Borderline Indications and Selection of Gastroesophageal Reflux Disease Patients: ‘Is Surgery Better than Medical Therapy'?

Abstract

Modern medical therapies for gastroesophageal reflux disease (GERD) are totally dedicated to the control of the acid component of the refluxate. In chronic erosive GERD, antireflux surgery has proven to be very efficacious and superior to traditional medical therapies, such as H₂ blockers. The introduction of proton pump inhibitors (PPIs), however, substantially improved medical therapy. Still, treatment failures are inevitable regardless of which of these two effective therapies is chosen. Some recent reports have presented conflicting results from trials comparing antireflux surgery and PPIs. This may be due to differences in trial designs as well as in the structure and content of the therapeutic strategies that are compared. The study with the longest clinical follow-up by far is the SOPRAN study comparing open antireflux surgery and omeprazole. The protocol provides for a follow-up period of more than a decade and the clinical outcomes have recently been published. There has always been concern about the long-term effectiveness of reflux prevention whether by surgery or PPI therapy. It is likely that a marker for an emerging risk for recurrence of GERD is abnormal acid reflux as assessed by ambulatory 24-hour pH-metry. The LOTUS trial compared maintenance therapy provided by esomeprazole (dose-adjusted when required) with standardized laparoscopic antireflux surgery in patients with good response to acid suppressive therapy. An operation is suitable when symptoms are poorly controlled despite medication, especially for patients who suffer large-volume regurgitation and those who wake at night coughing and choking and who regurgitate acidic fluid or food into their throat and airways. Regurgitation into the throat upon stooping or exercising can limit a patient's ability to work, play sports or even do simple housework. A few patients cannot tolerate medical treatment. If surgery is to be a good option, it must be ensured that the right surgeon performs a standardized operation for the right indications on the right patient and provides good preoperative counseling and testing along with postoperative support. When a patient is refractory to medical treatment, the diagnosis of GERD should be reconsidered before surgery is advised; extradigestive manifestations should be accounted for with care. Conclusions: Laparoscopic fundoplication (LF) substantially improves GERD symptoms, although in some individuals symptoms return and acid-suppressive medication use increases. Limited data suggest that LF is less effective at reducing symptoms in partial responders to medical therapy than in complete responders. This may affect cost arguments for using fundoplication surgery rather than acid-suppressive medications, as data are based largely on complete responders.