Background: Gastroesophageal reflux disease (GERD) is one of the most common health conditions affecting Americans. Despite the availability of medical, surgical, and endoscopic options, optimal management strategies remain unsettled.
Purpose: The purpose was to systematically review and update our previous Comparative Effectiveness Review, which compared the effectiveness of different management options for adults with GERD.
Data Sources: We searched MEDLINE,® Cochrane Central Register of Controlled Trials, and other relevant databases, as well as other existing systematic reviews.
Study Selection: Studies of various designs were sought, including comparative randomized controlled trials, nonrandomized and cohort studies, and systematic reviews.
Data Extraction: A standardized protocol was used to extract details on study design, diagnoses, interventions, outcomes, and quality.
Data Synthesis: In total, 166 studies met eligibility criteria. We found a moderate strength of evidence that laparoscopic fundoplication in patients whose GERD symptoms were already well controlled by medical treatments was at least as effective as continued medical treatment (and in some cases superior) in controlling GERD-related symptoms for the first 1 to 3 years following surgery. However, the rate of serious adverse events was generally higher in patients who underwent fundoplication compared with those who had medical treatment. We did not identify sufficient evidence to conclude whether medical or surgical treatment was more effective in preventing long-term complications of GERD, such as the development of Barrett's esophagus or esophageal adenocarcinoma. We found a moderate strength of evidence that proton pump inhibitors were superior to histamine-2 receptor antagonists in resolving GERD symptoms at 4 weeks and promoting healing of esophagitis at 8 weeks. Evidence regarding the effectiveness of endoscopic procedures was insufficient. Evidence regarding the effectiveness of treatment of GERD on asthma symptoms was inconclusive.
Limitations: Studies directly comparing surgery to medical therapy generally had high dropout rates in long-term followup. There was a great deal of variability in the rigor with which the outcomes were evaluated across studies, particularly in subjective endpoints.
Conclusions: Medical therapy and laparoscopic fundoplication were similarly effective in improving GERD symptoms in patients whose symptoms were already well controlled by medical therapy for at least the first 1 to 3 years following surgery. Serious adverse events were more common after surgery. The effectiveness of endoscopic procedures remains substantially uncertain.