Antireflux Surgery in Korea: A Nationwide Study from 2011 to 2014

A Phase III Head-to-Head Study to Compare the Efficacy and Safety of Fexuprazan and Esomeprazole in Treating Patients with Erosive Esophagitis

Background: Fexuprazan (Fexuclue®; Daewoong Pharmaceutical Co., Ltd., Seoul, Korea) is a novel potassium-competitive acid blocker (P-CAB). This multi-center, randomized, double-blind, active-controlled, parallel-group, therapeutic confirmatory, phase III study was conducted to assess its efficacy and safety compared with esomeprazole (Nexium®; AstraZeneca, Gothenburg, Mölndal, Sweden) in Korean patients with erosive esophagitis (EE). Methods: This study evaluated patients diagnosed with EE at a total of 25 institutions in Korea between 13 December 2018 and 7 August 2019. After voluntarily submitting a written informed consent form, the patients were evaluated using a screening test and then randomized to either of the two treatment arms. The proportion of the patients who achieved the complete recovery of mucosal breaks at 4 and 8 weeks, the proportion of those who achieved the complete recovery of heartburn at 3 and 7 days and 8 weeks, and changes in the GERD-Health-Related Quality of Life Questionnaire (GERD-HRQL) scores at 4 and 8 weeks from baseline served as efficacy outcome measures. The incidence of treatment-emergent adverse events (TEAEs) and adverse drug reactions (ADRs) and the serum gastrin levels served as safety outcome measures. Results: The study population comprised a total of 231 patients (n = 231) with EE, including 152 men (65.80%) and 79 women (34.20%); their mean age was 54.37 ± 12.66 years old. There were no significant differences in the efficacy and safety outcome measures between the two treatment arms (p > 0.05). Conclusions: It can be concluded that the efficacy and safety of Fexuclue® are not inferior to those of esomeprazole in Korean patients with EE.

Antireflux Surgery Versus Antireflux Medication and Risk of Esophageal Adenocarcinoma in Patients With Barrett's Esophagus

BACKGROUND & AIMS

Antireflux treatment is recommended to reduce esophageal adenocarcinoma in patients with Barrett's esophagus. Antireflux surgery (fundoplication) counteracts gastroesophageal reflux of all types of carcinogenic gastric content and reduces esophageal acid exposure to a greater extent than antireflux medication (eg, proton pump inhibitors). We examined the hypothesis that antireflux surgery prevents esophageal adenocarcinoma to a larger degree than antireflux medication in patients with Barrett's esophagus.

METHODS

This multinational and population-based cohort study included all patients with a diagnosis of Barrett's esophagus in any of the national patient registries in Denmark (2012-2020), Finland (1987-1996 and 2010-2020), Norway (2008-2020), or Sweden (2006-2020). Patients who underwent antireflux surgery were compared with nonoperated patients using antireflux medication. The risk of esophageal adenocarcinoma was calculated using multivariable Cox regression, providing hazard ratios (HRs) and 95% CIs adjusted for age, sex, country, calendar year, and comorbidity.

RESULTS

The cohort consisted of 33,939 patients with Barrett's esophagus. Of these, 542 (1.6%) had undergone antireflux surgery. During up to 32 years of follow-up, the overall HR was not decreased in patients having undergone antireflux surgery compared with nonoperated patients using antireflux medication, but rather increased (adjusted HR, 1.9; 95% CI, 1.1-3.5). In addition, HRs did not decrease with longer follow-up, but instead increased for each follow-up category, from 1.8 (95% CI, 0.6-5.0) within 1-4 years of follow-up to 4.4 (95% CI, 1.4-13.5) after 10-32 years of follow-up.

CONCLUSIONS

Patients with Barrett's esophagus who undergo antireflux surgery do not seem to have a lower risk of esophageal adenocarcinoma than those using antireflux medication.

Exploring objective factors to predict successful outcomes after laparoscopic Nissen fundoplication

BACKGROUND

Currently, the reported parameters that predict the resolution of symptoms after surgery are largely subjective and unreliable. Considering that fundoplication rebuilds the structural integrity of the lower esophageal sphincter (LES), the authors focused on searching for objective and quantitative predictors for the resolution of symptoms based on the anatomical issues and whether an antireflux barrier can be well established or not.

MATERIALS AND METHODS

The authors reviewed the prospectively collected data of 266 patients with gastroesophageal reflux disease (GERD) who had undergone laparoscopic Nissen fundoplication (LNF). All patients were diagnosed with GERD using preoperative esophagogastroduodenoscopy, 24-h ambulatory esophageal pH monitoring, and high-resolution esophageal manometry. The patients received GERD symptom surveys using the validated Korean Antireflux Surgery Group questionnaire twice: preoperatively and 3 months after the surgery.

