Surgery in gastro-oesophageal reflux disease

Fundoplication offers the possibility of curing oesophagitis and relieving symptoms without the need for long-term medication

• laparoscopic funoplication
  • operation (fundoplication) involves partial (Toupet 270°) or total (Nissen 360°) wrapping of the fundus of the stomach around the lower oesophagus to recreate a high pressure zone
  • resolution of reflux symptoms is observed in up to 90% of patients
  • main side effects of the procedure includes dysphagia and bloating which may vary in severity from mild to severe (1)

Surgical treatment has a place in treating those who are (1):

• refractory to or intolerant of medical therapy, or,
• those with large-volume reflux
• symptoms such as chronic cough that prove refractory to PPI treatment
• possibly younger patients who wish to avoid life-long medication (1)

A randomised controlled trial (RCT) investigated the long term outcomes of surgical and medical treatments in patients with uncomplicated gastro-oesophageal reflux disease (GORD) (2):

• design - randomised controlled trial; mean follow-up 10 years
• patients - involved 247 patients (mean age of 58 years) with uncomplicated GORD. Follow-up analysis involved 129 of 160 surviving patients (mean age 67 years, 98% men)
• intervention
  • surgical treatment (n=82) - Nissen fundoplication, or,
  • continuous medical treatment (n=77) - using ranitidine 150mg bd and metoclopramide 10 mg qds, sucralfate 1g in 10ml of warm water after meals when necessary for persistent symptoms, or,
  • symptomatic medical treatment, medication as in continuous treatment arm but used on as necessary basis, (n=88)
• results
  • intention to treat analysis was used. For analysis purposes the 2 medical treatment groups were combined because of similar baseline characteristics, study treatments and outcomes
  • survival during a 140 month period was lower in the surgical group than the medical group (p=0.047)
  • surgical and medical treatments did not differ in the use of prokinetics (p=0.39) or subsequent antireflux surgery (p=0.38)
  • surgical treatment reduced the use of antireflux medications after the treatment period
  • after surgical treatment - 62% of patients returned to using medication for their GORD, and 32% returned to using proton pump inhibitors; however during the follow-up period 64% of patients treated with medications used proton pump inhibitors
• conclusions:
  • this study provides evidence that, in patients with uncomplicated GORD, surgical treatment led to a reduction in the use of antireflux medication and decreased survival in comparison with medical treatment - the authors suggest that future studies need to prospectively address the lower survival rate in the surgical treatment group (60%) compared with that in the medical treatment group (72%)
  • there was no different in the rate of subsequent antireflux surgery in comparison of medical and surgical treatment

Grant et al (3) undertook a study that revealed:

• in patients with chronic grastro-oesophageal reflux disease, a strategy of early laparoscopic surgery improved quality of life and reduced symptoms more than continued medical management at least up to 1 year after surgery

Reference:

• (1) Roman S, Kahrilas PJ. The diagnosis and management of hiatus hernia. BMJ. 2014;349:g6154 .
• (2) Spechler SJ et al. Long-term outcome of medical and surgical therapies for gastroesophageal reflux disease. Follow-up of a randomized controlled trial. JAMA 2001; 285: 2331-8
• (3) Grant AM et al. Minimal access surgery compared with medical management for chronic gastro-oesophageal reflux disease: UK collaborative randomised trial.REFLUX Trial Group. BMJ. 2008 Dec 15;337:a2664. doi: 10.1136/bmj.a2664.