|Year : 2022 | Volume
| Issue : 5 | Page : 197-198
Gastroesophageal reflux disease – Current perspective
Ashish Dey, Vinod K Malik
Department of Laparoscopic, Laser and General Surgery, Sir Ganga Ram Hospital, New Delhi, India
|Date of Submission||29-Sep-2022|
|Date of Decision||14-Oct-2022|
|Date of Acceptance||19-Oct-2022|
|Date of Web Publication||31-Oct-2022|
Vinod K Malik
Department of Laparoscopic, Laser and General Surgery, Sir Ganga Ram Hospital, New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Dey A, Malik VK. Gastroesophageal reflux disease – Current perspective. Curr Med Res Pract 2022;12:197-8
Gastroesophageal reflux is a common condition in which stomach contents reflux into the oesophagus, resulting in symptoms of retrosternal burning and regurgitation of gastric contents into the mouth. Although this condition was given the status of disease in the mid-1930s, it was not until after World War II that a causal relationship between reflux and oesophagitis was established. Only later did it become apparent that oesophagitis is associated with Barrett's change of the squamocolumnar junction. The natural history of Barrett's changes and adenocarcinoma risk is now clearly understood to help guide the management of this condition.
A large number of people suffer from this disorder. In a study conducted in the United States, 50 million Americans reported experiencing nighttime reflux at least once a week over the past year. In a recent epidemiological study, the prevalence of cases worldwide increased by an astounding 77.53% between 1990 and 2019. The study estimated the prevalence of gastroesophageal reflux (GER) at 783.95 million people.
With the increasing number of cases of this disease, it is imperative not only to understand the causes but also to develop effective strategies to provide adequate health coverage for individuals who have simple or advanced forms of this disease. In this context, it is relevant to understand the hierarchy of symptoms, which can range from relatively innocuous heartburns affecting the quality of life and sleep to bothersome dysphagia; extraesophageal symptoms such as a persistent cough and hoarseness of voice and finally, adenocarcinoma oesophagus is a life-threatening complication of Barrett's changes.
This requires infrastructure to diagnose the condition accurately, to be able to treat the condition effectively and to identify complications of disease and treatment early to provide mitigation, surgical or otherwise. For uncomplicated reflux, there are two effective treatment options: proton-pump inhibitors and surgical antireflux procedures. As a non-surgical option is preferred by the majority, as this is a long-term treatment, the importance of monitoring long-term side effects cannot be overstated.
Surgical treatment, along with other evolving interventional treatments, when performed correctly, offers the opportunity to provide a one-time fix not only to alleviate symptoms but also to prevent complications related to this condition.
An article by Rudolf Nissen published around the middle of the twentieth century described how antireflux surgery has evolved over the decades. Although our understanding of the disease has improved dramatically in recent years, the correct diagnosis and its optimal management remain elusive in a few select cases. Even though many patients with severe reflux disease had favourable results after antireflux surgery, this was not always the case for those with diseases of lesser severity. Overcorrection of the lower oesophageal sphincter (LES) with the original Nissen technique often led to a high rate of post-operative dysphagia due to a lack of basic knowledge about GER disease (GERD). It was only with the evolution of modern appropriate diagnostic techniques that it became apparent that GERD patients had suboptimal outcomes after surgery due to defective LESs, weak oesophageal peristalsis and transient LES relaxations.
There used to be only two types of investigations available until a few years ago: upper gastrointestinal endoscopy and barium or gastrografin studies. The development of water-perfused catheters and later solid-state catheters, as well as the use of computer programmes to analyse results, have enhanced our understanding of oesophageal motility and its clinical implications. Furthermore, ambulatory 24-h pH monitoring continues to be a standard test for quantifying acid reflux severity or indicating the presence of duodenogastric reflux as a cause of symptoms. Combined pH and oesophageal impedance measurements are now being used to diagnose hypersensitive oesophageal linings and to discriminate between reflux types. In addition, the availability of affordable diagnostic tools and equipment contributed to the widespread detection of GERD and subsequent treatment of the disease.
In addition to tools, guidelines were developed. The use of guidelines assists in standardising the detection and treatment of this complex disease. It has been generally discouraged to perform reflux monitoring or high-resolution manometry solely as a diagnostic test for GERD in patients who are known to have endoscopic evidence of Los Angeles grade C or D reflux oesophagitis or long-segment Barrett's oesophagus.
There have been tremendous changes and evolutions in diagnostic methods, but critical clinical judgement is still a mandatory element of treatment. In a study of 237 patients with extraesophageal symptoms resistant to medical treatment, traditional reflux parameters were found to be better predictors of the outcome of fundoplication as compared to impedance testing. Due to the lack of a clear definition of 'normal' proximal oesophageal reflux, interpretation of the impedance results related to extraesophageal GERD has proven challenging and surgical outcomes seem to be better predicted by traditional reflux parameters.
In the early 1990s along with GERD research, minimally invasive surgery also evolved. With acceptable results, antireflux surgery became a popular choice for patients as well as surgeons. This resulted in an increase in the number of fundoplications worldwide. Fundoplications are currently recommended only after extensive pre-operative evaluation and for the right indications, such as severe reflux oesophagitis (grade C or D), large hiatal hernias and/or persistent and troublesome GERD symptoms. In recent times, large series with long-term follow-up results have been published that show fundoplication in its various forms showing good results, including symptomatic relief and quality of life.
Currently, medical and surgical antireflux treatments are not recommended as an alternative to magnetic sphincter augmentation, radiofrequency energy (Stretta, USA) or transoral incisionless fundoplication, as they have inconsistent and highly variable results. Selective indications for antireflux surgery like GERD in children, refractory GERD and redo fundoplications are an area of intense research. In addition, endoluminal techniques are on the horizon, although they have not yet demonstrated much efficacy.
The level of evidence in surgery for GERD and Hiatus hernias differs because operative details differ from series to series, making them hardly comparable. Therefore, it is very important to keep one's own database and personal follow-up of one's own patients both for the purpose of research and also for one's own quality control.
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Conflicts of interest
There are no conflicts of interest.
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