Secrets for the best possible outcomes in reflux patients

They aren’t really secrets at all and indeed are mostly derived from simple common sense and self-evident “truths”. However, they are also based upon published evidence, the opinion of experts in the treatment of patients with these problems and best practice. The list may not be comprehensive but while the contents may seem obvious, sadly too often they are not all implemented or developed consistently within a single service. We suggest that they should form the key principles defining a specialist reflux centre or service:

Specialisation

It’s accepted in many fields of medicine and indeed in most aspects of human endeavour that when individuals and teams specialise, they tend to get better at what they do. That’s why there are for instance specialist cancer centres and surgeons. Of course, this wasn’t always the case and clinicians and their supporting teams have gradually moved away from being generalists to allow them to focus on specific problems. It’s a quirk of history that non-malignant gastro-oesophageal problems haven’t ever been seen as a specialist field in their own right. There are very few specialist training programmes or consultant gastroenterologists, upper GI or ENT surgeons who specialise in functional disease. Consequently, most patients get treated by clinicians who spend the majority of their time treating other conditions, perhaps cancer or obesity. While this approach may be dictated by the constraints and priorities of the NHS or other large healthcare systems, it doesn’t help many patients achieve the best outcomes. And there’s a lot of published evidence that more experienced clinicians are likely to achieve better results than less experienced ones- common sense really!

RefluxUK’s approach.

We specialise in the assessment and treatment of benign foregut pathology. Our clinicians are specialists in the management of benign gastro-oesophageal symptoms, their investigation and treatment; that’s why they’re part of our team as they share our focus.

Numbers matter

It’s also accepted that surgeons and their teams deliver the best outcomes when they perform procedures regularly. Again, this should come as no big surprise; you wouldn’t expect to become good at anything if you did it only infrequently. There’s good evidence to support this; studies have shown that complications occur twice as often in centres performing small rather than even modest numbers of anti-reflux operations. And yet there are no guidelines let alone regulations dictating the numbers of procedures that reflux surgeons should perform annually. Consequently, even in the UK there are centres and surgeons performing on average considerably less than one reflux operation per week.

RefluxUK’s approach.

Because we see so many patients with reflux symptoms, we get to treat many of them with interventions. The RefluxUK team collectively perform more reflux operations than any other private group in the UK and even many NHS centres. All our clinicians regularly undertake high volumes of diagnostic and treatment procedures. Our surgeons are leaders in their fields and include pioneers in LINX®️ and robotic surgery. All perform among the highest numbers of anti-reflux operations each year in the UK. Similarly, because they’re specialised the ENT surgeons, gastroenterologists and physiologists we work with also see enormous numbers of reflux patients every week and so we hope to achieve as good outcomes in the majority of patients who never need surgery.

Outcome and data collection

Measuring outcomes is obviously important. Today, in most fields of medicine there are complex and comprehensive systems in place to record these; for instance survival rates after cancer surgery, or revision rates after hip replacement. This is not the case in centres treating patients with reflux symptoms. It’s true that most hospitals will record specific measures such as complications following surgery, wound infections or unexpected re-admission. But in the treatment of patients with reflux symptoms this is only of marginal value. What matters most to the majority of patients with reflux symptoms is getting the right diagnosis, treatment and enjoying an improved quality of life. This is especially important following interventions such as surgery which have the potential to have negative as well as positive effects. Most hospitals do not record for instance patient reported outcomes following anti-reflux operations even 6 months later let alone after 5 years and even fewer whether or not the service provided to patients who do not undergo surgery was viewed by the patients themselves as successful or not. We think it’s true to say that most clinicians and surgeons treating patients for reflux won’t have more than a very superficial appreciation of whether or not their whole service is successful or not.

RefluxUK’s approach.

We collect Patient Reported Outcome Data from every patient that we see. We’ve been collecting similar data on every patient undergoing surgery up to five years following their operation and publish this from time to time. And we ask everyone how they rate our service. As we develop we will be collecting more and more information automatically to guide better our systems and treatment.

Access to modern tests and investigations performed by experts

The assessment of all medical conditions in based upon the history, clinical examination and then special investigations. There’s no doubt that experienced clinicians are likely to be in a position to learn more from a patient’s history than others. But, reflux symptoms can be caused by many different conditions requiring very different treatment options and are often complex in origin. Reliance on simple assessments of anatomy to exclude other serious pathology often provide little help in reaching a definitive diagnosis and multiple investigations can sometimes be necessary to reach one. So, for instance a normal upper GI endoscopy (Gastroscopy) does not rule out reflux, and a barium swallow is a very inaccurate test to measure reflux. Reaching the right diagnosis often depends on specific tests. Furthermore there is good evidence that even with routine investigations such as endoscopy there can be variation in reporting and that expert and experienced upper GI endoscopists will achieve the most accurate results.

Furthermore, in recent years there have been enormous advances in technology and the introduction of new sophisticated investigations that allows a far greater understanding of the functional causes of symptoms derived from the oesophagus, stomach, small bowel and their impact on the oesophagus, throat and lungs. For instance, the measurement of non-acidic reflux as well as reflux in throat itself is now possible and its impact on the precipitation of symptoms in the throat caused by reflux (so-called LPR). These tests are not widely available and certainly the interpretation of the results depends upon a very close working relationship between the clinicians who request them and the physiologists who perform them.

RefluxUK’s approach.

