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Surgery Is Not the Treatment of Choice for GERD

Many surgeons argue that surgical treatment of severe gastroesophageal reflux disease (GERD) is the best long-term approach because it provides long-lasting benefits, obviates expensive acid-suppressor medications, and reduces cancer risks associated with Barrett's esophagus. However, this opinion is challenged by long-term follow-up data on 247 patients (mean age, 58) with complicated GERD who were randomized to receive pharmacologic therapy or open fundoplication in a Veterans Affairs cooperative study (N Engl J Med 1992; 326:786).

Researchers located 97 percent of the original 247 patients 10 to 13 years after initial enrollment. Within that group, 92 percent of medically treated patients and 62 percent of surgically treated patients reported regular use of antireflux medications. No differences were found in symptom or health survey (SF-36) scores or in the frequency of strictures, adenocarcinoma development, or subsequent antireflux surgery. There was no difference in the incidence of esophageal cancer between the 2 groups, and surgery did not prevent the development of cancer. Unexpectedly, the mortality rate at follow-up was significantly higher in the surgical group than in the medical group (40 percent vs. 28 percent, respectively; relative risk, 1.57); cardiovascular disease was responsible for most deaths (48 percent and 20 percent, respectively). There were no surgery-related deaths.

Comment: Our surgical colleagues have advocated for a surgical GERD cure, but these long-term results demonstrate that surgery has few, if any, advantages over medical therapy. Instead of providing longer-lasting benefits, replacing antireflux medications, and reducing cancer risks, surgery is associated with upfront morbidity and mortality risks, eventual return to medical therapy, higher death rates due to cardiac disease and higher costs, and it does not prevent cancer. Therefore, it seems that the optimal therapeutic approach for most GERD patients is a pharmacologic one.

— DA Johnson

Published in Journal Watch Gastroenterology June 13, 2001

Citation(s):

Spechler JS et al. Long-term outcome of medical and surgical therapies for gastroesophageal reflux disease: Follow-up of a randomized controlled trial. JAMA 2001 May 9 285 2331-2338.

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Kahrilas PJ. Surgical therapy for reflux disease. JAMA 2001 May 9 285 2376-2378.

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