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Although the technical principles of surgical repair remain the same in laparoscopic practice as in the classical open procedure, the increasing enthusiasm of patients and many physicians for this so-called “mini invasive” surgery has led to its greater use and wider indications for surgery in gastro-oesophageal reflux disease (GORD). The notion behind this proposed change in current practice is that antireflux surgery (ARS) is more “cost effective” than medical therapy and possibly safer with regard to the long term effects of acid suppression and occurrence of adenocarcinoma of the oesophagus in patients with severe chronic GORD. Our position challenges this view, which in our opinion is not supported by scientific evidence and data in the recent literature. If it is assumed that modern drug therapy and ARS are both effective in the treatment of GORD, a comparison between them should concentrate on several end points that have been recognised as major goals of antireflux therapy. Hence in addition to healing of oesophagitis, emphasis now needs to be given to complete symptom relief, return to a normal quality of life, and long term control of the disease (that is, prevention of recurrences and complications). Tolerance, safety, and costs are also important issues.
EFFICACY OF ARS VERSUS MEDICAL THERAPY
Comparison is limited by lack of randomised trials between laparoscopic surgery and modern drug therapy (that is, proton pump inhibitors (PPIs)). Although Spechler1 first reported that open ARS was significantly better than medical therapy after two or three years of follow up, the comparison involved drugs which are no longer considered as optimal therapy for GORD. Interestingly, the same author recently reassessed the long term outcome of these cohorts of medically and surgically treated patients after a median follow up of approximately 10 years.2 Oesophagitis grade, quality of life scores, satisfaction with antireflux therapy, and frequency of …