Therapy of Gastroesophageal Reflux: Evidence-Based Approach to Antireflux Surgery

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Abstract

Background: Due to the chronic, relapsing nature of gastroesophageal reflux disease, lifelong therapeutic options have to be considered and recommended in many patients. Accordingly, surgical repair has to be evaluated based on modern, evidence-based methodologies. Methods: A careful review has been carried out of the relevant surgical literature also including trials incorporating direct comparisons between medical and surgical therapies. The outcome of such a survey has been structured according to the grading of evidence from highest grade I to the lowest III. Results: Grade I evidence exists to show that antireflux surgery is more effective than proton pump inhibition in the control of reflux-related symptoms. Side effects are burdening surgical repair, many of which do not decrease over time. Data are not consistent to show any benefit of surgery whenever health economic outcomes are required. Minor differences are in favor of laparoscopic operations and it does matter who is doing the operation and how the repair is completed. Better data are requested to assess the true long-term efficacy (>10 years) of corresponding operations. Conclusion: Antireflux surgery is an effective and durable therapeutic modality in the long-term management of gastroesophageal reflux disease.

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Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease.

, Donald Castell, Kenneth DeVault (2004)

Guidelines for the diagnosis and treatment of gastroesophageal reflux disease (GERD) were published in 1995 and updated in 1999. These and other guidelines undergo periodic review. Advances continue to be made in the area of GERD, leading us to review and revise previous guideline statements. GERD is defined as symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus. These guidelines were developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee, and approved by the Board of Trustees. Diagnostic guidelines address empiric therapy and the use of endoscopy, ambulatory reflux monitoring, and esophageal manometry in GERD. Treatment guidelines address the role of lifestyle changes, patient directed (OTC) therapy, acid suppression, promotility therapy, maintenance therapy, antireflux surgery, and endoscopic therapy in GERD. Finally, there is a discussion of the rare patient with refractory GERD and a list of areas in need of additional study.

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Effectiveness of proton pump inhibitors in nonerosive reflux disease.

Joshua Ofman, Kevin Knight, Ronnie Fass … (2004)

Little information is available about the efficacy of proton pump inhibitors (PPIs) in patients with nonerosive reflux disease (NERD). We aimed to synthesize available data and determine the effectiveness of PPIs on symptom resolution in patients with NERD. A systematic review of the literature identified studies reporting the effects of PPIs in patients with NERD. Heartburn resolution data were pooled across studies. The effectiveness of PPI therapy in inducing complete heartburn resolution was compared in patients with NERD vs. erosive esophagitis (EE). Seven trials evaluating heartburn resolution in NERD were identified. Higher proportions of patients reported achieving sufficient heartburn resolution compared with complete heartburn resolution. The effect of PPIs on sufficient heartburn resolution was observed sooner than was complete heartburn resolution. Therapeutic gain of PPI therapy over placebo ranged from 30% to 35% for sufficient heartburn control and from 25% to 30% for complete heartburn control. Pooled response rates at 4 weeks were significantly higher for patients with EE compared with NERD (56% vs. 37%, P < 0.0001). PPIs provide a more modest therapeutic gain in patients with NERD as compared with those with EE. A trend in increased therapeutic gain for NERD patients was shown throughout the 4 weeks, suggesting that 4 weeks of follow-up evaluation may be insufficient to show full therapeutic gain in this patient population.

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Quality of life in patients with upper gastrointestinal symptoms. An improved evaluation of treatment regimens?

H Hernqvist, H Glise, E Dimenäs … (1993)

There is growing interest in measuring quality of life (QoL) in medicine. Together with objective variables such as healing rate, as recorded with endoscopy, this is believed to give a better basis for evaluation of treatment regimens in patients with upper gastrointestinal diseases. A strategy for the assessment of QoL in patients with upper gastrointestinal symptoms is presented here. The QoL evaluation was based on a battery of questionnaires, covering both general and specific aspects of life. General well-being was evaluated with the Psychological General Well-being Index (PGWB), and subjective symptoms with two specific questionnaires, the Gastrointestinal Symptom Rating Scale (GSRS) and the Ulcus Esophagitis Subjective Symptoms Scale (UESS). This new strategy was applied clinically in a study including 146 outpatients with suspected peptic ulcer. Initially, the patients reported a low degree of general well-being as evaluated with the PGWB, but the values returned to those found in normal populations within 4 weeks. Evaluation of the GSRS and UESS with regard to internal consistency, construct validity, and the ability to detect changes showed them to be satisfactory. The psychometric documentation of the measures indicates that they may give reliable and clinically valid information when used for evaluation of medical treatments in upper gastrointestinal disease. Further documentation of the methods is, however, needed to establish a generally acceptable QoL assessment in gastroenterology.

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Author and article information

Journal

Journal ID (publisher-id): DDI

Journal ID (nlm-ta): Dig Dis

Journal ID (doi): 10.1159/issn.0257-2753

Title: Digestive Diseases

Publisher: S. Karger AG

ISBN: 978-3-8055-8333-6

ISBN: 978-3-318-01487-7

ISSN (Print): 0257-2753

ISSN (Electronic): 1421-9875

Publication date Subscription-year: 2007

Publication date (Print): September 2007

Publication date (Electronic): 10 September 2007

Volume: 25

Issue: 3

Pages: 188-196

Affiliations

Department of Surgery, Karolinska University Hospital, Huddinge, Stockholm, Sweden

Article

Publisher ID: 103883 Other ID: Dig Dis 2007;25:188–196

DOI: 10.1159/000103883

PubMed ID: 17827938

SO-VID: 062859ae-a943-4a7c-b548-d5847040d74e

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Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

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Therapy of Gastroesophageal Reflux: Evidence-Based Approach to Antireflux Surgery

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Karger: Gastroenterology

Most cited references 72

Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease.

Effectiveness of proton pump inhibitors in nonerosive reflux disease.

Quality of life in patients with upper gastrointestinal symptoms. An improved evaluation of treatment regimens?

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