Medical versus surgical management for gastro-oesophageal reflux disease (GORD) in adults
ABSTRACT Gastro-oesophageal reflux disease (GORD) is a common condition with up to 20% of patients from Westernised countries experiencing heartburn, reflux or both intermittently. It is unclear whether medical or surgical (laparoscopic fundoplication) management is the most clinically and cost-effective treatment for controlling GORD.
To compare the effects of medical management versus laparoscopic fundoplication surgery on health-related and GORD-specific quality of life (QOL) in adults with GORD.
We searched CENTRAL (Issue 2, 2009), MEDLINE (1966 to May 2009) and EMBASE (1980 to May 2009). We handsearched conference abstracts and reference lists from published trials to identify further trials. We contacted experts in the field for relevant unpublished material.
All randomised or quasi-randomised controlled trials comparing medical management with laparoscopic fundoplication surgery.
Two authors independently extracted data from articles identified for inclusion and assessed the methodological quality of eligible trials. Primary outcomes were: health-related and GORD-specific QOL, heartburn, regurgitation and dysphagia.
Four trials were included with a total of 1232 randomised participants. Health-related QOL was reported by four studies although data were combined using fixed-effect models for two studies (Anvari 2006; REFLUX Trial 2008). There were statistically significant improvements in health-related QOL at three months and one year after surgery compared to medical therapy (mean difference (MD) SF36 general health score -5.23, 95% CI -6.83 to -3.62; I(2) = 0%). All four studies reported significant improvements in GORD-specific QOL after surgery compared to medical therapy although data were not combined. There is evidence to suggest that symptoms of heartburn, reflux and bloating are improved after surgery compared to medical therapy, but a small proportion of participants have persistent postoperative dysphagia. Overall rates of postoperative complications were low but surgery is not without risk and postoperative adverse events occurred although they were uncommon. The costs of surgery are considerably higher than the cost of medical management although data are based on the first year of treatment therefore the cost and side effects associated with long-term treatment of chronic GORD need to be considered.
There is evidence that laparoscopic fundoplication surgery is more effective than medical management for the treatment of GORD at least in the short to medium term. Surgery does carry some risk and whether the benefits of surgery are sustained in the long term remains uncertain. Treatment decisions for GORD should be based on patient and surgeon preference.
SourceAvailable from: Francisco Huerta-IgaRevista de gastroenterologia de Mexico 10/2013; 78(4):231-239. DOI:10.1016/j.rgmx.2013.05.001
10/2013; 78(4):231-239. DOI:10.1016/j.rgmxen.2014.02.010
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ABSTRACT: Background & aims – The aim of this systematic review was to determine the safety, technical efficacy, and effectiveness of 48-hour wireless pH monitoring (WM) for gastroesophageal reflux disease (GERD), compared to the catheter-based monitoring test (CBM) or no pH-monitoring, in patients who have failed CBM or where it is anatomically inappropriate. Methods – A systematic literature search was conducted to identify relevant comparative studies from 2001 to May 2014 in Cochrane Library, Current Contents, Embase, PubMed, Web of Science, Cinahl, Econlit and Scopus. Results – Studies assessing WM in the defined study population were lacking. The population had to be broadened to GERD-patients tolerating CBM. Chest pain occurred more often with WM compared to CBM, however, other adverse events were reported less with WM. More technical failures occurred with WM, compared to CBM (RR=3.3; 95%CI 1.63, 6.81; I2 = 0%, p=0.012; k = 8 studies). Sensitivity and specificity of WM varied from 67% to 100% and from 66% to 100%, respectively, depending on monitoring time, capsule placement, reference standard and cut-off value was used. In general, studies were of medium quality and there was a lack of good comparative evidence. Conclusions – WM is usually better tolerated than CBM. However, WM faced more technical problems. The accuracy results were likely to be biased. Consensus needs to be reached on the use of a standardized cut-off value, capsule position and appropriate reference standard. As a result, no conclusion can be drawn regarding the accuracy of WM compared with CBM. The full report is available from http://www.msac.gov.au/internet/msac/publishing.nsf/Content/completed-assessments