Treatment of Reflux Disease at the Sachsenhausen Clinic, Germany, Frankfurt

Treatment of Reflux Disease

General Measures

In the case of a mild form of reflux disease, there are general measures to relieve the main symptoms of the disease. The patient's condition will improve if he or she sleeps with his or her upper part of the body slightly uplifted throughout the night. The natural position of the body is effectively used as a measure to prevent the backflow of hydrochloric acid. Regular physical activity followed by loss of weight if you are overweight is also helpful in reducing abdominal pressure. Besides, it actively stimulates natural digestion.

Nutrition

The patient should eat high-protein foods, as they trigger the additional production of the peptide hormone gastrin. Gastrin increases the muscular tension of the esophageal sphincter. Food should be taken in small portions long before night's sleep (a heavy meal will cause hydrochloric acid to be pumped into the esophagus when you are in a horizontal position). In addition, alcohol consumption should be reduced or completely eliminated as it will directly irritate the mucous membrane and cause relaxation of the lower esophageal sphincter.

The harmful effect of caffeine is disputed by doctors because, on the one hand, coffee stimulates the production of gastric juice and, on the other hand, caffeine increases the production of the hormone gastrin. Active or passive smoking should also be avoided, as nicotine leads to an increased production of hydrochloric acid.

Taking Medications

Proton pump inhibitors have been used for decades for conservative treatment. Due to their effectiveness, the number of surgical interventions on the stomach has considerably decreased. These medications significantly reduce the production of hydrochloric acid. Accordingly, they are considered to be the main medications for the treatment of reflux disease, peptic ulcer disease and duodenal ulcer disease, as well as part of the strategies to treat Helicobacter pylori infection and Zollinger-Ellison syndrome. The medications are usually well tolerated and most of them have no adverse effects. However, long-lasting treatment with proton pump inhibitors is sometimes associated with the occurrence of significant side effects such as osteoporosis, renal problems, diarrhoea and increased risk of heart attack.

H2-Receptor Antagonists

H2-receptor blockers, such as ranitidine, block the production of hydrochloric acid and are considered an alternative medication if proton pump inhibitors cannot be prescribed. H2-receptor blockers are effective approximately 30 minutes after intake and the effect lasts from 8 to 12 hours.

Antacids

Antacids can be effective in neutralizing gastric juices, but they are much less effective than proton pump inhibitors or H2-receptor antagonists. These medications are well tolerated by patients, but cannot be bought at a pharmacy without a prescription.

Medicinal measures in reflux

If these measures do not work or if the mucous membrane has already been damaged, the doctor will start a drug therapy, which may take several weeks to months depending on the severity. There are various means available for this:

  • Proton pump inhibitors (PPIs) inhibit an enzyme in the stomach, which is responsible for gastric acid production.
  • H2 receptor blockers inhibit acid production in the glandular cells of the gastric mucosa.

Antacids neutralize excess stomach acid and help protect the esophagus. They work within minutes and may only be taken if symptoms actually occur. Also used as a supplement to PPI.

Alginates are swelling agents that cover the stomach contents like a blanket.

A combination of hyaluronic acid, chondroitin sulfate and poloxamer 407 protectively adhere to the esophageal wall, promoting regeneration and wound healing of the damaged mucosa. Can be used in addition to reflux therapy.

The measures in the area of ​​lifestyle and nutritional habits should, however, also be continued under a drug therapy.

Surgical Treatment

Operational measures

Reflux surgery is recommended when medications are of little or no use, when patients do not want to take medicines for life, or when they already have esophageal damage. There are several surgical methods available:

  • Anti-reflux surgery (fundoplication): The goal is to prevent acid from entering the stomach into the esophagus. The procedure is performed laparoscopically, ie via tiny cuts in the abdominal wall. The upper part of the stomach is wrapped around the lower end of the esophagus and sutured to the diaphragm, stomach or esophagus. This strengthens the occlusion at the lower end of the esophagus and prevents backflow of the chyme.
  • LINX Surgery: This new surgical procedure uses a magnetic ring around the exit of the esophagus to prevent backflow of the chyme. Also, this operation is laparoscopic, but is not suitable for all reflux patients

