In procedures that function only by supporting the barrier function of the LES, symptoms typically recur in 6-12 months, requiring resumption of PPIs, if they were ever discontinued, Dr. Damani said. They also include the return of the complications of GERD in lung disease, which includes the damage to lung tissue associated with aspiration of acid as well as the extraesophageal symptoms, including cough, laryngitis and chest pain.
Nissen fundoplication performed with hiatal hernia repair was long regarded as the gold standard for surgical management of GERD, but this is now changing, according to Dr. Damani. She said most centers, including her own, are moving from this to the related Toupet fundoplication, which differs primarily by its use of a 270-degree rather than a 360-degree fundoplication.
By incompletely wrapping the esophagus with the gastric fundus, “the benefit is the same, but the risk of adverse events is much lower,” said Dr. Damani, referring to the bloating, flatulence, and discomfort experienced by some patients following the Nissen procedure. “It is now our operation of choice.”
This Toupet fundoplication, like the Nissen, can be performed laparoscopically or robotically, according to Dr. Damani, who said that efficacy and safety are achieved at a very high rate of consistency in high-volume centers.
However, Dr. Damani also reported that there has been progress with endoscopic approaches and reversible interventions for GERD. These expand the array of options and might be particularly attractive in patients who are poor candidates for surgery or those seeking a reversible intervention.
Of these options, Dr. Damani paid particular attention to the Linx reflux management system. This device is composed of a chain of titanium beads with a magnetic cord that are looped around the lower esophagus to add a barrier function. The level of the magnetic force allows the chain of beads to expand when food descends or gas rises but prevents transient LES relaxations. As a result of its ability to expand and contract, the device is “very dynamic,” Dr. Damani said.
Prior to placement of the device, “the hiatal hernia is dissected and closed like other effective procedures. Then the Linx device is sized and placed,” Dr. Damani explained. Importantly, this procedure can be reversed simply by removing the device.
“There is no side-by-side comparison with a Nissen, but the results have been excellent so far,” Dr. Damani said. The most significant concern is foreign body reactions, but the erosion rates have been reported as less than 0.1%, according to Dr. Damani, who noted that erosion, if it occurs, can be managed endoscopically.
She did caution that candidates for the Linx device must have normal esophageal motility and be free of metal allergies, but she has been impressed with its durable function.
Perhaps the most difficult question in assessing and treating GERD in the context of bronchiectasis is to determine when it is needed. Dr. Damani warned that many patients with lung disease exacerbated by GERD are asymptomatic, requiring a workup to determine if GERD is present. Even if present, it can be challenging to confirm that GERD is a major treatable contributor to poor lung function.
Illustrative of that point, Doreen J. Addrizzo-Harris, MD, codirector of the NYU Langone Health bronchiectasis & NTM clinical and translational program, and President of American College of Chest Physicians, described a patient with advanced bronchiectasis whose poorly controlled lung function had not been considered to be GERD related even though the patent had been inadequately responsive to multiple aggressive treatment strategies. The decision to surgically correct GERD was taken on the basis of diminishing alternative options.
“The improvement in lung function was substantial and rapid,” she said.
Dr. Addrizzo-Harris, who served as a chair of the 2023 World Bronchiectasis & NTM Conference, recounted this case to support the major potential improvements in selected patients with advanced lung disease when GERD is treated. She indicated that even experts overlook this variable.
This still does not answer the question of when to consider an invasive procedure for GERD, but “there is no hard and fast answer,” according to David Kamelhar, MD, who is the other codirector of the NYU Langone Health bronchiectasis & NTM clinical and translational program.
Dr. Kamelhar admitted that he does not immediately think of GERD as a strategy to control lung disease treatable in patients without GERD-related symptoms, but he has pursued this comorbidity in cases when he has “nothing else to offer.” He suggested that multidisciplinary management is one way to consider GERD as treatment target before it becomes a last resort.
As pulmonologists, “we are not GERD experts, so we need to bring in a gastroenterologist or a surgeon who can help with this decision,” he said, referring to when and how to intervene.
From Dr. Damani’s talk, he suggested that the take-home message is that GERD treatment options have improved, and it might make more sense to consider GERD as a treatable comorbidity of lung disease in earlier rather than later stages of disease.
Dr. Damani, Dr. Addrizzo-Harris, and Dr. Kamelhar reported having no potential conflicts of interest relevant to this topic.