Page 22 - Jourmal of World Association of Laparoscopic Surgeon

Mohamed Solih

because various studies has shown that laparoscopic superior compared to H2RAs. In patients with heartburn
fundoplication is safe in experienced hands, is effective for (NERD), PPI administration resolved symptoms only in 61%
symptomatic relief and controlling recurrence, improves of the patients, which is approximately 20 to 30% lower
quality life, reduce hospital stay and also, following laparos- effectiveness than that of patients with erosive
copic fundoplication patients can return to work earlier as esophagitis. 17,18
compared to conventional Nissen fundoplication. 11,12 In this Fourty percent of the patients diagnosed with GERD
review, an attempt will be made to compare the pros and fail to respond to once daily PPI regimen and majority of
cons of medical and surgical management of GERD based these patients belong to the NERD group and functional
on the available literature and recommend a management heartburn. In this situation, experts generally recommend
approach for patient with GERD. to switch over to twice daily dosing regimen, however,
before escalating the dose of PPI, it is important to analysis
AVAILABLE TREATMENT OPTIONS FOR GERD and consider other potential causes for nonresponsiveness
like, poor compliance, improper dosing schedules, residual
Nonsurgical Treatment Approaches
reflux reduced bioavailability. Unless these factors are
First-line treatment for GERD has been lifestyle considered and addressed, simply increasing the dose of
modifications, supplemented by different medical PPIs might not be effective. 19
formulations ranging from antacids to PPIs. Lifestyle and Treatment failures for PPIs occur both in GERD with
dietary modifications that appear to decrease gastric acid positive and negative endoscopic findings. Failure rate is
exposure of lower end of esophagus include; reducing high in the subgroup; NERD. To address this issue
dietary fat intake, reducing weight, cessation of smoking, researched was focused on novel approaches like ‘reflux
elevation of the head end of the bed and avoiding inhibition’ rather than acid secretion suppression. One such
recumbency for 3 hours postprandial. 13 approach is inhibition of transient lower esophageal
sphincter relaxations (TLESRs). GABA type B receptor
ACID SUPPRESSION THERAPY FOR GERD blockage is one of the mechanisms through which TLSERs
could be modulated. Baclofen is a GABA agonist and it
B
Histamine 2 receptor antagonists (H2RAs) have been in use may be considered in patients with positive esophageal
since 1970s, for symptomatic relief in the patients with impedance test for weakly acid reflux, as it reduces the rate
GERD symptoms. H2RAs are effective in decreasing gastric of TLESRs. Baclofen is known to have frequent side effects
acid secretion and have a longer duration of action compared and hence, it is recommended to start with a low dose and
to antacids. Drawbacks of H2RAs included relapse gradually increase as tolerated. Visceral pain modulators
while on standard dose and also fails to heal severe like trazodone (tricyclic antidepressant) and selective
esophagitis. 14,15 serotonin reuptake inhibitors when used in nonmood altering
Another group of drugs that emerged into the market doses are useful in GERD patients who are found to have
for the management of GERD were the PPIs. This is negative esophageal impedance monitoring. These drugs
regarded as the most effective drugs for gastric acid secretion act in the central nervous system to produce visceral
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suppression and they act by irreversibly binding to H K - analgesia. 19,20
ATPase, which is the final step in the gastric acid secretion. 15 Another group of drugs that has been used in conjunction
Though PPIs are effective in healing duodenal ulcers, gastric with PPIs were prokinetic drugs. One representative drug
ulcers and ulcerative and erosive GERD, there are from this group is cisapride, but it was withdrawn from the
differences in the effectiveness within the drugs in this class. market because it is associated with fatal arrhythmias.
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Rabeprazole, which is a PPI, acts more rapidly on H K - Cispride is a selective agonist of 5-HT4 receptor and it could
ATPase to inhibit it compared to other PPIs. Another significantly reduce TLSERs during sleep and hence, used
significant difference between rabeprazole and omeprazole to be combined with PPIs for the treatment of nocturnal
is that, the former has a greater effect on intragastric pH reflux. Newer 5-HT4 partial agonists are promising and in
16
after the first dose. Several trials have compared H2RA a recent study it was shown that tegaserod (selective
and PPIs for their respective efficacy in gastroduodenal ulcer 5-HT4 receptor partial agonist) reduced postprandial
healing and also healing of ulcerative and erosive GERD. esophageal acid reflux episodes without an apparent effect
These studies have demonstrated the superiority of PPIs on lower esophageal pressure. 19
16
over H2RAs. PPIs are more effective in controlling GERD
symptoms in patients who have positive endoscopic finding MAINTENANCE THERAPY
like erosive or ulcerative esophagitis as compared to patients As noted earlier GERD is a chronic disorder and large
with nonerosive reflux disorder (NERD), but they are still proportion of GERD sufferers would require prolonged
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