Are Proton Pump Inhibitors Comparable to Laparoscopic Anti-reflux Surgery in Long-Term Symptom Control of Gastroesophageal Reflux Disease? An Evidence-Based Review

Abstract

Purpose: The prevalence of gastroesophageal reflux disease (GERD) in United States is about 24%. GERD affects health-related quality of life and increases socio-economic burden due to its chronic nature. While medical treatment with proton pump inhibitors (PPIs) has been the main mode of treatment, laparoscopic anti-reflux surgery (LARS) is reserved for patients resistant to medical treatment. Though there are many clinical trials to compare the effectiveness of PPIs to LARS in symptom control of GERD, there is lack of evidence for the effectiveness of these treatments in the long-term symptom control. The objective of our evidence-based review is to compare efficacy of PPIs to LARS in long-term control of symptoms in patients with GERD. Methods: We searched “PubMed” and “Cochrane Library” using key words, “Gastroesophageal reflux disease”, “Proton pump inhibitors” and “Laparoscopic Anti-reflux Surgery.” We included randomized controlled trials comparing PPIs to LARS in patients with GERD from 1980 to 2011 and published in English. We included trials with a minimum follow-up of three years. Results: Two trials met the inclusion criteria and were included in this evidence-based review (trial by Galmiche et al. and trial by Anvari et al.). In the trial by Galmiche et al., the primary outcome of remission rates at 5 years in the esomeprazole group (n=288) and the LARS group (n =266) was 92% vs. 85% respectively (P = 0.05). Though there was no difference in remission rates in two groups, there was a difference in the prevalence of symptoms at 5 years. Frequency of symptoms in the esomeprazole and LARS groups was 16% vs. 8% for heartburn (P=0.14), 13% vs. 2% for acid regurgitation (P<0.001), 5% vs. 11% for dysphagia (P<0.001), 28% vs. 40% for bloating (P<0.001), and 40% vs. 57% for flatulence (P<0.001) respectively. In the study by Anvari et al., Gastro-Esophageal Reflux Symptom Score (GERSS) was used to compare the effectiveness of treatments at 3 years. At 3 years, the primary outcome, GERSS in the PPI group (n=52) was 9.05 as compared 6.21 in the LARS group (n=52) (P=0.17). However, heartburn-free days per week in PPI group were less compared to LARS group 5.98 vs. 6.81 days respectively (P=0.007). At 3 years, PPI group had improved acid reflux 9.46 (baseline) to 4.29 and the LARS group had improved acid reflux from 10.26 (baseline) to 2.11. However, the two groups did not differ significantly at 3 years in change from baseline (P=0.13). Conclusion: Our review shows that both PPIs and LARS have similar efficacy in long-term symptom control of GERD.