Laparoscopic Fundoplication Surgery May Be Effective for Treating GERD
By Laurie Barclay, MD
Medscape Medical News
March 24, 2010 — Laparoscopic fundoplication surgery is more effective than medical management for treating gastro-oesophageal reflux disease (GERD, also referred to as GORD), at least in the short to medium term, according to the results of a systematic review reported online in the March 17 issue of the Cochrane Database of Systematic Reviews.
"...GORD is a common condition with up to 20% of patients from Westernised countries experiencing heartburn, reflux or both intermittently," write Samantha M. Wileman, PhD, from the Health Services Research Unit at the University of Aberdeen, Aberdeen, United Kingdom, and colleagues from the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group. "It is unclear whether medical or surgical (laparoscopic fundoplication) management is the most clinically and cost-effective treatment for controlling GORD."
The goals of this review were to compare the effects of medical management vs laparoscopic fundoplication surgery on health-related and GERD-specific quality of life (QOL) in adults with GERD. The search included an electronic search of CENTRAL (Issue 2, 2009), MEDLINE (1966 to May 2009), and EMBASE (1980 to May 2009), as well as a manual search of conference abstracts and reference lists from published trials. The reviewers also contacted experts to identify relevant unpublished material.
Inclusion criteria were all randomized or quasirandomized controlled trials in which medical management was compared vs laparoscopic fundoplication surgery. Two authors independently extracted data from identified articles and evaluated the methodologic quality of eligible trials. The main study endpoints were health-related and GERD-specific QOL, heartburn, regurgitation, and dysphagia.
There were 4 trials meeting selection criteria, enrolling a total of 1232 randomly assigned participants. Four studies reported health-related QOL, although data were combined with use of fixed-effect models for 2 studies. Compared with medical therapy, surgery was associated with statistically significant improvements in health-related QOL at 3 months and at 1 year postoperatively (mean difference 36-item Short Form Survey general health score, –5.23; 95% confidence interval, –6.83 to –3.62; I 2 = 0%).
Although data were not combined, there were significant improvements in GERD-specific QOL after surgery vs medical therapy in all 4 studies. Symptoms of heartburn, reflux, and bloating appeared to be reduced after surgery vs medical therapy. However, a small proportion of participants had persistent postoperative dysphagia.
Postoperative adverse events were uncommon, and overall rates of postoperative complications were low, but surgery is not without risk, and surgical costs are considerably higher than those of medical management. Because these data are based on the first year of treatment, the cost and adverse effects associated with long-term treatment of chronic GERD need to be considered, and treatment decisions for GERD should be based on patient and surgeon preference.
"There is evidence to suggest that, at least in the short to medium term, surgery is more effective than tablets for treatment of GORD," said Dr. Wileman in a news release. "But surgery does carry a risk and whether this is outweighed by the benefits in the long term is still not certain."
Limitations of this review include medium risk or low risk for bias in the 4 included studies and some lack of detailed information for particular secondary outcomes at different follow-up time points. In addition, 2 studies failed to provide detailed information about whether allocation was concealed.
"Previous research, prior to the development of keyhole surgery for GORD, has suggested that the benefits of surgery for GORD are not sustained over time, highlighting the importance for future keyhole fundoplication studies to include longer term follow-up," Dr. Wileman concluded. "We also need to know more about the clinical and cost implications of long term medication versus surgery."
The review authors have disclosed no relevant financial relationships.
Cochrane Database Syst Rev. Published online March 17, 2010.
