Endoscopic and Pharmacologic Therapy after a Failed Anti Reflux Surgery

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Once it has been objectively determined through appropriate and increasingly accurate diagnostic testing that the symptoms a patient has in the postoperative state are related to continued or recurrent reflux, the next decision one needs to make is how best to manage the patient's GERD. Options include repeat anti-reflux surgery in a center with skill and experience in this type of surgery, endoscopic anti-reflux procedures, or pharmacologic anti-reflux therapy. The treatment choice in this situation, as noted in Chapter 10, is heavily dependent on the patient's preferences regarding further therapy for GERD as well as their unique physiology and anatomy determined by a careful evaluation. Furthermore, the availability of surgical or endoscopic skill in performing these types of repeat procedures may limit or expand the options offered the patient. It is likely that continued improvements and innovation in surgical, endoscopic, and pharmaco-logic anti-reflux therapy will further expand the clinician's options in managing these patients.

We are not optimistic that we will see controlled trial information on the effectiveness of endoscopic anti-reflux devices in patients with prior failed anti-reflux surgery. Although the anecdotal experience in this clinical arena is likely to expand exponentially, there are few incentives for device manufacturers to test their technology in this patient population that is difficult to study and treat. It is likely that most of what we learn in using endoscopic anti-reflux devices in the failed anti-reflux surgical patient will be based on "experience" rather than science.

Having said this, we do believe that as we further develop data regarding the impact of the endoscopic anti-reflux procedures on lower esophageal sphincter anatomy and physiology, we will more intelligently apply one or more of the devices in the failed postoperative patient. It is also likely that data derived in this setting will allow us to more accurately predict who is a viable candidate for such therapy as well as which procedure is most likely to succeed. In patients with a more intact postoperative


anatomy, we suspect that one of the injection techniques will suffice, whereas those with more disrupted anatomy will require more definitive closure of the hiatus, possibly with one of the plication techniques. What we really need to acquire are data regarding the durability, long-term safety, and cost-effectiveness of the devices in the failed postoperative setting. If these devices prove to be durable as an adjunctive therapy for failed anti-reflux surgery, then even a high initial acquisition cost may not be prohibitive in using them in this clinical setting.

What will drive the choice of treatment for the patient with a failed anti-reflux operation will always be dependent on patient-centered goals of therapy, their unique anatomy and physiology, and the availability of expertise in surgical or endoscopic anti-reflux salvage therapy. However, the options within the realm of pharmacologic and endoscopic anti-reflux therapies and evidence for the success of those options in this clinical scenario will likely greatly expand in the coming years. Physicians caring for patients such as these will need to stay abreast of the developments in this field and not only use the most accurate tools available for evaluating the patients with persistent or recurrent GERD after anti-reflux surgery, but also consider all of the various options available to the patient.

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