Ask An Expert: Treatments for GERD

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Ask An Expert: Treatments for GERD

Question:

What types of procedures are offered to treat GERD other than the Stretta procedure?

Answer:

A number of procedures are available to treat GERD when medications fail. These procedures can be divided into two types: those performed through an endoscope passed down the mouth and those that require incisions through the abdomen. The incisions must be performed under general anesthesia. Endoscopic procedures are performed after medications are given to induce so-called "conscious sedation."

The Stretta procedure is done through the endoscope. A ring of tiny super-heated needles is inserted into the lower esophageal sphincter. This causes local scarring and perhaps destroys the nerves that relax the sphincter. The desired result is that the sphincter with tighten to prevent unwanted reflux.

Several other endoscopic techniques are also available. One injects bulking agents into the area where the stomach and esophagus meet. This can narrow the zone of the sphincter. There are also a variety of stitching devices that can be passed through an endoscope and, when properly deployed, tighten the lower esophageal sphincter.

It is important to emphasize that all of these endoscopic techniques are relatively new and the reports on their effectiveness vary, perhaps in part because of variability of the skill of those performing the procedure. Moreover, people who have served as controls by receiving sham procedures during trials also have a fairly high rate of apparent benefit.

Often the improvement noted initially is lost after six months. Although the stitching techniques seem to be the most promising, the long-term benefit, which must be measured over many years, cannot be assessed. Also, these endoscopic procedures are not performed on people who have large hiatal hernias.

The most commonly used surgical treatment for GERD is called a Nissen fundoplication. The upper stomach is wrapped around the lower esophagus, creating a natural barrier to protect against reflux. The surgeon is also able to reduce a hiatal hernia at the time of the operation.

When the operation is performed laparoscopically, as it often is nowadays, the hospital stay is brief and recovery is quite swift. Unfortunately, there aren't hard data on long-term benefit of laparoscopic fundoplication, but it is regarded as a more reliable procedure than the recently introduced endoscopic therapies.

One of the most important things to remember is the value of selecting a highly experienced person — endoscopist or surgeon — to perform the procedure.

Stephen Goldfinger, M.D., is a professor of medicine at Harvard Medical School. He is a graduate of Columbia College of Physicians and Surgeons, and his clinical base is at the Massachusetts General Hospital.

Last updated:	April 17, 2007
Reviewed By:	Faculty of Harvard Medical School