LARS vs PPIs for Treatment of GERD?
Patients receiving laparoscopic anti-reflux surgery (LARS) for chronic gastroesophageal reflux disease (GERD) had significantly greater long-term reductions in 24-hour esophageal acid exposure than patients given esomeprazole, researchers report in the May issue of Clinical Gastroenterology and Hepatology. However, both treatments controlled symptoms in most patients, and esophageal and gastric pH were not associated with long-term outcomes.
GERD is caused by the excessive exposure of esophageal mucosa to gastric acid. In patients with reflux esophagitis, the rate of healing associates with esophageal acid exposure and reduction in gastric acidity. Intra-gastric pH monitoring has been used to compare the effects of inhibitory agents on gastric acidity.
Proton pump inhibitors (PPIs) are commonly used to treat patients with GERD. However, LARS can be used for long-term control of GERD. It is not clear whether PPIs can control intra-esophageal acid exposure over time, or produce the same level of acid reflux and symptom control as LARS.
Jan G. Hatlebakk et al performed a randomized controlled trial of the abilities of LARS vs esomeprazole (20 or 40 mg/d) to control esophageal acid exposure over a 5-year period in 267 patients with chronic GERD.
They found that in the LARS group (n = 116), the median 24-hour esophageal acid exposure was 8.6% at baseline and 0.7% after 6 months and 5 years (see figure). In the esomeprazole group (n = 151), the median 24-hour esophageal acid exposure was 8.8% at baseline, 2.1% after 6 months, and 1.9% after 5 years.
However, esophageal and intra-gastric pH parameters, off and on therapy, did not predict the return of symptoms over the study period. In the LARS group, 8.5% of patients reported moderate-to-severe heartburn and 0.9% reported acid regurgitation of corresponding severity after 5 years. In the esomeprazole group, the corresponding numbers were 17.2% and 14.6%, respectively.
Neither intraesophageal nor intragastric pH parameters at baseline differed significantly between patients with treatment failure vs patients who remained in remission over the 5 years of follow-up evaluation.
The authors say these findings indicate that response to GERD therapy is not related directly to normalization of acid reflux parameters alone.
The greatest difference between the 2 groups was observed in esophageal acid exposure in supine patients, suggesting that a once-daily dose of esomeprazole 20 mg, despite its significantly longer duration of action than other PPIs, is inadequate to control gastric acidity overnight for some patients.
The authors conclude that long-term therapy with esomeprazole or LARS is effective in controlling esophageal acid exposure—significant reductions were observed in the proportion of time with an esophageal pH less than 4.0, as well as the number of long-lasting reflux episodes.
However, the weak associations between esophageal acid exposure and symptom control casts doubt on the relevance of intra-esophageal and intra-gastric pH parameters for predicting clinical outcomes.