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An evidence-based appraisal of reflux disease management — the Genval Workshop Report
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  1. J Denta,
  2. J Brunb,
  3. A M Fendrickc,
  4. M B Fennertyd,
  5. J Janssense,
  6. P J Kahrilasf,
  7. K Lauritseng,
  8. J C Reynoldsh,
  9. M Shawi,
  10. N J Talley on behalf of the Genval Workshop Groupj
  1. aDepartment of Gastrointestinal Medicine, Royal Adelaide Hospital, Adelaide, Australia, bSödra Hõlsocentralen, Hudiksvall, Sweden, cUniversity of Michigan Health Centre, Ann Arbor, Michigan, USA, dSchool of Medicine, Oregon Health Sciences University, Portland, Oregon, USA, eDepartment of Pathophysiology and Gastroenterology, University of Leuven, Leuven, Belgium, fDepartment of Medicine, Northwestern University Medical School, Chicago, Illinois, USA, gDepartment of Medical Gastroenterology, Odense University Hospital, Odense, Denmark, hGastroenterology and Hepatology, Allegheny University of the Health Sciences, Department of Medicine, Philadelphia, Pennsylvania, USA, iDepartment of Medicine, Park Nicollet Medical Centre, St Louis Park, Minnesota, USA, jDepartment of Medicine, The University of Sydney, The Nepean Hospital, Penrith, Australia
  1. Professor John Dent, Department of Gastrointestinal Medicine, Royal Adelaide Hospital, North Terrace Adelaide 5000, South Australia.

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Summary

This report summarises conclusions from an evidence-based workshop which evaluated major clinical strategies for the management of the full spectrum of gastro-oesophageal reflux disease, with an emphasis on medical management.

The disease was defined by the presence of oesophageal mucosal breaks or by the occurrence of reflux induced symptoms severe enough to impair quality of life. Endoscopy negative patients were recognised as the most common subgroup; most of these patients can be diagnosed by a well structured symptom analysis. There is a consistent hierarchy of effectiveness of available initial and long term therapies that applies for all patient subgroups. Lifestyle measures were judged to be of such low efficacy that they were rejected as a primary therapy for all patient subgroups. Proton pump inhibitor therapy was considered the initial medical treatment of choice because of its clearly superior efficacy which results in the most prompt achievement of desirable outcomes at the lowest overall medical cost. It was acknowledged that most of patients require long term management and that any maintenance therapy should be chosen by step down to the regimen that is still effective, but least costly. Endoscopic monitoring of routine long term therapy was considered inappropriate, on the basis that control of symptoms is an acceptably reliable indicator of healing in patients with oesophagitis.

Laparoscopic antireflux surgery was recognised as a significant therapeutic advance, the results of which, however, depend substantially on the experience of the surgeon. There are currently no published direct comparisons of cost and efficacy outcomes of optimal medical and surgical therapies for reflux disease. To a significant degree, the choice between medical and surgical therapy should depend on informed patient preference.

Substantial advances have occurred recently in the understanding and treatment of reflux disease. By contrast, there has been relatively little research into the best …

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