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SSAT Patient Care Guidelines

Surgical Treatment of Reflux Esophagitis

Gastroesophageal reflux disease (GERD) occurs when gastric or duodenal contents back up (reflux) into the esophagus. About 10% of adult Americans have daily symptoms of heartburn. Repeated episodes of reflux can damage the esophageal epithelium, leading to esophagitis. A small proportion of patients progress to severe esophagitis.

In most cases, the underlying cause of reflux is a defective lower esophageal sphincter. The risk of GERD is higher in patients with a hiatal hernia. Inability of the esophagus to clear refluxed material may compound the problem in some patients. Symptoms of heartburn can usually be controlled with medical therapy directed at buffering or suppressing secretion of gastric acid.

A surgical procedure directed at creating a functional lower esophageal sphincter is also an effective treatment for patients whose reflux esophagitis is either dependent upon or uncontrolled by continuous medical therapy. Patients who have regurgitation and aspiration of gastric contents into the tracheobronchial tree are also candidates for surgical treatment.

GERD can usually be diagnosed by a careful history. Gastroesophageal reflux typically results in substernal burning discomfort or heartburn, which is often relieved by antacids. Some patients may also experience esophageal spasm with a squeezing chest pain that is often confused with angina. Refluxed material can be aspirated into the larynx, causing hoarseness, or into the tracheobronchial tree causing wheezing and coughing. Dysphagia may occur as a complication of chronic reflux.

The diagnosis of GERD and the determination of the extent of damage to the esophageal epithelium may require a series of investigations. The mainstay of diagnosis is flexible esophagoscopy, in which demonstration of mucosal erosion or ulceration is evidence of reflux damage. Endoscopy is also essential in the diagnosis of Barrett's metaplasia (replacement of the normal squamous epithelium of the lower esophagus by intestinal type columnar cells). Barrett's esophagus, a consequence of chronic reflux, is associated with an increased risk of adenocarcinoma of the esophagus. Barium esophagography is a useful diagnostic test to evaluate for hiatal hernia, strictures, and esophageal shortening.

Esophageal manometry is important prior to planning surgery to evaluate lower esophageal sphincter function and peristaltic activity in the body of the esophagus. Impaired motor activity in the body of the esophagus may influence the choice of surgical procedure.

Ambulatory 24-48 hour pH monitoring can document reflux episodes by indicating a drop in esophageal pH to acid levels (less than 4.0). It is particularly useful in patients with atypical symptoms, or in those with typical symptoms but normal endoscopic findings. It is best to perform pH testing off of all antisecretory medications. It is preferable to stop proton pump inhibitors 14 days prior and H2 antagonists 72 hours prior to testing. A gastric emptying scan should be performed in patients at risk for delayed gastric emptying (i.e. diabetes, scleroderma) or in patients with atypical symptoms.

Patients with typical gastroesophageal reflux symptoms should initially be managed by lifestyle modifications. Foods and beverages that can relax the lower esophageal sphincter should be avoided, including chocolate, peppermint, fatty foods, coffee, and alcoholic beverages. Also to be avoided are foods and beverages that can irritate an inflamed esophageal mucosa, such as citrus fruits and juices, tomato products, and pepper. Elevation of the head while sleeping, not lying down immediately after meals, and abstinence from smoking are also helpful.

Medical therapy, including antacids, H-2 receptor blocking drugs, and proton pump inhibitors, is directed at reducing the acid content of refluxed material. Acid inhibition is most effectively achieved with proton pump inhibitors. Promotility drugs (including metoclopramide and domperidone) are of little benefit in patients with severe reflux symptoms, unless they have delayed gastric emptying.

Although medical therapy is highly effective in controlling the signs and symptoms of gastroesophageal reflux, approximately 80% of patients will relapse within three months if therapy is discontinued, and up to 50% will require escalating doses of proton pump inhibitors.

Indications for Surgery
Surgery should be considered for patients who do not respond to medical therapy, have complications of gastroesophageal reflux (such as a stricture), are non-compliant with medical therapy, or are totally dependent upon medical treatment to prevent recurrence of their symptoms. Some patients choose surgery due to the expense and inconvenience of long-term medical therapy and concern about the possible consequences of long-term acid suppression. The indications for surgery in patients with Barrett's esophagus are addressed in another SSAT guideline (See Barrett's Esophagus). There are several innovative endoscopic techniques aimed at treating reflux disease. The long-term effectiveness of these procedures has not been established.

Fundoplication may be more cost effective than long-term medical therapy, and it has been clearly shown to improve the patient's quality of life. The most common surgical procedures include those described by Nissen, Hill, Belsey, Dor, and Toupet. These techniques are designed to create a functional lower esophageal sphincter and to repair a hiatal hernia if present. The most common antireflux procedure is the Nissen fundoplication or a modification of this technique, which involves mobilization and wrapping of the fundus of the stomach completely around the lower esophagus.

