Medical or surgical treatment for chronic gastrooesophageal reflux? A systematic review of published evidence of effectiveness

Randomized controlled trial of transoral incisionless fundoplication vs. proton pump inhibitors for treatment of gastroesophageal reflux disease

OBJECTIVES

Transoral incisionless fundoplication (TIF) was developed in an attempt to create a minimally invasive endoscopic procedure that mimics antireflux surgery. The objective of this trial was to evaluate effectiveness of TIF compared with proton pump inhibition in a population consisting of gastroesophageal reflux disease (GERD) patients controlled with proton pump inhibitors (PPIs) who opted for an endoscopic intervention over lifelong drug dependence.

METHODS

Patients with chronic GERD were randomized (2:1) for TIF or continuation of PPI therapy. American Society of Anesthesiologists >2, body mass index >35 kg/m(2), hiatal hernia >2 cm, and esophageal motility disorders were exclusion criteria. Primary outcome measure was GERD-related quality of life. Secondary outcome measures were esophageal acid exposure, number of reflux episodes, PPI usage, appearance of the gastroesophageal valve, and healing of reflux esophagitis. Crossover for the PPI group was allowed after 6 months.

RESULTS

A total of 60 patients (TIF n=40, PPI n=20, mean body mass index 26 kg/m(2), 37 male) were included. At 6 months, GERD symptoms were more improved in the TIF group compared with the PPI group (P<0.001), with a similar improvement of distal esophageal acid exposure (P=0.228) compared with baseline. The pH normalization for TIF group and PPI group was 50% and 63%, respectively. All patients allocated for PPI treatment opted for crossover. At 12 months, quality of life remained improved after TIF compared with baseline (P<0.05), but no improvement in esophageal acid exposure compared with baseline was found (P=0.171) and normalization of pH was accomplished in only 29% in conjunction with deteriorated valve appearances at endoscopy and resumption of PPIs in 61%.

CONCLUSION

Although TIF resulted in an improved GERD-related quality of life and produced a short-term improvement of the antireflux barrier in a selected group of GERD patients, no long-term objective reflux control was achieved.

The effects of transoral incisionless fundoplication on chronic GERD patients: 12-month prospective multicenter experience

PURPOSE

This study aimed to assess the impact of transoral incisionless fundoplication (TIF) on patients with chronic gastroesophageal reflux disease (GERD) at 12-month follow-up.

METHODS

Clinical outcomes of 100 consecutive patients with chronic GERD who underwent TIF between January 2010 and February 2011 were analyzed.

RESULTS

There were no major complications reported. Esophageal acid exposure was normalized in 14/27 (52%) of patients who underwent 12-month pH testing. Seventy-four percent of all patients were off proton pump inhibitors versus 92% on daily proton pump inhibitors before TIF, P<0.001. Daily bothersome heartburn and regurgitation symptoms were eliminated in 66/85 (78%) and 48/58 (83%) of patients. Median reflux symptom index score was reduced from 20 (0 to 41) to 5 (0 to 44), P<0.001. Two patients reported de novo dysphagia and 1 patient reported bloating (scores 0 to 3). Six patients underwent revision; 5 laparoscopic Nissen fundoplication and 1 TIF.

CONCLUSIONS

TIF provided a safe and effective therapeutic option for carefully selected patients with chronic GERD.

Fundoplication versus medical management of gastroesophageal reflux disease: systematic review and meta-analysis

BACKGROUND

Medical, endoscopic, and open/laparoscopic surgical methods are used to treat gastroesophageal reflux disease (GERD). This study aimed to perform a systematic review of randomized controlled trials comparing medical and surgical treatments of GERD in adult patients.

METHODS

For the study, MEDLINE and EMBASE (1980-2012) were searched. Two reviewers independently assessed methodologic aspects and extracted data from eligible studies, focusing on patient-relevant outcomes. The primary outcomes were health-related and GERD-specific quality-of-life aspects. Standardized mean differences (SMDs) between treatment groups were calculated and combined using random-effect meta-analysis.