With severe cases of gastroesophageal reflux disease, ulcerative esophagitis, stricture (narrowing) of the esophagus, Barrett's esophagus or late-onset esophageal cancer may occur. In order to prevent the occurrence of complications, well-established surgical methods are used. These usually include removing the diaphragmatic hernia and restoring the mechanism of occlusion between the esophagus and the stomach. A cuff is surgically created, consisting of the upper wall of the stomach, and it is freely guided around the esophagus and attached to it by several sutures. This operation, known worldwide as fundoplication, has been a standard procedure for decades. In recent years, the technique has undergone some positive changes and can be adapted to any patient. Most patients have completely ceased to have symptoms after such an operation.

New surgical treatments have emerged in recent years in the field of surgery, which are now vital for many patients. These include the LINX® or EndoStim® system. It is important that all modern surgical procedures are performed and monitored by an interdisciplinary team of surgeons, gastroenterologists and radiologists based on the complaints and specifics of each individual patient to ensure maximum patient safety and complete recovery from the disease.

Due to the gentle surgical procedure, only a short hospital stay of about five days is necessary today. Of course, even after such an operation problems may occur, but these have become rare. Sometimes a so-called gas-bloating syndrome or a so-called dysphagia occurs after the operation.

Dysphagia describes the reduced ability to swallow food, and the gas-bloating syndrome has the reduced ability to recharge swallowed air from the stomach. Both the gas-bloating syndrome and the dysphagia are usually due to a postoperative Verschwellung the cuff and form in the vast majority of cases by themselves without further therapy in a short time back. The dermal thread is resorbable in most cases and does not have to be pulled.

Of decisive importance, however, is that the quality of life of those affected improves significantly after the operation and over 90% of patients, if they were again faced with the decision to undergo surgery, would have surgery again.

What are the chances of recovery and what can you do yourself?

Particularly in the case of mild and moderate forms, reflux disease can be successfully treated through the aforementioned changes in diet and lifestyle habits and, if necessary, by the use of medication. Since the actual cause, ie the weakness of the esophageal sphincter, but does not disappear, the symptoms may return. Therefore, it is important to continue to abide by the "rules" even with an improvement of the complaints.

Especially for longer-lasting symptoms, medical attention should be sought. Apart from an improvement in the quality of life must be ruled out that forms by the chronic reflux Barrett's esophagus, a pathological change in the tissue in the lower part of the esophagus.

Endoscopic therapy procedures

For the sake of completeness, the endoscopic therapy methods should also be mentioned, which are currently only of minor importance in everyday practice and the success of which has only been proven by a few studies.

In particular, the long-term results are still completely unknown. The target structure of the endoscopic therapy procedures is also the lower esophageal sphincter with the aim of improving the function and reducing the esophageal acid exposure. There are three categories of procedures available, all of which can be performed on an outpatient basis. Serious complications [bleeding (EndoCinch), perforation (Stretta) and several deaths (Stretta, Enteryx)] were registered for the Stretta manufacturer as well as for Enteryx and EndoCinch.

Enteryx, Gatekeeper and Wilson-Cook Endoscopic Suturing Device are no longer available. The endoscopic procedures are indicated for patients with GERD symptoms that are refractory despite drug therapy, but are critical of invasive surgery or are not available for surgery due to other contraindications. The high reintervention rate of is disadvantageous 10% (Stretta) up to 55% (EndoCinch) within 2 years.

Since the anatomy of the gastro-oesophageal junction is not significantly changed, there is still the possibility of surgical reflux therapy after endoscopy.

The therapeutic principles are as follows:

