Pills or Surgery for Heartburn?

Gastroesophageal reflux disease, aka, GERD, is medicalese for heartburn, and it's a very, very common condition, affecting millions of people both domestically and worldwide.  While some may think it's rather benign, more recent evidence points to the fact that chronic heartburn can give rise to chronic irritation of the esophagus known as Barrett's esophagus.  Barrett's can then give rise to esophageal cancer, which has a fairly dismal prognosis.  So GERD isn't something to simply ignore.  Is it best to treat GERD with medication or surgery?  Rick and I debate the issue in this week's podcast, based on a study in JAMA.

About 500 people with established GERD were randomized to either medical therapy with esomeprazole, one of a number of medications known as proton pump inhibitors which are usually very effective in managing heartburn, or standardized laparoscopic antireflux surgery (LARS).  Patients who took the medication were optimized to do so; they were allowed to increase their dosage or split a daily maximal dose into two administrations in an attempt to avoid nighttime breakthrough of symptoms.  The subjects were followed for five years.

Both treatment strategies turned out to be both effective for most people and comparable to each other in this long term follow up.  There were some differences in symptoms of GERD between the treatment groups:  those who took the medication reported about twice as much heartburn as those who underwent surgery, but the surgical group had more trouble with bloating and swallowing.

So how can someone who has GERD decide which of the two treatments to elect?  Rick brings out the point that many people don't like to take medications over the long term, perhaps for their remaining lifetime, and therefore may choose surgery.  I take the alternate view (surprise!) that just as many others, including and perhaps especially me,  would rather not undergo a procedure unless no alternatives exist.  Something neither of us land on very hard but is absolutely worth considering is the various lifestyle strategies that everyone who seems to be falling into chronic heartburn should try:  not eating within three or so hours of retiring, avoiding caffeine, alcohol, spicy foods and the like before bedtime, elevating your head while sleeping, and turning to more benign medications such as antacids before bringing out the big guns like proton pump inhibitors.  Weight loss and exercise are also known to help.

Long term concerns related to proton pump inhibitors may be an increased risk for fractures and pneumonia.  In this study no complications were reported secondary to LARS (with the caveat that all procedures were performed by experienced surgeons and centers), so perhaps over the long term such a strategy minimizes risk.  In conclusion, as Rick and I say so often, an informed patient is the best solution.  When all the information is at hand one's own risk and tolerance profile is likely the most important factor.

Other topics this week include the success of treating one HIV positive partner in preventing transmission to their negative partner (NIAID trial), the success of telemedicine in managing patients in the ICU in JAMA, and the addition of a third agent to manage type 2 diabetes in Annals of Internal Medicine.  Until next week, y'all live well.

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Is Heartburn Surgery A Good Idea?
November 17, 2011 at 9:16 am

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