Medical versus surgical management for gastro-oesophageal reflux disease (GORD) in adults

Wileman SM, McCann S, Grant AM, Krukowski ZH, Bruce J

Published Online:

April 14, 2010

There is evidence that laparoscopic fundoplication surgery (stomach wrap) is more effective than medical management (tablets) in the treatment of gastro-oesophageal reflux disease (GORD) in adults, at least in the short to medium term.

All four studies included in the review found that there was greater improvement in GORD-related symptoms and general health after laparoscopic (key-hole) surgery compared to medical treatment (drug tablets). Like all surgery, laparoscopic fundoplication does have risks, but data from the trials indicate that these are not common.

Abstract (click to read)

Background:

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.

Objectives:

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.

Search strategy:

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 We contacted experts in the field for relevant unpublished material.

Selection criteria:

All randomised or quasi-randomised controlled trials comparing medical management with laparoscopic fundoplication surgery.

Data collection and analysis:

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.

Main results:

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; I2 = 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.

Authors' conclusions:

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.

This record should be cited as:

Wileman SM, McCann S, Grant AM, Krukowski ZH, Bruce J. Medical versus surgical management for gastro-oesophageal reflux disease (GORD) in adults. Cochrane Database of Systematic Reviews 2010, Issue 3. Art. No.: CD003243. DOI: 10.1002/14651858.CD003243.pub2

Assessed as up to date:

May 6, 2009

Find the research

Get full text at The Cochrane Library

Primary Review Group:

Upper Gastrointestinal and Pancreatic Diseases Group

PEARLS - Practical Evidence About Real Life Situations (click to read)

Clinical question:

How effective is medical management compared with surgery (laparoscopic fundoplication) for adults with gastro-oesophageal reflux disease (GORD)?

Bottom line:

There were statistically significant improvements in health-related quality of life (QOL) at three months and one year after surgery, compared with medical therapy. The size of the change reported, about 5 points on the SF36 scale, can be interpreted as “minimal detectable change”.¹ There were also significant improvements in GORD-specific QOL after surgery compared with medical therapy. There was evidence to suggest symptoms of heartburn, reflux and bloating were improved after surgery compared with medical therapy, but a small proportion of participants had persistent postoperative dysphagia. 1. Wyrwich, KW et al. Health Serv Res 2005;40:577–91.

Caveat:

Overall rates of postoperative complications were low, but surgery was not without risk, and postoperative adverse events occurred, although they were uncommon. The costs of surgery are considerably higher (between 3 and 6 times) than the cost of medical management, although data were 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.

Context:

GORD is a common condition, with up to 20% of patients from westernised countries experiencing heartburn, reflux, or both intermittently.

Cochrane Systematic Review:

Wileman SM et al. Medical versus surgical management for gastro-oesophageal reflux disease (GORD) in adults. Cochrane Reviews 2010, Issue 3. Article No. CD003243. DOI: 10.1002/14651858.CD003243.pub2. This review contains 4 studies involving 1232 participants.

Authored by:

Brian R McAvoy

Cochrane Primary Health Care Field

Health topics:

Gastroenterology > Gastro-oesophageal reflux > Maintenance therapy

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Medical versus surgical management for gastro-oesophageal reflux disease (GORD) in adults

More like this

Copyright © 2012 - The Cochrane Collaboration