Surgery May Be Best Option for Some With Refractory Heartburn
Heartburn that is both truly PPI-refractory and reflux-related occurs in a minority of patients
WEDNESDAY, Oct. 16, 2019 (HealthDay News) -- In patients who truly have proton pump inhibitor (PPI)-refractory heartburn, including those with reflux hypersensitivity, surgery may be the best treatment option, according to a study published in the Oct. 16 issue of the New England Journal of Medicine.
Stuart J. Spechler, M.D., from the Baylor University Medical Center in Dallas, and colleagues assessed treatment success among patients referred to a Veterans Affairs gastroenterology clinic with reflux-related heartburn. Seventy-eight patients (mean age, 48.5 years) were randomly assigned to receive either surgical treatment (laparoscopic Nissen fundoplication), active medical treatment (omeprazole plus baclofen, with desipramine added depending on symptoms), or control medical treatment (omeprazole plus placebo).
The researchers report they previously excluded 42 patients who had relief of their heartburn during a two-week omeprazole trial, 23 who had non-gastroesophageal reflux disease (GERD) esophageal disorders, and 99 who had functional heartburn (not due to GERD or other histopathologic, motility, or structural abnormality). Of the patients who were randomly assigned, the incidence of treatment success with surgery (67 percent of 27 patients) was significantly superior to that seen with active medical treatment (28 percent of 25 patients; P = 0.007) or control medical treatment (12 percent of 26 patients; P < 0.001). The difference in treatment success between the active medical group and the control medical group was nonsignificant (95 percent confidence interval, −5 to 38; P = 0.17).
"Among patients referred to VA gastroenterology clinics for PPI-refractory heartburn, systematic workup revealed truly PPI-refractory and reflux-related heartburn in a minority of patients," write the authors. "For that highly selected subgroup, surgery was superior to medical treatment."