July 17, 2011

Medicine by Mechanics

Here's a little abstract from what really should be a bit of an earthmoving study for tuber folk, especially when we're talking paediatrics.


In essential form, what it points to is this: that the routine practice of doing "antireflux surgery" along with gastrostomy placement seems like a really bad idea now that some evidence is in.  We can safely assume that the "antireflux surgery" spoken of is the Nissen Fundoplication and its variations as this is the main surgical procedure currently indicated in modern medical practice for GER (Gastro Esophageal Reflux).  It's where a section of the stomach is grabbed and wrapped tightly around the bottom of the esophagus, like this:

But let's dig just a little deeper in, because this is interesting, and affects so many people.

This study is published in the Journal Of Pediatric Surgery, and the very first line of the abstract reads :

Previously, we performed concomitant antireflux surgery in patients with abnormal pH study undergoing gastrostomy. This increased complications without always alleviating the troublesome symptom of vomiting.

For me, this is a bit of a facepalm moment in itself.  Where, oh where, has the Hippocratic oath gone; you know, the one that roughly translates as "first, do no harm"?  I have this little problem with the trigger-happy attitude seen so widely - not everywhere mind you, but VERY VERY commonly encountered - in paediatric surgeons when it comes to dealing with reflux problems.

When you have a look at the participants in this study, the vast majority of them (93%) were having a tube placed due to 'oral insufficiency' - for one reason or another they could not take enough nutrition by mouth.  And only 10% of the patients did NOT have GER symptoms.  That is, they usually would have been getting a Fundoplication routinely along with their tube placement.  The study does not make clear exactly for whom the authors are speaking, but this is a peer-reviewed publication, and it would not be unwise to assume it speaks to the average American practice.  For this study though they just put the tube in and where reflux still occurred (and there is no data pulled to show whether the tube placement alone helped with the reflux, which I'd find rather useful to see) they managed it with meds.  Ultimately 7% of the patients were deemed to need surgical intervention.  As opposed to the 90% that would have got it previously just as a matter of course.  The Nissen Fundoplication has been with us since 1955 and only now does a study actually look into the outcomes in a quantifiable and responsible way.  I know I shouldn't be amazed, but such is the price of my eternal optimistic faith in humanity and rationality.

But did anyone notice how else we can read those figures?  Namely that there is an extremely high correlation between oral insufficiency and a pH test indicating GER.  Are we to be surprised that a person (child or adult) who is hungry, who does not have enough food in their stomach, has a high acid level?  All that stomach acid with not enough to do?

Seems to me some very simple things get overlooked when we let those who would see our bodies as mechanisms with parts first and as a whole organism second run away with their thinking.  We know from thee study done on this very site that changing diet from formula to a food-based mixture correlates extremely highly with improving or resolving reflux.  I know, I know, and I know how seldom this would ever be wondered about by doctors and dietitians when a tube-fed person is being spoken of.  In this day and age it's common for doctors not to even address diet with their oral-eating GER patients - "mostly it'd be just a waste of time" one doctor told me as "most people won't change their habits longterm anyway and they'll end up on meds sooner or later."


Anyway, pass this along.  Now we have some actual decent science showing clearly what so many of us have been saying for years.  That the vast majority of surgical interventions for reflux are just plain harmful.