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Medical vs Surgical Treatment of Gastroesophageal Reflux

Medical vs Surgical Treatment of Gastroesophageal Reflux To the Editor: Dr Spechler and colleagues1 found that 62% of patients who underwent surgical therapy for gastroesophageal reflux disease (GERD) later required antisecretory therapy. However, their study design limits the conclusions on treatment efficacy because they did not follow their patients longitudinally over the entire follow-up period, but only assessed them at 1 point 10 to 13 years after the surgery or the initial medical treatment period. Patient outcomes during the decade preceding the time of the study are not known. This is a problem, particularly in assessing efficacy as measured by symptom and medication questionnaires, endoscopy, and pH monitoring. Questionnaires regarding symptoms or medication use, even if they include questions about the distant past, are known to reflect only events in the recent past.2 The endoscopic and pH monitoring studies could not reveal the patients' status years before they were actually performed. Because the surgical repairs are not permanent in some patients who undergo antireflux surgery,3,4 any advantage of surgical over medical therapy will diminish over time as more patients in the surgery cohort experience failure of their repairs. Perhaps the results comparing medical and surgical therapy would have been different if measured 3, 5, or 7 years after the initial surgery. All that can be concluded from this study is that the differences in efficacy between medical and surgical treatments are modest or minimal after 10 to 13 years; whether surgery confers medium-term benefit is an important question, which cannot be answered by this study. References 1. Spechler SJLee EAhnen D et al. Long-term outcome of medical and surgical therapies for gastroesophageal reflux disease: follow-up of a randomized controlled trial. JAMA. 2001;285:2331-2338.Google Scholar 2. Wentland EJSmith KW Survey Responses: An Evaluation of Their Validity. New York, NY: Academic Press; 1993. 3. Stein HJFeussner JRSiewert MD Failure of antireflux surgery: causes and management strategies. Am J Surg. 1996;171:36-40.Google Scholar 4. Lundell LMiettinen PMyrvold HE et al. Continued (5-year) follow-up of a randomized clinical study comparing antireflux surgery and omeprazole in gastroesophageal reflux disease. J Am Coll Surg. 2001;192:172-181.Google Scholar http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA American Medical Association

Medical vs Surgical Treatment of Gastroesophageal Reflux

JAMA , Volume 286 (14) – Oct 10, 2001

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Publisher
American Medical Association
Copyright
Copyright © 2001 American Medical Association. All Rights Reserved.
ISSN
0098-7484
eISSN
1538-3598
DOI
10.1001/jama.286.14.1709
Publisher site
See Article on Publisher Site

Abstract

To the Editor: Dr Spechler and colleagues1 found that 62% of patients who underwent surgical therapy for gastroesophageal reflux disease (GERD) later required antisecretory therapy. However, their study design limits the conclusions on treatment efficacy because they did not follow their patients longitudinally over the entire follow-up period, but only assessed them at 1 point 10 to 13 years after the surgery or the initial medical treatment period. Patient outcomes during the decade preceding the time of the study are not known. This is a problem, particularly in assessing efficacy as measured by symptom and medication questionnaires, endoscopy, and pH monitoring. Questionnaires regarding symptoms or medication use, even if they include questions about the distant past, are known to reflect only events in the recent past.2 The endoscopic and pH monitoring studies could not reveal the patients' status years before they were actually performed. Because the surgical repairs are not permanent in some patients who undergo antireflux surgery,3,4 any advantage of surgical over medical therapy will diminish over time as more patients in the surgery cohort experience failure of their repairs. Perhaps the results comparing medical and surgical therapy would have been different if measured 3, 5, or 7 years after the initial surgery. All that can be concluded from this study is that the differences in efficacy between medical and surgical treatments are modest or minimal after 10 to 13 years; whether surgery confers medium-term benefit is an important question, which cannot be answered by this study. References 1. Spechler SJLee EAhnen D et al. Long-term outcome of medical and surgical therapies for gastroesophageal reflux disease: follow-up of a randomized controlled trial. JAMA. 2001;285:2331-2338.Google Scholar 2. Wentland EJSmith KW Survey Responses: An Evaluation of Their Validity. New York, NY: Academic Press; 1993. 3. Stein HJFeussner JRSiewert MD Failure of antireflux surgery: causes and management strategies. Am J Surg. 1996;171:36-40.Google Scholar 4. Lundell LMiettinen PMyrvold HE et al. Continued (5-year) follow-up of a randomized clinical study comparing antireflux surgery and omeprazole in gastroesophageal reflux disease. J Am Coll Surg. 2001;192:172-181.Google Scholar

Journal

JAMAAmerican Medical Association

Published: Oct 10, 2001

References