RESULTS

After excluding patients with insufficient follow-up data, 152 patients were included in the analysis. Multivariate logistic regression analyses revealed that a longer length of the LES and lower BMI determined better resolution of typical symptoms after LNF (all P <0.05). Regarding atypical symptoms, higher resting pressure of LES and DeMeester score greater than or equal to 14.7 were associated with better resolution after the surgery (all P <0.05). After LNF, typical symptoms improved in 34 out of 37 patients (91.9%) with a length of LES >greater than .05 cm, BMI less than 23.67 kg/m 2 , and atypical symptoms were resolved in 16 out of 19 patients (84.2%) with resting pressure of LES greater than or equal to 19.65 mm Hg, DeMeester score greater than or equal to 14.7.

CONCLUSION

These results show that the preoperative length and resting pressure of LES is important in the objective prediction of symptom improvement after LNF.

Trends in laparoscopic anti-reflux surgery: a Korea nationwide study

BACKGROUND

In 2014, the results derived from the nationwide data of the Korean Anti-reflux Surgery Study (KARS) demonstrated short-term feasibility and safety of anti-reflux surgery. This study aimed to update the longer-term safety and feasibility of laparoscopic anti-reflux surgery up to 1-year follow-up with the KARS nationwide cohort.

METHODS

The data of 310 patients with GERD who received anti-reflux surgery up to 2018 were analyzed. Baseline patient characteristics, postoperative symptom resolution, and postoperative complications were evaluated at postoperative 3 months and 1 year using the questionnaire designed by KARS. We divided the patients into two groups according to the operation period (up to and after 2014) to identify changes in the trends of the characteristics of surgical patients and operative qualities.

RESULTS

The typical preoperative symptoms were present in 275 patients (91.7%), and atypical symptoms were present in 208 patients (71.0%). Ninety-seven (35.5%) and 124 patients (46.1%) had inadequate PPI responses and hiatal hernia, respectively. At postoperative 1 year, typical and atypical symptoms were either completely or partially controlled in 90.3% and 73.5.0% of patients, respectively. Moderate-to-severe dysphagia, inability to belch, gas bloating, and flatulence at postoperative 1 year were identified in 23.5%, 29.4%, 23.2%, and 22.0% of patients, respectively. The number of surgical patients continuously increased from 2011 to 2018 in Korea. The proportion of patients with hiatal hernia and comorbidities increased (p < 0.01, p = 0.053), and the operation time decreased significantly (p < 0.01) in the late period (2015-2018) as compared with the early period (2011-2014). Symptom control and complication rate were equivalent between the two periods.

CONCLUSIONS

Anti-reflux surgery was effective with > 90% of typical symptom resolution and posed a comparable postoperative complication rate with those in Western studies with mid-term to long-term follow-up. This result supports the feasibility and safety of anti-reflux surgery as a treatment for GERD in the Korean population.

The characteristics of antireflux surgery compared to proton pump inhibitor treatment in Korea: a nationwide study using claim data from 2007 to 2016

Purpose

Laparoscopic antireflux surgery is not widely used in Korea, but published data suggest that its results are comparable to those of Western countries. The purpose of this study was to compare the clinical characteristics, medical utilization, and medical costs of antireflux surgery and proton pump inhibitor (PPI) treatments.

Methods

We used Korean patients who underwent fundoplication (n = 342, surgery group) and a 25% random sample of all patients diagnosed with gastroesophageal reflux disease (GERD) who were prescribed PPIs for more than 12 weeks (n = 130,987, medication group) between 2007 to 2016. We compared medical costs and utilization between the 2 groups.

Results

The average cost of fundoplication was $4,631. The costs of GERD treatment in the first year after surgery and during the follow-up period were $78.1 and $50.1 per month, respectively. In the surgery group, the average monthly medical expenses decreased as the year progressed, but the average monthly medical expenses ($137.5 per month) did not decrease in the medication group. After stratifying by age group, the medical costs of the surgery group were lower than those of the medication group for all ages except for patients between the ages of 70 and 79. The cost difference between the 2 groups was prominent between the ages of 20 and 49.

Conclusion

This study showed that a significant decrease in cost was observed 1 year after surgery, and it was more apparent in younger patients. Further research is needed to determine the appropriateness of antireflux surgery for each group of patients.

