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 24 February 2018

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News

Antisecretory drugs are still needed after antireflux surgery

The long-term follow up of a randomized trial of medical and surgical antireflux treatments in patients with complicated GERD is reported in this week's JAMA.

News image

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The aim of this study, reported by Stuart Spechler and colleagues, was to determine the long-term outcome of medical and surgical therapies for GERD.

In the late 1980s, the Department of Veterans Affairs (VA) Cooperative Studies Program conducted a randomized trial of medical and surgical antireflux treatments for 247 patients with complicated GERD. N Engl J Med 1992 Mar 19;326(12):786-92.

This follow-up study was conducted by the VA from October 1997 to October 1999. Mean (median) duration of follow-up was 10.6 years (7.3 years) for the medical patients, and 9.1 years (6.3 years) for the surgical patients.

Two hundred thirty-nine (97%) of the original 247 study patients were found (79 were confirmed dead). Among the 160 survivors (157 men and 3 women; mean age, 67 years), 129 (91 in the medical treatment group and 38 in the surgical treatment group) participated in the follow-up.

Eighty-three (92%) of 90 medical patients and 23 (62%) of 37 surgical patients reported that they used antireflux medications regularly (P<.001). During a 1-week period after discontinuation of medication, mean GRACI symptom scores were significantly lower in the surgical treatment group (82.6 vs 96.7 in the medical treatment group; P = .003).

However, no significant differences between the groups were found in grade of esophagitis, frequency of treatment of esophageal stricture and subsequent antireflux operations, SF-36 standardized physical and mental component scale scores, and overall satisfaction with antireflux therapy. Survival during a period of 140 months was decreased significantly in the surgical vs the medical treatment group (relative risk of death in the medical group, 1.57; 95% confidence interval, 1.01-2.46; P = .047), largely because of excess deaths from heart disease.

Patients with Barrett's esophagus at baseline developed esophageal adenocarcinomas at an annual rate of 0.4%, whereas these cancers developed in patients without Barrett's esophagus at an annual rate of only 0.07%. There was no significant difference between groups in incidence of esophageal cancer.

The authors conclude that their study suggests that antireflux surgery should not be advised with the expectation that patients with GERD will no longer need to take antisecretory medications.

Anti-reflux surgery did not prevent malignancy in those with Barrett's esophagus.
JAMA

They also emphasise that the procedure will not prevent esophageal cancer among those with GERD and Barrett's esophagus.

Writing in JAMA, also, Dr Peter Kahrilas, of the Northwestern University Medical School, Chicago, USA, says: "Rather than trying to compete with a proven safe and effective medical approach for most patients, anti-reflux surgery should be reserved for patients with unique circumstances who might selectively benefit."

He says: "For a patient with reflux symptoms, with or without a history of esophagitis, fundoplication introduces a risk of death that is not present in patients undergoing maintenance treatment with proton pump inhibitors.

"The basic tenets of the surgical argument - permanence, cancer prevention, and freedom from use of anti-secretory medications - have all been seriously challenged."

Journal of the American Medical Association 2001; 285 (18):2331-2338
11 May 2001

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