Report equates PPIs, surgery as GERD treatments.(Clinical Rounds)

Proton pump inhibitors are as effective as surgery for the treatment of most patients with uncomplicated gastroesophageal reflux disease, according to a new report from the Agency for Healthcare Research and Quality, Rockville, Md.

The report is the first in a series that will be released as part of the agency's Effective Health Care Program. It includes a review of findings of studies comparing various gastroesophageal reflux disease (GERD) treatment options, including medical, surgical, and endoscopic treatments.

According to the findings of three head-to-head comparisons of PPIs and fundo-plication, the two treatment modalities are similarly effective for improving symptoms and quality of life, decreasing esophageal acid exposure, and preventing Barrett's esophagus and esophageal adenocarcinoma, the report states. And although surgery is often chosen with a goal of eliminating the need for medical therapy, up to 65% of surgical patients in these studies still required PPI therapy, according to the agency's report, entitled Comparative Effectiveness of Management Strategies for Gastroesophageal Reflux Disease. The three studies were considered to be of fair (grade B) quality.

Based on the best available evidence, the authors of the report also reached these conclusions: PPIs are superior to over-the-counter histamine type 2 receptor antagonists for symptom resolution at 4 weeks, and for healing of esophagitis at 8 weeks, but PPIs are associated with more side effects, including headache, diarrhea, and abdominal pain. Also, various PPIs are of similar clinical effectiveness. For maintenance therapy of 6-month to 1-year duration, PPIs taken at a standard dose are more effective than PPIs taken at a reduced dose (usually half the standard dose). These conclusions were based on findings from three recent metaanalyses considered by the authors to be of good (grade A) quality.

Laparoscopic fundoplication is as effective as open fundoplication for relieving symptoms, decreasing antisecretory medication use, and improving quality of life, according to data from one grade B, randomized controlled study, and one poor quality (grade C) nonrandomized study. Nearly 90% of patients in both arms who were followed for at least 5 years reported ...