  • Thermal ablation techniques (Stretta Procedure, Cruon Medical Inc.), in which the muscles at the UÖS are treated by targeted heat. The exact mechanism of action remains unclear. Recent studies suggest a change in the neuromuscular control function of the lower jaw. Furthermore, a reversible reduced stretchability (compliance) of the gastroesophageal junction was observed as a result of the radio frequency application. In placebo-controlled studies, a significant improvement in GERD symptoms and quality of life was demonstrated, which was not measurable in the placebo group. Data that can be objectified by pH measurement or manometry could not be demonstrated in the current study either. Since esophageal acid exposure is not reduced, this procedure plays a minor role in the treatment of GERD, if at all.
  • Endoscopic suturing techniques [Bard Endo Cinch (CR Bard, Murray Hill, New Jersey, USA), Wilson-Cook Endoscopic Suturing Device (Wilson-Cook Medical, Winston-Salem, North Carolina, USA), NDO Plicator (NDO Surgical, Mansfield, Massachusetts , USA)], which is analogous to lap. Fundoplication form one or more consecutive endoluminal plications at the level of the UOS. It could
  • A moderate but significant reduction in transient UÖS relaxation and a slight increase in UÖS resting pressure were achieved, which reduced the percentage acid exposure time, especially in an upright position, but the number of refluxes was not reduced. Even after a short observation period of 6 months, only one out of two created plications could be detected in 2/3 of the study patients. While a permanent improvement in quality of life (SF-36, GERD-HRQL) could be demonstrated even after 12 months in patients with 2 remaining plications, the loss of a plication correlated with a significantly poorer clinical result.
  • Injection or implantation techniques [Enteryx (Boston Scinetific, Natick, Massachusetts, USA), Gatekeeper Reflux Repair System (Medtronic, Minneapolis, Minnesota, USA), plexiglass] that cushion the UOS by injection of inert biopolymers into the muscles.
  • Similar to the radio frequency application, the presumed mechanism of action consists in a reduction in the elasticity as well as a change in the geometry of the UÖS. An extension of the UÖS was also achieved, in accordance with one of the goals of surgical therapy. In the prospective multicenter study by Johnson et al. 70% of the treated patients were free of PPI after 12 months, a significant reduction in acid exposure in the distal esophagus was also described. Another RCT study, however, showed no significant difference in acid exposure time between Enteryx and placebo groups in significantly improved GERDHRQL.

However, none of the endoscopic procedures mentioned meets all the required criteria of safety, effectiveness, cost efficiency, durability and reversibility.

Surgical therapy

According to the guidelines, a number of criteria are used to determine the indication for surgical therapy. These include in particular the existence of a long-term need for treatment (usually longer than 12 months), a proven drug intolerance (even after changing the preparation) as well as intolerable residual complaints (e.g. regurgitation, aspiration) despite adequate medication therapy. The patient's request and the patient's rejection of drug therapy despite proven efficacy are considered to be relative indications, whereby a feeling of suffering with a significant reduction in quality of life due to GERD can be seen as a justified indication for a surgical intervention. In young patients, the indication for surgery is because of the presumably lifelong PPI intake and the associated possible long-term consequences. For preoperative diagnostics, endoscopy, esophageal pH monitoring and manometry are recommended for optimal patient selection.

Predictive criteria for a good postoperative result are a symptomatic response to PPI therapy (PPI response), a proven pathological acid exposure of the esophagus by pH measurement and the presence of typical reflux symptoms such as heartburn and acid regurgitation.

In the area of ​​surgical procedures, a distinction is made between the reconstructive (reconstructing the sphincter apparatus) and the augmentative (supporting the sphincter apparatus) procedures. Reconstructive procedures are e.g. the fundoplication according to Nissen / DeMeester and the partial fundoplication according to Toupet.

For a time, the so-called Angelchik prosthesis, which was first used in 1973, was popular as an augmentative procedure.

It was a silicone band implant which was implanted at the level of the gastroesophageal junction and thus an increase in the pressure of the lower esophageal sphincter was achieved. The main benefit of the prosthesis was the ease of implantation with low postoperative morbidity and reduced hospitalization. The prosthesis was removed due to serious complications such as ligament migration. Dislocation and the frequent occurrence of postoperative dysphagia in the long-term course withdrawn from the market.

Another augmentative procedure is implantation of a magnetic anti-reflux tape (LINX Reflux Management System, Torax Medical, Shoreview, MN, USA). The individual processes are discussed in detail below.

All surgical procedures can be done laparoscopically be performed. Another common feature of the operative therapeutic procedures is the causal approach, with the aim of avoiding any reflux, whether acidic or non-acidic. In contrast, drug therapy is symptomatic rather than suppressing reflux events as such.

Prof., Dr. Stein

Prof., Dr. Stein

Head physician

Holger Bahn

Holger Bahn

Senior physician

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