Lifetime costs of surgical versus medical treatment of severe gastro-oesophageal reflux disease in Finland

A cost-effectiveness analysis of RefluxStop against relevant therapeutic alternatives for chronic gastroesophageal reflux disease in Sweden

INTRODUCTION

The standard treatment for gastroesophageal reflux disease (GERD) is proton pump inhibitors (PPIs). In selected cases, Nissen fundoplication is offered as a surgical treatment option, but alternative endoscopic and minimally invasive surgical alternatives are emerging. RefluxStop is a new technology for the treatment of GERD.

RESEARCH DESIGN AND METHODS

A cost-effectiveness analysis of RefluxStop in comparison to PPI therapy and Nissen fundoplication in the Swedish healthcare setting was conducted using a Markov model and available comprehensive population and clinical trial-based long-term data. Benefits were measured in quality-adjusted life-years (QALYs). Uncertainty was determined by deterministic and probabilistic sensitivity analyses.

RESULTS

The base case incremental cost-effectiveness ratios (ICERs) for RefluxStop in comparison to PPIs and Nissen fundoplications were SEK 48,152 (€ 4,531) and SEK 62,966 (€ 5,925) per QALY gained, respectively. At a cost-effectiveness threshold of SEK 500,000 per QALY gained, RefluxStop has a high likelihood of being cost-effective, with probabilities of 96% and 100% against Nissen fundoplication and PPIs, respectively. The results of the model remained robust with sensitivity analysis.

CONCLUSIONS

RefluxStop may offer a highly cost-effective long-term treatment alternative for chronic GERD patients over lifelong PPI therapy, but also in comparison with laparoscopic Nissen fundoplication.

Cost-effectiveness of proton pump inhibitors versus laparoscopic Nissen fundoplication for patients with gastroesophageal reflux disease: a systematic review of the literature

BACKGROUND

Gastroesophageal reflux disease is a common condition in Western countries. It is unknown whether medical or surgical treatment is more cost-effective. This study was conducted to determine whether laparoscopic Nissen fundoplication or treatment by proton pump inhibitors is the most cost-effective for gastroesophageal reflux disease in the long term.

METHODS

Medline, EMBASE, and Cochrane databases were searched for articles published between January 1990 and 2010. The search results were screened by two independent reviewers for economic evaluations comparing costs and effects of laparoscopic Nissen fundoplication and proton pump inhibitors in adults eligible for both treatments. Cost and effectiveness or utility data were extracted for both treatment modalities. The quality of the economic evaluations was scored using a dedicated checklist, as were the levels of evidence.

RESULTS

Four publications were included; all were based on decision analytic models. The economic evaluations were all of similar quality and all based on data with a variety of evidence levels. Surgery was more expensive than medical treatment in three publications. Two papers reported more quality-adjusted life-years for surgery. However, one of these reported more symptom-free months for medical treatment. In two publications surgery was considered to be the most cost-effective treatment, whereas the other two favored medical treatment.

CONCLUSIONS

The results with regard to cost-effectiveness are inconclusive. All four economic models are based on high- and low-quality data. More reliable estimates of cost-effectiveness based on long-term trial data are needed.

Review article: the role of surgery in gastro-oesophageal reflux disease

BACKGROUND

Rates for laparoscopic fundoplication are declining in the United States and there is no consensus on the indications for referral to surgery in gastro-oesophageal reflux disease.

AIM

To highlight recent studies on the outcomes of laparoscopic fundoplication in adults that cast doubt on the traditional indications for surgery in reflux disease.

RESULTS

Patients who are well maintained on medical therapy have more to lose with surgical intervention than to gain, and should not be offered surgery. Likewise, the notion that surgery prevents oesophageal cancer is a hypothesis that is not supported by current evidence, therefore surgical intervention should not be offered to these patients. The only clear-cut candidates for surgery include: patients with anatomic abnormalities such as a large hiatus hernia, or those with persistent regurgitation that causes troublesome symptoms despite medical therapy; and carefully selected patients with extra-oesophageal disorders who have symptoms of reflux disease such as heartburn and regurgitation, an incomplete response to medical therapy and persistent plus demonstrable reflux on pH or impedance testing that is associated with their symptoms. Patients should be aware of the high likelihood of needing continued acid inhibitory therapy following surgery and the possibility of side-effects.

CONCLUSION

Only a few carefully selected patients should undergo fundoplication for reflux disease.

