A multidisciplinary team of US surgeons and interventional gastroenterologists have released recommendations for managing patients with heartburn or regurgitation-predominant gastroesophageal reflux disease (GERD) based on response to proton pump inhibitors (PPIs). The recommendations were published in Gastrointestinal Endoscopy.
The use of PPIs is often the first-line therapy prescribed to patients with symptoms of GERD, yet a substantial proportion of these patients have incomplete or no treatment response. Many of these patients are referred to specialists to find a more effective intervention for managing symptoms. A panel of GERD experts convened to form a consensus on the surgical and therapeutic endoscopy management of distinct GERD cases.
This expert panel consisted of 8 foregut surgeons and 7 interventional/therapeutic gastroenterologists with a mean of 20.7 years in practice. Using distinct hypothetical patient scenarios, panelists completed a survey that assessed baseline characteristics and another survey that asked panelists to rank the appropriateness of interventions for these patient cases.
Appropriateness was defined as any intervention that featured an expected benefit that could exceed the expected negative effects by a wide margin. The panelists ranked appropriateness of each intervention on a 9-point scale.
Each of the hypothetical patients discussed in the surveys were ≥18 years of age and had objective GERD evidenced by reflux esophagitis, Barrett esophagus, and/or elevated esophageal acid exposure on pH monitoring. Additionally, each hypothetical patient was treated with a maximum PPI dose and had troublesome heartburn or regurgitation symptoms. All patients were characterized by their response to PPI therapy (ie, complete, partial, or none).
Based on high-quality evidence, the panel supports the recommendation of laparoscopic antireflux surgery in patients with heartburn or regurgitation and clinically insignificant hernia who respond to PPIs. Magnetic sphincter augmentation was also considered appropriate for PPI responders with heartburn or regurgitation with or without a clinically significant hiatal hernia.
For patients with heartburn who have a complete PPI response and are without a clinically significant hiatal hernia, the panel recommends optimization of medical therapy, which would consist of continuing a PPI while attempting to reduce the lowest effective PPI dose.
The panelists also recommended laparoscopic antireflux surgery and magnetic sphincter augmentation as appropriate interventions in partial PPI responders with heartburn or regurgitation symptoms with some response to PPI with or without a clinically significant hiatal hernia.
For partial PPI responders without a clinically significant hiatal hernia, the panel ranked radiofrequency energy delivery as indeterminate, suggesting that currently published data from randomized controlled trials are of variable and low quality. While the panelists agreed that radiofrequency energy delivery is not inappropriate, the data do not support it as the best practice for patients with partial PPI response.
For patients with heartburn or regurgitation symptoms with a clinically significant hiatal hernia and no response to PPI therapy, 80% of the panel ranked laparoscopic antireflux surgery as an appropriate strategy. In addition, approximately 80% of the panel agreed that MSA is appropriate for PPI nonresponders with regurgitation regardless of presence of hernia.
In patients without clinically significant hernia and no response to PPIs, transoral incisionless fundoplication without crural repair was considered an appropriate conservative intervention. In PPI nonresponders without a clinically significant hernia, radiofrequency energy delivery nearly met agreement criteria for ranking as an appropriate intervention.
According to the panelists, optimization of medical therapy was considered inappropriate in patients with heartburn or regurgitation symptoms with a clinically significant hiatal hernia and without response to PPI therapy. Continuation of PPI therapy in these patients without additional treatment was also considered inappropriate.
Laparoscopic antireflux surgery as well as magnetic sphincter augmentation were ranked as appropriate treatments for all PPI nonresponders based on impedance-pH testing. This intervention was not considered appropriate for patients with heartburn-predominant symptoms and evidence of reflux hypersensitivity who do not present with a clinically significant hernia. Transoral incisionless fundoplication without crural repair and radiofrequency energy delivery alone was considered inappropriate for all PPI nonresponders with a clinically significant hiatal hernia, irrespective of impedance-pH results.
In their paper, the panelists suggested that the results of their survey should not be used in therapeutic decision making. “Rather,” they wrote, “our hope is that these findings in combination with the results incorporating diagnostic esophagologist perspectives provide a foundation to balance ‘thinking fast and slow’ in cases of complex decision making to avoid error prone emotionally driven decisions.” In addition, the panelists recommend that physicians should approach patients with complex GERD “in a collaborative, multidisciplinary fashion and try to understand their own and others personal biases that may be driving diagnostic and therapeutic preferences.”
Gawron AJ, Bell R, Abu Dayyeh BK, et al. Surgical and endoscopic management options for patients with GERD based on proton pump inhibitor symptom response: recommendations from an expert U.S. panel [published online January 30, 2020]. Gastrointest Endosc. doi: 10.1016/j.gie.2020.01.037