American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

GERD surgery prevents cancers, but is it worth it?

OCTOBER 23, 2017
Clinical Congress Daily Highlights, Monday Second Edition

We’ve known for years that gastroesophageal reflux disease (GERD) can lead to esophageal cancer, said   Kenric Michael Murayama, MD FACS, Queen's Medical Center, Honolulu, HI. The unresolved issue is whether surgery to minimize acid reflux can ultimately prevent progression to cancer.

In a panel discussion moderated by Dr. Maruyama and Katie S. Nason, MD, MPH, FACS,  University of Pittsburgh, PA, speakers viewed this question from several angles — including considering alternatives to the “gold standard” of laparoscopic Nissen fundoplication, such as robotic fundoplication, LINX, and trans oral fundoplication (TIF).

Although robotic-assisted fundoplication is feasible, the outcomes are generally not better when compared with laparoscopic surgery, said Santiago Horgan, MD, FACS, University of California, San Diego. “The costs of robots are high and not justified considering the lack of patient benefits,” Dr. Horgan said.

Yet the cost of robotic surgery may come down as more makers of robotic surgery devices enter the market, he said. Robotic redo fundoplication may have better outcomes than laparoscopic procedures and should be considered for those patients, he said.

Another innovative approach is called LINX, in which a magnetic band is placed around the esophagus to act as a sphincter, reducing acid exposure without the side effects of other treatments such as surgery, said John Clarence Lipham, MD, FACS, University of Southern California, Los Angeles. LINX can also be used in cases of hiatal hernia, as long as the hernia is surgically repaired first. Patients often prefer this approach to more invasive approaches, especially since it minimizes symptoms of GERD. Surgeons can consider LINX as another tool to restore the GERD barrier, and to reduce acid reflux and potentially prevent cancer.

Trans oral fundoplication (TIF) is another alternative treatment to Nissen, said Siva Raja MD, PhD, FACS, Cleveland Clinic Foundation, Cleveland, OH. While the benefits of TIF include no incisions, a low complication rate and a low rate of dysphagia, bloating, and other postfundoplication symptoms, it appears to offer inferior antireflux control to fundoplication, and can be challenging to convert to conventional anti-reflux surgery. As a result, TIF’s role in the spectrum of GERD therapy, including cancer risk reduction, is at best uncertain, he said.

Once these alternatives to surgery were considered, two speakers presented the debate on whether or not surgery should be used to prevent cancer.

Defending surgery as a way to prevent esophageal cancer was Brian Edward Louie, MD, FACS, Swedish Medical Center, Seattle, WA. The pathway from GERD to Barrett’s and on to esophageal cancer is based on inflammatory changes, and antireflux surgery has been shown to reduce key inflammatory markers associated with Barrett’s development, he said. Surgery is likely to have a role in preventing development of Barrett’s, stabilizing, regressing or transforming Barrett’s, and treating dysplastic Barrett’s or cancer when combined with endoscopic therapy, he concluded.

Arguing against surgery was Sumeet K. Mittal, MD, FACS, Creighton University, Omaha, NE. Although he agrees that surgery likely decreases the rate of development of cancer, it should not be recommended as a standard mode of prevention. One reason is that you would have to treat 40 million cases of GERD to prevent 9,000 cases of esophageal cancer. However, in appropriately selected patients, surgery can provide a significant improvement in quality of life over current medical therapy.

Additional Information:
The Panel Session, GERD to Cancer: What's the Best Intervention?, was held October 23, at the 2017 Clinical Congress of the American College of Surgeons in San Diego, CA. Program, webcast and audio information is available online at FACS.org/clincon2017.

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