A comparison of the cost effectiveness of pharmacotherapy or surgery (laparoscopic fundoplication) in the treatment of GORD

BACKGROUND

Gastro-oesophageal reflux disease (GORD) causes some of the most frequently seen symptoms in both primary and secondary care. An estimated 4-5 patients (age range 18-60 years) per 10,000 (0.045% of the general population) are receiving maintenance proton pump inhibitors (PPIs) for oesophagitis and reflux. The treatment of reflux disease represents significant prescription drug costs to the UK NHS. An alternative to lifelong pharmacotherapy is surgical treatment of reflux using the laparoscopic fundoplication technique to effect a cure. A multicentre study (REFLUX trial) comparing laparoscopic fundoplication with medical management (PPIs) among patients with GORD is currently underway in the UK. This study includes data collection to contribute to a cost-effectiveness analysis.

OBJECTIVE

To generate some preliminary estimates of the cost effectiveness of surgical and medical management of GORD to guide UK NHS decision making before the REFLUX trial reports.

METHODS

A Markov model was developed in Excel. Probabilistic sensitivity analysis was employed to assess the uncertainty associated with the point estimates. Two strategies were compared: long-term medical management or immediate laparoscopic surgery for GORD. Health outcomes were expressed in terms of QALYs with a lifetime time horizon (30 years) for a patient aged 45 years at commencement of treatment. Costs (pound, 2004 values) of drugs and costs associated with surgery were obtained from five of the REFLUX study centres. Costs and outcomes were discounted by 3.5% per anum. Value of information analysis was used to quantify the cost of uncertainty associated with the decision about which therapy to adopt, indicating the maximum value of future research.

RESULTS

Treatment with laparoscopic fundoplication is the most costly strategy but is also associated with more QALYs. The incremental cost per additional QALY for surgery versus medical management was 180 pounds. However, the cost effectiveness of surgery was uncertain, and the probability that it is cost effective at the threshold of 30,000 pounds per QALY was 0.639. Value of information analysis suggests that further research in this area could be potentially worthwhile. Specifically, this research should focus on the health-related quality of life of patients on medical management or post-surgery.

CONCLUSIONS

The results of the model suggest that, on the basis of current evidence, laparoscopic fundoplication represents a cost effective means of treating GORD rather than lifelong medical management.

Major Depression Due to Primary Hyperparathyroidism: A Frequent and Correctable Disorder

While primary hyperparathyroidism (1° HPT) is recognized as a correctable cause of nephrolithiasis and osteoporosis, its role as an organic cause of major depression is less clear. The rate of major depression in 1° HPT, response of symptoms to parathyroidectomy, and potential cost benefits were reviewed. From August 1994 to September 2002, 360 patients underwent parathyroidectomy for 1° HPT. Thirty-five patients met Diagnostic and Statistical Manual of Mental Disorders TV-Text Revision (DSM IV-TR) criteria for major depression. Postoperatively, a modified form of the Outcomes Institutes Health Status Questionnaire 2.0 was used to evaluate patient mood and continued need for antidepressant medication (ADM). Cost analysis of ADM use was performed. Thirty-five of 360 patients (10%) with 1° HPT met criteria for major depression. Thirteen of 35 (37%) required ADM preoperatively. Postoperatively, 29/35 (83%) patients responded to a phone survey: 90 per cent stated depression no longer impacted their ability to work or activities of daily living; 52 per cent reported an improved quality of life; 27 per cent discontinued preoperative ADM; and 27 per cent reduced their ADM dose. Reduction in ADM resulted in a savings of $700 to $3000 per patient per year. Major depression occurs in 10 per cent of patients undergoing parathyroidectomy for 1° HPT. Parathyroidectomy reduces symptoms of major depression, improves quality of life, and can eliminate or reduce the need for antidepressant medication in up to 54 per cent of patients.

The Cost of Enhanced Acid Suppression

Peptic ulcer disease (PUD), gastroesophageal reflux disease (GERD), and upper gastrointestinal bleeding are conditions that can make large demands on health care resources. Acid suppression is common therapy for these conditions. The economic implications of managing Helicobacter pylori-related PUD, GERD, and upper gastrointestinal bleeds were considered by several investigators. Economic analyses of drug regimens for PUD show that eradication is more cost effective than H2-receptor antagonist (H2RA) maintenance therapy. Although various eradication regimens have been compared, the results depend on a number of assumptions that preclude general conclusions regarding cost-effectiveness. Economic analyses related to GERD are hindered by the often chronic, relapsing nature of the disease, particularly once therapy is discontinued. Therefore, as with PUD, results of the economic analyses depend largely on initial assumptions relative to the model employed. With regard to upper gastrointestinal bleeding, proton pump inhibitors (PPIs) are potent acid suppressors that may help prevent rebleeding that was managed endoscopically. Further clinical and economic investigations of PPIs for stress ulcer prophylaxis are necessary. Cost-effectiveness studies comparing PPIs and H2RAs should focus on overall costs of managing these conditions and include economic benefits of preventing complications, and not on drug-acquisition costs alone.

