Fundoplication versus medical management of gastroesophageal reflux disease: systematic review and meta-analysis
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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.
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.
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.
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.
KeywordsFundoplication Gastroesophageal reflux Anti-ulcer agents Proton pump inhibitors Review Meta-analysis
We thank Dr. Michaela Hänsel, Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, for her help in performing the literature search and screening of eliglible articles. This work was conducted only with the resources of the Institute for Social Medicine and Epidemiology, University of Lübeck, Germany, and the Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Germany.
Nadja Rickenbacher, Thomas Kötter, Michael M. Kochen, Martin Scherer, and Eva Blozik have no conflicts of interests or financial ties to disclose.
- 15.Spechler SJ, Lee E, Ahnen D, Goyal RK, Hirano I, Ramirez F, Raufman JP, Sampliner R, Schnell T, Sontag S, Vlahcevic ZR, Young R, Williford W (2001) Long-term outcome of medical and surgical therapies for gastroesophageal reflux disease: follow-up of a randomized con-trolled trial. JAMA 285:2331–2338PubMedCrossRefGoogle Scholar
- 16.Lundell L, Miettinen P, Myrvold HE, Pedersen SA, Liedman B, Hatlebakk JG, Julkonen R, Levander K, Carlsson J, Lamm M, Wiklund I (2001) Continued (5-year) follow-up of a randomized clinical study comparing antireflux surgery and omeprazole in gastroesophageal reflux disease. J Am Coll Surg 192:172–179PubMedCrossRefGoogle Scholar
- 17.Lundell L, Miettinen P, Myrvold HE, Hatlebakk JG, Wallin L, Engström C, Julkunen R, Montgomery M, Malm A, Lind T, Walan A, Nordic GERD Study Group (2009) Comparison of outcomes twelve years after antireflux surgery or omeprazole maintenance therapy for reflux esophagitis. Clin Gastroenterol Hepatol 7:1292–1298PubMedCrossRefGoogle Scholar
- 20.Anvari M, Allen C, Marshall J, Armstrong D, Goeree R, Ungar W, Goldsmith C (2006) A randomized controlled trial of laparoscopic Nissen fundoplication versus proton pump inhibitors for treatment of patients with chronic gastroesophageal reflux disease: one-year follow-up. Surg Innov 13:238–249PubMedCrossRefGoogle Scholar
- 21.Anvari M, Allen C, Marshall J, Armstrong D, Goeree R, Ungar W, Goldsmith C (2011) A randomized controlled trial of laparoscopic Nissen fundoplication versus proton pump inhibitors for the treatment of patients with chronic gastroesophageal reflux disease (GERD): 3-year outcomes. Surg Endosc 25:2547–2554PubMedCrossRefGoogle Scholar
- 22.Grant AM, Wileman SM, Ramsay CR, Mowat NA, Krukowski ZH, Heading RC, Thursz MR, Campbell MK, REFLUX Trial Group (2008) Minimal access surgery compared with medical management for chronic gastro-oesophageal reflux disease: UK collaborative randomised trial. BMJ 337:a2664PubMedCentralPubMedCrossRefGoogle Scholar
- 23.Grant AM, Cotton SC, Boachie C, Ramsay CR, Krukowski ZH, Heading RC, Campbell MK, REFLUX Trial Group (2013) Minimal access surgery compared with medical management for gastro-oesophageal reflux disease: five year follow-up of a randomised controlled trial (REFLUX). BMJ 346:f1908PubMedCentralPubMedCrossRefGoogle Scholar
- 24.Lundell L, Attwood S, Ell C, Fiocca R, Galmiche JP, Hatlebakk J, Lind T, Junghard O, LOTUS trial collaborators (2008) Comparing laparoscopic antireflux surgery with esomeprazole in the management of patients with chronic gastro-oesophageal reflux disease: a 3-year interim analysis of the LOTUS trial. Gut 57:1207–1213PubMedCentralPubMedCrossRefGoogle Scholar
- 27.Higgins JPT, Green S (2009) Cochrane handbook for systematic reviews of interventions, version 5.0.2. at www.cochrane-handbook.org. Accessed 18 Mar 2013
- 29.Wileman SM, McCann S, Grant AM, Krukowski ZH, Bruce J (2010) Medical versus surgical management for gastro-oesophageal reflux disease (GORD) in adults. Cochrane Database Syst Rev 17(3):CD003243Google Scholar
- 32.NICE (2004) Dyspepsia: managing dyspepsia in adults in primary care: clinical guidelines, CG17. at http://www.nice.org.uk/nicemedia/pdf/CG017fullguideline.pdf. Accessed 18 Mar 2013