FAMILY MEDICINE® COLUMN
By John C. Wolf, D.O.
Associate Professor of Family Medicine®
Ohio University College of Osteopathic Medicine

SURGERY TO CURE REFLUX DISEASE HAS HIGH SUCCESS RATE

Question: I've had heartburn trouble for years. I've taken several different medicines, and currently I'm comfortable with Prilosec that I've used for the last 2 years. I saw my doctor last week, and he wants me to go to a surgeon. He thinks an operation would be better than continuing to take medicine. I haven't made the appointment yet. What do you think about having surgery for heartburn?

Answer: The label "heartburn" covers a wide range of symptoms. Most of use have occasional episodes of heartburn after we overeat or consume foods that don't agree with us. This uncomfortable sensation is actually the result of stomach acid leaking out of the stomach and into the esophagus. If we experience this frequently, we may have what is called reflux esophagitis or gastroesophageal reflux disease (GERD).

An episode of heartburn is the result the lower esophageal sphincter (LES) -- a muscular band around the esophagus just above the stomach -- opening at a time other than when you are swallowing food or drink. This can happen when the LES relaxes at an inappropriate time or because the pressure within the stomach simply overpowers it. Dietary indiscretions, medicine use, alcohol, anatomical defect such as hiatal hernia, or obesity can all make this scenario more likely.

The consequence of chronic reflux, regardless of the underlying cause, can be significant. The strong stomach acid that causes the heartburn sensation over a period of time damages the lining of the esophagus. This damage can range from mild inflammation to scarring that blocks the esophagus. In some cases it can lead to the development of a precancerous condition that, if left untreated, will lead to esophageal cancer.

Medicines called proton pump inhibitors, including the Prilosec you take, are effective at reducing stomach acid levels and, thereby, reducing the damage it can cause when it "backs-up" into the esophagus. Treatment with one of these medicines is usually sufficiently effective that the esophagus heals. Diet, weight reduction, elevating the head of the bed and other life style changes are then usually all that is necessary to continue living without the discomfort of frequent heartburn.

Surgery for heartburn typically involves narrowing the opening of the diaphragm through which the esophagus passes. In addition, the junction of the esophagus and stomach is narrowed while simultaneously changing the angle of it. This is called "fundoplication" in surgeon-speak. Surgical treatment for GERD is appropriate for those who fail to gain relief with medical treatment. It is also used for those who have significant side effects from medical treatment. An additional group for consideration is those who need continuous use of proton pump inhibitors but otherwise have no discomfort or damage to the esophageal lining. You may fall into this last group.

The surgery for GERD is now commonly performed by using high tech "laparoscopic methods." This means that the surgeon uses special instruments inserted through several small cuts into the abdomen. This is substantially easier on the patient than the previous surgery that required an incision large enough for the surgeon to get both of his or her hands into the abdomen.

The fundoplication surgery is 95 to 97 percent effective at eliminating GERD with a similar percent of patient satisfaction at one year. At 10 years the success rate remains an amazingly high 90 percent.

So, I'd suggest you talk to the surgeon. He or she will probably want to do some additional tests such as looking into your esophagus, a procedure called EGD, and also do 24 hour pH monitoring. These tests will determine the effectiveness of your current treatment as well as help predict your risk of future problems. You, your doctors and your family can then talk about the benefits and risks of having surgery to correct your chronic GERD. Eventually YOU will decide if YOU want to proceed with surgery. Remember, it is always your choice, not your doctor's.

Family Medicine® is a weekly column. To submit questions, write to John C. Wolf, D.O., Ohio University College of Osteopathic Medicine, Grosvenor Hall, Athens, Ohio 45701. Past columns are available online at http://www.FamilyMedicineNews.org.