RESULTS

The study identified 11 publications reporting on 7 trials comparing surgical (open or laparoscopic) and medical treatment of GERD. Meta-analysis of both quality-of-life aspects showed a pooled-effect estimate in favor of fundoplication (SMD 0.18; 95 % confidence interval [CI] 0.01-0.35; SMD 0.33; 95 % CI 0.13-0.54). Heartburn and regurgitation were less frequent after surgical intervention. However, a considerable proportion of patients still needed antireflux medication after fundoplication. Nevertheless, the surgical patients were significantly more satisfied with their symptom control and showed higher satisfaction with the treatment received.

CONCLUSIONS

This systematic review showed that surgical management of GERD is more effective than medical management with respect to patient-relevant outcomes in the short and medium term. However, long-term studies still are needed to determine whether antireflux surgery is an equivalent alternative to lifelong medical treatment.

Endolumenal therapies for gastroesophageal reflux disease

TIF Stretta and Endocinch all seem technically safe in well-selected patients including those with prior esophageal and gastric surgeries. Long-term effectiveness is being evaluated. Given the current enthusiasm for increasingly less invasive surgical techniques, the inertia for endolumenal therapies continues to grow. Other endolumenal therapies for Gastroesophageal reflux disease (GERD) have initiated trials. These pursue similar fundoplication or lower esophageal sphincter reconstruction using simpler techniques with fewer steps. Because all endolumenal approaches to GERD evolve, objective evaluation for symptom resolution and reduced esophageal acid exposure with improved esophagogastric physiology will remain a constant.

Comparison of outcomes twelve years after antireflux surgery or omeprazole maintenance therapy for reflux esophagitis

BACKGROUND & AIMS

It is important to evaluate the long-term effects of therapies for gastroesophageal reflux disease (GERD). In a 12-year study, we compared the effects of therapy with omeprazole with those of antireflux surgery.

METHODS

This open, parallel group study included 310 patients with esophagitis enrolled from outpatient clinics in Nordic countries. Of the 155 patients randomly assigned to each arm of the study, 154 received omeprazole (1 withdrew before therapy began), and 144 received surgery (11 withdrew before surgery). In patients who remained in remission after treatment, post-fundoplication complaints, other symptoms, and safety variables were assessed.

RESULTS

Of the patients enrolled in the study, 71 who were given omeprazole (46%) and 53 treated with surgery (37%) were followed for a 12-year follow-up period. At this time point, 53% of patients who underwent surgery remained in continuous remission, compared with 45% of patients given omeprazole with a dose adjustment (P = .022) and 40% without dose adjustment (P = .002). In addition, 38% of surgical patients required a change in therapeutic strategy (eg, to medical therapy or another operation), compared with 15% of those on omeprazole. Heartburn and regurgitation were significantly more common in patients given omeprazole, whereas dysphagia, rectal flatulence, and the inability to belch or vomit were significantly more common in surgical patients. The therapies were otherwise well-tolerated.

CONCLUSIONS

As long-term therapeutic strategies for chronic GERD, surgery and omeprazole are effective and well-tolerated. Antireflux surgery is superior to omeprazole in controlling overall disease manifestations, but post-fundoplication complaints continue after surgery.

Two-year results of a feasibility study on antireflux transoral incisionless fundoplication using EsophyX

BACKGROUND

A feasibility study (n = 19) evaluated the safety and initial efficacy of transoral incisionless fundoplication (TIF) for the treatment of gastroesophageal disease (GERD). The results at 1 year (n = 17) indicated that TIF was safe and had a significant effect on reducing GERD symptoms, proton pump inhibitor (PPI) usage, acid exposure, and small hiatal hernia. This study was designed to evaluate the long-term safety and durability of TIF.

METHODS

Fourteen patients (50% female; median age, 34 years) completed the 2-year follow-up assessment tests. Three patients were excluded from the study after 1 year because two of them underwent retreatment and one was lost to follow-up.

