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Abstract & Commentary
Synopsis: Surgical therapy is not appropriately recommended as a means of averting future medical therapy or as a preventive measure against esophageal adenocarcinoma.
Source: Spechler SJ, et al. JAMA. 2001;285:2331-2338.
This article provides follow-up on a large cohort of medically and surgically treated gastroesophageal reflux disease (GERD) patients in the VA system for more than 10 years. Of the original patients, 239 (97%) were found. A total of 92% of medical patients (n = 83) and 62% of surgical patients (n = 23) still required regular antireflux medicines. Survival was actually decreased in the surgical vs. medical group, apparently due to cardiovascular deaths. Barrett’s esophagus was associated with an annual cancer risk of 0.4% in both medical and surgical patients. One concludes that surgical therapy is not appropriately recommended as a means of averting future medical therapy or as a preventive measure against esophageal adenocarcinoma.
Comment by Malcolm Robinson, MD, FACP, FACG
GERD is extremely common, often presenting to a wide range of physicians. Between 20% and 40% of Americans may have significant GERD symptoms. More ominously, presumably GERD-related esophageal adenocarcinoma has nearly quadrupled in the past 2 decades. There has been considerable controversy regarding the proper role of surgery (such as open or laparoscopic fundoplication) in management of chronic GERD. Some surgeons have suggested that surgery might be an alternative to expensive long-term medical management and that surgery might lessen the risk of subsequent esophageal adenocarcinoma. This VA study provides useful data to refute both of these assertions, and similar results have also been seen in an ongoing European study. For most GERD patients, chronic medical management continues to be the treatment of choice. Needless to say, enthusiastic boosters of new endoscopic techniques for GERD management with the so-called Stretta procedure or endoscopic suturing have no long-term data and such approaches cannot be recommended on other than an investigational basis.