Medication usage and additional esophageal procedures after antireflux surgery

One of the goals of antireflux surgery (ARS) is to lower medications usage for heartburn symptoms. There has been some controversy as to whether this is accomplished by surgery. In addition, there is little comparative data of medical usage in patients suffering from gastroesophageal reflux disease (GERD) treated nonoperatively with those treated with surgery, and no data on additional esophageal procedures, such as upper endoscopy or dilation. The purpose of this study was to determine these differences in a matched group of medically and surgically treated patients with at least 1 year of follow-up. All patients who underwent ARS with at least 1 year of follow-up were included. These patients were matched to a group of medically treated patients for gender, age, and month of surgery to month of gastroenterologic clinic visit. Information was gathered through the medical record or direct contact for the present use of medications and additional esophageal procedures related to GERD. One hundred twenty-two patients in each group were studied. Medication usage consisted of 13% of ARS patients versus 95% of medical patients (P < 0.0001). ARS patients had used 359 patient-months of medications versus 3578 in the medical group (P < 0.0001). Only 25% of ARS patients prescribe medications actually responded to their use. Additional procedures consisted of 9% of ARS patients versus 64% of medical patients (P < 0.0001). In conclusion, ARS leads to decreased medication use and to decreased use of subsequent esophageal procedures. In addition, most postoperative ARS patients placed on medications do not respond, and therefore require an objective evaluation for their symptoms.

Long-term results of a randomized prospective study comparing medical and surgical treatment of Barrett's esophagus

OBJECTIVE

To compare the results of medical treatment and antireflux surgery in patients with Barrett's esophagus (BE).

SUMMARY BACKGROUND DATA

The treatment of choice in BE is still controversial. Some clinical studies suggest that surgery could be more effective than medical treatment in preventing BE from progressing to dysplasia and adenocarcinoma. However, data from prospective comparative studies are necessary to answer this question.

METHODS

One hundred one patients were included in a randomized prospective study, 43 with medical treatment and 58 with antireflux surgery. All patients underwent clinical, endoscopic, and histologic assessment. Functional studies were performed in all the operated patients and in a subgroup of patients receiving medical treatment. The median follow-up was 5 years (range 1-18) in the medical treatment group and 6 years (range 1-18) in the surgical treatment group.

RESULTS

Satisfactory clinical results (excellent to good) were achieved in 39 of the 43 patients (91%) undergoing medical treatment and in 53 of the 58 patients (91%) following antireflux surgery. The persistence of added inflammatory lesions was significantly higher in the medical treatment group. The metaplastic segment did not disappear in any case. Postoperative functional studies showed a significant decrease in the median percentage of total time with pH below 4, although 9 of the 58 patients (15%) showed pathologic rates of acid reflux. High-grade dysplasia appeared in 2 of the 43 patients (5%) in the medical treatment group and in 2 of the 58 patients (3%) in the surgical treatment group. In the latter, both patients presented with clinical and pH-metric recurrence. There was no case of malignancy after successful antireflux surgery.

CONCLUSIONS

These results show that there are no differences between the two types of treatment with respect to preventing BE from progressing to dysplasia and adenocarcinoma. However, successful antireflux surgery proved to be more efficient than medical treatment in this sense, perhaps because it completely controls acid and biliopancreatic reflux to the esophagus.

Long-term results of a randomized prospective study comparing medical and surgical treatment of Barrett's esophagus

OBJECTIVE

To compare the results of medical treatment and antireflux surgery in patients with Barrett's esophagus (BE).

SUMMARY BACKGROUND DATA

The treatment of choice in BE is still controversial. Some clinical studies suggest that surgery could be more effective than medical treatment in preventing BE from progressing to dysplasia and adenocarcinoma. However, data from prospective comparative studies are necessary to answer this question.

METHODS

One hundred one patients were included in a randomized prospective study, 43 with medical treatment and 58 with antireflux surgery. All patients underwent clinical, endoscopic, and histologic assessment. Functional studies were performed in all the operated patients and in a subgroup of patients receiving medical treatment. The median follow-up was 5 years (range 1-18) in the medical treatment group and 6 years (range 1-18) in the surgical treatment group.

