Gastroesophageal reflux: medical treatment or surgical treatment?

Gastroesophageal reflux is the passage of stomach contents into the esophagus. Reflux is not always pathological, some reflux episodes occur physiologically, especially after meals.

We speak of gastroesophageal reflux disease when reflux episodes become more frequent and prolonged, and produce symptoms and inflammation of the esophageal mucosa (esophagitis).

Reflux disease covers a wide spectrum of patients from those with recurrent heartburn without esophageal lesions to those with severe esophagitis even if they do not present symptoms.

The most common cause of reflux is hiatal hernia, present in 75-90% of cases.

Symptoms of gastroesophageal reflux disease

The most frequent and characteristic symptom is heartburn, which is an unpleasant burning sensation that rises and descends behind the sternum. It increases when lying down and bending over, and is relieved by taking antacids.

Other symptoms are:

  • Regurgitation of acidic contents into the mouth.
  • Difficulty in swallowing, i.e. dysphagia
  • Chest pain

Gastroesophageal reflux disease can also produce atypical symptoms such as chronic cough, laryngitis, tracheitis, hoarseness, pulmonary aspiration, asthma…

What does it cause?

Reflux esophagitis is an esophageal inflammation due to refluxed acid damaging the esophageal mucosa and causing scarring. There are different degrees of esophagitis depending on the duration and severity of the process, which can cause stenosis, esophageal ulcer or Barret’s esophagus.

How can gastroesophageal reflux disease be diagnosed?

Diagnosis is usually based on clinical history. The existence of typical symptoms and good response to antacid treatment is fundamental for the diagnosis. However, the absence of reflux symptoms does not rule out the disease. Currently we have a series of complementary tests that contribute effectively to the diagnosis:

  • 24-hour pHmetry is the best test to diagnose the existence of pathological reflux.
  • Endoscopy is the method of choice to evaluate the consequences of reflux.
  • Barium transit is the most useful examination for hiatal hernia, which is the most common cause of gastroesophageal reflux. In some cases, manometry may be necessary to rule out motor disturbances in the esophagus.
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Medical or surgical treatment?

The goal of reflux treatment is to eliminate symptoms and prevent complications. Initial treatment is medical:

  • Elevate the head of the bed
  • Avoid smoking
  • Avoid foods such as fats, coffee, alcohol, chocolate…
  • Avoid antacids, prokinetics and mainly proton pump inhibitors (omeprazole, lansoprazole, pantoprazole…).

Specialists in this pathology point out that surgical treatment of reflux is very effective and allows most patients to stop taking medication.

It is indicated in patients who do not wish to take medication all their lives because of its cost or for fear of side effects. It is also indicated in patients who do not fully control their symptoms or whose symptoms recur as soon as they stop treatment, and in those who have repeated respiratory complications or anemia due to reflux, and of course in patients who present complications such as peptic stenosis or Barret’s esophagus.

Currently, reflux surgery is performed laparoscopically, which means that the technique is much less aggressive compared to the same procedure performed by open surgery. As with other laparoscopic surgeries, hospital admission is much shorter, the postoperative period is more comfortable and the resumption of normal activities is much earlier.

The technique of choice is fundoplication, which consists of creating a valve mechanism that prevents reflux by wrapping the distal esophagus with part of the patient’s own stomach.