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
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