Use in This Clinical Situation

Why choose medical therapy over a repeat operation or an endoscopic therapy for recurrent GERD symptoms after surgery? The most obvious reason would be that the patient chose to be placed back on pharmacological therapy rather than undergo a second operation or have an invasive endoscopic anti-reflux procedure. This is not an evidence-based decision but one based solely on patient preference (perhaps with some understanding of the outcomes of the other various treatment options). Another reason for this choice would be that pharmacological therapy was superior in outcomes versus a repeat anti-reflux surgical or endoscopic procedure.

However, there have been no comparative studies of these differing management approaches nor are we aware of any trials comparing these therapeutic approaches being planned. However, there are limited data suggesting that pharmacological therapy remains effective (as it would be expected to be) after anti-reflux surgical failure. In a study of children who had postsurgical failure and a return of GERD, both symptoms and complications could be effectively managed with PPI therapy and none of the 18 children presenting with recurrent GERD symptoms or findings "required" a second operation.80 In the Veterans Affairs Cooperative randomized trial comparing medical and surgical therapy, patients originally treated surgically and now on medical therapy expressed similar satisfaction with their outcome as those still in surgically induced remission.18 These findings would imply that pharmacological therapy after failed surgery remains effective. Indeed, most clinicians have found similarly. We have never encountered a patient successfully treated with PPIs before surgery whose typical GERD symptoms that recurred after surgery could not be effectively retreated by reinstitution of PPI therapy. The same success with PPIs cannot be assumed for new or atypical symptoms. A third reason to choose drugs over endoscopic or repeat surgical anti-reflux therapy may be one of cost-effectiveness. It has long been debated as to whether the long-term costs of therapy for GERD are greater with pharmacological versus surgical therapy and more recently endoscopic therapy has entered this debate.70-73 Part of the difficulty in determining which management approach is more cost-effective has to do with the difficulties in relying on models of economic outcomes given the near absence of directly measured costs from randomized controlled trials comparing these various strategies. Myrvold et al.72 as part of a previously reported randomized controlled trial, measured the direct costs of PPI therapy versus surgical therapy in a number of European countries participating in the study. Costs for surgical therapy were higher in Sweden, Denmark, and Norway but not Finland. Although both therapies were equally effective in controlling GERD symptoms, it was stated that PPI therapy was more cost-effective. What was ignored in the study was the fact that surgery demonstrated statistically significant reductions in heartburn scores although "treatment failure" was not different between arms.

Thus, without reporting confidence intervals for the treatment effect to allow insight into potential sample size limitations of a study, it may be that one strategy is not really economically dominant over another and therefore cost alone should not be a basis for a decision regarding choice of therapy for GERD. Additionally, given there are no comparative cost data for any therapy after failed anti-reflux surgery, this issue of cost in making a decision regarding therapy after failed anti-reflux surgery becomes a moot point in helping one select therapy in this clinical situation.

Thus, it really comes down to patient preference based in part on local availability of endo-scopic or surgical anti-reflux therapy expertise that will determine the treatment decision. The only downside to this clinical approach is that in a patient who chooses surgical anti-reflux therapy because of the inconvenience, intolerance, or cost of continuous PPI therapy, may be back to where they started from without resolu

THE MEDICAL AND ENDOSCOPIC MANAGEMENT OF FAILED SURGICAL PROCEDURES

tion of their problem. Thus, offering them PPI therapy to manage their recurrent GERD symptoms after anti-reflux surgery may not be an option they wish to consider.

Herbal Remedies For Acid Reflux

Herbal Remedies For Acid Reflux

Gastroesophageal reflux disease is the medical term for what we know as acid reflux. Acid reflux occurs when the stomach releases its liquid back into the esophagus, causing inflammation and damage to the esophageal lining. The regurgitated acid most often consists of a few compoundsbr acid, bile, and pepsin.

Get My Free Ebook


Post a comment