RESULTS

Satisfactory clinical results (excellent to good) were achieved in 39 of the 43 patients (91%) undergoing medical treatment and in 53 of the 58 patients (91%) following antireflux surgery. The persistence of added inflammatory lesions was significantly higher in the medical treatment group. The metaplastic segment did not disappear in any case. Postoperative functional studies showed a significant decrease in the median percentage of total time with pH below 4, although 9 of the 58 patients (15%) showed pathologic rates of acid reflux. High-grade dysplasia appeared in 2 of the 43 patients (5%) in the medical treatment group and in 2 of the 58 patients (3%) in the surgical treatment group. In the latter, both patients presented with clinical and pH-metric recurrence. There was no case of malignancy after successful antireflux surgery.

CONCLUSIONS

These results show that there are no differences between the two types of treatment with respect to preventing BE from progressing to dysplasia and adenocarcinoma. However, successful antireflux surgery proved to be more efficient than medical treatment in this sense, perhaps because it completely controls acid and biliopancreatic reflux to the esophagus.

Long-term results of a randomized prospective study comparing medical and surgical treatment of Barrett's esophagus

OBJECTIVE

To compare the results of medical treatment and antireflux surgery in patients with Barrett's esophagus (BE).

SUMMARY BACKGROUND DATA

The treatment of choice in BE is still controversial. Some clinical studies suggest that surgery could be more effective than medical treatment in preventing BE from progressing to dysplasia and adenocarcinoma. However, data from prospective comparative studies are necessary to answer this question.

METHODS

One hundred one patients were included in a randomized prospective study, 43 with medical treatment and 58 with antireflux surgery. All patients underwent clinical, endoscopic, and histologic assessment. Functional studies were performed in all the operated patients and in a subgroup of patients receiving medical treatment. The median follow-up was 5 years (range 1-18) in the medical treatment group and 6 years (range 1-18) in the surgical treatment group.

RESULTS

Satisfactory clinical results (excellent to good) were achieved in 39 of the 43 patients (91%) undergoing medical treatment and in 53 of the 58 patients (91%) following antireflux surgery. The persistence of added inflammatory lesions was significantly higher in the medical treatment group. The metaplastic segment did not disappear in any case. Postoperative functional studies showed a significant decrease in the median percentage of total time with pH below 4, although 9 of the 58 patients (15%) showed pathologic rates of acid reflux. High-grade dysplasia appeared in 2 of the 43 patients (5%) in the medical treatment group and in 2 of the 58 patients (3%) in the surgical treatment group. In the latter, both patients presented with clinical and pH-metric recurrence. There was no case of malignancy after successful antireflux surgery.

CONCLUSIONS

These results show that there are no differences between the two types of treatment with respect to preventing BE from progressing to dysplasia and adenocarcinoma. However, successful antireflux surgery proved to be more efficient than medical treatment in this sense, perhaps because it completely controls acid and biliopancreatic reflux to the esophagus.

Antireflux surgery for Barrett's oesophagus

Barrett's oesophagus is usually the result of severe reflux disease. Relief of reflux symptoms is the primary aim of treatment in patients with Barrett's oesophagus who do not have high-grade dysplasia. Some studies with medium-term (2-5 years) follow up show that antireflux surgery can provide good or excellent symptom control, with normal oesophageal acid exposure, in more than 90% of patients with Barrett's oesophagus. Antireflux surgery, but not medical therapy, can also reduce duodenal nonacid reflux to normal levels. There is no conclusive evidence that antireflux surgery can prevent the development of dysplasia or cancer, or that it can reliably induce regression of dysplasia, and patients with Barrett's oesophagus should therefore remain in a surveillance programme after operation. Some data suggest that antireflux surgery can prevent the development of intestinal metaplasia (IM) in patients with reflux disease but no IM. The combination of antireflux surgery plus an endoscopic ablation procedure is a promising treatment for patients with Barrett's oesophagus with low-grade dysplasia.

Long-term results of a randomized prospective study comparing medical and surgical treatment of Barrett's esophagus

OBJECTIVE

To compare the results of medical treatment and antireflux surgery in patients with Barrett's esophagus (BE).

SUMMARY BACKGROUND DATA

The treatment of choice in BE is still controversial. Some clinical studies suggest that surgery could be more effective than medical treatment in preventing BE from progressing to dysplasia and adenocarcinoma. However, data from prospective comparative studies are necessary to answer this question.

