Medical versus surgical management for gastro‐oesophageal reflux disease (GORD) in adults

Gastro-oesophageal reflux disease is also known as GORD and the most common symptoms are heartburn, acid regurgitation and difficulty swallowing. Treatments cover a range of options and for most people, who have only mild symptoms, changes to diet or acid suppression tablets will probably be sufficient. These tablets are usually proton pump inhibitors (PPIs). However, patients with severe symptoms of GORD, where PPIs do not work, require an operation called a fundoplication. This involves wrapping part of the stomach around the lower part of the gullet or oesophagus and, since the 1990s, it has been done by keyhole, or laparoscopic, surgery. However, it's unclear whether surgery or medical treatment is better for patients with persistent GORD, whose symptoms place them in between the mild and severe groups. Therefore, we did our Cochrane review to compare medical versus laparoscopic fundoplication surgery, with a particular focus on the effects on the patient's quality of life (1). We found that fundoplication performed by keyhole surgery was more effective than medical treatment, at least for the first year after treatment. Whilst taking acid suppression tablets is generally assumed to be safe, PPIs can cause short-term symptoms such as headaches, diarrhoea and abdominal pains. More importantly, their long-term use may cause high blood levels of gastrin, known as hypergastrinaemia. Conditions associated with persistent hypergastrinaemia and low stomach acid levels have been linked to a long-term increased risk of gastic cancer. These risks have led to much interest in surgery as an alternative to the long-term use of acid suppression tablets, especially since the introduction of the keyhole operation. Fundoplication is thought to produce relief of GORD symptoms for over 90% of patients, but there are also concerns about its possible risks, as well as the general side effects of surgery. Therefore, choices between surgical and medical treatments need to be informed by evidence on their relative benefits and harms. Although there have been a number of studies comparing medical versus surgical treatment for GORD; only four studies, which involved about 1200 participants, have looked specifically at the keyhole approach to fundoplication. These studies were published between 2005 and 2009 and took place across a number of international centres. Two were performed in multiple centres across the UK, one was conducted in 11 European countries and the final study was done in a single centre in Canada. We were able to draw conclusions about the period up to one year after treatment. Our main finding is that there was significantly more improvement in both health-related and GORD specific quality of life at three months and one year after surgery, compared to medical treatment. All four studies showed that heartburn, reflux and bloating were improved after surgery compared to medical treatment, although a small proportion of participants still had persistent difficulty with swallowing after the operation. The results also showed that complications after surgery were low but not non-existent, and that the cost of surgery over one year is considerably higher than the cost of medical treatment. In summary, fundoplication operations performed by keyhole surgery were more effective at reducing the symptoms of GORD over one year, but little data are currently available to show whether these benefits are sustained over longer periods. We know that at least two of the four studies are following up participants over the longer term, and we hope that the next update of our review will provide a more conclusive answer as to which treatment is the best for controlling persistent symptoms of GORD.

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