Scientific News: Reflux Disorders

Article by Article by Eduardo G. Segal

Corresponding address: Eduardo Segal, M.D. Pueyrredn 60S - Piso 1 1032 Capital Federal Argentina

Fax: +54-1-961-9056

Although we are about to enter the new millennium, one of the major problems still to be solved in gastroenterology is that of gastroesophageal reflux disease (GERD), a condition that affects 40 million people in the United States alone.

Even though substantial advances have been made from the point of view of treatment, as well as in the pharmacological and surgical fields, we are still far from having heard the last word on the matter, since the pathogenesis of the disease is still uncertain. To date, transient lower esophageal sphincter (LES) relaxation, the control system of which may be located at the brain stem level, appears to be the most important mecha­nism for explaining reflux. However, drugs that might be able to inhibit initiation of LES relaxation are at present no more than possibilities for the future.

There is still controversy as to whether pharmacological or surgical treatment is prefer­able, and the two studies listed above are drawn from each of these fields. Surgeons have always taken part in round-table

discussions on the topic of GERD, and even before the advent of laparoscopic surgery, they participated in the treat­ment of patients with severe and refractory reflux episodes, or patients whose cases were com­plicated by stenosis refractory to endoscopic treatment, aspira­tion, or severe dysplasia. The recent advances in laparoscopic techniques for fundoplication, which are less invasive, have created renewed interest in the surgical field, and the leading proponents of these methods have been encouraging gastroenterologists' interest in them.

The laparoscopic focus of antireflux surgery now provides more acceptable options for the patient, with less postsurgical pain and a faster recovery. Frantzides and Richards last year published the largest series yet reported describing laparoscopic Nissen fundoplications. The series included 362 patients with GERD documented by radiography, endoscopy and/or pH surveillance during the 24 hours before surgery, who were followed up for a six-year period. The complication rate was 2% (n = 7), with no mortal­ities.

The postsurgical gastrointes­tinal symptoms were divided into two categories, those appearing within two months after surgery (Table 1), and those persisting for more than two months after surgery (Table 2).

Table 1 Laparoscopic Nissenjundoplication in the treatment of gastroesophageal reflux in 362 patients: gastrointestinal symptoms in the early postsurgical period (up to two months) (Frantzides and Richards, Surgery 1998; 124: 651-5).

Table 2 Laparoscopic Nissenfundoplication in the treatment of gastroesophageal reflux in 362 patients: gastrointestinal symptoms persistingfor more than two months (Frantzides and Richards, Surgery 1998; 124: 651-5).

As shown in Figure 1, lower esophageal sphincter pressure in patients before surgery (n = 58) was4± 1.2mmHg, and after surgery (n = 39) it was 14.6 +1.8 mmHg. As expe­rience grew and the equipment used improved, the mean sur­gery time was reduced from 2.7 + 0.4 hours during the peri­od 1991-94 to 1.8 (0.3 hours between 1994 and 1997. The hospitalization time required for the procedure decreased from 2.2 days in the first period to a mean of 1.5 days in the second. The authors conclude that, with strict selection criteria, increased experience and a standardized technique, laparos­copic Nissen fundoplication may provide safe and effective results for GERD patients.

Although pharmacological treatment has a high success rate (at least when there are no GERD complications), the length of the treatment time required has not yet been determined. This means that the costs of drug treatment are unpredictable—one of the argu­ments providing justification for the surgical approach. Eggleston et al. examined the cost-benefit ratio of medical treatment for GERD by analyzing cases includ­ed in a very large database, the Mediplus UK Database.

Figure 1. Lower esophageal sphincter pressure in patients before and after surgery. Presurgery pressure(n~ 58) of 4+ 1.2mmHg compared to postsurgery value (n = 39) of 14.6 ±1.8 mmHg.

The database was used to identify the health resources required during the first six months of treatment in three groups of patients initially prescribed cisapride, ranitidine, or omeprazole. Patients initially presenting with complicated GERD were excluded from the study.

The main strategies analyzed in previous studies have been those termed "step-up" and "step-down" treatments, used in the initial therapy for non­complicated GERD. The step-up approach follows the principle of applying the minimum phar­macological effort necessary to achieve the therapeutic goal. The step-down approach, by contrast, suggests patients should be treated initially with a proton-pump inhibitor. The main problem inherent in the latter approach is the universal application of a powerful and expensive drug, even in patients in whom a minor intervention might suffice.

Table 3 Resource use and costs per 100 patients in the treatment of uncomplicated GERD in it. ■: Mediplus UK Database (Eggleston etal, Gut 1998; 42: 13-6).

Although the step-up approach was initially regarded as being the most effective option from the cost-benefit point of view, this view was not supported by the results of the study by Eggleston et al. The cost per patient for the initial six months of treatment based on therapy with cisapride, ranitidine, and omeprazole were £136, £177, and £189, respectively. All other results obtained from the analysis are presented in Table 3.

The study concludes that the step-up approach, starting with proki-netics or H 2-receptor antago­nists, represents the initial therapeutic strategy with the higher cost-benefit ratio for the general practitioner treating a patient with an early diagnosis of non-complicated GERD.