Wrong-Way Traffic in the Gullet

Abstract

The traditional rivalry between medicine and surgery in the therapy of gastrointestinal disorders—peptic ulcer, Crohn disease, ulcerative colitis—has not bypassed gastroesophageal reflux. As expected, competition focuses on the moderately severe cases. Patients with mild to moderate symptoms of postprandial or postural discomfort, who do well on medical treatment, pose no dilemmas, nor do the advanced cases with intractable esophagitis, bleeding, esophageal ulcer, or stricture, for whom surgery appears to be the inevitable answer. Quandaries arise only when patients with distressing symptoms of as yet uncomplicated reflux respond poorly to medical treatment. Should the physician persist with this treatment? And, if so, for how long? As a result of recently acquired insights into the nature of gastroesophageal reflux, surgery has much more to offer to the sufferer from this disorder than it did but a short while back. Manometric measurements have now conclusively demonstrated that an incompetent physiologic gastroesophageal sphincter (pressure