Reflux surgery tops pills in the short term

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People who suffer from chronic severe stomach acid reflux have two options—long-term medication or anti-reflux surgery. A new review of the medical literature shows that surgery is more effective than medication at reducing reflux symptoms over one year.

However, whether or not these benefits are sustained over longer periods remains to be seen.

After one year, it is unclear whether the differences in effectiveness between these two treatment options “remain the same, diminish or increase over the long term,” Dr. Samantha Wileman, of the Health Services Research Unit at the University of Aberdeen in the UK, told Reuters Health.

Gastroesophageal reflux disease, or GERD, is a common chronic condition in which stomach acid backs up into the esophagus, irritating its lining and causing inflammation. Persistent, often severe heartburn is the most common symptom.

Most people are helped by a class of drugs called proton pump inhibitors—for example Nexium, Prilosec, Prevacid. For those who are not helped by these medications, there are few options short of a type of surgery called fundoplication that tightens the junction between the esophagus and stomach.

However, it’s unclear whether surgery or medication is better for people with persistent GERD. To investigate, Wileman’s team reviewed four trials that compared medication with anti-reflux surgery in about 1,200 adults with GERD.

In all four studies, surgery led to far greater improvement in GERD symptoms and general health than medication up to one year, the authors report in the Cochrane Database of Systematic Reviews.

“All four studies showed that heartburn, reflux and bloating were improved after surgery compared to medical treatment, although a small proportion of participants still had persistent difficulty with swallowing after the operation,” Wileman told Reuters Health.

She emphasized, however, that it’s not possible to draw any conclusions beyond one year. “We know that at least two of the four studies are following up participants over the longer term, and we hope that the next update of our review will provide a more conclusive answer as to which treatment is the best for controlling persistent symptoms of (reflux).”

As with any surgery, antireflux surgery does carry a risk and whether this is outweighed by the benefits in the long term “is still not certain,” Wileman said. In the four studies reviewed, complications after anti-reflux surgery were “low but not non-existent,” she noted. “The key risks of the surgery are conversion from laparoscopic (keyhole) to open surgery.”

And the cost of surgery over one year is also considerably higher than the cost of medical treatment.

But long-term use of anti-reflux pills also has drawbacks. “While taking acid suppression tablets is generally assumed to be safe, they can cause short-term symptoms such as headaches, diarrhea and stomach pains,” Wileman explained.

“More importantly,” she said, their long-term use may cause high levels of gastrin, a hormone produced by the stomach, which may increase the risk of stomach cancer. “These risks have led to much interest in surgery as an alternative to the long-term use of acid suppression tablets, especially since the introduction of the keyhole operation,” Wileman said.

SOURCE: Cochrane Database of Systematic Reviews, online March 17, 2010.

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