[Anti-reflux surgery in patients with adequate response to proton pump inhibitors - is there an indication?]

Abstract

Background: The indication for anti-reflux-surgery in patients with gastroesophageal reflux disease (GERD) who are totally symptom-free under conservative treatment with proton pump inhibitors (PPI) is still seen controversially. Arguments for PPI-treatment include the missing trauma and few side-effects, arguments against include the life-time-long drug intake. We prospectively observed the indication of anti-reflux-surgery in symptom-free patients in comparison to patients with remaining symptoms under treatment with PPI.

Patients and methods: Between January 1999 and December 2001, 317 patients with GERD were treated by laparoscopic hemifundoplication and grouped in patients with adequate response to PPI (n = 103) and patients with residual discomfort in spite of or by PPI (n = 214). Preoperative diagnostic included endoscopy, ph-testing, manometry and quality of life scoring by a standardized questionnaire. Peri- and postoperative morbidity as well as quality of life were analyzed and compared with healthy individuals (n = 50).

Results: Patient demographics and surgical procedures did not differ between the two groups. After a median follow-up of 49 months and a follow-up rate of 89.9 %, the recurrence rate was 2.5 % and perioperative complication rate was 6.3 % without any significant differences between the groups. Patients with GERD and adequate response to PPI showed preoperatively during PPI omission a significant lower incidence of esophagitis (3.9 % vs. 18.2 %) and higher quality of life score (93.7 +/- 11.3 vs. 75.3 +/- 12.6), which significantly decreased in comparison to healthy individuals (132.9 +/- 10.5). After anti-reflux surgery the quality of life has been increased in both groups (130.5 +/- 11.4 vs. 121.8 +/- 13.2). However, only patients with adequate response to PPI reached the quality of life score of healthy individuals.

Conclusion: Patients with preoperatively adequate response to PPI profit of anti-reflux surgery in terms of postoperative quality of life. Concerning the indication for anti-reflux surgery in these patients, one has to balance between the individual inconvenience due to the long-lasting drug intake on the one hand and the operative risk, morbidity and outcome of a specialized surgical department on the other hand.