Endoscopic versus surgical therapies for GERD: a systematic review and network meta-analysis

The objective of our study was to compare the outcomes of endoscopic and surgical therapies for GERD using a network meta-analysis.

Only randomized control trials with adult patients were included in the study. Radiofrequency energy (RFe) delivery, transoral incisionless fundoplication (TIF), magnetic sphincter augmentation (MSA), and Nissen, Toupet, and anterior fundoplication were studied. Outcomes of interest were GERD health-related quality of life (GERD-HRQL), proton pump inhibitor (PPI) use, presence of esophagitis, percentage of time with pH <4 on 24-hour esophageal pH monitoring (% time pH <4), and lower esophageal sphincter pressure (LESP) at ≤12-month follow-up.

Twenty-seven studies (3515 patients) were included. GERD-HRQL scores for TIF and RFe were not significantly different (mean difference [MD], -3.81; 95% confidence interval [CI], -10.65 to 3.04) but were significantly better than PPI use alone. No significant differences occurred between endoscopic and surgical procedures in terms of esophagitis, % time pH <4, or cessation of PPI use. Regarding LESP, RFe was inferior to TIF (MD, -9.23; 95% CI, -13.89 to -4.58) and to Nissen (MD, -9.00; 95% CI, -14.55 to -3.45), Toupet (MD, -6.83; 95% CI, -12.50 to -1.55), and anterior (MD, -7.5; 95% CI, -13.35 to -1.71) fundoplication. LESP was comparable for endoscopic and surgical fundoplication.

TIF did not demonstrate significantly different short-term outcomes compared with surgical fundoplication procedures. TIF should be considered on a case-by-case basis in patients who do not want surgery or are not surgical candidates. RFe is inferior to TIF and surgical fundoplication. MSA requires more randomized control trial data.