Treatment of Reflux Esophagitis (GERD)

Is gastroesophageal reflux dangerous

Gastroesophageal reflux is a backflow of acidic contents from the stomach into the esophagus. Normally, such backflow should not occur, since the lower esophageal sphincter performs a barrier function: it passes food from the esophagus into the stomach, but blocks its reverse movement. This sphincter is made up of muscles. Its damage, an increase in pressure in the stomach or a violation of the innervation of the sphincter with its relaxation result in reflux. Hydrochloric acid burns the lining of the esophagus. If this happens regularly, esophagitis develops.

The prevalence of gastroesophageal reflux disease is very high:

• 44% of people suffer from heartburn at least once a month.
• 7% of people have it every day.
• 18% have to constantly or periodically intake drugs.

In 80% of cases, the disease is mild or moderate, but about 20% of patients develop severe esophagitis. Without treatment, it leads to complications, such as ulcers, cicatricial narrowing of the esophagus (strictures), bleeding. The prolonged disease can lead to life-threatening complications, including Barrett's esophagus (a precancerous condition) and esophageal cancer.

For the diagnosis of GERD, it is sufficient for doctors to assess the clinical symptoms. However, to clarify the diagnosis and detect signs of esophagitis, instrumental tests are used. These include gastroscopy, 24-hour pH-metry and chest X-ray.

Treatment principles

In most patients, GERD and esophagitis do not affect life expectancy, but significantly impair its quality. The treatment involves the use of both conservative and surgical methods.

Most patients take proton pump inhibitors for a long time. These drugs block the production of hydrochloric acid in the stomach. As a result, even if reflux persists, the contents of the stomach no longer burn the esophagus. After 1-2 months of therapy, all the symptoms of esophagitis disappear, including a burning sensation in the chest and difficulty in swallowing food.

However, conservative treatment has two main problems:

• It is ineffective in 10% of patients.
• For the rest, the effect persists only during the treatment period and for a short time after its completion.

Many patients take medications for years. However, after their cancellation, 50% of the symptoms return after six months, and 80% manifest themselves again after a year. In longer follow-up monitoring, the likelihood of reflux symptoms returning is 100%.

Unlike conservative therapy, surgical treatment involves eliminating the cause of reflux, and therefore provides long-term results. In the twentieth century, surgery was traumatic, often caused complications, so it was performed only in the presence of severe symptoms of esophagitis. However, over the past 20 years, many new surgical interventions have been developed. They are minimally traumatic, more effective, safe, and therefore surgical interventions can be performed even in the absence of severe complications of esophagitis, if the patient wants to get rid of symptoms and avoid the need for long-term conservative therapy.

Benefits of surgical treatment for GERD with esophagitis:

• Cause of reflux is eliminated, so the problem of esophagitis is solved once and for all.
• Only 14% of patients need to continue drug therapy after surgery, but the doses and frequency of drug intake are reduced.
• Patients do not need constant monitoring to detect complications of esophagitis and prevent esophageal cancer.

Absolute indications for surgery are:

• Precancerous disease of the esophagus (epithelial metaplasia).
• Stenosis (narrowing) of the esophagus.
• Chronic esophagitis.
• Shortening of the esophagus.
• Bleeding.

Surgical intervention is recommended for patients with complications from the respiratory system and reflecting angina pectoris (vasoconstriction of the heart and with the development of pressing pain behind the breastbone). Another argument in favor of the surgery is the lack of effectiveness of drug therapy.

Endoscopic treatment

Endoscopic procedures for the treatment of gastroesophageal reflux disease have obvious advantages, because manipulations on the gastrointestinal organs are performed without abdominal incisions. The instruments are inserted into the esophagus through the mouth. Doctors use two main surgical interventions:

• Stretta procedure. It involves radiofrequency ablation of the lower esophageal sphincter. The essence of the method is the effect of radiofrequency energy on the cardiac (closest to the esophagus) stomach. The result is a thickening of the affected area and a decrease in its sensitivity. The stomach stretches less after eating. The mechanical barrier to reflux is improved. The conductive pathways of the vagus nerve are damaged, and therefore the amount of transient relaxations of the lower esophageal sphincter is reduced.
• Transoral incisionless fundoplication. The operation was developed by R.J. Mason. The essence of the procedure is intussusception (eversion) of the junction of the stomach and esophagus to create a functional nipple valve in the lower part of the esophagus.

