Gastro-oesophageal reflux

Comparing laparoscopic antireflux surgery with esomeprazole in the management of patients with chronic gastro-oesophageal reflux disease: a 3-year interim analysis of the LOTUS trial

L Lundell¹, S Attwood², C Ell³, R Fiocca⁴, J-P Galmiche⁵, J Hatlebakk⁶, T Lind⁷, O Junghard⁷, on behalf of the LOTUS trial collaborators

¹ Department of Surgery, Karolinska University Hospital, Huddinge, Sweden
² Department of Surgery, North Tyneside General Hospital, North Shields, Tyne and Wear, UK
³ Department of Gastroenterology, Dr Horst Schmidt-Hospital, Wiesbaden, Germany
⁴ Department of Surgical and Morphological Sciences, Anatomic Pathology Division, University of Genova, Italy
⁵ Department of Gastroenterology and Hepatology, Nantes University and CIC INSERM, Nantes, France
⁶ Institute of Medicine, Haukeland University Hospital, University of Bergen, Norway
⁷ Astra Zeneca R & D, Mölndal, Sweden

Professor L Lundell, Department of Surgery, Karolinska University Hospital, Huddinge, S 141 66 Stockholm, Sweden; lars.lundell{at}karolinska.se

Background: With the introduction of laparoscopic antireflux surgery (LARS) for gastro-oesophageal reflux disease (GORD) along with the increasing efficacy of modern medical treatment, a direct comparison is warranted. The 3-year interim results of a randomised study comparing both the efficacy and safety of LARS and esomeprazole (ESO) are reported.

Methods: LOTUS is an open, parallel-group multicentre, randomised and controlled trial conducted in dedicated centres in 11 European countries. LARS was completed according to a standardised protocol, comprising a total fundoplication and a crural repair. Medical treatment comprised ESO 20 mg once daily, which could be increased stepwise to 40 mg once daily and then 20 mg twice daily in the case of incomplete GORD control. The primary outcome variable was time to treatment failure (Kaplan–Meier analysis). Treatment failure was defined on the basis of symptomatic relapse requiring treatment beyond that stated in the protocol.

Results: 554 patients were randomised, of whom 288 were allocated to LARS and 266 to ESO. The two study arms were well matched. The proportions of patients who remained in remission after 3 years were similar for the two therapies: 90% of surgical patients compared with 93% medically treated for the intention to treat population, p = 0.25 (90% vs 95% per protocol). No major unexpected postoperative complications were experienced and ESO was well tolerated. However, postfundoplication complaints remain a problem after LARS.

Conclusions: Over the first 3 years of this long-term study, both laparoscopic total fundoplication and continuous ESO treatment were similarly effective and well-tolerated therapeutic strategies for providing effective control of GORD.

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