Continued (5-year) followup of a randomized clinical study comparing antireflux surgery and omeprazole in gastroesophageal reflux disease

BACKGROUND: The efficacy of antireflux surgery (ARS) and proton pump inhibi tor therapy in the control of gastroesophageal reflux disease is well estab lished. A direct comparison between these therapies is warranted to assess the benefits of respective therapies. STUDY DESIGN: There were 310 patients with erosive esophagitis enrolled in the trial. There were 155 patients randomized to continuous omeprazole ther apy and 155 to open antireflux surgery, of whom 144 later had an operation. Because of various withdrawals during the study course, 122 patients origi nally having an antireflux operation completed the 5-year followup; the cor responding figure in the omeprazole group was 133. Symptoms, endoscopy, and quality-of-life questionnaires were used to document clinical out comes. T reatment failure was defined to occur if at least one of the following crit eria were fulfilled: Moderate or severe heartburn or acid regurgitation dur ing the last 7 days before the respective visit; Esophagitis of at least gr ade 2; Moderate or severe dysphagia or odynophagia symptoms reported in com bination with mild heartburn or regurgitation; If randomized to surgery and subsequently required omeprazole for more than 8 weeks to control symptoms , or having a reoperation; If randomized to omeprazole and considered by th e responsible physician ro require antireflux surgery to control symptoms; If randomized to omeprazole and the patient, for any reason, preferred anti reflux surgery during the course of the study. Treatment failure was the pr imary outcomes variable. RESULTS: When the time to treatment failure was analyzed by use of the inte ntion to treat approach, applying the life table analysis technique, a high ly significant difference between the two strategies was revealed (p < 0.00 1), with more treatment failures in patients who originally were randomized to omeprazole treatment. The protocol also allowed dose adjustment in pati ents allocated to omeprazole therapy to tither 40 or 60 mg daily in case of symptom recurrence. The curves subsequently describing the failure rates s till remained separated in favor of surgery although the difference did not reach statistical significance (p = 0.088). Quality of life assessment rev ealed values within normal ranges in both therapy arms during the 5 years. CONCLUSIONS: In this randomized multicenter trial with a 5-year followup, w e found antireflux surgery to be more effective than omeprazole in controll ing gastroesophageal reflux disease as measured by the treatment failure ra tes. But if the dose of omeprazole was adjusted in case of relapse, the two therapeutic strategies reached levels of efficacy that were not statistica lly different. (J Am Coll Surg 2001;192:172-181. (C) 2001 by the American C ollege of Surgeons).