So far, both endoscopic procedures are not considered standard treatment methods for esophagitis and gastroesophageal reflux disease. The surgical interventions are relatively new, so their long-term effects have not been determined. However, it seems like an attractive opportunity for many patients to cure esophagitis and get rid of heartburn permanently without abdominal incisions. Several European hospitals offer endoscopic treatment options for patients with esophagitis.

LINX reflux management system

In 2012, the FDA approved a new device for treating GERD called LINX. The technique is used in Europe as well. It provides patients with the same results as surgery for esophagitis. In this case, the treatment is minimally traumatic, since during the operation neither the esophagus nor the stomach is damaged.

The essence of the method is that a ring consisting of titanium balls with a magnetic core is put on the lower part of the esophagus. These balls are attracted, trying to connect. However, their attraction is not strong enough to block the lower esophageal sphincter completely, so they only strengthen it.

The LINX system requires a small laparoscopic surgery for implantation. A ring of balls is put on the esophagus, like a bracelet. As a result, the sphincter works better: it completely keeps the contents of the stomach at rest, including at night. When swallowing, the balls move away from each other, and the sphincter opens. After the LINX device implantation, the possibility of belching or vomiting remains.

The patient can eat food almost immediately after the surgery. However, after 2 weeks, scar tissue forms, which can impair the function of the lower esophageal sphincter. To prevent this from happening, the patient is recommended fractional frequent meals. The patient has to eat using this mode for several weeks. After 2 weeks, swallowing discomfort may appear, but it completely disappears after a month. After 3 months, a person can eat any food, does not suffer from heartburn caused by GERD, and the risk of developing esophagitis and its complications is minimal, since gastric acid no longer enters the esophagus.

Other surgical options

More than 40 operations have been developed for the treatment of gastroesophageal reflux and esophagitis. Here are the main types of interventions, many of which are no longer used in developed countries, but are still used in countries with poorly developed medicine:

• Cruraphy – suturing the crura of the diaphragm to reduce the esophageal opening of the diaphragm.
• Gastropexy – lowering of the upper part of the stomach by suturing the upper parts of the lesser curvature to the anterior abdominal wall.
• Esophagofundorafia – fixation of the fundus of the stomach to the esophagus.
• Fundopexy – fixation of the fundus of the stomach to the lower surface of the diaphragm.
• Removal of a narrowed, damaged area of ​​the esophagus with plastic gastric tube.

In the second half of the twentieth century, a Nissen fundoplication was developed. It became the basis for the treatment of GERD with esophagitis. The essence of the intervention is that the upper part of the stomach is wrapped around the esophagus, thereby forming a cuff. It strengthens the lower esophageal sphincter by stopping gastroesophageal reflux.

In 1991 T. Geagea and B.D. Dallemagne were the first to perform fundoplication laparoscopically: through short abdominal incisions and with the use of video endoscopic equipment. There were also other laparoscopic interventions for the treatment of GERD with esophagitis: strengthening of the esophagogastric junction with the round ligament of the liver, reconstruction of the angle of His, anterior valvuloplasty using the Angelchik technique. However, most surgeons still prefer fundoplication in the treatment for esophagitis, since this surgery provides the most consistent results.

The main types of laparoscopic fundoplication are:

• 360-degree Nissen fundoplication – the fundus of the stomach is wrapped around the intra-abdominal esophagus in the form of a cuff.
• Nissen-Rossetti fundoplication – a part of the stomach is left in the chest cavity.
• 210-270-degree posterior partial and bilateral classic Toupet fundoplication – the upper part of the stomach is wrapped around the abdominal part of the esophagus along its posterior surface.
• Anterior partial fundoplication using the Dor technique.