METHODS

One hundred one patients were included in a randomized prospective study, 43 with medical treatment and 58 with antireflux surgery. All patients underwent clinical, endoscopic, and histologic assessment. Functional studies were performed in all the operated patients and in a subgroup of patients receiving medical treatment. The median follow-up was 5 years (range 1-18) in the medical treatment group and 6 years (range 1-18) in the surgical treatment group.

RESULTS

Satisfactory clinical results (excellent to good) were achieved in 39 of the 43 patients (91%) undergoing medical treatment and in 53 of the 58 patients (91%) following antireflux surgery. The persistence of added inflammatory lesions was significantly higher in the medical treatment group. The metaplastic segment did not disappear in any case. Postoperative functional studies showed a significant decrease in the median percentage of total time with pH below 4, although 9 of the 58 patients (15%) showed pathologic rates of acid reflux. High-grade dysplasia appeared in 2 of the 43 patients (5%) in the medical treatment group and in 2 of the 58 patients (3%) in the surgical treatment group. In the latter, both patients presented with clinical and pH-metric recurrence. There was no case of malignancy after successful antireflux surgery.

CONCLUSIONS

These results show that there are no differences between the two types of treatment with respect to preventing BE from progressing to dysplasia and adenocarcinoma. However, successful antireflux surgery proved to be more efficient than medical treatment in this sense, perhaps because it completely controls acid and biliopancreatic reflux to the esophagus.

Medical or invasive therapy for GERD: an acidulous analysis

This review critically appraises the evidence on the benefits and costs of the available treatments for gastroesophageal reflux disease (GERD) and concludes that antireflux surgery has no clear advantages over medical therapy for efficacy of healing, prevention of complications, safety, side effects, and cost. Indeed, medical therapy is safer and, probably, more cost-effective. Compared with medically treated patients, those who have successful fundoplication may be less inconvenienced by GERD because they are less likely to need to take pills on a daily basis. The patient and physician must judge whether that benefit justifies the risks of surgery for a benign condition. There is not yet sufficient data available on the endoscopic antireflux procedures to make meaningful conclusions regarding their safety and efficacy.

Trends in surgery for gastroesophageal reflux disease: the effect of laparoscopic surgery on utilization

BACKGROUND

In addition to substituting for open surgery, minimally invasive surgery may lower thresholds for intervention and thus increase overall utilization rates. The degree to which laparoscopy may have lowered the threshold for elective anti-reflux surgery is unknown.

METHODS

Using the Uniform Hospital Discharge Dataset and ICD-9 procedure and diagnosis codes, we identified all laparoscopic and open anti-reflux procedures performed on adults in Massachusetts, New Hampshire, and Vermont for each year from 1993 to 1998. We then examined secular trends and regional variation in the use of laparoscopic and open anti-reflux surgery.

RESULTS

The population-based rate of anti-reflux surgery more than doubled between 1993 (4.8 per 100,000) and 1998 (11.7 per 100,000). Laparoscopic anti-reflux procedures increased more than 6-fold between 1993 and 1998, from 1.2 to 8.9 procedures per 100,000 adults, with accompanying declines in overall length of stay and mortality. However, the number of open anti-reflux procedures decreased only modestly (22%) over this time period. In the year hospitals performed their first laparoscopic anti-reflux operation, procedure rates nearly tripled, on average, and then increased slowly in subsequent years. In 1997 and 1998, rates of anti-reflux surgery varied nearly 5-fold across hospital referral regions, ranging from 5.4 to 24.5 per 100,000.

CONCLUSIONS

With the growth of minimally invasive surgery, rates of anti-reflux surgery have increased substantially, with wide regional variation in intervention rates. Further research is needed to determine the appropriate threshold for surgical treatment in patients with gastroesophageal reflux.

Determining an appropriate threshold for referral to surgery for gastroesophageal reflux disease

BACKGROUND

Persistent symptomatic gastroesophageal reflux disease (GERD) can be treated with medication or surgery. The purposes of this study were (1) to determine how poor the quality of life on medication would need to be to justify assuming the risks of surgery, and (2) to estimate the proportion of patients currently on medication whose quality of life is below this value.

METHODS

We developed a Markov decision analysis model to simulate health outcomes (measured in quality adjusted life years [QALY]) over 10 years for medication and surgery in patients with typical GERD symptoms. We included probabilities of events obtained from a systematic literature review. Quality of life adjustments, expressed as utilities, were drawn from a survey of 131 patients 1 to 5 years after antireflux surgery. By using this model, we calculated what quality of life on medications would change the optimal strategy from medication to surgery (threshold). To determine the proportion of patients below this value, we prospectively surveyed 40 medically treated GERD patients at our hospital.

