Aggressive medical therapy can be expected to control symptoms in up to 90 percent of patients with GERD. The success with medical treatment of patients with more advanced degrees of GERD (Barrett's esophagus, esophageal stricture) may not be as effective. Several treatment options are commonly utilized by physicians to treat their patients with GERD. Current therapeutic regimens make use of the histamine H2-receptor antagonists (e.g., cimetidine or ranitidine) for control of mild to moderate reflux symptoms. Many of these agents are now available as "over-the-counter" lower-strength versions (e.g., Axid, Tagamet and PepcidTM). Some patients will require the use of more powerful anti-secretory medicines (e.g., omeprazole or lansaproxole) to reverse reflux symptoms and the associated esophageal inflammation caused by the refluxed acidic stomach contents. Many primary care physicians and gastroenterologists also include the prokinetic agent cisapride (propulsid) in the therapeutic regimen. This combination of acid suppression and prokinetic agents can improve symptoms in the majority of GERD patients. At the present time, many physicians elect to keep their patients on long-term intermediate dose acid suppression drug regimens if the regimens appear to be clinically effective. The concern of possible induction of gastric neoplasia among long-term users of these acid-suppressing agents appears to be diminishing. The absolute answer regarding this cancer risk is yet to be determined as the long term (greater than 10 year) follow-up with these agents is inadequate. However, many surgeons caring for patients with esophago-gastric cancer are concerned by the apparent increase in the frequency of adenocarcinoma involving the gastroesophageal junction, which coincidently occurred since the introduction of the histamine H2-receptor antagonists (e.g., cimetidine and ranitidine). The more intense acid suppression caused by the proton pump inhibitors previously mentioned (prilosec and prevacid) provide even more cause for concern. Accordingly, we continue to recommend only intermediate-term use of these proton pump inhibitors as medicinal measures for the acute reversal of acid-reflux-induced esophageal injury. We recommend an esophago-gastro-duodenoscopic examination to assess the degree of esophagitis associated with recalcitrant symptoms prior to utilizing proton-pump inhibitor therapy among our patients who have failed to respond to histamine-2 blocker therapy. When significant esophageal inflammation consistent with reflux esophagitis is present, we recommend an 8- to 12-week treatment trial with prilosec or prevacid. Many gastroenterologists elect to rapidly escalate the prescribed dose within reason during the early phase of therapy until GERD symptoms are abated. Endoscopic surveillance two to three months after the initiation of therapy with these proton pump inhibitors is usually recommended to ensure that the inflammatory process has cleared. Most physicians tend to replace the proton pump inhibitor regimen with histamine-2 blocker maintenance therapy once the inflammation has come under control.

Table 3 - Indications for anti-reflux surgery

Intractable persistent reflux symptoms despite aggressive medical management Persistent troubling regurgitation or reflux-induced respiratory symptoms after control of acidic reflux Recurring severe reflux symptoms or reflux injury (peptic stricture, esophageal ulceration, bleeding) in spite of adequate maintenance medical anti-reflux therapy Barrett's esophageal metaplasia

Although many GERD patients will respond to this treatment algorithm, some will have recurrence of unacceptable symptoms once the prilosec or prevacid is discontinued. Another subset of patients will have only partial relief of symptoms with standard dosage regimens of proton pump inhibitor therapy. As GERD is recognized to be a disease with peaks and valleys in symptom intensity, it is reasonable to repeat the therapeutic cycle. However, anti-reflux surgery may have considerable benefit among this group of patients with recurring GERD symptoms. Surgical reconstruction of the lower esophageal sphincter has also been shown to be an effective means of reversing the esophageal injury (esophagitis) resulting from GERD (Table 3). Surgical management has also been successful in obtaining long-term relief of GERD symptoms and in improving the quality of these patients' lives. The maturation of clinical experience with minimally invasive laparoscopic approaches to anti-reflux surgery over the last few years has moved many gastroenterologists, surgeons and patients to look to these operative procedures as attractive alternatives to long-term medical management of GERD.

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