Objective
To evaluate the clinical role of a defective lower esophageal sphincter in the long-term outcome of medical and surgical treatment for gastroesophageal reflux disease.
Design
Nonrandomized control study (median followup, 33 months).
Setting
Referred care.
Patients
Fifty-five patients with gastroesophageal reflux disease were prospectively evaluated using a symptom questionnaire, upper endoscopy, esophageal manometry, and 24-hour pH monitoring. Patients were classified into three groups: (1) those with a manometrically defective lower esophageal sphincter, treated surgically; (2) those with a manometrically defective lower esophageal sphincter, treated medically; and (3) those with a manometrically normal lower esophageal sphincter, treated medically.
Intervention
Nissen antireflux procedure and medical therapy with H2-blockers and/or omeprazole.
Main Outcome Measures
Symptomatic improvement after treatment and need for continuous medication.
Results
After therapy, symptoms improved significantly in all three groups (P<.05), but least in the patients who declined surgery. Among patients with a defective lower esophageal sphincter, medical therapy could be discontinued in 13 of 14 patients who had surgery compared with one of 14 who declined surgery. Of the 27 patients with a normal lower esophageal sphincter who were treated medically, medical therapy could be discontinued in 12.
Conclusions
In patients with gastroesophageal reflux disease who have a defective lower esophageal sphincter, surgery can ensure durable symptom control. Patients with a defective sphincter who decline surgery are destined for lifelong therapy, whereas in approximately half of those with a normal sphincter, medical therapy can eventually be discontinued.
(Arch Surg. 1996;131:655-659)
