Fundoplication Helps Relieve Refractory Heartburn

For gastroesophageal reflux disease (GERD) patients that are refractory to proton pump inhibitors (PPIs), surgery offers the better option, according to a new study.

Researchers at Baylor University Medical Center (Dallas, TX, USA), the VA Office of Research and Development (Washington, DC, USA), the University of Maryland (Baltimore, USA), and other institutions conducted a study involving 78 patients referred to Veterans Affairs (VA) gastroenterology clinics for PPI-refractory heartburn, a frequent clinical problem with multiple causes. Treatments for PPI-refractory heartburn are of unproven efficacy, and focus on controlling GERD with reflux-reducing medication (such as baclofen), antireflux surgery, or dampening visceral hypersensitivity with neuromodulators such as desipramine.

Study patients were randomly assigned to receive surgical treatment via laparoscopic fundoplication, medical treatment that included the PPI omeprazole plus baclofen (with desipramine added depending on symptoms), or to a control medical treatment (omeprazole plus placebo). The results revealed that the incidence of treatment success with surgery (67%) was significantly superior to that with active medical treatment (28%) or control medical treatment (12%). The study was published on October 16, 2018, in the New England Journal of Medicine (NEJM).

“GERD is an extremely common problem, and heartburn is the main symptom. PPIs are the best treatments we have, but as many as 30% of people still have symptoms when taking PPIs,” said lead author Stuart Jon Spechler, MD, chief of gastroenterology at Baylor University Medical Center. “There are a lot of other things that can cause that burning feeling, and patients can't tell if they have reflux or another kind of heartburn. If their heartburn isn't reflux-related, surgery won't provide relief. We only want to operate on the group that will benefit from the surgery.”

In GERD patients, the esophageal sphincter is weakened and does not close tightly, allowing digestive juices to return and irritate the esophageal lining. Treatment options usually include lifestyle changes, medications such as over-the-counter antacids and PPIs, and laparoscopic Nissen fundoplication to reinforce and strengthen the lower esophageal sphincter (LES). The procedure involves folding and wrapping the upper portion of the stomach around the lowest portion of the esophagus, much the way a bun wraps around a hot dog.

Related Links:
Baylor University Medical Center
VA Office of Research and Development
University of Maryland