Yvonne Romero, MD
Do medical management and laparoscopic fundoplication surgery (LFS) differ for quality of life in adults with gastroesophageal reflux disease (GERD)?
Included studies compared medical management (proton pump inhibitors or histamine-receptor antagonists) with LFS in patients (> 14 y of age) who had GERD. Outcomes included health-related and GERD-specific quality of life, heartburn, regurgitation, dysphagia, and costs.
MEDLINE, EMBASE/Excerpta Medica, and Cochrane Upper Gastrointestinal and Pancreatic Diseases Group trials register (all to May 2009); CENTRAL (Cochrane Library, 2009, Issue 2); and reference lists were searched for randomized controlled trials (RCTs) and quasi-RCTs. Experts were contacted. 4 RCTs (n = 1232, mean or median age range 43 to 48 y, 61% men) met the selection criteria. 1 RCT used esomeprazole, 20 to 40 mg daily, for medical management, and 3 used a pragmatic approach; 3 RCTs mostly used laparoscopic total Nissen fundoplication, and 1 allowed any LFS technique. 2 RCTs reported adequate allocation concealment, 3 reported adequate generation of the allocation sequence, 3 were considered free of selective reporting, and 3 reported > 80% patient follow-up.
Meta-analysis of 2 RCTs showed that LFS was better than medical management for some quality-of-life measures at 1 year (Table); 1 RCT found that LFS improved Psychological General Well-being Index scores more than medical management (n = 165, mean 106 vs 100, difference 5.8, 95% CI 0.43 to 11.2). 3 studies (n = 975) found that LFS improved GERD-specific quality of life at 1 year more than medical management using various measures; results were unclear in 1 study (n = 166). 1 RCT (n = 104) reported that LFS was better than medical management for heartburn (mean Gastroesophageal Reflux Symptom Score [GERSS] 0.8 vs 2.8, P < 0.001) and acid reflux (mean GERSS for regurgitation 0.7 vs 2.7, P = 0.002) at 1 year. Another study (n = 554) reported that LFS improved both outcomes more than medical management over 3 years (data not provided). 2 studies (n = 771) reported postoperative dysphagia compared with few or no episodes of dysphagia in medical management. Meta-analysis showed that costs were greater with LFS than with medical management (Table).
In adults with gastroesophageal reflux disease, laparoscopic fundoplication improves some measures of quality of life more than medical management at 1 year.
Laparoscopic fundoplication surgery vs medical management for gastroesophageal reflux disease*
*Abbreviations defined in Glossary.
†Negative values indicate a benefit for laparoscopic fundoplication surgery.
Romero Y. Review: Laparoscopic fundoplication is better than medical management for some quality-of-life measures in GERD. Ann Intern Med. ;153:JC3–10. doi: 10.7326/0003-4819-153-6-201009210-02010
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Published: Ann Intern Med. 2010;153(6):JC3-10.
Esophageal Disorders, Gastroenterology/Hepatology, Gastroesophageal Reflux Disease, Peptic Disease.
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