Treatment Pattern and Economic Burden of Refractory Gastroesophageal Reflux Disease Patients in Korea

Background/Aims

The prevalence of gastroesophageal reflux disease (GERD) has increased in Korea, and the economic burden of this chronic disease is substantial. We aim to investigate the treatment pattern and economic burden in Korea of refractory GERD requiring long-term use of proton pump inhibitors (PPIs).

Methods

We conducted a cross-sectional analysis of nationally representative sample data obtained from 2012 to 2016 and provided by the Health Insurance Review and Assessment Service. The participants were 86 936 in the medication group and 40 in the surgery group. Age- and sex-standardized prevalence of refractory GERD requiring PPIs medication for more than 12 weeks were analyzed. Generalized linear models were used to estimate cost ratios for comparing the medical costs of the surgery and medication groups after adjustment for demographics and comorbidity.

Results

The prevalence of refractory GERD increased from 1.2% in 2012 to 1.9% in 2016, and the estimated total number of GERD patients increased from 402 000 to 736 000 during this time period. The medical expenditures of the surgery group within 90 days of antireflux surgery (ARS) were 16.9-fold higher compared to those of the medication group; the significant difference in medical costs between the 2 groups disappeared after 90 days post-surgery.

Conclusions

The prevalence of refractory GERD requiring long-term use of PPIs has been trending upwards recently. Nevertheless, ARS is very rarely performed. Considering the increasing medical costs of long-term PPI use, further cost-effectiveness analysis is needed to compare ARS and PPI therapy for the treatment of GERD in Korea.

Multicenter Prospective Study of Laparoscopic Nissen Fundoplication for Gastroesophageal Reflux Disease in Korea

Backgrounds/Aims

This multicenter study aims to evaluate the effect and feasibility of anti-reflux surgery compared with medical treatment for gastroesophageal reflux disease (GERD).

Methods

Patients with GERD who were undergoing medical treatment with proton pump inhibitors for more than 8 weeks and those who were scheduled to undergo anti-reflux surgery were enrolled. Efficacy of pre-operative medical treatment was evaluated retrospectively and effect of anti-reflux surgery was prospectively evaluated at 1 week and 3 months after surgery. Quality of life (QOL) was also investigated before and after surgery.

Results

Between February and October 2018, 51 patients underwent laparoscopic Nissen fundoplication for treating GERD at 5 hospitals in Korea. Thirty-four patients (66.7%) showed poor proton pump inhibitor response. At 3 months after surgery, heartburn was completely resolved in 87.9% patients and partially improved in 9.1%. Acid regurgitation was completely resolved in 82.9% and partially improved in 11.4%. Atypical extraesophageal symptoms were completely controlled in 45.5% and partially controlled in 36.4%. GERD-related QOL scores at 1 week after surgery significantly improved compared with pre-operative scores. There was no difference in GERD-related QOL scores between 1 week and 3 months after surgery. General QOL measured with European QOL-5 dimensions and health-related QOL instrument with 8 items significantly improved after anti-reflux surgery. Satisfaction with treatment was significantly higher after surgery than before surgery (72.5% vs 11.8%, P < 0.001).

Conclusion

Anti-reflux surgery improved GERD symptoms and QOL in patients. Anti-reflux surgery is an effective treatment option compared with medical treatment for GERD patients selected for surgical treatment.

Nationwide survey of partial fundoplication in Korea: comparison with total fundoplication

Purpose

Laparoscopic total fundoplication is the standard surgery for gastroesophageal reflux disease. However, partial fundoplication may be a viable alternative. Here, we conducted a nationwide survey of partial fundoplication in Korea.

Methods

The Korean Anti-Reflux Surgery study group recorded 32 cases of partial fundoplication at eight hospitals between September 2009 and January 2016. The surgical outcomes and postoperative adverse symptoms in these cases were evaluated and compared with 86 cases of total fundoplication.

Results

Anterior partial fundoplication was performed in 20 cases (62.5%) and posterior in 12 (37.5%). In most cases, partial fundoplication was a secondary procedure after operations for other conditions. Half of patients who underwent partial fundoplication had typical symptoms at the time of initial diagnosis, and most of them showed excellent (68.8%), good (25.0%), or fair (6.3%) symptom resolution at discharge. Compared to total fundoplication, partial fundoplication showed no difference in the resolution rate of typical and atypical symptoms. However, adverse symptoms such as dysphagia, difficult belching, gas bloating and flatulence were less common after partial fundoplication.

Conclusion

Although antireflux surgery is not popular in Korea and total fundoplication is the primary surgical choice for gastroesophageal reflux disease, partial fundoplication may be useful in certain conditions because it has less postoperative adverse symptoms but similar efficacy to total fundoplication.