Two Surgeries for Chronic GERD Yield Similar Long-Term Outcomes

Fifteen years after a laparoscopic partial or total fundoplication for chronic gastroesophageal reflux disease (GERD), the two approaches appeared equally effective when it came to the ability to swallow foods, reflux control, and quality of life, long-term data from a single-center randomized trial in Sweden showed.

Mean dysphagia scores -- on a scale of 1 to 4 (no episodes to more than three) -- were identical for both solid and liquid foods at this time point, regardless of whether patients received a 270° posterior partial fundoplication or a 360° total fundoplication:

• Solid foods: 1.3 for each approach (P=0.97)
• Liquid foods: 1.2 for each (P=0.58)

And both procedures provided similar long-term outcomes for reflux control, with low Gastrointestinal Symptom Rating Scale (GSRS) scores that were not significantly different between groups, reported Apostolos Analatos, MD, of the Nyköping Hospital in Sweden, and colleagues in JAMA Surgery.

Additionally, the two groups both saw quality-of-life improvements from baseline, in both average physical component scores and average mental component scores.

"TF [total fundoplication] has been claimed to be superior to PF [partial fundoplication] in terms of gastroesophageal reflux control, durability of wrap function, number of subsequent herniations, and recurrence rates of GERD," noted Analatos and colleagues in their introduction.

"This claim prompted attempts to further modify PF to encircle 270° of the esophageal circumference," they continued. "The objective was to maintain the mechanical advantages of the partial wrap without compromising the efficacy to control gastroesophageal reflux."

In an accompanying editorial, Bernard Dallemagne, MD, and Silvana Perretta, MD, both of the University of Strasbourg in France, pointed out that Analatos and colleagues "do not mention or stress the importance of the surgical technique used in this study, which is clearly accountable for the consistent and homogenous results."

"It seems important to emphasize that the authors applied the principles of a tension-free repair, namely that of a floppy valve, total or partial, based on the correct identification and freeing of the upper part of the gastric fundus and extensive esophageal mobilization," wrote Dallemagne and Perretta. "The combination of various (mis)interpretations of the adequate technique to build a partial or total fundoplication, together with a short follow-up, can largely explain the variety and inconsistency of the results reported in the literature."

The duo also highlighted a key limitation in the new analysis, which was the lack of any objective measures of reflux control, and noted the "small but consistent increase in dysphagia rate over time in the partial fundoplication group."

From 2001 to 2006, the trial enrolled 456 patients with chronic GERD at Ersta Hospital in Stockholm and randomized them to partial or total fundoplication.

At 1 and 2 years following surgery, mean dysphagia scores favored partial versus total fundoplication:

• Liquid foods at 1 year: 1.0 vs 1.1, respectively (P=0.04)
• Solid foods at 1 year: 1.1 vs 1.3 (P=0.01)
• Solid foods at 2 years: 1.1 vs 1.3 (P=0.01)

"Although PF was superior in the first years after surgery in terms of less dysphagia recorded, this difference did not prevail when assessed a decade later," Analatos and colleagues concluded.

With 46 patients from the trial deceased, the current analysis included 301 of the 407 remaining patients who completed validated questionnaires (76% response rate). More than half of the patients were men (59%), mean age was 66, and around 20% had Barrett's esophagus.

During the mean 16 years of follow-up, 3% of patients in the partial fundoplication group and 7% of those in the total fundoplication group underwent additional surgery for recurrent GERD (P=0.08).

No significant differences between the groups were observed for daily proton pump inhibitor (PPI) use (24% vs 28%, respectively). Among PPI users, about two-thirds reported using them to control GERD symptoms, while other reasons cited included swallowing difficulties or abdominal pain.

In the initial 5 years of follow-up, however, only about 10% of the cohort relied on PPIs.

"Previous observations indicate that few of those who are prescribed PPIs after antireflux surgery are ultimately found to have recurrent GERD, which was also confirmed in our study cohort," Analatos and co-authors wrote. "Nevertheless, this trend over time, which has also been observed in population-based studies, constitutes a concern that needs to be addressed in future studies."

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