The Role of a Defective Lower Esophageal Sphincter in the Clinical Outcome of Treatment for Gastroesophageal Reflux Disease

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Abstract
Objective: To evaluate the clinical role of a defective lower esophageal sphincter in the long-term outcome of medical and surgical treatment for gastroesophageal reflux disease. Design: Nonrandomized control study (median followup, 33 months). Setting: Referred care. Patients: Fifty-five patients with gastroesophageal reflux disease were prospectively evaluated using a symptom questionnaire, upper endoscopy, esophageal manometry, and 24-hour pH monitoring. Patients were classified into three groups: (1) those with a manometrically defective lower esophageal sphincter, treated surgically; (2) those with a manometrically defective lower esophageal sphincter, treated medically; and (3) those with a manometrically normal lower esophageal sphincter, treated medically. Intervention: Nissen antireflux procedure and medical therapy with H2-blockers and/or omeprazole. Main Outcome Measures: Symptomatic improvement after treatment and need for continuous medication. Results: After therapy, symptoms improved significantly in all three groups (P<.05), but least in the patients who declined surgery. Among patients with a defective lower esophageal sphincter, medical therapy could be discontinued in 13 of 14 patients who had surgery compared with one of 14 who declined surgery. Of the 27 patients with a normal lower esophageal sphincter who were treated medically, medical therapy could be discontinued in 12. Conclusions: In patients with gastroesophageal reflux disease who have a defective lower esophageal sphincter, surgery can ensure durable symptom control. Patients with a defective sphincter who decline surgery are destined for lifelong therapy, whereas in approximately half of those with a normal sphincter, medical therapy can eventually be discontinued. (Arch Surg. 1996;131:655-659)