Page 23 - Jourmal of World Association of Laparoscopic Surgeon

WJOLS

What Should be the Approach in the Long-term Management of Patients with Gastroesophageal Reflux Disease?

maintenance therapy, in order to maintain a reasonable finding that a fundal patch performed to reinforce the
quality of life. Both endoscopy-positive and-negative GERD esophageal suture line could also correct gastroesophageal
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patients experience relapse. Studies have shown that PPIs reflux. Later Belsyey and Toupet applied a modified fundal
are the most effective pharmaceutical agents in the wrap where a partial wrap was performed for GERD. Over
management of GERD for maintenance therapy and they time the procedures has been refined and outcomes
are effective in reverting esophageal inflammation and following the procedures in the immediate postoperative
providing symptomatic relief. 21,22 period and in the long-term has improved. With better
understanding and insight into the pathogenesis of GERD,
CONCERNS IN THE LONG-TERM USE OF PPIs antireflux surgery aims at lengthening the intra-abdominal

PPIs are not free from potential side effects, especially in portion of lower esophageal sphincter and to prevent
prolonged use. Though risk of developing carcinoid tumors effacing of the lower esophageal sphincter that occurs as a
due to atrophic gastritis and or hypergastrinemia is remote consequence of postprandial stomach distension. 23
but is a significant concern. Other problems associated with The long-term clinical outcome of antireflux surgery is
prolonged use of PPIs are the potential for development of now well established and several studies have shown that
clostridium difficile colitis and bacterial gastroenteritis. 23,24 there is over 90% reflux control in the long-term following
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Other concerns that have been raised against long-term Nissen fundoplication. Following first documentation of
use of PPIs include; concerns regarding vitamin B 12 successful laparoscopic cholecystectomy, minimally
absortion, interference with iron absorption and interference invasive surgery has revolutionized the way various surgical
in calcium absorption. Increased risk of gastric and colon procedures are performed and laparoscopic fundoplication
cancer is also another concern that has been raised against became a reality.
prolonged use of PPIs. 23
Several studies have studied the association between Laparoscopic Antireflux Surgery
vitamin B absorption and prolonged PPI use but they have It is Geagea from Canada and Dallenmagne from Belgium
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failed to substantiate the claim that prolonged PPI use in 1991 who had first reported series of fundoplication for
interferes with vitamin B absorption. On theoretical GERD. Since, then laparoscopic fundoplication has
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12
grounds it is assumed that prolonged use of PPIs can become the procedure of choice for patients with GERD.
interfere with iron absorption and again the available data It is also interesting to note that the threshold in offering
is not sufficient to conclude that prolonged PPI use could surgery for patients with GERD has been lowered following
cause iron deficiency. 23 the introduction of laparoscopic fundoplication. This is
Several studies have linked potential for development because of the advantages of minimally invasive surgery.
of osteoporosis and consequent increased risk for fractures Laparoscopic fundoplication is well-accepted both by the
in patients on long-term PPI. However, there are no patients and the practitioners alike as it is a straightforward
sufficient grounds to recommend discontinuation of PPI procedure and has an acceptable complication rate in the
therapy for patients on PPI with recommended dose for hands of surgeons experienced in the procedure. Though,
proper indications. 23 laparoscopic fundoplication has been well-established as
Though, theoretically there is increased risk of the procedure of choice for patients with GERD requiring
developing gastric and colonic cancers in patients on long- surgical intervention, new approaches are been explored
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term PPIs, this has not been validated in prospective for the management of the same. One such approach is endo-
randomized trials. 23 luminal surgery.

SURGICAL TREATMENT FOR GERD ENDOLUMINAL ANTIREFLUX PROCEDURES
Open Antireflux Surgery Endoscopic approached like endoluminal gastroplication

Open antireflux surgery was initiated in 1950s as a treatment and another technique using a plicator device had been
for patients with hiatal hernia and was aimed at keeping the introduced in the recent past. Endoluminal gastroplication
lower esophageal sphincter within the peritoneal cavity. 25 was the first endoscopic procedure to be proposed for the
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Subsequently with the recognition of low esophageal management of GERD. A commercially available suturing
sphincter pressure as the cause of GERD, antireflux surgery system called EndoCinch was used for endoluminal
was offered to patients with GERD to increase lower gastroplication. This procedure was reported to be safe and
esophageal sphincter pressure. It was Nissen in 1956 who found to be effective in 60% of patients with GERD. Though
had introduced antireflux surgery following an incidental the procedure was reported to be safe and relatively effective
World Journal of Laparoscopic Surgery, January-April 2013;6(1):23-28 25