Fundoplication is superior to medical therapy for Barrett's esophagus disease regression and progression: a systematic review and meta-analysis

Abstract

Background: Fundoplication and medical management are current mainstays for management of Barrett's esophagus (BE), however our understanding of differences in outcomes between these two treatments is limited. The aim of this study was to perform a systematic review and meta-analysis to evaluate the efficacy of these interventions on BE disease regression and progression.

Methods and procedures: A comprehensive search in MEDLINE, EMBASE, Scopus, Web of Science, and Cochrane Library databases was performed on February 22, 2021. Inclusion criteria were studies with both medical and surgical management comparators, BE diagnosis prior to treatment, patients aged ≥ 18 years, and studies with greater than five patients. Primary outcomes of interest included evaluating changes in histopathologic BE regression and disease progression between interventions. Meta-analysis was performed using a Mantel-Haenszel random-effects model (RevMan 5.4.1).

Results: A total of 7231 studies were retrieved after initial search with nine studies (1 randomized trial, 7 prospective cohorts, 1 retrospective cohort) meeting final inclusion criteria. Of included studies, 890 (65%) patients received medical management while 470 (35%) received surgical management. Medical management included proton pump inhibitors (n = 807, 91%; 6 studies), H2-receptor blockers (n = 40, 4% patients; 3 studies), and combination therapy (n = 43, 5%; 1 study). Nissen fundoplication was the most commonly performed type of fundoplication (n = 265, 93%). Median length of follow-up ranged from 1.5-7 years. Meta-analysis revealed that fundoplication was associated with improved histopathologic regression of metaplasia/low-grade dysplasia (OR 4.38; 95% CI 2.28-8.42; p < 0.00001) and disease progression to dysplasia/adenocarcinoma (OR 0.34; 95% CI 0.12-0.96; p = 0.04) compared to medical therapy.

Conclusion: Fundoplication is superior to medical therapy with regards to improved odds of histopathologic BE disease regression and disease progression. Additional randomized trials which directly compare medical management and surgical intervention are required to delineate the optimal delivery and timing of these interventions.

Keywords: Barrett’s esophagus; Dysplasia; Fundoplication; Proton pump inhibitors.