Esomeprazole vs. Surgery for Chronic GERD

The long-term “best treatment” for patients with symptomatic gastroesophageal reflux disease (GERD) has been the subject of a common debate between surgeons and medical physicians. Although the surgical literature is replete with excellent sustained outcomes of laparoscopic antireflux surgery (LARS) for patients of renowned experts, results with less-experienced surgeons have not been as successful.

To test the efficacy of the proton-pump inhibitor esomeprazole compared with LARS, European researchers conducted a multicenter study in which 554 patients with established GERD and verified responsiveness to PPIs were randomized to receive either esomeprazole (20 mg/day, increased to 40 mg/day if needed) or LARS. The trial was sponsored by the maker of esomeprazole. The primary outcome was time to treatment failure (i.e., need for additional treatment in the esomeprazole group, and need for drug therapy or certain additional procedures in the LARS group). Secondary outcomes included various individual symptoms.

At 5 years, the remission rate was slightly higher in the esomeprazole group than the LARS group (92% vs. 85%; P=0.048). Safety outcomes were excellent, with no perioperative deaths, a low rate of perioperative morbidity (3%), and no serious adverse events attributed to esomeprazole therapy alone. Acid regurgitation was more common in the esomeprazole group than the LARS group (13% vs. 2%; P<0.001), but dysphagia was less common (5% vs. 11%; P<0.001), as were bloating (28% vs. 40%; P<0.001) and flatulence (40% vs. 57%; P<0.001). Heartburn, epigastric pain, and diarrhea were similar in the two groups.