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

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.

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.

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.

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.