We use the most up-to-date technology and work with some of the UK’s leading endoscopists and physiologists to help reach a definitive diagnosis. As well as the usual and widely available tests such as endoscopy we also regularly offer other tests including impedance reflux testing, Bravo capsule endoscopic pH tests and Restech 24 hour pharyngeal pH tests. We provide home breath tests for SIBO and gastric emptying. We’re constantly looking at new ways to assess GI function to improve our understanding of disease and its effect on symptoms and well-being.

A truly patient focused approach

Treating patients with reflux symptoms requires a different approach to many other conditions. What really matters is listening to what functional effect symptoms are having upon their quality of life and what they want to achieve rather than basing treatment on specific diagnoses or test results. For instance, many people will have a hiatus hernia which causes no symptoms at all- its presence does not require surgery. Equally, assuming that because a hiatus hernia is only small must mean that it doesn’t require treatment is equally wrong. On the other hand, reflux causing vocal problems which to most people may be only irritating may be catastrophic for a singer. And while the evidence is that PPI drugs are mostly safe, many patients simply don’t want to take them long-term. It’s therefore imperative that patients are given the opportunity to guide their own treatment by being advised as to all the options and their pros and cons. This approach has been adopted in many fields of medicine but the historical deferential relationship between doctor and patient in which the latter “advises” the former what to do sadly persists too often in the treatment of patients with reflux symptoms.

RefluxUK’s approach.

RefluxUK’s fundamental philosophy is to empower patients. Our website is designed to inform and educate and we use the same approach when discussing the options for investigation and treatment. We employ a specialist nurse to help provide clinical advice and to liaise with patients directly and of course we ask all our patients to tell us how we’ve done. Ultimately we’re only as good as the outcomes we achieve and they’re dependent on the perceptions of our patients.

Teamwork and a multi-disciplinary approach

Diseases of the foregut can manifest themselves in myriad different ways. For instance, it's increasingly recognised that Laryngo-Pharyngeal symptoms can be caused by reflux from the stomach. This may be caused by a defective lower oesophageal valve but equally it's being increasingly understood that problems originating much further along the gut in the small bowel may also be responsible. Patients can present with all sorts of symptoms and often their assessment requires complex investigations to reach a diagnosis.

It’s been known for decades that in complex conditions the best outcomes are achieved when clinicians with different but complementary expertise work together in so called “Multi-Disciplinary Teams” or MDT’s. Because traditionally patients with reflux symptoms haven’t been seen as a priority by either clinicians or health systems there are very few functioning MDTs dedicated to assessing and treating this group of patients.

RefluxUK’s approach.

To our knowledge we were the first group of clinicians in the UK to introduce a regular MDT meeting in which all complicated patients and those awaiting surgery are discussed. It is organised by our specialist nurse and its membership include some of the UK’s foremost experts in medical and surgical gastroenterology, ENT, physiology and psychology. We all contribute our advice and experience and collaborate in decision making with the intention of reaching the best conclusion for every patient.

Not giving up

Reaching a diagnosis in patients presenting with reflux symptoms can be difficult. Gastro-oesophageal reflux itself is incompletely understood. There are many misconceptions among non-specialist clinicians and even debate among experts. For instance, we now know that non-acidic reflux can cause reflux symptoms, but the condition is historically defined by measuring excessive acid in the oesophagus. A negative pH acid test therefore does not necessarily exclude reflux as a cause of symptoms although many would presume it did. Similarly, a poor response to PPIs does not exclude the diagnosis of reflux either for similar reasons. And there are other potential rarer causes of symptoms which often require specialist tests. Reaching a treatment plan can therefore take time and can require a relentless pursuit of the cause of symptoms. Simply excluding a serious cause such as cancer often will not solve a patient’s quality of life issues.

RefluxUK’s approach.

It’s not always possible to reach a completely satisfactory outcome but we know from the experience of treating so many patients that it is usually possible with determination and perseverance. Many will come to us because they’ve entered what we call “the cycle of frustration”, seeing clinician after clinician without reaching a conclusion. We can’t promise that we can always achieve this but can promise that we will do our best.

Comprehensive treatment options

Most patients with functional foregut diseases can be successfully treated by relatively simple interventions such as dietary modification or simple anti-acid medications. However, for many these are ineffective. There is an increasing choice of options for these patients including endoscopic procedures such Stretta®️, Esophyx®️ and GERD-X®️, newer surgical operations such as LINX®️ and RefluxStop™ as well as the traditional fundoplication procedures. These all have potential benefits and risks and it's certainly likely to be true that what’s right for one patient is not necessarily right for another. Most centres will offer a limited programme and inevitably this limits choice and options for patients, potentially depriving them of the best outcome.

RefluxUK’s approach.

Our approach is to offer a comprehensive choice of treatment options to all our patients. We work with some of the UK’s most expert reflux surgeons who are at the cutting edge of new technology and procedures. We offer LINX and RefluxStop as well as both Nissen’s and partial fundoplication. Many patients will not be suitable for the endoscopic procedures but for those who are we offer the TIF procedure and, in the next few months, will be able to provide the GERD-X. We believe that it is important to participate in clinical research and treat patients according to the best scientific evidence.

Passion and focus

The biggest secret of all is the simplest but the most difficult to pin down. Without passion it's always going to be a challenge to excel at any human endeavour. We hope that it's obvious from the aforementioned and everything that we do that RefluxUK and everyone who works in partnership with us is completely focused on achieving the best possible outcomes in reflux patients- because that’s what we do!