Efficacy of surgery needs to be compared with that of proton pump inhibitors

EDITOR—Galmiche et al reviewed the treatment of gastro-oesophageal reflux disease in adults and claimed that surgery is an efficient treatment with a success rate of up to 90%.1Among the few available controlled trials comparing surgery with medical treatment they cited the study of Spechler et al, which showed that surgery is more effective than medical treatment in improving symptoms and oesophagitis for up to two years.2Unfortunately, this trial is flawed. At the time of the study the most efficient drugs (proton pump inhibitors) were not available, and the medical arm used ranitidine, metoclopramide, and antacids. Altogether 247patients were included, but after randomisation 40of them refused to participate, 32of them being allocated to the surgery group. Follow up data were available at two years for only 106 patients, which invalidates all the results. The grade of oesophagitis (range 1-4) on endoscopy in the surgery group and in the continuous medical treatment group was better at two years (1.5(SD 0.2) and 1.9(0.1) respectively) than at baseline (2.9(0.1) for both groups). But no direct statistical comparison was made between the two groups. The patients' satisfaction was also assessed; this was in favour of surgery. This result tells us little, since it was evaluated by a technician aware of the treatment received by the patients. Lastly, an activity index score (range 74-122) was better in the surgery group (78(2)) than in the continuous medical treatment group (88(2)). This evaluation was also not …