Surgery for Gastroesophageal Reflux Disease: Esophageal Impedance to Progress?

In the era that preceded the availability of proton pump inhibitors (PPIs) for the treatment of gastroesophageal reflux disease (GERD), physicians debated about which component of refluxed gastric juice was most harmful—acid, bile salts, or other noxious gastric substances. Those debates largely ceased in the 1990s when numerous studies showed that reflux esophagitis, no matter how severe, healed in the large majority of cases when gastric acid secretion was blocked by PPIs.¹ Today, medical therapy for GERD focuses almost exclusively on the control of gastric acid production with antisecretory medications, such as PPIs. Despite their great success in healing reflux esophagitis, however, PPIs fail to completely eliminate symptoms attributed to GERD in up to 40% of patients.² Furthermore, there has been a recent spate of publications warning of the potential dangers of chronic PPI therapy, such as increased risk for pneumonias, Clostridium difficile colitis, and hip fractures.³ Clearly, the medical treatment of GERD is far from ideal.