Reflux treatment (Surgical treatment of gastroesophageal reflux disease)

Gastroesophageal reflux disease is a morphological change and a complex of symptoms that develops when the contents of the stomach and duodenum gets into the esophagus. Gastroesophageal reflux disease is one of the most widespread pathologies of gastrointestinal tract among patients who are prone to multiple complications. High degree of spread, severe symptoms that affect life quality, tendency to developing life-threatening conditions and atypical development make gastroesophageal reflux disease one of the most relevant problems in modern gastroenterology. Since the condition becomes more and more widespread, doctors try to research the mechanism of gastroesophageal reflux disease, improve diagnostics methods and introduce efficient measures of treatment.

One of the most significant complications of gastroesophageal reflux disease is development of Barrett esophagus – change of esophagus mucosa membrane that may lead to cancer (increases the risk of esophagus cancer development). In order to reveal changes of esophagus mucosa, all patients with chronic heartburn are recommended to go through gastroscopy with biopsy of esophagus mucosa.

The main factor provoking development of gastroesophageal reflux disease is failure of lower esophagus sphincter. In healthy people, this muscle formation keeps the gap between the esophagus and the stomach closed in normal state, which prevents reverse movement of food (reflux). In case of sphincter failure, this gap is open, and the contents of the stomach keep getting into the esophagus. Aggressive stomach acid irritates esophagus walls and causes pathological disorders in its mucosa leading to ulcers. In healthy people, reflux can occur when body is bent, during physical exercises or at night.

Reflux feels like heartburn – burning sensation under the chest and belching. If heartburn occurs regularly (more than twice a week), it can be a symptom of gastroesophageal reflux disease, and medical examination is required. Chronic reflux that occurs during a long time can lead to chronic esophagitis, and later – to changes of morphological structure of lower esophagus mucosa and formation of Barrett esophagus.

Reasons of gastroesophageal reflux disease development

The main factors causing gastroesophageal reflux disease development: disorder of motor functions of upper sections in gastrointestinal tract, hyperacidity, lowered protective function of esophagus mucosa.

Most often, in case of gastroesophageal reflux disease, two natural protective processes of esophagus against aggressive stomach acids are disordered: esophagal clearance (the ability of esophagus to advance contents to the stomach), and resistance of esophagus wall mucosa.

Other factors increasing the risk of gastroesophageal reflux disease are stress, smoking, frequent pregnancy, diaphragmatic hernia, and some medications (beta-adrenergic blocking agents, calcium channel blockers, anticholinergic drugs, and nitrates).

Symptoms of of gastroesophageal reflux disease

Typical development of gastroesophageal reflux disease is characterized by heartburn that can become stronger when a person bends, lies or experiences physical loading, after generous fare, and is accompanied by belching with sour or bitter taste. Nausea and vomiting are also possible. Depending on the severity of condition, there can be dysphagia – disorder of swallowing, which can be primary (after motoric disorders), or secondary (caused by development of esophagus narrowing).

Sometimes patients experience gastroesophageal reflux disease with atypical clinical symptoms: pain in chest (as a rule, after meal, and it gets more severe when a person bends), heaviness in abdomen after eating, increased saliva production during sleep, bad breath, hoarseness.

Indirect signs of gastroesophageal reflux disease are frequent pneumonia and bronchial spasms, idiopathic pulmonary fibrosis, tendency tolaryngitis, otitis, damage of dental enamel, cancer of throat. However, the worst complications are caused by gastroesophageal reflux disease without pronounced symptoms.

Complications of gastroesophageal reflux disease

In 30-45% of cases, gastroesophageal reflux disease causes development of reflux-esophagitis – inflammation of lower esophagus mucosa that’s caused by the contents of stomach irritating it. If ulcers and erosion damage mucosa but heal, the scars left afterwards can lead to esophagus strictures – narrowing of esophagus gaps. Poor passability of esophagus is manifested into dysphagia combined with heartburn and belching.

Prolonged inflammation of esophagus walls can lead to development of ulcer – a defect that damages esophagus wall right to submucous membranes. Esophagus ulcer often contributes to bleeding. Prolonged gastroesophageal reflux and chronic esophagitis changes normal esophagus epithelium into stomach or intestinal epithelium. This reformation is called Barrrett disease. This is a precancerous state that leads to adenocarcinoma of esophagus in 2-5% of patients – cancerous tumor of epithelium.

Diagnostics of gastroesophageal reflux disease

The main method of diagnostics of gastroesophageal reflux disease is esophagogastroduodenoscopy. It also defines the degree of severity and morphological changes. It’s performed after consultation with endoscopist. During this examination, doctors also take biopsy material in order to check the state of mucosa and diagnose Barrett esophagus.

X-ray imaging of esophagus can show ulcers, strictures and diaphragmatic hernia. Pressure of lower esophagus sphincter can also be revealed with manometry.

During diagnostics of gastroesophageal reflux disease, doctors also use Bernshtein tests: when 0,1% solution of salt acid is injected into esophagus, a person has burning sensation. The symptoms subside when antiacid medications are administered (alcaline test). Motor funciton of esophagus is examined with the help of electromyography.

Pretty often, patients complain about cough and coarseness. Consultation of otolaryngologist is required to reveal inflammation of throat and pharynx. If laryngitis or pharyngitis are caused by reflux, patients are administered antiacid drugs – they diminish the symptoms.