RESULTS

At 2 years, no adverse events related to TIF were reported. A >or=50% improvement in GERD-HRQL scores compared with those at baseline on PPIs was sustained by 64% of patients. TIF was effective in eliminating heartburn in 93% of patients and daily PPI therapy in 71% of patients. Significantly (p < 0.05) more patients were able to consume reflux-causing foods and maintain lifestyle activities without GERD symptoms compared with baseline on PPIs. Fundoplications were durable and maintained their geometric dimensions. TIF was effective in eliminating hiatal hernia in 60% of patients and esophagitis in 55% of patients. Global assessment of all outcomes in each patient revealed that 79% of patients experienced complete cure (29%) or remission (50%) of GERD at 2 years after TIF.

CONCLUSION

The results at 2 years supported the long-term safety and durability of TIF and its sustained effect on the elimination of heartburn, esophagitis, <or=2 cm hiatal hernia, and daily dependence on PPIs.

Antireflux transoral incisionless fundoplication using EsophyX: 12-month results of a prospective multicenter study

Background

A novel transoral incisionless fundoplication (TIF) procedure using the EsophyX system with SerosaFuse fasteners was designed to reconstruct a full-thickness valve at the gastroesophageal junction through tailored delivery of multiple fasteners during a single-device insertion. The safety and efficacy of TIF for treating gastroesophageal reflux disease (GERD) were evaluated in a prospective multicenter trial.

Methods

Patients (n = 86) with chronic GERD treated with proton pump inhibitors (PPIs) were enrolled. Exclusion criteria included an irreducible hiatal hernia > 2 cm.

Results

The TIF procedure (n = 84) reduced all hiatal hernias (n = 49) and constructed valves measuring 4 cm (2–6 cm) and 230° (160°–300°). Serious adverse events consisted of two esophageal perforations upon device insertion and one case of postoperative intraluminal bleeding. Other adverse events were mild and transient. At 12 months, aggregate (n = 79) and stratified Hill grade I tight (n = 21) results showed 73% and 86% of patients with ≥50% improvement in GERD health-related quality of life (HRQL) scores, 85% discontinuation of daily PPI use, and 81% complete cessation of PPIs; 37% and 48% normalization of esophageal acid exposure; 60% and 89% hiatal hernia reduction; and 62% and 80% esophagitis reduction, respectively. More than 50% of patients with Hill grade I tight valves had a normalized cardia circumference. Resting pressure of the lower esophageal sphincter (LES) was improved significantly (p < 0.001), by 53%. EsophyX-TIF cured GERD in 56% of patients based on their symptom reduction and PPI discontinuation.

Conclusion

The 12-month results showed that EsophyX-TIF was safe and effective in improving quality of life and for reducing symptoms, PPI use, hiatal hernia, and esophagitis, as well as increasing the LES resting pressure and normalizing esophageal pH and cardia circumference in chronic GERD patients.

Short-term symptom and quality-of-life comparison between laparoscopic Nissen and Toupet fundoplications

Laparoscopic antireflux surgery is an established method of treatment of gastroesophageal reflux disease (GERD). This study evaluates the efficacy of Nissen versus Toupet fundoplication in alleviating the symptoms of GERD and compares the two techniques for the development of post-fundoplication symptoms and quality of life (QOL) at 12 months post-surgery. In this prospective consecutive cohort study, 94 patients presenting for laparoscopic antireflux surgery underwent either laparoscopic Nissen fundoplication (LN) (n = 51) from February 2002 to February 2004 or a laparoscopic Toupet fundoplication (LT) (n = 43) from March 2004 to March 2006, performed by a single surgeon (G. S. S.). Symptom assessment, a QOL scoring instrument, and dysphagia questionnaires were applied pre- and postoperatively. At 12 months post-surgery, patient satisfaction levels in both groups were high and similar (LT: 98%, LN: 90%; P = 0.21). The proportion of patients reporting improvement in their reflux symptoms was similar in both groups (LT: 95%, LN: 92%; P = 0.68), as were post-fundoplication symptoms (LT: 30%, LN: 37%; P = 0.52). Six patients in the Nissen group required dilatation for dysphagia compared with one in the Toupet group (LT: 2%, LN: 12%; P = 0.12). One patient in the Nissen group required conversion to Toupet for persistent dysphagia (P = 0.54). In this series, overall symptom improvement, QOL, and patient satisfaction were equivalent 12 months following laparoscopic Nissen or Toupet fundoplication. There was no difference in post-fundoplication symptoms between the two groups, although there was a trend toward a higher dilatation requirement and reoperation after Nissen fundoplication.

