Surgical Treatment for Gastroesophageal Reflux Disease: Is It Effective Even for Asians?

Abstract

c 2019 The Korean Society of Neurogastroenterology and Motility J Neurogastroenterol Motil, Vol. 25 No. 3 July, 2019 www.jnmjournal.org Gastroesophageal reflux disease (GERD) is a prevalent disease worldwide, and its prevalence is the highest in North America (18.1-27.8%). The prevalence of GERD is low in East Asia (2.57.8%); however, it is gradually increasing in this region. Although various treatment options are available, proton pump inhibitors (PPIs) are still a mainstay in the management of patients with GERD. An approximately 70% healing rate and 60-90% complete symptom relief rate can be achieved by 4 weeks of PPI medication in patients with erosive reflux disease. The guidelines in the United States strongly recommend an 8-week course of PPIs as the therapy of choice for symptom relief and healing of erosive esophagitis. However, medical treatment of GERD has clinically unmet needs. First, GERD impairs patients’ quality of life and work productivity despite antireflux medications. Refractory GERD symptoms have been identified in 10-40% of patients with GERD who are treated with PPIs. The economic burden due to longterm medication is also a concern. In recent years, potential adverse events, including bone fracture, Clostridium difficile infection, pneumonia, micronutrient deficiency, dementia, and chronic kidney disease, have been suggested in patients with chronic PPI use. A study even showed that PPI administration may be related to the development of gastric cancer, although several critical biases in the study were raised. Now that more than 40 years have passed since PPIs began to be used, it is time to consider another treatment for GERD, such as antireflux surgery. In fact, Nissen fundoplication, a representative surgical treatment for GERD, is not a novel treatment. It was first performed in 1955 by Rudolph Nissen. In Nissen fundoplication, the fundus is wrapped around the lower esophagus. This procedure tightens up the valve and closes off the esophagus whenever the stomach contracts. It is now usually performed laparoscopically since laparoscopic Nissen fundoplication was first described by Dallemagne et al in 1991. The efficacy of laparoscopic antireflux surgery has been found to be comparable with that of PPIs in a multicenter randomized trial conducted in Europe. In the study, the estimated 5-year remission rate in patients who had undergone laparoscopic antireflux surgery was 85% (95% confidence interval, 81-90%). Although the study enrolled only PPI responders, longterm results are promising because most patients who had undergone surgery could discontinue medications, including PPIs. In this issue of the Journal of Neurogastroenterology and Motility, Park et al reported a multicenter prospective study on the Article: Multicenter prospective study of laparoscopic Nissen fundoplication for gastroesophageal reflux disease in Korea Park S, Park J, Kim J, et al (J Neurogastroenterol Motil 2019;25:394-402) Surgical Treatment for Gastroesophageal Reflux Disease: Is It Effective Even for Asians?