Gastroesophageal reflux disease: the ongoing saga of pill versus knife.

Abstract

The Department of Veterans Affairs Cooperative Studies Program conducted a trial comparing the efficacy of medical and surgical therapy for complicated gastroesophageal reflux disease (GERD) in the 1980s and found surgery to be more effective in improving symptoms and endoscopic signs of esophagitis for up to 2 yr. To determine the long term efficacy of medical and surgical therapies, Spechler et al. conducted a follow-up of the trial. Ninety-one medical and 38 surgical patients of the original 247 patients were asked to maintain 2-wk GERD symptoms diaries (1 wk on and 1 wk off antireflux medications). Gastroesophageal Reflux Disease Activity Index (GRACI) scores were calculated, with the range being 74 (no symptoms) to 172 (worst symptoms). Patients also underwent upper endoscopy and 24-hr esophageal pH monitoring after stopping antireflux medications. One week after discontinuing medications, Gastroesophageal Reflux Disease Activity Index scores were found to be significantly lower in the surgical group (82) than in the medical group (96). There was no difference in the grade of esophagitis, occurrence of esophageal adenocarcinoma, frequency of treatment of esophageal strictures, quality of life scores, and overall satisfaction with antireflux therapy. More deaths were reported in the surgical group, though none of the deaths were related to surgery. Ninety-two percent of the medical and 62% of the surgical patients had continued to use antireflux medications regularly over a mean follow-up of 10.6 and 9.1 yr, respectively. Cancer incidence among patients with severe GERD without Barrett's esophagus was found to be 0.07%/yr. The authors concluded that antireflux surgery should not be advised with the expectation that GERD patients will no longer require antireflux medications or that the surgery will prevent esophageal cancer among patients with GERD and Barrett's esophagus.