[Gastroesophageal reflux disease: an overview]

BACKGROUND

Gastroesophageal reflux disease, considered one of the most common digestive diseases in western countries, has been very much studied. The great number of publications in medical literature based upon this issue must be pointed out. However, some of its aspects remain controversial.

AIMS

To emphasize important topics of the disease and to present a review on the theme. The following topics were reviewed: defi nition, prevalence, clinical complaints, indications and limitations of the major diagnostic methods and medical, surgical and endoscopic treatments.

MATERIAL AND METHODS

We searched, by internet: selected review articles, consensus, guidelines and systematic reviews with meta-analysis, published in the last 5 years (from 2000 to 2005), in the following data bases: Cochrane Central Register of Controlled Trials (The Cochrane Library) and PubMed. Among lots of papers which were found, we selected nine systematic reviews with meta-analysis, fi ve review articles, fi ve guidelines and four consensus, that dealt with the topics we had decided to review. It must be pointed out that, as it has been observed in our bibliographical references, not only the publications found were taken into account; other relevant ones (some of them published previously to the analyzed time period) were considered in the composition of this present paper.

CONCLUSIONS

Among the 12 conclusions presented, two have to be emphasized: 1. the esophageal multichannel intraluminal impedance has largely contributed to the better knowledge of the gastroesophageal reflux disease and it suggests, when associated with pHmetry (esophageal impedance-pHmetry), as a new gold standard to the gastroesophageal reflux diagnosis and 2: among the gastroesophageal reflux disease symptoms some of them may be considered acid dependents and can usually get good responses to the proton pump inhibitors. Nevertheless, there are also some symptoms which are more dependent on the physical presence of the reflux rather than its acidity. Such symptoms, which do not depend so much on the acidity of the reflux, are not well controlled by the proton pump inhibitors.

The many manifestations of gastroesophageal reflux disease: presentation, evaluation, and treatment

Gastroesophageal reflux disease (GERD) is a common problem that is expensive to diagnose and treat. The disease is increasing in prevalence in the Western world, with important risk factors being obesity and the eradication of Helicobacter pylori. Heartburn and acid regurgitation are classic symptoms of GERD, but their sensitivity is poor. Ambulatory esophageal pH testing is the most sensitive test for GERD, whereas endoscopy is the most specific test. Medical treatment with proton pump inhibitors (PPIs) has revolutionized the treatment of GERD and its complications, but long-term side effects do exist. Laparoscopic anti-reflux surgery and PPIs have similar efficacy in the few available long-term trials. This article reviews the presentation, evaluation, and treatment of GERD.

Gastrooesophageal reflux disease

Gastrooesophageal reflux disease, GERD, is a common problem which is expensive to diagnose and treat. The disease is increasing in prevalence in the Western world with important risk factors being obesity and the eradication of Helicobacter pylori. Increasing research points to transient LES relaxation and spatial separation of the diaphragm and LES (hiatal hernia in chest) being the critical mechanisms of acid reflux. Heartburn and acid regurgitation are classic symptoms of GERD, but their sensitivity is poor. Ambulatory oesophageal pH testing is the most sensitive test for GERD, while endoscopy is the most specific test. Medical treatment with PPIs has revolutionized the treatment of GERD and its complications, but long-term side effects do exist. Laparoscopic antireflux surgery and PPIs have similar efficacy in the few available long-term trials. Currently, endoscopic treatments for GERD should not be a clinical alternative outside of research trials. New drug therapies should be directed at modulating transient LES relaxation.

Gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease refers to reflux of gastric contents into the oesophagus leading to oesophagitis, reflux symptoms sufficient to impair quality of life, or long-term complications. Transient relaxation of the lower oesophageal sphincter is believed to be the primary mechanism of the disease although the underlying cause remains uncertain. Obesity and smoking are weakly associated with the disease and genetic factors might be important. A negative association with Helicobacter pylori exists, but eradication of H pylori does not seem to cause reflux disease. Diagnosis is imprecise as there is no gold standard. Reflux symptoms are helpful in diagnosis but they lack sensitivity. Ambulatory oesophageal pH monitoring also seems to be insensitive despite high specificity. Empirical acid suppression with a proton-pump inhibitor (PPI) has reasonable sensitivity but poor specificity. Some evidence suggests that once patients develop the disease, severity is determined early and patients seem to continue with that phenotype long term. Unfortunately, most patients do not respond to life-style advice and require further therapy. H2 receptor antagonists and PPIs are better than placebo in oesophagitis, with a number needed to treat of five and two, respectively. In non-erosive reflux disease, acid suppression is better than placebo but the response rate is lower. Most patients need long-term treatment because the disease usually relapses. The role of endoscopic therapy is uncertain. Anti-reflux surgery is probably as effective as PPI therapy although there is a low operative mortality and morbidity.

Randomized clinical trial of laparoscopic Nissen fundoplication compared with proton-pump inhibitors for treatment of chronic gastro-oesophageal reflux

BACKGROUND

Both laparoscopic Nissen fundoplication (LNF) and proton-pump inhibitor (PPI) therapy are established in the treatment of gastro-oesophageal reflux disease (GORD). The aim of this study was to compare these two treatments in a randomized clinical trial.

METHODS

Between July 1997 and August 2001, 340 patients with a history of GORD for at least 6 months were investigated by endoscopy, 24-h pH monitoring and manometry. Of these, 217 were randomized, 109 to LNF and 108 to PPI therapy. The two groups were well matched for age, sex, weight and severity of reflux. Twenty-four-hour pH monitoring and manometry were performed 3 months after treatment, and quality of life was assessed in both groups using the Psychological General Well-being Index and the Gastrointestinal Symptom Rating Scale at 3 and 12 months after treatment.

RESULTS

At 3 months there was an improvement in lower oesophageal sphincter pressure from 6.3 to 17.2 mmHg in the LNF group but no change in the PPI group (8.1 and 7.9 mmHg before and after treatment respectively) (P < 0.001). The mean DeMeester acid exposure score improved from 42.7 to 8.6 (P < 0.001) in the LNF group and from 36.9 to 17.7 in the PPI group (P < 0.001). The mean gastrointestinal symptom and general well-being scores improved from 31.7 and 95.4 respectively before treatment to 37.0 and 106.2 at 12 months after LNF, compared with changes from 34.3 and 98.5 to 35.0 and 100.4 respectively in the PPI group. The differences in both of these scores were significant between the two groups at 12 months (P = 0.003).

CONCLUSION

LNF leads to significantly less acid exposure of the lower oesophagus at 3 months and significantly greater improvements in both gastrointestinal and general well-being after 12 months compared with PPI treatment.

Gastro-oesophageal reflux and bronchial asthma: current status and future directions

In recent years there have been several reports suggesting an association between bronchial asthma and gastro-oesophageal reflux; however a cause and effect relationship has not been proven yet. Confirmation of such a relationship is likely to have far reaching implications on the management of asthma. Reliable assessment of this issue is hampered by the presence of various lacunae in most of the published studies. Hence it is essential to carefully examine the strength of data suggesting a link between asthma and reflux. This article critically analyses currently available literature on the subject (including published reviews, meta-analyses, and randomised clinical trials in the English language) and summarises valid conclusions that can be drawn; it also proposes a framework for future studies to resolve the issue.

