I read with great interest the newly published article titled “Comparative Analysis of Perioperative Outcomes and Costs Between Laparoscopic and Open Anti-reflux Surgery” in the journal of the American College of Surgeons by Patti el al. This is a retrospective study based on the National Inpatient Sample for the period between 2000 and 2013. A total of 75544 patients were included with 58% undergoing laparoscopic fundoplication and 42% receiving an open acid reflux surgery. As expected the rate of minimally invasive procedures for acid reflux has increased over time.
The study has shown that laparoscopic fundoplication is associated with lower postoperative morbidity and mortality rate, shorter length of hospital stay, and lower cost than open fundoplication. Interestingly, the number of fundoplications for GERD treatment has decreased from 2000 till 2013 despite an increase in GERD prevalence. The authors attribute this decrease to patients’ and gastroenterologists’ concerns about acid reflux surgery outcome including efficacy and durability. While this assumption makes sense, I think that the widespread use of proton pump inhibitors, and the trivialization of GERD as a complex medical disease have diverted both patients and physicians from properly addressing acid reflux disease. Over the past 15 years GERD has become a nuisance that patients had to live with one way or the other. Only after hiatal hernia repair and Nissen fundoplication, patients realize the full effect of GERD on their health and lifestyle.
Furthermore, despite an increase in laparoscopic acid reflux procedures, 15% of fundoplications are still performed using an open approach. This may be due to older surgeons who have not embraced laparoscopy. Other factors may be related to difficult revision acid reflux surgeries or complicated cases due to previous abdominal surgery.
In conclusion, laparoscopic fundoplication is currently the standard of care for treatment of GERD. Nissen fundoplication has stood the test of time and is currently the most effective and most reliable treatment of GERD.