Vall d'Hebron has participated in the creation of a guide for the surgical treatment of gastroesophageal reflux in obese and non-obese populations

Health professionals from the Vall d'Hebron University Hospital have participated in the elaboration of the guide for the surgical treatment of gastroesophageal reflux created by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Unlike previous versions, this guideline has had the participation and approval of 6 international scientific societies, which makes it a document that will easily cross borders and have a worldwide scope. The paper was signed by 26 experts, the only Spanish representative being Dr. Ramon Villalonga, head of section of the Endocrine, Bariatric and Metabolic Surgery Unit of the Vall d'Hebron Hospital and researcher of the General Surgery research group at the Vall d'Hebron Research Institute. The final text has made it possible to create a visual treatment algorithm that serves as a guide for both the patient and the healthcare personnel.

Another innovation of the guideline is that it is the first time that preoperative tests, non-invasive techniques and the treatment of patients with obesity have been included in the analysis of the experts. The result has been thirteen recommendations divided into three aspects: Preoperative tests, possible treatments and specificities of care for the obese patient.

Regarding the most useful and effective preoperative tests, the research team classifies patients into two categories. If they have the typical symptoms of the disease, such as heartburn or vomiting, the essential tests are a pH test and esophageal manometry. The latter will be used to detect or rule out other conditions, such as achalasia. If they have less common symptoms (cough, chest pain, or hoarseness), a pH/impedance test should also be performed. This test uses a nasal catheter to measure the reflux experienced by a person over a 24-hour period.

Laparoscopic fundoplication remains the main intervention.

Next, the research team focused on the wide range of interventions available to treat reflux. As the most popular and longest-standing is gastric fundoplication, this was used as the main point of comparison.

The fundoplication is a surgical operation that consists of folding the upper part of the stomach around the end of the esophagus, creating a "scarf" that wraps around the digestive tract. This can be total, the fold makes a complete circle or partial, the fold makes a "U" shape, that is to say that its ends do not touch, leaving a space in which the esophagus is "bare". The latter is considered optimal by experts as it has fewer post-intervention complications. The recommendation is even stronger in patients who experience swallowing difficulties.

The other surgical intervention proposed to combat the pathology is the MSA which consists of placing a magnetic titanium ring around the lower esophagus. The idea is to strengthen the tube passage to prevent reflux from coming up. These two operations have been considered to have similar results, therefore, the choice will depend on the decision of the physician and the patient according to the results of the international study.

New less-invasive interventions

In addition to operations that require a significant incision, the research team has also analyzed less invasive interventions. These include an endoscopic fundoplication, which is the same procedure as the traditional one, but with much smaller cuts. The main problem is that it requires a great deal of experience from the surgeon and is still too recent to have reliable data on its long-term effectiveness.

Another possibility is TIF 2.0, which is a process similar to fundoplication but done from the inside, that is, a robotic arm is introduced through the mouth into the stomach and once there, the upper wall of the stomach is folded into the esophagus from the inside. The guide considers that this operation is not as consolidated as the previous ones, therefore it is only recommended for people who do not want to undergo surgery. They remind that this intervention is especially dangerous for people who have a small jaw opening or difficulties with experiencing a hyperextension of the neck. Although they recognize that there is not enough data to make a definitive assessment and that further studies could improve the position of the TIF 2.0.

The latest intervention they have analyzed is called Stretta, a new method that uses radiofrequency wave pulses to tighten the esophageal sphincter and thus improve its function. It is an intervention for which there is not much data to demonstrate its efficacy, and in fact it has not yet been ruled out that the improvements experienced by some patients are not due to the placebo effect. On the other hand, it is a relatively simple operation, which can be performed more than once and is not incompatible with other more invasive operations if there is not enough improvement. In view of all these considerations, the scientific team recommends using this technique only with people who have mild symptoms and fear an intervention.

The last three techniques have in common that they all involve an easier recovery; even so, they do not allow treating other pathologies in the same intervention. Many patients with severe reflux also have a hiatal hernia, and surgeons use fundoplication and MSA to repair it. Therefore, in case of hernia, it is more advisable to choose an operation that allows both pathologies to be repaired.

All interventions have been considered preferable to the chronic use of proton pump inhibitor pills, as these can cause osteoporosis in the long term, with a subsequent increase in the risk of fractures and other complications.

Specificities for patients with obesity

A great part of adults with obesity suffer from reflux, it is considered that a Body Index higher than 30 means 2.5 more possibilities of developing the pathology. Although the optimal operation to stop reflux is still fundoplication, it will not help to fight obesity, therefore, it may be only a temporary solution. In addition, if the patient's body index is very high, it is not advisable to perform several operations.

From here, the research team analyzed whether some weight reduction operations could do double duty and help reflux. Vertical sleeve gastrectomy, which involves cutting out part of the stomach, was found to be suboptimal. Studies suggest that it may even cause reflux in patients who did not previously suffer from it. Instead, they recommend a gastric bypass, which combines a greatly reduced stomach capacity with a bypass into the small intestine that results in reduced absorption of nutrients. This strategy of performing a gastric bypass is most beneficial for patients with grade I, II or III obesity, because it treats the underlying disease (obesity) as well as severe reflux disease with hiatal hernia or not concomitant. This operation has been effective in achieving the dual purpose of reducing weight and reflux.

The research team hopes that the guide will help in the treatment of this disease which affects between 8.8% and 25.9% of the European population, in Spain it is estimated to be 15%.