Robotic Laparoscopic Fundoplication

Gastroesophageal reflux disease is a very common disorder, and both medical and surgical treatments have shown outstanding results. Whereas proton pump inhibitors are the mainstay of treatment, laparoscopic fundoplication has become a very attractive alternative due to its efficacy and low morbidity. There are defined patient categories that may benefit more from laparoscopy than medical therapy, but a conclusive comparison between the two is lacking. Robotic laparoscopic fundoplication can be performed safely without increased morbidity. Potential advantages include enhanced precision, improved dexterity, and remote telesurgical applications. Disadvantages include increased cost and prolonged operative times. Further studies and more long-term outcome data are needed to fully evaluate the procedure. Robotic surgery is currently in its infancy and not cost effective but has a very promising future. With further development of automatization and miniaturization features, robotic surgery may prove more efficient than conventional laparoscopy.

Teflon pledget reinforced fundoplication causes symptomatic gastric and esophageal lumenal penetration

BACKGROUND

Nissen fundoplication has become the standard operative procedure for the treatment of severe gastroesophageal reflux disease. The use of Teflon pledgets in Nissen fundoplications by our unit has been associated with a number of complications that has led to a change of technique in performing these operations.

METHODS

We reviewed our database of all patients who had fundoplications that involved the use of pledgets and identified those who had represented with postoperative complications related to pledget erosion/migration.

RESULTS

We identified 11 patients to date from a total of 1,175 fundoplications who had symptomatic pledget erosion occurring between 2 and 85 months after surgery (mean time 33.3 months). Symptoms included dysphagia, recurrent symptomatic gastroesophageal reflux, chest pain, and melaena, and in some cases significant morbidity was associated with the erosion. No common factor predisposing these patients to pledget erosion was identified. In the majority of cases removal of the pledget was associated with resolution of the symptoms. A review of the literature does not reveal any similar studies but problems associated with the erosion and migration of Teflon prostheses are described.

CONCLUSIONS

The use of Teflon pledgets in fundoplication is associated with a small but significant risk of complications that has led to our unit abandoning this technique.

Feline esophagitis secondary to gastroesophageal reflux disease: clinical signs and radiographic, endoscopic, and histopathological findings

Chronic esophagitis due to gastroesophageal reflux (GER) is rarely reported in the cat. This paper describes the clinical signs and diagnostic findings, including radiographic, endoscopic, and histopathological abnormalities, in three young, purebred, male cats with esophagitis presumed to be secondary to GER. Clinical signs included regurgitation, dysphagia, and weight loss. Contrast radiography revealed GER, esophageal dilatation, and decreased motility. Endoscopy showed hyperemia, increased vascularity, ulcers, erosion, and an abnormal lower esophageal sphincter. Histopathological lesions included squamous hyperplasia and dysplasia, erosions, ulcers, and an inflammatory infiltrate of lymphocytes, plasma cells, and neutrophils. Long-term follow-up demonstrated progression of the disease in two of the cats.

Surgical and endoscopic treatment of gastroesophageal reflux disease

There is no evidence to advocate medical or surgical therapy as the best therapy for GERD. The decision to have antireflux surgery must be individualized. All patients taking long-term medications for GERD should receive advice on the safety and wisdom of staying on that therapy and information on antireflux surgery. Fundoplication should be considered in three circumstances [4]: 1. Patients who are intolerant of PPI therapy because of side effects should be considered for surgery. This situation will be less common now with five PPIs, however. 2. Patients who are poorly responsive to PPI therapy should be considered for surgery. This situation is probably not common, given the effectiveness of the currently available PPIs. It is more common in patients with atypical GERD. The gastroenterologist should be as certain as possible that the patient not only has GERD, but also that the patient's symptoms are reflux related. 3. Surgery should be considered when patients desire a permanent solution to free them of the need to take medications. These patients must be warned about the potential suboptimal results, including the frequent need for medication within a few years of having the procedure and the small but real possibility of becoming worse after the operation. Even in experienced hands, 1% to 2% of patients are worse after the procedure. A careful preoperative evaluation to ensure that the patient's symptoms are reflux related and that the right operative procedure is performed offers the patient the best opportunity for success. Widespread use of endoscopic therapy for GERD is probably still several years away. The best endoscopic therapy is yet to be determined, but it will need to be safe, effective, and easy to use.