Posted by: Robert Sewell, MD, FACS on 1/13/2011 | 1 Comment
Exceptionalism in the Face of Disaster

 Gastroesophageal Reflux Disease (GERD) is an extremely common ailment, affecting millions of Americans everyday. Prior to the mid-1970’s all you heard about treating heartburn was the classic ad line, “How do you spell relief? R-O-L-A-I-D-S.” Well times have changed, and today we have a variety of medications, both prescription and over the counter, which have become the mainstay of the medical treatment of acid reflux. Beginning with the introduction of Tagamet and Zantac in the mid-1970s the list of heartburn medications has grown steadily for the last 35 years. As a group these drugs now represent the most widely prescribed and frequently taken class of medications in the US. It’s no wonder because they really do work. People who suffer with heartburn due to acid reflux often believe they are “cured” by these drugs because they are capable of essentially shutting off acid production by the stomach. So, even though they still reflux it doesn’t burn any more and they can go about living their lives.

The most powerful of the modern GERD drugs are known as proton pump inhibitors, or PPIs. They include Prilosec and Zegerid (Omeprazole), Protonix (Pantoprazole), Prevacid (Lanzoprazole), Aciphex (Rabeprazole), Nexium (Esomeprazole) and Dexilant (Dexlansoprazole). If you look at the generic names of each of these drugs they all end in prazole, referring to that chemical component responsible for stopping acid from being produced by the stomach. While some patients get better results from one than they do from another, the fact is they all work pretty much the same way. Interestingly it is not uncommon for one drug to work well for a period of time only to become ineffective. Changing to a different PPI may prove effective, assuming your insurance will pay for it; but that’s a whole different discussion.

For two decades the PPIs have been widely prescribed for both proven as well as merely suspected reflux. During that time there was little mention of potential side effects other than the fact that they occasionally cause cramping abdominal pain, diarrhea or constipation and excess gas, as well as a known interaction with the blood thinner Plavix®, But if you look more closely at the long-term effects of eliminating stomach acid there is a concern over what this does to Calcium absorption by the intestinal tract. Recently, the FDA reported on its review of a number of studies that demonstrated an increased risk of osteoporosis and pathologic fractures in patients who have been on PPI’s more than one year. This risk appears to be greatest in women over the age of 50 and increases with prolonged use of these medications. Calcium is simply not well absorbed when there is no acid in the stomach.

Certainly neither I nor the FDA are suggesting that everyone should stop taking PPIs; that is not at all practical. But if you are one of the millions of people who take medicine everydayfor heartburn you should know there are minimally invasive surgical procedures that can stop your reflux and thus the need for medications altogether. Perhaps the most exciting news in recent years has been the introduction of an incisionless surgery option for treating chronic reflux. The Transoral Incisionless Fundoplication (TIF procedure) can be used to strengthen the muscular valve between the esophagus and the stomach, and is performed entirely through the mouth, requiring no incisions. It is truly the definition of minimally invasive surgery.

While operations for reflux can provide some patients permanent relief from symptoms, they are not indicated for everyone. Prospective patients must first be properly evaluated, which includes an upper GI endoscopy to look for associated problems like hiatal hernia, esophageal stricture and other associated conditions. Additional tests may also be needed to not only prove the diagnosis of reflux, but also to help determine whether surgery is an appropriate alternative to a lifetime of pills.

If you’re interested in learning more about gastroesophageal reflux disease and its surgical treatment options go to www.robertsewellmd.com. There you’ll find videos explaining reflux as well as the available surgical options along with a number of patient testimonials. 

 


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