In the Journals

Anti-reflux surgery only appropriate in ‘a select few’ GERD patients

Rena Yadlapati
Rena Yadlapati

Noninvasive procedures like behavioral interventions and low-dose antidepressants are appropriate for most patients with GERD that does not respond to PPI therapy, while only certain subgroups of patients should be referred for surgery, according to an expert panel.

“When you have a subset of patients who are not responding to drug therapy you need to respond in a thoughtful way,” Rena Yadlapati, MD, MHS, assistant professor of medicine-gastroenterology at the University of Colorado School of Medicine, who co-authored a report on the panel’s recommendations, said in a press release. “Only a select few should be referred to surgery.”

Yadlapati and colleagues surveyed 14 expert esophagologists on appropriate treatment strategies for subsets of GERD patients with persistent symptoms despite PPI therapy. The panel judged several hypothetical scenarios, indicating which of four invasive procedures were most appropriate — including laparoscopic fundoplication, magnetic sphincter augmentation, transoral incisionless fundoplication or radiofrequency energy delivery — and if they preferred pharmacologic or behavioral therapy.

“A nuanced understanding of both the literature and the patient’s unique physiologic profile is critical to appropriate decision-making, as inappropriate recommendations may compromise outcomes and patient safety,” Yadlapati said in the press release.

Overall, the panel considered invasive anti-reflux interventions to be inappropriate in the majority of patients.

However, the panel found laparoscopic fundoplication appropriate for patients with elevated esophageal acid exposure time (EAE > 6%), and “moderately appropriate” for patients with normal EAE who have positive symptom-reflux association for regurgitation and a large hiatal hernia.

Additionally, they found magnetic sphincter augmentation to be “moderately appropriate” for patients with elevated EAE but without a large hiatal hernia.

Notably, they did not find transoral incisionless fundoplication or radiofrequency energy delivery to be appropriate in any of the hypothetical scenarios.

Regarding noninvasive options, the panel preferred H2RA therapy for patients with elevated EAE, transient lower esophageal sphincter relaxation inhibitors for patients with elevated reflux episodes, and neuromodulation/behavioral therapy for patients with positive symptom-reflux association.

Yadlapati and colleagues noted that because some patients who are unresponsive to PPI therapy have hypersensitivity to symptoms, invasive procedures are unlikely to improve outcomes and could increase morbidity and health care costs while reducing quality of life. Low-dose antidepressants and behavioral interventions play an important role in these patients, they said.

“Behavioral modification and relaxation therapy are also potentially effective,” she said in the press release. “In a study of nine patients with functional heartburn, esophageal-directed hypnotherapy was associated with significant improvements in symptoms, visceral anxiety and quality of life.”

She concluded that treatment should be personalized for each patient, but this study shows that surgery is not the recommended approach for most patients with GERD.

“We are not opposed to surgery for the right patients,” she said. “But we should not be reflexively referring patients for these invasive treatments before considering all of the options.” – by Adam Leitenberger

Disclosures: The authors report no relevant financial disclosures.

Rena Yadlapati
Rena Yadlapati

Noninvasive procedures like behavioral interventions and low-dose antidepressants are appropriate for most patients with GERD that does not respond to PPI therapy, while only certain subgroups of patients should be referred for surgery, according to an expert panel.

“When you have a subset of patients who are not responding to drug therapy you need to respond in a thoughtful way,” Rena Yadlapati, MD, MHS, assistant professor of medicine-gastroenterology at the University of Colorado School of Medicine, who co-authored a report on the panel’s recommendations, said in a press release. “Only a select few should be referred to surgery.”

Yadlapati and colleagues surveyed 14 expert esophagologists on appropriate treatment strategies for subsets of GERD patients with persistent symptoms despite PPI therapy. The panel judged several hypothetical scenarios, indicating which of four invasive procedures were most appropriate — including laparoscopic fundoplication, magnetic sphincter augmentation, transoral incisionless fundoplication or radiofrequency energy delivery — and if they preferred pharmacologic or behavioral therapy.

“A nuanced understanding of both the literature and the patient’s unique physiologic profile is critical to appropriate decision-making, as inappropriate recommendations may compromise outcomes and patient safety,” Yadlapati said in the press release.

Overall, the panel considered invasive anti-reflux interventions to be inappropriate in the majority of patients.

However, the panel found laparoscopic fundoplication appropriate for patients with elevated esophageal acid exposure time (EAE > 6%), and “moderately appropriate” for patients with normal EAE who have positive symptom-reflux association for regurgitation and a large hiatal hernia.

Additionally, they found magnetic sphincter augmentation to be “moderately appropriate” for patients with elevated EAE but without a large hiatal hernia.

Notably, they did not find transoral incisionless fundoplication or radiofrequency energy delivery to be appropriate in any of the hypothetical scenarios.

Regarding noninvasive options, the panel preferred H2RA therapy for patients with elevated EAE, transient lower esophageal sphincter relaxation inhibitors for patients with elevated reflux episodes, and neuromodulation/behavioral therapy for patients with positive symptom-reflux association.

Yadlapati and colleagues noted that because some patients who are unresponsive to PPI therapy have hypersensitivity to symptoms, invasive procedures are unlikely to improve outcomes and could increase morbidity and health care costs while reducing quality of life. Low-dose antidepressants and behavioral interventions play an important role in these patients, they said.

“Behavioral modification and relaxation therapy are also potentially effective,” she said in the press release. “In a study of nine patients with functional heartburn, esophageal-directed hypnotherapy was associated with significant improvements in symptoms, visceral anxiety and quality of life.”

She concluded that treatment should be personalized for each patient, but this study shows that surgery is not the recommended approach for most patients with GERD.

“We are not opposed to surgery for the right patients,” she said. “But we should not be reflexively referring patients for these invasive treatments before considering all of the options.” – by Adam Leitenberger

Disclosures: The authors report no relevant financial disclosures.