For most middle-aged Americans, occasional heartburn is nothing serious. But when these episodes occur too often, they may signal a health problem: gastrointestinal esophageal reflux disease (GERD). During the past decade, surgeons have developed a laparoscopic procedure that is safe and effective in treating severe GERD. But is this kind of surgery as safe in the elderly as in younger patients?
L. Michael Brunt, M.D., associate professor of surgery at Washington University School of Medicine in St. Louis, decided to find out. He and several colleagues studied 339 patients ‹ male and female, old and young ‹ who underwent laparoscopic anti-reflux surgery at Washington University Medical Center between May 1992 and June 1998. Brunt divided the patients into two groups: 18 to 64 and 65 and older. Then he compared their post-operative results.
His findings, published in the September 1999 issue of Surgical Endoscopy, were decisive. Although the elderly patients had slightly longer hospital stays and a few more minor complications than the younger patients, their functional outcome was much the same. Both groups returned to full activity quickly, and neither had serious surgical side effects.
"We concluded that patients should not be excluded from undergoing laparoscopic anti-reflux surgery simply on the basis of age," says Brunt. "If elderly people have significant reflux disease that is not controlled by medical therapy and they have no factors that place them at high risk [during surgery], they should be candidates for this operation."
GERD is a common disorder. Seven percent of all Americans have symptoms of reflux, a burning sensation in the chest, sour-tasting fluid in the mouth and difficulty swallowing as often as twice a week. Smoking, caffeine and alcohol make the situation worse.
The problem is a one-way valve of the lower esophageal sphincter at the opening to the stomach. Normally this valve opens to admit food into the stomach; then it closes quickly. With GERD, the sphincter malfunctions, allowing food and stomach acid to flow back into the esophagus. The acid irritates the sensitive tissue in the esophagus, and over time can lead to inflammation, ulcers and scarring, or even a pre-cancerous change known as Barrettís esophagus.
In mild cases of GERD, patients and physicians can work together to find relief through non-surgical options. Raising the head of a bed can help; so can avoiding spicy foods and meals close to bedtime. Several over-the-counter drugs and prescription medications also may be effective.
But for some patients, the best solution is surgery. Over the years, surgeons devised effective open operations to prevent this reflux from happening. But they involved large, painful incisions and hospital stays of up to a week. Many patients were reluctant to have the procedure because of the surgical trauma.
In the early 1990s, many centers, Washington University Medical Center among them, introduced minimally invasive surgery, which offered fewer complications, less pain and faster recovery. It requires the use of a laparoscope, a tiny telescope attached to a miniature camera, which is inserted into the patient's body through a small incision. Images from inside the body are projected onto a television screen, allowing the surgical team to coordinate its movements and perform more complex operations.
Along with reflux surgery, this procedure has been used for gall bladder, hiatal hernia, spleen, adrenal, groin and colon surgery. Chest physicians and gynecologic surgeons do laparoscopic procedures. In 1990, the world's first laparoscopic kidney removal for a renal tumor was performed at Washington University Medical Center by Ralph Clayman, M.D.
A changing patient base
Several years ago, Brunt and his colleagues were asked to write a book chapter on minimally invasive surgery in the elderly. Brunt had already studied the effects of gall bladder surgery in older patients, but he found that little research had been done nationally on the effects of anti-reflux surgery in the same population.
"The elderly group is important to look at," he says. "It is the fastest-growing segment of the population. Often, the elderly may have other illnesses such as diabetes or high blood pressure that make surgery riskier; they also may present in a more advanced disease state."
So this elderly group would benefit if physicians could offer them a less traumatic, less invasive treatment. They might tolerate a minimally invasive procedure better; they would also be less likely to develop such complications as pneumonia and blood clots.
Brunt studied his two groups of patients, all of whom had been diagnosed with GERD. He excluded the few elderly patients with para-esophageal hernia, a condition that requires more complex repair. Instead, his team selected GERD patients who had standard laparoscopic anti-reflux surgery followed by routine check-ups one, three and 12 months later.
There was little difference between the younger and older groups. The average hospital stay for the elderly group was one-half day longer and these patients had a few more minor complications, but the results were otherwise comparable. Clearly, elderly GERD patients make good candidates for laparoscopic anti-reflux surgery and obtain much benefit from it.
"As our population ages, people not only are living longer but are also more active, doing things the elderly didn't used to do," says Brunt. "For older people with significant reflux, this operation can have a huge impact on the quality of their lives."
Note: For more information, refer to Brunt LM, Quasebarth MA, Dunnegan DL, Soper NJ, "Is Laparoscopic Anti-reflux Surgery for Gastroesophageal Reflux Disease in the Elderly Safe and Effective?" Surgical Endoscopy-Ultrasound & Interventional Techniques, 13(9), pp. 838-842, September 1999.
Journal
Surgical Endoscopy