Treatment of gastroesophageal reflux disease

Non-medication therapy for gastroesophageal reflux disease include:

• normalization of body weight, following meal intake regime (small portions every 3-4 hours, the last meal should be at least 3 hours before sleep), a person should obtain from products that relax esophagus sphincter (fatty foods, chocolate, coffee, oranges, tomato juice, onion, mint, alcohol drinks), increased consumption of animal protein, refusal from hot foods and alcohol;
• a person should obtain from tight clothes pressing body;
• it’s recommended to sleep on bed with bed head elevated by 15 cm;
• refusal from smoking;
• a person should not keep body bent for too long, and must avoid heavy physical load;
• medications that affect esophagus movement (beta-adrenergic blocking agents, calcium channel blockers, anticholinergic drugs, progesterone, antidepressants and nitrates), as well as anti-inflammatory medications that intoxicate esophagus mucosa are prohibited.

Medication treatment of gastroesophageal reflux disease is performed by a gastroenterologist. Therapy takes from 5 to 8 weeks (sometimes the course can last for up to 26 weeks), and it includes the following groups of medications: antoacids (aluminum phosphate, aluminum hydroxide, magnesium carbonate, magnesium oxide), H2-histamine blockers (ranitidine, famotidine), inhibitors of proton pomp (omeprazole, rebeprazole, exomeprazole).

If conservative treatment of gastroesophageal reflux disease does not give any effect (5-10% cases), or there are complications and diaphragmal hernia taking place, surgical treatment is required. Surgical invasion for gastroesophageal reflux disease includes: endoscopic plication of esophagus connection (stitches are put on cardias), radiofrequency ablation of esophagus (damage of muscle layer of cardia and esophagus connection to make them scar and reduce reflux), gastrocardiopexy, and Nissen laparoscopic fundoplication.

Surgical treatment

Generally, surgical operations aimed at treating gastroesophageal reflux disease can be divided into two types:

1. Surgeries to treat direct causes of GERD.
2. Elimination of outcomes and complications that were left after incorrect or non-timely treatment.

The first type of surgical treatment is made as planned, while the second is performed in emergency cases, for instance, if there’s massive bleeding occurring.

When a person should resolve to surgical kinds of treatment?

• Surgeries are recommended when long-term intake of medications in maximal doses doesn’t eliminate symptoms.
• Aggressive development of GERD. When the quantity of reflux (discharge of stomach acid into esophagus) exceeds 50 a day, and pain cannot be relieved by medications, and heartburn makes a person suffer regardless of food intake. This is when esophagitis of 5 degree is diagnosed.
• Hernia of esophagus gap of diaphragm combined with gastroesophageal reflux disease can also be cured by a surgical method.
• Any complication is an indication for surgery – esophagus bleeding, Barrett esophagus, multiple ulcers and significant narrowing (stricture).
• Relative indication for surgical treatment is lack of budget for long-term therapies. Medical treatment may last for 3-4 months, or up to a year and more in ase wit esophagitis of 3 and 4 degree. Blockers of proton pump should be used, as well as courses of antiacids and prokinetics. Sometimes therapy combines five groups of medications or even more. Not every person can afford such treatment.
• Heavy allergic reactions to all groups of medications for GERD.

Sometimes there’s no point in going through surgical treatment:

• When a person has some serious pathology: heart rhythm disorders, kidney failure.
• Old age.

One of the main reasons of GERD development is poor functioning of lower esophagus sphincter (the muscle that keeps food from moving back into esophagus). As the result, stomach contents gets back into the esophagus – reflux leads to heartburn and chest pain.

In order to eliminate these symptoms, a person should strengthen the muscle. There are several ways to do that:

1. Fundoplication is one of the most widespread surgeries for GERD. During this operation, one part of stomach is stitched to esophagus (the stomach is pulled up to wrap the lower part of esophagus tube). There are several types of operation, and Nissen fundoplication is the most widely used one.
2. Another variant – endoscopic correction of sphincter (through a catheter).

Surgeons have tried many different ways of sphincter correction – stitching musles to strengthen them or even inject silicone in sphyncter. These method have physical and therapeutic effect but don’t bring visible results.

The type of surgical treatment depends on the complications caused by GERD.

• Multiple ulcers are treated both in hospital and on outpatient basis. If they don’t heal and start bleeding because of vessel damage, these defects are stitched.
• Strictures (narrowing of esophagus caused by growth of scar tissue) are eliminated, because the gap becomes smaller. They’re cut out to restore normal passage of esophagus.
• Barrett esophagus is cured two ways: laser coagulation (burning) of replaced epithelium areas, or surgical removal of damaged esophagus area.

Don’t be afraid of surgical treatment of GERD. These are simple operations with small cuts and minimal outcomes. They help people to avoid permanent medication treatment. Any type of treatment should be considered well.

Prophylactics and prognosis for GERD

The main prevention measure for GERD is healthy lifestyle excluding risk factors (smoking, alcohol abuse, fat and spicy foods, overeating, heavy lifting, bending a lot, etc.). Besides, it’s important to diagnose disorders of movement function of gastrointestinal tract and cure diaphragmal hernia.

If the condition is revealed in a timely manner, and a person follows recommendations and healthy lifestyle, prognosis for GERD is positive. When the condition reoccurs and regular refluxes take place, complications develop, which leads to Barrett esophagus development.