GERD: When Medication Management Fails

JULY 19, 2017
Casandra A. Holveck, 2018 PharmD Candidate, the University of Connecticut

More than 60 million Americans experience heartburn at least once a month and 15 million suffer daily. Heartburn and acid regurgitation are hallmark gastroesophageal reflux disease (GERD) symptoms.

Lifestyle interventions and anti-secretory medications like proton pump inhibitors (PPIs) are commonly used for GERD management. Seventeen to 32% of patients experience persistent symptoms despite medical therapy and are considered to have refractory GERD.

Physicians can manage refractory GERD surgically, but must consider its phenotype. Reflux hypersensitivity may only partially respond to surgery and functional heartburn should not be managed surgically.

A June 2017 article published in Journal of Gastrointestinal Surgery explores surgical advancements in management of GERD.

Laparoscopic Nissen fundoplication and concurrent hiatal hernia repair, if necessary, is the backbone in surgical GERD treatment. GERD and obesity are closely related and symptoms improve with weight loss. Laparoscopic Roux-en-Y gastric bypass surgery is recommended in obese patients who meet American Society for Metabolic and Bariatric Surgery.

Researchers are currently studying other GERD treatment technologies.

The Linx Reflux Management System uses a circular ring of magnetic beads to augment the lower esophageal sphincter (LES) and demonstrates symptomatic improvement in patients with small hiatal hernias.

Lower Esophageal Sphincter Stimulation for GERD (LESS-GERD) is a randomized, controlled, trial studying EndoStim LES stimulation system in patients who respond partially to PPIs. Here, electrodes are placed anteriorly along the esophagus at the gastroesophageal junction. LESS-GERD results seems to result in esophageal acid exposure and less PPI use.

Other novel technologies and minimally invasive endoscopic methods exist, but they lack long-term evidence and are not consistently used.

Surgical and endoscopic GERD management methods have similar risks including: infection, post-operative dysphagia, and recurrent symptoms. Studies show surgical management is effective for refractory patients and outcomes depend on appropriate procedure selection.

Reference

Kethman W, Hawn M. New Approaches to GERD.  J Gastrointest Surg. 2017; doi:10.1007/s11605-017-3439-5.

 



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