The results of different operations are comparable. In addition, laparoscopic treatment is not inferior to classical open surgical interventions in both immediate and long-term results. Therefore, most cases of GERD with esophagitis are treated in Europe using minimally invasive techniques.

This approach has the following advantages:

• Three times less need for analgesics after surgery due to less pain.
• Less tissue trauma, less abdominal scar, better aesthetic results.
• Less time to spend in the hospital.
• Lower risk of complications.
• Person loses less blood.
• Patient recovers faster after surgery.

On average, the results persist for 10 years in 80% of patients after surgical treatment. Doctors in Europe use advanced surgical techniques, so the efficiency exceeds 90% within 10 years.

The risk of developing complications in different hospitals ranges from 2 to 10%. To minimize your health risks, you can undergo reflux esophagitis treatment abroad. In the best hospitals in the world, mortality rates are close to zero and the risk of complications is about 2%.

Why is it worth undergoing medical treatment abroad

If your country has poorly developed medicine, you can undergo medical treatment abroad. European experts achieve excellent results in the fight against esophagitis and gastroesophageal reflux.

There are several reasons for you to undergo medical treatment abroad:

• Outdated surgical techniques are not used, since they are traumatic, unsafe and provide short-term results.
• Surgeons perform advanced surgical interventions, namely fundoplication using the Nissen, Toupet and Dor techniques. They are effective in almost all patients, and in 90% of cases, the effect lasts for at least 10 years. Most treated patients will never again suffer from the symptoms and complications of esophagitis.
• Almost all patients undergo laparoscopic surgery for the treatment of reflux esophagitis. Minimally invasive surgery contributes to a shorter recovery period.
• The risk of complications does not exceed 2%. It is 5 times lower than in countries with poorly developed medicine.
• Availability of innovative treatment methods, which are even more sparing: endoscopic procedures for gastroesophageal reflux and esophagitis treatment, implantation of the LINX system.

Treatment in Europe at an affordable price

To undergo medical treatment in one of the European hospitals, please use the services of the Booking Health company. On our website, you can see the cost of treatment in Europe and compare prices in order to book a medical care program at a favorable price. Medical treatment in Europe will be easier and faster for you, and the cost of treatment will be lower.

You are welcome to leave your request on the Booking Health website. Our specialist will contact you and provide a free consultation on treatment in Europe. Booking Health will take care of the organization of your trip abroad. We will provide the following benefits for you:

• We will select a hospital for medical treatment in Europe, whose doctors specialize in the treatment of esophageal diseases and achieve the best results.
• We will take care of the problem of the language barrier and help you to establish communication with your attending physician.
• We will reduce the waiting time for the medical care program. You will undergo treatment on the most suitable dates.
• We will reduce the price. The cost of treatment in European hospitals will be lower due to the lack of overpricing and additional coefficients for foreign patients.
• We will take care of all organizational issues: we will draw up documents, meet you abroad and take you to the hospital, book a hotel, provide interpreting services.
• We will prepare a medical care program and translate medical documents. You do not have to repeat the previously performed diagnostic procedures.
• We will help you keep in touch with the hospital after treatment in Europe.
• We will arrange additional diagnostic examinations and treatment in a European hospital, if required.
• We will buy medicines abroad and forward them to your native country.

The world's leading doctors will take care of your health. The Booking Health specialists will help reduce the cost of treatment, organize your trip, and you will only have to focus on restoring your health.

Authors: 

The article was edited by medical experts, board certified doctors Dr. Vadim Zhiliuk and Dr. Sergey Pashchenko. For the treatment of the conditions referred to in the article, you must consult a doctor; the information in the article is not intended for self-medication!

Sources:

National Library of Medicine

Centers for Disease Control and Prevention

MedicineNet