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A debate on the roles of antireflux surgery and long term acid suppression in the management of gastro-oesophageal reflux disease
  1. Stephen E Attwood1,
  2. Jean Paul Galmiche2
  1. 1Department of Surgery, Northumbria Healthcare NHS Trust, North Tyneside General Hospital, North Shields, UK
  2. 2Department of Gastroenterology, IMAD, CHU Hôtel Dieu, Nantes Cedex, France
  1. Correspondence to Mr SE Attwood, Department of Surgery, Northumbria Healthcare NHS Trust, North Tyneside General Hospital, North Shields, Tyne and Wear NE29 8NH, UK; Stephen.attwood{at}nhct.nhs.uk

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Introduction

According to the Montreal definition, gastro-oesophageal reflux disease (GORD) is a condition that develops when reflux of the stomach contents into the oesophagus causes troublesome symptoms and/or complications.1 GORD is a chronic disorder which impacts health related quality of life (HR-QOL) and reduces work productivity.2,,4 During the past two decades, the superiority of proton pump inhibitors (PPIs) over other drugs (antacids, prokinetics and H2 receptor antagonists) has been established beyond doubt and PPIs are now considered as the mainstay of antireflux medical therapy.5 6 However, once healing of mucosal breaks and sufficient symptom relief have been achieved by initial therapy, the main goals of long term management are to maintain symptom control and prevent lesion recurrence, allowing a return to a nearly normal quality of life. Maintenance treatment with a PPI may be an option, offering high rates of symptom resolution and healing of oesophagitis.6 However, some patients are reluctant to take long term medication and may prefer to have antireflux surgery which has also be revolutionised by the development of the laparoscopic route. In this debate, we will discuss the advantages/inconvenience of both long term strategies—that is, drugs versus surgery. Our purpose is not to oppose treatments but rather to help the clinician and especially the primary care doctor who has the opportunity of making a major difference by the correct choice of treatment and investigations.

The medical arguments

There are several reasons to choose PPI long term strategy

PPI therapy is indeed a simple and quick way of bringing about symptom relief for typical heartburn. When the patient presents with typical symptoms such as heartburn and/or regurgitation, the diagnosis does not require complex or invasive clinical investigation and is further confirmed by PPI efficacy.

Then, continuous PPI maintenance can be considered as an option if the patient relapses after one or several …

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