely understood.

Surgery should not be considered without objective evidence of reflux. Based on the available evidence, the diagnosis of GERD can be confirmed if at least one of the following conditions exists: a mucosal break (inflammation and ulceration) seen on endoscopy in a patient with typical symptoms, Barrett’s esophagus on biopsy (considered to be a premalignant condition), a peptic stricture (narrowing due to chronic ulcer) in the absence of malignancy, or positive pH-metry (checks for the presence of acid reflux in the esophagus).

Clinical Guidelines published in 2010 by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) makes the following recommendation regarding surgical management of GERD:

“Surgical therapy for GERD is an equally effective alternative to medical therapy and should be offered to appropriately selected patients by appropriately skilled surgeons. Surgical therapy effectively addresses the mechanical issues associated with the disease and results in long-term patient satisfaction. For surgery to compete with medical treatment, it has to be associated with minimal morbidity and cost.”

The antireflux surgery is done laparoscopically or by open method by surgeons thoroughly trained in this technique. Laparoscopic technique requires a short hospital stay and early return to work compared to open technique which requires a long abdominal incision and longer hospital stay with about six weeks of post op recovery. The two approaches have been demonstrated to have similar postoperative outcomes at the reported follow-up intervals (range three to 24 months) including reflux recurrence, dysphagia (difficulty swallowing), bloating, and reoperation rates.

SAGES recommendation says laparoscopic fundoplication should be preferred over its open alternative as it is associated with superior early outcomes (shorter hospital stay and return to normal activities, and fewer complications) and no significant differences in late outcomes (failure rates). If you are referred to a surgeon for this procedure then you should carefully discuss pros and cons of medical vs. surgical treatment. Your case may be different than your neighbour’s. What is good for your neighbour may not be good for you.

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