Medical Versus Surgical Treatment for Refractory Heartburn: What Should You Do?
Prateek Sharma, MD, FASGE reviewing Spechler SJ, et al. New Engl J Med 2019 Oct 17.
Although proton pump inhibitors (PPIs) are widely utilized for GERD management, 20% to 30% of patients continue to experience heartburn symptoms despite therapy. Treatment options for such patients with proven reflux, such as continued abnormal acid exposure or reflux hypersensitivity, are limited to use of medications (baclofen or neuromodulators) or antireflux surgery.
Veteran patients with heartburn refractory to PPIs were screened, and eligible patients (n=366) were given a trial of 20 mg of omeprazole twice daily for 2 weeks. Those with persistent heartburn underwent a systematic workup with endoscopy, esophageal biopsies, esophageal manometry, and impedance–pH monitoring to rule out functional heartburn and non-GERD conditions. The 78 patients with documented reflux were randomized to laparoscopic Nissen fundoplication (n=27), medical treatment (omeprazole plus baclofen, with desipramine added, depending on symptoms; n=25), or control (omeprazole plus placebo; n=26). Treatment success was defined as a decrease of >50% in the GERD Health-Related Quality of Life score at 1 year. Treatment success achieved in 67% of the patients in the surgical group was significantly higher compared to that in the medical group (28%; P=0.007) or the control group (12%; P<0.0001). Serious adverse events were noted in 4, 4, and 3 patients, respectively, in the surgery, medical, and control groups. One patient in the surgery group had a herniated fundoplication that resulted in repeat surgery, complicated by postoperative pneumonia.
COMMENT
True reflux-related heartburn is uncommon and was documented in 20% of patients with PPI-refractory GERD in this study after an extensive workup with endoscopy, esophageal biopsies, manometry, and ph-impedance monitoring. At 1 year of follow-up, laparoscopic Nissen fundoplication was significantly superior to PPI therapy alone or PPI therapy along with baclofen in those with documented reflux and refractory heartburn.
Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.
Prateek Sharma, MD, FASGE
CITATION(S)
Spechler SJ, Hunter JG, Jones KM, et al. Randomized trial of medical versus surgical treatment for refractory heartburn. New Engl J Med 2019;381:1513-1523. (https://doi.org/10.1056/NEJMoa1811424)
