Surgery versus medical therapy for gastroesophageal reflux disease

Abstract

Three hundred ten patients with erosive esophagitis were randomized to either open antireflux surgery or continuous therapy with omeprazole. Symptoms, endoscopy, and quality of life questionnaires were used to document the clinical outcomes. Treatment failure was the primary outcome variable. Treatment failure was deemed to have occurred if the patients developed moderate or severe heartburn or regurgitation, grade 2 esophagitis, or milder heartburn with odynophagia or dysphagia. The surgical patients were also considered failures if they required ≥8 wk of omeprazole therapy or if repeat surgery was considered. The medical patients were failures when their primary physician referred them for surgery while on medical therapy or if the patient decided for surgery. Follow-up data were available for 133/155 medically treated patients and 122/155 surgical patients. On omeprazole, 20 mg daily, 65/133 patients (49%) were in remission at 5 yr and 83/122 surgical patients (68%) were in remission. The authors state that when the omeprazole dose was increased to 40 or 60 mg/day, surgery was still slightly superior to medical therapy, but there was no statistical difference. The surgery group had more dysphagia, rectal flatus, and inability to belch than the medical group. Quality of life did not differ between the two groups. There were no differences in the outcome of Barrett’s esophagus or the recurrence of strictures. In fact, no new cases of Barrett’s were identified in either group.