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Surgery No Savior for Severe Heartburn

Complications, cancer risk aren't lowered

TUESDAY, May 8 (HealthScout) -- Surgery does no better than drug treatment to reduce the symptoms of the painful, periodic heartburn called gastroesophageal reflux disease (GERD), and most people who have the operation eventually have to start taking medications again, a new study finds.

But the study also has some good news. "The thing people with GERD worry about most is cancer of the esophagus. Even though the risk of cancer is increased, the increase is smaller than we thought," reports study leader Dr. Stuart Jon Spechler in the May 9 Journal of the American Medical Association.

Spechler says a major point of the study is that "if you are going into the operation with the expectation that you will never have to take medication again, that is not the case. For the short term, that may be true. But after about two years, it appears that the effect wears off, and two-thirds of the people who had surgery are taking medication on a regular basis." Spechler is chief of the division of gastroenterology at the Department of Veterans Affairs Medical Center in Dallas.

Perhaps one in five Americans experiences GERD symptoms, such as heartburn and stomach acid regurgitation at least once a week, surveys have found. GERD can be accompanied by Barrett's esophagus, a chronic irritation associated with an increased risk of esophageal cancer. Most patients can get relief by taking proton pump inhibitors, drugs such as Prilosec and Prevacid that reduce production of stomach acid. But development of minimally invasive techniques have made surgery more popular.

The study took a second look at 160 patients who had either surgical or medical treatment for GERD in a 1986-1988 Veterans Administration study which originally included 239 patients.

Answers to a detailed 36-item questionnaire showed that 83 of the 90 medical patients were still taking anti-reflux drugs regularly. But so were 23, or 62 percent, of the 37 surgical patients. And "we couldn't find any significant difference between medically and surgically treated patients in the incidence of any complication," says Spechler, who is also professor of medicine at the University of Texas Southwestern Medical Center in Dallas.

The incidence of esophageal cancer was low, occurring at an annual rate of 0.4 percent in patients with Barrett's esophagus and 0.04 in those without the condition. Those rates are lower than generally estimated and should prompt "a re-evaluation of current screening and surveillance guidelines," the researchers say.

One bad-news finding was a higher death rate among surgical patients. The study found most deaths were caused by heart disease, and so "it seems prudent to advise patients who are to undergo or who have had anti-reflux surgery to make extra efforts to control their risk factors for cardiovascular disease."

Who should have surgery for GERD? "People who are shown to be refractory to or intolerant of medical treatment," says Dr. Peter J. Kahrilas, chief of gastroenterology at Northwestern University Medical School in Chicago and author of an accompanying editorial. "That represents a small percentage of cases."

The study is convincing because "it is the largest ever published, with the longest follow-up," Kahrilas says. "It has become a bit easier for physicians to offer patients with GERD reasons not to have anti-reflux surgery," he writes.

Proton pump inhibitor drugs so far have had only minimal side effects, Spechler says, "but what we worry about are possible long-term effects, because they have been available only since about 1990. There are theoretical concerns about the effects of reducing stomach acid over a long period of time. But for the 10-year experience we do have, they seem to be extremely safe."

What To Do

Anyone with GERD may consider surgery "if you have very bad symptoms, or complications such as ulcers in the esophagus. That would be about the top 5 percent of patients," says Spechler.

For more information on heartburn, try the National Institute of Diabetes and Digestive and Kidney Disorders or the American College of Gastroenterology .

Read other HealthScout articles about GERD.

SOURCES: Interviews with Stuart Jon Spechler, M.D., professor of medicine, University of Texas Southwestern Medical Center, Dallas, and chief, division of gastroenterology, Department of Veterans Affairs Medical Center, Dallas, and Peter J. Kahrilas, M.D., chief of gastroenterology, Northwestern University Medical School, Chicago; May 9, 2001 Journal of the American Medical Association
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