All surgical procedures incorporate some form of fundoplication, which is a wrap of the gastric fundus completely or partially around the distal esophagus. The Belsey procedure is performed through a thoracotomy and the others are usually performed using either open abdominal or laparoscopic approaches

Risks and Expected Outcomes
The most common risks associated with open or laparoscopic operations include bleeding or damage to structures such as the spleen, vagus nerves, esophagus or stomach. These complications occur at a rate of less than 5%. Respiratory complications, such as atelectasis or pneumonia, are less frequent after laparoscopic surgery than after open upper abdominal surgery.

Most patients will experience temporary difficulty in swallowing after surgery, especially with solid foods, but nearly all patients are able to swallow normally and eat an unrestricted diet by six weeks after surgery. A feeling of fullness (satiety) is another common but temporary occurrence. Gas-bloat syndrome, a sensation of bloating associated with inability to belch, may occur after fundoplication. Prior to surgery, in a subconscious effort to neutralize refluxed gastric acid with saliva, many patients with reflux esophagitis swallow frequently. Persistent aerophagia after surgery may cause bloating and increased flatus. The majority of patients require a hospital stay of 1-3 days after laparoscopic fundoplication, or 3-5 days after an open operation. Hospitalization may be prolonged in the presence of other comorbid conditions or postoperative complications. Data suggest that long-term outcome is equivalent after open or laparoscopic procedures, with relief of reflux symptoms equivalent to that achieved with optimal medical therapy. Recurrent symptoms should be investigated for cause, and appropriate medical or surgical treatment determined.

Qualifications for Performing Surgery for Gastroesophageal Reflux
The qualifications of a surgeon performing any operative procedure should be based on training (education), experience, and outcomes. At a minimum, surgeons who are certified or eligible for certification by the American Board of Surgery, the Royal College of Physicians and Surgeons of Canada, or their equivalent should perform operations for reflux esophagitis. Antireflux surgery should preferably be performed by surgeons with special knowledge, training and experience in the management of gastroesophageal disease. These surgeons have successfully completed at least 5 years of surgical training after medical school graduation and are qualified to perform operations on the esophagus and stomach. When performing laparoscopic fundoplication, it is highly desirable that the surgeon has advanced laparoscopic skills. The level of training in advanced laparoscopic techniques necessary to conduct minimally invasive surgery is important to assess.

Suggested Readings
Hunter JG, Trus TL, Branum GD, et al. A physiologic approach to laparoscopic fundoplication for gastroesophageal reflux disease. Ann Surg 1999;223:673-685.

Van Den Boom G, Go PM, Hameeteman W, et al. Cost effectiveness of medical versus surgical treatment in patients with severe or refractory gastroesophageal reflux disease in the Netherlands. Scand J Gastroenterol 1996;31:1-9.

Hinder RA, Perdikis G, Klinger PJ, et al. The surgical option for gastroesophageal reflux disease. Am J Med 1997;103:144S-148S.

Feldman LS, Mayrand S, Stanbridge D, Mercier L, Barkun JS, Fried GM: Laparoscopic fundoplication: a model for assessing new technology in surgical procedures. Surgery 2001; 130: 686-695

Key Words
patient, guideline, heartburn, Barrett's esophagus, esophagitis, Nissen fundoplication, gastroesophageal reflux, reflux esophagitis, deglutition disorders, regurgitation.

Written 1/23/96
Revised 4-3-96
Revised 9-27-96
Revised 10-10-96
Revised 2-5-97
Revised 5-8-97
Revised 5-11-97
Revised 8-21-97
Revised 9/26/99
Revised 11/1/99
Proofed 1/8/00
Revised 10/7/01
Revised 5/02
Board Approved 10/7/02
Revised 10/12/04
Revised 1/20/05
Board Approved 5/14/05
Reviewed 11/22/13

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SSAT Patient Care Committee Guidelines

These patient care guidelines were written for the primary care physicians on a variety of digestive diseases to assist on when to refer the patient for surgical consultation.
Their goal is to guide PRIMARY CARE physicians to the appropriate utilization of surgical procedures on the alimentary tract or related organs and they are based on critical review of the literature and expert opinion. Both of the latter sources of information result in a consensus that is recorded in the form of these Guidelines. The consensus addressses the range of acceptable clinical practice and should not be construed as a standard of care. These Guidelines require periodic revision to ensure that clinicians utilize procedures appropriately but the reader must realize that clinical judgment may justify a course of action outside of the recommendations contained herein.

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