Medical Management vs. Surgery for Gastroesophageal Reflux Disease
Am Fam Physician. 2010 Aug 1;82(3):244.
For adults, does medical or surgical management of gastroesophageal reflux disease (GERD) result in better outcomes?
At one to three years, adults with GERD who were treated with laparoscopic fundoplication had more improvement in overall and GERD-specific quality of life scores and less exposure to acid in the lower esophagus compared with patients who use proton pump inhibitors (PPIs) and histamine H2 blockers. Participants in the study had characteristics typical of patients with GERD for whom surgery might be considered. (Strength of Recommendation = A, based on consistent, good-quality patient-oriented evidence)
Options for GERD management include lifestyle changes such as losing weight, elevating the head of the bed, avoiding late meals or specific foods, and avoiding specific activities that exacerbate symptoms. However, these measures have not been studied in clinical trials. For medical management, PPIs are more effective than H2 blockers, and both are more effective than placebo. Long-term use of PPIs is often necessary to control symptoms in patients with esophagitis.1
In this Cochrane review, the authors searched for randomized and quasirandomized trials comparing treatment of GERD with medical management versus any type of surgical fundoplication. The authors found four studies with a total of 1,232 participants who were followed from one to three years. The studies had a low to medium risk of bias. Although all four studies favored surgery over medical management for the outcome measure of health-related quality of life, data from only two studies could be combined.
The 36-Item Short Form Health Survey (SF-36) is scored from 0 to 100 and measures physical and social functioning, physical and emotional role limitations, mental health, energy, pain, and general health. Compared with medical therapy, the mean difference on scores from the SF-36 was –5.2 (95% confidence interval, –6.8 to –3.6) in favor of surgery. However, a difference of less than 10 may not be clinically significant on this scale. GERD-specific quality of life measures also favored surgery in all four studies. Complication rates in both groups were low. Overall, 4 percent of patients had postoperative complications. In one study, serious adverse events occurred in 21 percent of the surgical group and 14 percent of the medical group. Longer-term comparisons of outcomes were not identified by the authors. Although laparoscopic fundoplication is more costly than medical management in the short and medium term, it may be cost-effective in the longer term.1
Because of their safety, the American Gastroenterological Association recommends that PPIs should be the initial therapy, with surgery offered as an alternative if the patient is not responsive to or does not tolerate medical therapy.2
Wileman SM, McCann S, Grant AM, Krukowski ZH, Bruce J. Medical versus surgical management for gastrooesophageal reflux disease (GORD) in adults. Cochrane Database Syst Rev. 2010;(3):CD003243.
1. Epstein D, Bojke L, Sculpher MJ; Reflux trial group. Laparoscopic fundoplication compared with medical management for gastrooesophageal reflux disease: cost effectiveness study. BMJ. 2009;339:b2576.
2. Kahrilas PJ, Shaheen NJ, Vaezi MF, et al. American Gastroenterological Association Medical Position Statement on the management of gastroesophageal reflux disease. Gastroenterology. 2008;135(4):1383–1391, 1391.e1–5.
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