DALLAS — The steep decline in antireflux surgery since the 1990s may be caused by skepticism following publication of a study suggesting that most patients who undergo surgery eventually resume taking antireflux medication, said Dr. Jonathan F. Finks at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.
“Antireflux surgery took off in the 1990s, in large part because of the introduction of the laparoscopic Nissen fundoplication procedure,” said Dr. Finks of the division of gastrointestinal surgery at the University of Michigan in Ann Arbor.
Based on data obtained from the Nationwide Inpatient Sample, the number of patients older than age 18 who underwent antireflux surgery in the United States reached a peak at 32,907 in the year 2000. By 2003, the number undergoing surgery fell 27% to 23,998 patients.
“The rate of decline was approximately three times greater for patients in the 30- to 50-year-old age range than it was for patients older than 60,” Dr. Finks reported.
The discrepancy between the two age groups may be explained by an increased likelihood on the part of gastroenterologists to recommend surgery for patients who have had problems for a longer time and who have not attained sufficient relief from medication.
On the heels of the antireflux surgery boom, results of a 2-year randomized controlled trial comparing surgical and medical management of gastroesophageal reflux disease (GERD) were published (JAMA 2001;285:2331–8). The study showed that although patients in the surgical treatment group were less likely to regularly use antireflux medications than were patients in the medical antireflux therapy group, the use of antireflux medication in the surgical group was still substantial.
In addition, there were no differences between the treatment groups in esophagitis grade, incidence of esophageal cancer, frequency of treatment of esophageal stricture, subsequent antireflux operations, or satisfaction with antireflux therapy.
The findings did not question the efficacy of antireflux surgery—which continues to be performed primarily via laparoscopic techniques, according to the data—but rather the supremacy of surgery over other management options, said Dr. Finks.
“Surgery is considered effective, with stable and low mortality and splenectomy rates, and it is associated with good patient satisfaction, but the study findings gave cause to gastroenterologists to reconsider the indications for surgery,” he said.
Surgical intervention may have declined in recent years in part because of the availability of several new endoscopic therapies and increased access to proton pump inhibiting medications, which are inexpensive and available over the counter, he noted.
Reliance on Nationwide Inpatient Sample data might not provide an accurate accounting of the surgical intervention rates, noted Dr. Finks.
“It only represents inpatient procedures, but the trends have been observed in other investigations,” Dr. Finks said.
The bottom line, he said, is that both surgical and medical management of gastrointestinal reflux are reasonable options, but the decision on which approach to use should be based on an assessment of the risks and benefits for individual patients.
The findings do suggest “the need for prospective randomized clinical trials assessing the short- and long-term effectiveness of the range of current therapies,” Dr. Finks concluded.
Dr. Finks reported no conflicts of interest with respect to his presentation.