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Acid Reflux and Heartburn

(Article Continued from GERD ) 

About the author

Dr. Minocha (http://www.diagnosishealth.com/minocha.htm) is the Professor of Medicine and Director, Division of Digestive Diseases at the University of Mississippi Medical Center in Jackson, MS, and is the author of How to Stop Heartburn; Simple Ways to Heal Heartburn and Acid Reflux.

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SURGERY IS ALWAYS THE SECOND BEST
  • So what can we do surgically for these pts with GERD especially the ones we cannot treat with drugs  and   endoscopic interventions. Actually, in contrast to peptic ulcer disease, surgery has a lot to offer to patients with GERD.

INDICATIONS FOR SURGERY

  • Every one has a different threshold for referring for surgery.

  • I believe that an anti-reflux operation performed by a skillful and experienced surgeon on an appropriately selected patient can be satisfying and cost effective treatment for reflux esophagitis and its complications.

  • A young patient with severe

    Gastro-Esophageal Reflux Disease may require years and years perhapslife long medical treatment. This entails lot of cost and while these drugs appear to be safe, long term effects are not known. So in YOUNGER patients with SEVERE esophagitis and normal PERISTALTIC function, surgical option should be considered even when medical treatment may be effective.

     

 

  • Stricture not responding to dilatation requires esophagus replacement. Perforation is a known complication of dilatation. Strictures that can be dilated are usually treated by fundoplication.

 

  • Patients with low grade dysplasia may be followed closely with aggressive acid suppression. High grade dysplasia need surgery because many of these pts have undetected malignancy.

SUCCESS OF SURGERY

  • On the basis of recent literature, approximately 70-90% of patients undergoing an operation by a highly experienced surgeon have good results that are maintained for 10 years after surgery. After about 20 years after surgery, approximately 1/3 have failed, although long term outcome has not been well studied. BEST chance of repair is the first one. Repeat anti-reflux procedures are much more technically difficult than the initial repair. Therefore success of first repair is important. Initial reports of Laprascopic Nissen's fundoplication.

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MEDICAL VERSUS SURGICAL TREATMENT

  • Randomized controlled trials comparing medical therapy and surgical anti-reflux procedure demonstrate that the surgical group overall fares better. However, the caveat is that these studies were done prior to advent of the very potent anti-secretory agents used today. So the jury is still out. In addition, the problem with surgical literature is that the published experience reflects the best experience and especially in the realm of anti-reflux surgery; the local experience and the published experience can be widely discrepant.

NON-SURGICAL ENDOSCOPIC TECHNIQUE

 

CONCLUSION

 
  • Gastro- Esophageal Reflux Disease (GERD) is extremely common disorder and is primarily treated with changes in lifestyle as well as acid suppression. Changes in life style like diet modification, elevation of head end of bed and cessation of smoking are important. Acid suppressive agents are the most frequently used drugs. GERD is a chronic problem and may need life long treatment to prevent relapses. Controlled studies have shown surgery to be superior although these studies were undertaken prior to the very effective and potent acid suppressive drugs available now. Surgical option should be considered in appropriately selected patients especially the ones difficult to manage or those with complications. Type of surgery should be tailored according to the presence of complications as well as the manometric characteristics.

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