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Which Treatment Is Better for GERD?

Compared with medical therapy, surgery was associated with higher rates of continuous remission, but the results are questionable.

In the long-standing debate about whether medical or surgical therapy is the better approach for managing gastroesophageal reflux disease, proponents of medical therapy argue that controlling gastric acid and the refluxate can achieve the primary goal of healing erosions and managing symptoms, whereas advocates of surgery contend that definitive correction of the anatomy is more appropriate and results in superior outcomes.

To resolve this issue, investigators conducted a long-term, prospective, randomized, multicenter trial of medical versus surgical therapy involving 310 Nordic patients with GERD symptoms and erosive esophagitis. Patients received either omeprazole (20 mg with or without escalation up to 60 mg) or surgery with open fundoplication. Follow-up at 12 years included 71 (46%) of the 155 patients in the initial omeprazole group and 53 (34%) of the 155 patients in the initial surgery group.

Continuous remission of GERD symptoms was achieved by more surgical patients (53%) than patients who received 20 mg of omeprazole (40%) and those who received escalated doses of omeprazole (45%). In the surgery group, 36% of patients ultimately received proton-pump inhibitors; in the medical-therapy group, 14% of patients underwent subsequent fundoplication. No significant differences in quality-of-life scores were found between the groups, but dysphagia, flatulence, and inability to belch or vomit were more common in the surgery group. One patient in the surgery group developed esophageal cancer.

Comment: Surgeons might herald this as a defining study for the superiority of surgical therapy. However, the high number of patients lost to follow-up in both groups raises a strong bias potential; typically, a >10% loss of patients to follow-up, particularly without intention-to-treat analysis, raises questions about the study conclusions. Moreover, small shifts in outcomes among the patient groups could reverse the conclusion. Also, because the surgeons involved in this study were all experts, extrapolation of results to less-skilled surgeons would be challengeable. Patients should be made aware that a sizeable proportion of those who opt for surgery will end up taking chronic medications and that other high-quality studies have shown that antireflux surgery does not protect against esophageal cancer.

— David A. Johnson, MD

Published in Journal Watch Gastroenterology January 29, 2010

Citation(s):

Lundell L et al. Comparison of outcomes twelve years after antireflux surgery or omeprazole maintenance therapy for reflux esophagitis. Clin Gastroenterol Hepatol 2009 Dec; 7:1292.

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Reader Remarks:

Review and add to remarks on this article

• GERD
  Anne Ryan, 1 Feb 2010 12:01 PM EST
  There are also studies circulating that indicate the possibility that GERD is an auto immune response. Considering that it is... [more]
• Preference for GERD management: Medicine vs Surgery.
  Dr. J. Sil, India., 11 Feb 2010 1:52 PM EST
  I am a medical doctor and am a victim of GERD. My remarks are from my personal experience as a... [more]
• GERD treatment
  monika kole, 17 Feb 2010 2:48 PM EST
  After the diagnosis of Gastroesophageal Reflux Disease is known for sure, the health care providers can apply the proper type... [more]

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