Controversies in long-term management of reflux disease

There are significant controversies about the long-term therapy of reflux disease that arise primarily from a lack of data on the risks of the disease and its therapies over the relevant time scale of several decades. Currently, there are no appropriately structured direct comparisons between the two current major treatment options of tailored long-term acid suppression and laparoscopic anti-reflux surgery. Critical review of the available literature does not support the assertion that anti-reflux surgery has a superior risk/benefit profile when compared to long-term proton pump inhibitor (PPI) therapy, since non-controlled data indicate that although both therapies are relatively safe, morbidity and mortality rates are lowest with PPI therapy, whilst efficacy is comparable. The clinical significance of the reflux that continues to occur after both anti-reflux surgery and during PPI therapy is uncertain, but probably over-estimated. As pathological duodenogastro-oesophageal reflux affects only a small minority of reflux disease patients, issues arising from it should not be regarded as mainstream influences on the choice of long-term therapy. Notwithstanding, this type of reflux is substantially reduced by both PPI therapy and anti-reflux surgery. The choice between laparoscopic surgery and long-term tailored acid suppression should be determined primarily by assessment of operative risk, the quality of surgery available to the patient and by patient preference, after balanced explanation of the risks and benefits of each option. Given that the cost of PPI therapy is likely to drop substantially in the next few years, drug cost should not be a major pressure for the choice of anti-reflux surgery.