Surgical Intervention for Acid-Reflux Control More Efficacious and Cost-Effective Than Long-Term PPI Use

acid reflux
acid reflux
Researchers assessed the efficacy and cost-effectiveness of proton pump inhibitors vs surgical intervention for acid reflux control.

According to results of a systematic review published in The American Surgeon, surgical interventions had fewer side effects than long-term proton pump inhibitor (PPI) use for acid-reflux control in patients with gastroesophageal reflux disease (GERD).

Researchers from the Dwight D. Eisenhower Army Medical Center searched publication databases for articles on PPI and anti-reflux surgery (ARS). A total of 50 articles were included in this analysis.

PPIs became widely used in the 1980s and 1990s. Between 2006 and 2016, 79.4 million patients were prescribed PPIs. Recent studies have identified that long-term users of PPIs developed renal disease and cardiovascular events more frequently than non-users.

Specifically, PPIs have been associated with a 4-fold increased risk for acute kidney injury, a 1.2-fold risk for chronic kidney disease, and a significant association with end-stage renal disease.

Risk for myocardial infarction has been reported as 1.58-fold higher among PPI users and cardiovascular mortality as 2-fold higher. However, the current perception is that the increased risk for cardiovascular events did not outweigh the consequences of long-term acid reflux, justifying the continued use of PPIs.

Studies which directly compared PPIs with ARS observed that in the long-term, ARS was more efficacious for the treatment of reflux. Recipients of ARS had fewer adverse events and lower rates of recurrence compared with PPIs. Patients who used PPIs long-term had higher esophageal acid exposure than ARS, increasing risk for progression to Barrett esophagus or high-grade dysplasia. However, these studies have high levels of heterogeneity and little consensus of conclusions were reported.

At 3 years, ARS becomes the more cost-effective therapy compared with long-term PPI use. In addition to direct costs, patients who underwent ARS tended to have improved quality of life and accrued less overall health care utilization costs, according to analysis of the National Health Service data collected in the United Kingdom.

These findings indicated that due to the increased risk for cardiovascular events and renal diseases associated with long-term PPI use, ARS was the more efficacious and safe treatment for chronic reflux. ARS was also more cost-effective beginning at 3 years and continuing long-term.


Friedman A J, Elseth A J, Brockmeyer J R. Proton pump inhibitors, associated complications, and alternative therapies: a shifting risk benefit ratio. Am Surg. Published online February 21, 2021. doi:10.1177/0003134821991988.