To the Editor,
In their review article, Rickenbacher et al. [1] used a meta-analysis to show that surgical management of GERD is more effective than medical therapy in regards to short- and medium-term, patient-relevant outcomes. One of the seven trials cited by the group was the LOTUS trial [2]. In Table 5, they cite the symptoms of dysphagia, bloating, and flatulence reported in the LOTUS trial as more frequent in the medical group. However, upon review of the original source material, Galmiche et al. [2] report significantly higher rates of dysphagia, bloating, and flatulence at 5 years in the surgical group versus the medical group. No significant difference at 5 years was observed between groups for heartburn severity, epigastric pain, or diarrhea. The LOTUS trial was a major component of this meta-analysis and was interpreted incorrectly. Based on the interpretation, the group concludes that evidence is inconsistent regarding the prevalence of gastrointestinal symptoms associated with surgery. The data appear to demonstrate that such GI symptoms are actually consistently more frequent with surgical therapy.
As the debate continues on the nuanced approach to the management of GERD, it is important to clarify the results of the large, randomized-control trials comparing medical and surgical therapy before conclusions are drawn.
References
Rickenbacher N, Kötter T, Kochen MM, Scherer M, Blozik E (2013) Fundoplication versus medical management of gastroesophageal reflux disease: systematic review and meta-analysis. Surg Endosc 28(1):143–155. doi:10.1007/s00464-013-3140-z
Galmiche JP, Hatlebakk J, Attwood S, Ell C, Fiocca R, Eklund S, Långström G, Lind T, Lundell L, LOTUS Trial Collaborators (2011) Laparoscopic antireflux surgery versus esomeprazole treatment for chronic GERD: the LOTUS randomized clinical trial. JAMA 305(19):1969–1977
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Miss Lockwood and Miss Giraldi have no conflict of interest or financial ties to disclose.
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Lockwood, M., Giraldi, E. Commentary on “Rickenbacher et al. Fundoplication versus medical management of gastroesophageal reflux disease: systematic review and meta-analysis.” Surg Endosc. doi: 10.1007/s00464-013-3140-z. Surg Endosc 28, 2001 (2014). https://doi.org/10.1007/s00464-013-3386-5
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DOI: https://doi.org/10.1007/s00464-013-3386-5