The knife or the pill in the long-term treatment of gastroesophageal reflux disease?

Gastroesophageal reflux disease (GERD) is a common condition, and it is now generally recognized that modern medical therapy allows the physician to both heal the esophagitis and relieve the patients from troublesome symptoms such as heartburn, acid regurgitation and disabling chest pain. In addition, long-term therapy with potent acid inhibitory drugs can maintain these patients in clinical remission. The indications for antireflux surgery and long-term medical therapy have developed and changed with time but are today essentially similar, and in fact, it can be hypothesized that the outcome of a short-term "therapeutic trials" with the proton pump inhibitor would be a useful clinical tool, not only as a diagnostic test for the disease but also in the selection process before referring the patient to antireflux surgery. Antireflux surgery is designed to improve the function of the antireflux barrier by reconstructing the physiology of the gastroesophageal junction. Studies have shown that a fundoplication procedure improves the strength and length of the lower esophageal sphincter and also restitutes the flutter valve mechanism. However, since gastroesophageal reflux disease is a common disorder, it is impossible for every patient to be attended by an expert surgeon, and this might be one important reason for the sometimes poor results presented after surgical treatment. When the question arises about which type of long-term therapy should be chosen in each clinical situation, this situation should also partly be influenced by some epidemiological information. If we assume that we expose a hypothetical group of 100 patients with symptomatic, chronic severe reflux disease, also presenting endoscopic evidence of esophagitis of varying severity, available clinical information would suggest that only 25 can be considered suitable for antireflux surgery, depending on the frequently associated complicating medical disorders and the age distribution of the actual patient population. Therefore, it deserves to be emphasized that the majority of patients with complicated reflux disease are not fit for surgery and should consequently be managed medically. For younger patients with disabling GERD, antireflux surgery is still the gold standard and obviously very cost effective.