RESULTS

Surgery resulted in more QALYs than medical therapy when the utility with medication use was below 0.90. Sensitivity analysis showed this value to be relatively insensitive to reasonable variations in surgical risks (mortality, failures, reoperation) and quality of life after surgery. Among those surveyed on medications, 48% fell below this threshold and would be predicted to benefit from surgery.

CONCLUSION

Our model suggests that surgery would likely benefit a high proportion of medically treated GERD patients. Individual assessment of quality of life with GERD should be considered to aid clinical decision making.

An overview of the success and failure of surgical therapy: standards against which the outcome of endoscopic therapy is measured

Medical therapy for reflux disease has evolved from frequent antacid use to once daily proton pump inhibitor therapy. Despite the efficacy of these agents in healing erosive esophagitis, there are several short-comings with medical therapy including incomplete symptom relief, the need for continuous maintenance therapy, and cost. Endoscopic and laparoscopic treatments for reflux disease are appealing because they could reduce or eliminate the need for chronic maintenance therapy with medications. While there is evidence of high quality on the efficacy of medical therapy from randomized controlled trials, data on endoscopic procedures and surgery is more limited. This article summarizes the needed studies and the standards against which these procedures should be measured.

Standard antireflux operations in patients who have Barrett's esophagus. Current results

Several therapeutic options exist for patients who have BE, and treatment should be individualized (Fig. 1). The best option in patients who have a high surgical risk or who reject surgery is lifelong conservative treatment, adjusting the PPI dosage with pH-metric controls. In patients who have a low surgical risk the best option is Nissen fundoplication. Only in cases in which esophageal shortening prevents a tension-free fundoplication from being done is a Collis gastroplasty associated with a fundoplication indicated. Other options may be indicated only in exceptional circumstances: (a) duodenal switch, when, after multiple failures with previous surgery, the approach to the esophagogastric junction is extremely difficult; and (b) esophageal resection, when there is a nondilatable esophageal stenosis and in cases in which the histologic study reveals the presence of high-grade dysplasia. Whatever treatment is used, an endoscopic surveillance program is mandatory, since, with the exception of total esophagectomy, no therapeutic option completely eliminates the risk for progression to adenocarcinoma.

Laparoscopic fundoplication versus lansoprazole for gastro-oesophageal reflux disease. A pH-metric comparison

BACKGROUND

Treatment strategies that abolish abnormal reflux could prevent long-term complications of gastro-oesophageal reflux disease.

AIMS

To compare the efficacy of laparoscopic fundoplication and lansoprazole in abolishing abnormal reflux in patients with gastro-oesophageal reflux disease.

PATIENTS

Study population comprised 130 patients referred for possible antireflux surgery and with heartburn as the dominant symptom.

METHODS

After oesophageal manometric and pH-metric evaluation and detailed information 55 patients asked to undergo laparoscopic antireflux surgery while 75 chose a medical treatment regimen based on lansoprazole. Treatment efficacy was assessed by ambulatory oesophageal pH-monitoring.

RESULTS

All 55 patients who underwent fundoplication became free of heartburn: oesophageal pH-monitoring gave normal results in 85%. In patients treated with lansoprazole, at individualized daily dosages titrated to abolish both heartburn and abnormal acid reflux, normal pH-metric results were obtained in 96% of cases (p<0.05 vs surgically treated patients).

CONCLUSIONS

Lansoprazole at individualized dosages was significantly more effective than laparoscopic fundoplication, in the short-term, in abolishing abnormal reflux in gastro-oesophageal reflux disease patients.

Lansoprazole vs. omeprazole for gastro-oesophageal reflux disease: a pH-metric comparison

BACKGROUND

Lansoprazole and omeprazole are widely used proton pump inhibitors for the management of gastro-oesophageal reflux. Normalization of oesophageal acid exposure is an important goal in the management of complicated and atypical gastro-oesophageal reflux disease.

AIM

To compare the efficacy of lansoprazole and omeprazole in the abolition of abnormal reflux as assessed by oesophageal pH monitoring.

METHODS

Seventy patients with complicated or atypical gastro-oesophageal reflux disease were randomly assigned to receive 30 mg lansoprazole or 20 mg omeprazole once daily. Three to four weeks after the start of treatment, patients underwent oesophageal pH monitoring while on therapy. If the results were still abnormal, the proton pump inhibitor dosage was doubled and 24-h pH-metry was repeated after 20-30 days.

