GERD with bronchiectasis: New invasive interventions show benefit

NEW YORK – Newer invasive procedures for gastroesophageal reflux disease (GERD) are associated with lower risks of postprocedural complications when performed to improve control of bronchiectasis or other serious lung diseases, according to a surgeon who addressed the 6th World Bronchiectasis & NTM Conference.

“The options are not what they were 20 or 30 years ago,” according to Tanuja Damani, MD, surgical director of the Center for Esophageal and Foregut Health, NYU Langone Health, New York.

The more favorable benefit-to-risk ratio of the newer options might make them more attractive to consider earlier for control of GERD in worsening lung disease than interventions have in the past, Dr. Damani suggested.

The association between the presence of GERD and increased severity of bronchiectasis or many other lung diseases is well established, according to Dr. Damani. In the case of bronchiectasis, GERD not only impairs lung function and quality of life, but is strongly linked to greater symptom burden, more exacerbations, more hospitalizations, and even increased mortality.

Proton pump inhibitors (PPIs) are effective in reducing intragastric acid, a source of irritation and discomfort when the contents of the stomach are refluxed past the lower esophageal sphincter (LES), but Dr. Damani explained that this therapy is often inadequate. Control of intragastric acid is an oversimplification of a more complex pathophysiology.

“It is not just the lower esophageal sphincter,” she said, explaining that other factors, particularly hiatal hernias that often contribute to transient LES relaxations, can play an important role in postprandial transit of gastric contents into the esophagus.

“Any procedure aimed at reinforcing just the LES [without addressing other mechanisms of GERD] are destined to fail,” Dr. Damani said.

She backed up this assertion with examples. These include the many endoscopic procedures designed to strengthen the barrier function of the LES, such as the Stretta procedure or transoral incisionless fundoplication (TIF). Neither addresses the hiatal hernia. Both typically provide immediate symptom relief, but acid in the lower esophagus and symptoms return over time. This has been shown with pH testing, which Dr. Damani called the gold standard for monitoring GERD control.

 

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.

NEW YORK – Newer invasive procedures for gastroesophageal reflux disease (GERD) are associated with lower risks of postprocedural complications when performed to improve control of bronchiectasis or other serious lung diseases, according to a surgeon who addressed the 6th World Bronchiectasis & NTM Conference.

“The options are not what they were 20 or 30 years ago,” according to Tanuja Damani, MD, surgical director of the Center for Esophageal and Foregut Health, NYU Langone Health, New York.

The more favorable benefit-to-risk ratio of the newer options might make them more attractive to consider earlier for control of GERD in worsening lung disease than interventions have in the past, Dr. Damani suggested.

The association between the presence of GERD and increased severity of bronchiectasis or many other lung diseases is well established, according to Dr. Damani. In the case of bronchiectasis, GERD not only impairs lung function and quality of life, but is strongly linked to greater symptom burden, more exacerbations, more hospitalizations, and even increased mortality.

Proton pump inhibitors (PPIs) are effective in reducing intragastric acid, a source of irritation and discomfort when the contents of the stomach are refluxed past the lower esophageal sphincter (LES), but Dr. Damani explained that this therapy is often inadequate. Control of intragastric acid is an oversimplification of a more complex pathophysiology.

“It is not just the lower esophageal sphincter,” she said, explaining that other factors, particularly hiatal hernias that often contribute to transient LES relaxations, can play an important role in postprandial transit of gastric contents into the esophagus.

“Any procedure aimed at reinforcing just the LES [without addressing other mechanisms of GERD] are destined to fail,” Dr. Damani said.

She backed up this assertion with examples. These include the many endoscopic procedures designed to strengthen the barrier function of the LES, such as the Stretta procedure or transoral incisionless fundoplication (TIF). Neither addresses the hiatal hernia. Both typically provide immediate symptom relief, but acid in the lower esophagus and symptoms return over time. This has been shown with pH testing, which Dr. Damani called the gold standard for monitoring GERD control.

 

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.

NEW YORK – Newer invasive procedures for gastroesophageal reflux disease (GERD) are associated with lower risks of postprocedural complications when performed to improve control of bronchiectasis or other serious lung diseases, according to a surgeon who addressed the 6th World Bronchiectasis & NTM Conference.

“The options are not what they were 20 or 30 years ago,” according to Tanuja Damani, MD, surgical director of the Center for Esophageal and Foregut Health, NYU Langone Health, New York.

The more favorable benefit-to-risk ratio of the newer options might make them more attractive to consider earlier for control of GERD in worsening lung disease than interventions have in the past, Dr. Damani suggested.

The association between the presence of GERD and increased severity of bronchiectasis or many other lung diseases is well established, according to Dr. Damani. In the case of bronchiectasis, GERD not only impairs lung function and quality of life, but is strongly linked to greater symptom burden, more exacerbations, more hospitalizations, and even increased mortality.

Proton pump inhibitors (PPIs) are effective in reducing intragastric acid, a source of irritation and discomfort when the contents of the stomach are refluxed past the lower esophageal sphincter (LES), but Dr. Damani explained that this therapy is often inadequate. Control of intragastric acid is an oversimplification of a more complex pathophysiology.

“It is not just the lower esophageal sphincter,” she said, explaining that other factors, particularly hiatal hernias that often contribute to transient LES relaxations, can play an important role in postprandial transit of gastric contents into the esophagus.

“Any procedure aimed at reinforcing just the LES [without addressing other mechanisms of GERD] are destined to fail,” Dr. Damani said.

She backed up this assertion with examples. These include the many endoscopic procedures designed to strengthen the barrier function of the LES, such as the Stretta procedure or transoral incisionless fundoplication (TIF). Neither addresses the hiatal hernia. Both typically provide immediate symptom relief, but acid in the lower esophagus and symptoms return over time. This has been shown with pH testing, which Dr. Damani called the gold standard for monitoring GERD control.

 

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.