Medical or surgical treatment for chronic gastro-oesophageal reflux? A systematic review of published evidence of effectiveness

Objective: To compare the effectiveness of medical (antacids, histamine ant agonists and proton pump inhibitors) and surgical (fundoplication) treatmen t of chronic GORD. Subjects: Patients with objective (endoscopic or pH) evidence of chronic re flux reported in 6 randomised trials and 3 cohort studies, 1966-1999. Methods: Systematic review of comparative studies identified from electroni c searches, citations, manual searches of journals, and correspondence with authors and experts. Main outcome measures: Improvements in prevalence or severity of symptoms, oesophagitis, pH reflux duration, lower oesophageal sphincter pressure, pat ients' satisfaction, and side-effects. Results: Improved outcomes were more common after surgical than medical tre atment with significant differences in objective outcomes in 5/6 randomised trials and in 2/3 cohort studies. Subjective outcomes (symptoms and patien ts' satisfaction) were also more common among surgical patients in all but one study that assessed them. Odds ratios for improvement with surgical rat her than medical treatment ranged from 1.2 to 200, and numbers needed to tr eat ranged from 1.2 to 58, where these could be calculated. Studies were to o heterogeneous for meta-analysis. Conclusions: In trials of chronic severe CORD, surgery is consistently more effective than medical treatment in relieving symptoms and objective oesop hagitis, although omeprazole can give similar symptom relief with adjustmen t of the dose.