RESULTS

Thirty-six patients were randomized to receive lansoprazole and 34 patients to receive omeprazole. Ten of the 36 (29%) patients treated with 30 mg lansoprazole once daily and 23 of the 34 (68%) patients treated with 20 mg omeprazole once daily had persistently abnormal reflux at oesophageal pH monitoring (P < 0.001). In all such cases, repeat pH monitoring after doubling the proton pump inhibitor dosage gave normal results.

CONCLUSIONS

At the currently marketed dosages of lansoprazole and omeprazole, normalization of oesophageal acid exposure in patients is accomplished more easily with lansoprazole.

Economic considerations in the treatment of gastroesophageal reflux disease: a review

Gastroesophageal reflux disease is a common problem. Most patients with erosive GERD require long-term treatment, without which relapse is common. The cost of ongoing medical care for GERD is substantial, and patients with symptomatic GERD have impaired quality of life. Treatment strategies for GERD should aim to improve patient outcome at a reasonable cost. Cost-effectiveness methodology facilitates the integration of costs and patient outcomes, enabling the clinician to choose the most cost-effective therapy in a variety of clinical circumstances. The published studies reviewed in this paper show that proton pump inhibitors are the most cost-effective initial and maintenance medical therapy for GERD under most circumstances. However, variations in drug acquisition costs, such as may occur in managed care practice settings, may lead to H2-receptor antagonists being preferred under some circumstances. In the long-term management of GERD, laparoscopic surgery is effective, but its high initial cost makes it less cost-effective than proton pump inhibitors in the early treatment years. Also, recent data suggest that the long-term morbidity is higher than previously suspected. Finally, appropriate application of cost-effectiveness analyses to clinical practice requires critical appraisal of model design and the perspective adopted. The purpose of this article is to describe the interpretation and application of the results of cost-effectiveness analyses in clinical practice, and to examine the published literature on the cost-effectiveness of treatment options for GERD.

Minimally invasive approaches to antireflux surgery

Gastroesophageal reflux disease is one of the most common disorders affecting western civilization. Historically, surgical antireflux therapy was reserved for patients who had failed medical therapy, typically in the presence of refractory ulcers or difficult-to-manage strictures. More recently, with improvements in acid control, these acid-pepsin-related complications of reflux have been replaced by the malignant complications of reflux disease, with emphasis now on total control of reflux. Recent developments in surgical technique and the demonstrated effectiveness of a variety of minimally invasive treatment options have changed our approach to these patients. This article summarizes the recommended diagnostic evaluation of patients with reflux symptoms and the current indications for antireflux surgery. The techniques of commonly performed minimally invasive antireflux procedures are described along with a review of the results to be expected. Future prospects for improving the management of reflux are discussed; these include recently described nonsurgical methods for restoring competency to the lower esophageal sphincter.

Long-term omeprazole treatment in resistant gastroesophageal reflux disease: efficacy, safety, and influence on gastric mucosa

BACKGROUND & AIMS

The efficacy and safety of long-term acid suppression remains a subject for debate. We report data from patients with refractory reflux esophagitis who were undergoing maintenance therapy with >/=20 mg omeprazole daily for a mean period of 6.5 years (range, 1.4-11.2 years).

METHODS

Patients with severe reflux esophagitis resistant to long-term therapy with H(2)-receptor antagonists and who were not eligible for surgery were evaluated at least annually for endoscopic relapse and histological changes in the gastric corpus.

RESULTS

In 230 patients (mean age, 63 years at entry; 36% were >/=70 years), there were 158 relapses of esophagitis during 1490 treatment years (1 per 9.4 years), with no significant difference in relapse rates between Helicobacter pylori-positive and -negative patients. All patients rehealed during continued therapy with omeprazole at the same or higher dose. The annual incidence of gastric corpus mucosal atrophy was 4.7% and 0.7% in H. pylori-positive and -negative patients, respectively, which was mainly observed in elderly patients who had moderate/severe gastritis at entry. In patients with baseline moderate/severe gastritis, the incidences were similar: 7.9% and 8.4%, respectively. Corpus intestinal metaplasia was rare, and no dysplasia or neoplasms were observed. The adverse event profile was as might be expected from this elderly group of patients.

CONCLUSIONS

Long-term omeprazole therapy (up to 11 years) is highly effective and safe for control of reflux esophagitis.

