Surgical versus medical therapy for heartburn refractory to proton-pump inhibitors (October 2019)

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Surgical versus medical therapy for heartburn refractory to proton-pump inhibitors (October 2019)

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The optimal approach to heartburn refractory to proton-pump inhibitors (PPI) is debated. In a randomized trial, patients with heartburn refractory to a two-week course of double-dose omeprazole underwent endoscopy, esophageal biopsy, esophageal manometry, and multichannel intraluminal impedance-pH monitoring while on PPI therapy. One-fifth had objective evidence that their symptoms were related to gastroesophageal reflux disease (GERD) and were randomly assigned to receive laparoscopic Nissen fundoplication, active medical management (omeprazole+baclofen±desipramine), or control medical management (omeprazole+placebo). At one year, the proportion of patients in the surgery, active medical, and control medical management groups that achieved ≥50 percent improvement in a GERD quality of life score was 67, 28, and 12 percent, respectively. These results support the efficacy of antireflux surgery, but also underscore the importance of careful patient selection, as 79 percent of patients referred for PPI-refractory heartburn lacked objective evidence of GERD.

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REF. N Engl J Med. 2019;381(16):1513.

UpToDate 2020.03.25