Treatment of gastro-oesophageal reflux disease in adultsBMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7146.1720 (Published 06 June 1998) Cite this as: BMJ 1998;316:1720
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References : 5
Editor- Galmiche et al reviewed the treatment of gastro-oesophageal reflux disease in adults . They claimed that surgery is an efficient treatment with up to 90% of success rate. Among the few available controlled trials comparing surgery to medical treatment, they cited the study of Spechler et al , showing that surgery is more effective than medical treatment in improving symptoms and oesophagitis for up to two years. Unfortunately, this trial is flawed by many biases. First, at the time of the study, the most efficient drugs - proton pump inhibitors - were not available, then the medical arm associated ranitidine, metoclopramide and antacids. 247 patients were included, but after randomisation, 40 of them refused to participate, 32 of them being allocated in 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 were statistically better at two years (respectively 1.5 0.2 and 1.9 0.1) compared to their baseline value (2.9 0.1 for both groups). But no direct statistical comparison was made between surgical and continuous medical treatment groups. There was also an assessment of the patient's satisfaction which was in favour of surgery. This result is poorly informative, since it was evaluated by a technician aware of the treatment received by patients. Last, an activity-index score (range 74-122) was statistically better with surgery treatment (78 2) than with continuous medical treatment (88 2). This evaluation was also not blinded, and authors did not discuss the clinical pertinence of a 10 points difference. This trial, although published in a major journal cannot be taken into consideration .
Another controlled trial, which was not cited by Galmiche et al, compared ranitidine 150 mg twice daily to fundoplication and concluded to the superiority of surgical treatment . This trial raises also major criticisms : only 31 patients included, no randomisation, no blinded evaluation, no comparison between ranitidine and surgical groups .
Since the availability of powerful proton pump inhibitors, the notion of refractory oesophagitis tends to disappear . Indications for surgery are now mostly limited to young patients with recurrent oesophagitis and refusing continuous treatment. But the efficacy of surgery still needs to be proved in comparison with proton pump inhibitor.
1. Galmiche JP, Letessier E, Scarpignato C. Treatment of gastro-oesophageal reflux disease in adults. BMJ 1998; 316: 1720-3.
2. Spechler SJ, and the Department of Veterans Affairs Gastroesophageal Reflux Disease Study Group. Comparison of medical and surgical therapy for complicated gastroesophageal reflux disease in veterans. N Engl J Med 1992; 326: 786-92.
3. Checklist for authors submitting reports of randomized controlled trials (CONSORT). JAMA 1996; 276: 637-639
4. Johansson KE, Tibbling L. Maintenance treatment with ranitidine compared with fundoplication in gastro-oesophageal reflux disease. Scand J Gastroenterol 1986; 21: 779-88.
5. Bardhan KD, Morris P, Thompson M et al. Omeprazole in the treatment of erosive oesophagitis refractory to high-dose cimetidine and ranitidine. Gut 1990; 31: 745-9.
Competing interests: No competing interests