Symptoms of gastro-oesophageal reflux are common—about 25% of the community experience heartburn and 5% have symptoms daily.1 Proton pump inhibitors are the mainstay of treatment for moderate to severe symptoms because randomised controlled trials (RCTs) show they are the most effective medical treatment.2 When these drugs are discontinued symptoms often relapse, so most patients take them long term.3 This is inconvenient for patients and expensive for the health service. Concerns also exist over the long term safety of this treatment—continued acid suppression is associated with increased risk of infective diarrhoea and hip fracture,4 5 although whether these associations are causal is unclear.

The alternative to long term treatment with proton pump inhibitors is surgery. In the linked study (doi:10.1136/bmj.b2576),6 Epstein and colleagues report the results of a cost effectiveness analysis of a large RCT by Grant and colleagues comparing laparoscopic fundoplication with proton pump inhibitors.7 The advent of this type of surgery has reduced the morbidity and cost of surgery and made it a viable alternative to drugs.8 Three …