Measuring improved quality of life after laparoscopic Nissen fundoplication

BACKGROUND

While the correction of pathologic gastroesophageal reflux by means of laparoscopic Nissen fundoplication (LNF) has been well documented, the psychological profiles of patients with this disease and the impact on their quality of life are less well understood. We obtained a baseline psychological profile and measured the impact of LNF on patients' quality of life with 2 standardized instruments: the psychological general well-being index (PGWB) and the gastrointestinal symptoms rating scale (GSRS). The study included 34 consecutive patients with typical symptoms of gastroesophageal reflux who underwent LNF in 1995 at a tertiary care university medical center.

METHODS

Patients filled out PGWB and GSRS surveys preoperatively and at 2 weeks, 2 months, and 12 months postoperatively. Data were collected in a blinded fashion by a study nurse and analyzed after completion of the study. Data are expressed as mean +/- standard deviation.

RESULTS

The mean preoperative PGWB score (69.6 +/- 17.3) of study patients with gastroesophageal reflux disease was lower than that expected for a healthy population. This was primarily attributable to low scores in the general health domain of the questionnaire, although LNF patients also had low scores in the vitality and positive well-being domains of the PGWB scale. LNF improved the PGWB score to a normal level (78.7 +/- 19.3) (P = .05 vs the preoperative PGWB score) at 12 months post surgery. The GSRS also showed improvement from 34.7 +/- 7.8 to 28.1 +/- 10 (P = .008). The improvement in GSRS was attributed to improvement in the heartburn (7.12 +/- 2.4 to 2.72 +/- 1.2, P < .001) and abdominal pain (6.58 +/- 2.5 to 4.92 +/- 1.6, P = .006) domains of the scale. LNF had no impact on the diarrhea, indigestion, and obstipation domains of the GSRS.

CONCLUSIONS

Patients with gastroesophageal reflux disease who are candidates for LNF have low psychological and general well-being scores that are restored to normal levels by successful LNF. When compared with baseline measurements, LNF effectively relieved heartburn and did not cause significant new gastrointestinal complaints.

Gastroesophageal reflux disease

Gastroesophageal reflux disease is a common clinical problem. Transient lower esophageal sphincter relaxation is central to the pathogenesis. New studies have identified the importance of nitric oxide and cholinergic pathways in modulating transient lower esophageal sphincter relaxation. Provocative information suggests that infection with Helicobacter pylori may protect patients from developing complications of gastroesophageal reflux disease. Endoscopy may be used by clinicians to tailor therapy, but an empiric trial of a proton pump inhibitor may be an alternative diagnostic approach. Nocturnal acid breakthrough during proton pump inhibitor therapy has emerged as an important new treatment concept, although its clinical importance remains unproven. Studies continue to show that laparoscopic antireflux surgery is a cost-effective treatment option for patients requiring maintenance therapy with proton pump inhibitors. However, the minimally invasive nature of the operation should not alter the indications for antireflux surgery, especially for patients with atypical symptoms.

Comparison of costs between laparoscopic and open Nissen fundoplication: a prospective randomized study with a 3-month followup

BACKGROUND

Laparoscopic antireflux surgery has replaced conventional operation despite the fact that currently no randomized trials have been published regarding its cost effectiveness. The objective of the present study was to compare costs and some short-term outcomes of laparoscopic and open Nissen fundoplication.

STUDY DESIGN

Forty-two patients with documented gastroesophageal reflux disease were randomized between October 1995 and October 1996 to either laparoscopic (LNF) or open (ONF) Nissen fundoplication. Some short-term outcomes, Gastrointestinal Quality of Life Index (GIQLI) hospital costs, and costs to society were assessed. Followup was 3 months.

RESULTS

Medians of operation times in the LNF and ONF groups were 98 min and 74 min, respectively. Hospital stay was 2.5 days shorter after laparoscopic operation (LNF 3 days versus ONF 5.5 days). Both operations were equally safe and effective, but the LNF group experienced significantly less pain and fatigue during the first 3 postoperative weeks. Improvement in the GIQLI and overall patient satisfaction were comparable between the methods. Convalescence was faster in the LNF group: return to normal life being 14 versus 31 days and return to work being 21 versus 44 days in the LNF and ONF groups, respectively. Hospital costs were similar, $2,981 and $3,140 in the LNF and ONF groups, respectively, but total costs were lower ($7,506 versus $13,118) in the LNF group as a result of an earlier return to work.

CONCLUSIONS

LNF is superior in cost effectiveness, assuming that the longterm results between the methods are comparable.