Endoscopy 2005; 37(3): 217-222
DOI: 10.1055/s-2005-860996
Original Article
© Georg Thieme Verlag KG Stuttgart · New York

Are Endoscopic Antireflux Therapies Cost-Effective Compared with Laparoscopic Fundoplication?

I.  Schiefke1 , C.  Rogalski2 , A.  Zabel-Langhennig1 , H.  Witzigmann3 , J.  Mössner1 , D.  Hasenclever2 , K.  Caca1
  • 1Department of Internal Medicine II, University of Leipzig, Leipzig, Germany
  • 2Institute for Medical Informatics, Statistics and Epidemiology (IMISE), University of Leipzig, Leipzig, Germany
  • 3Department of Surgery II, University of Leipzig, Leipzig, Germany
Weitere Informationen

Publikationsverlauf

Submitted 26 October 2003

Accepted after Revision 15 November 2003

Publikationsdatum:
24. Februar 2005 (online)

Background and Study Aims: A number of endoscopic antireflux therapies (EATs) have emerged as potential nonmedical treatment options for patients with gastroesophageal reflux disease (GERD). Concerns about clinical efficacy and costs have given rise to debate about their role in GERD management. The costs of laparoscopic fundoplication (LF) were compared with the costs of EAT when used in a sequential strategy that reserves the option of LF for EAT failure.
Methods: A simple mathematical criterion of direct medical costs was applied. Published articles concerning EAT were reviewed to assess its effectiveness, durability and costs, in order to estimate the parameters of the model. The costs of EAT and LF were evaluated from the perspective of a German third-party payer. Only direct medical costs were considered.
Results: Assuming that EAT has no impact on potential LF later on, the outcome of both strategies (LF, or EAT first with LF in case of failure of EAT) is identical and preference is a simple question of costs. The sequential strategy in nonmedical GERD treatment would be preferable if the long-term relief rate with EAT exceeds the ratio of the cost of EAT to the cost of LF. Long-term success rates of EAT do not exceed 0.65. At current prices EAT is clearly not cost-effective in Germany.
Conclusion: Our simple criterion indicates that EAT would only be cost-effective and beneficial in a sequential strategy if the costs of EAT were to be decreased to around 30 % of current retail prices. However, long-term studies and randomized controlled trials are necessary to finally determine the role of EAT in GERD treatment, and the preference may change in either direction.

References

  • 1 Dimenas E, Glise H, Hallerback B. et al . Quality of life in patients with upper gastrointestinal symptoms. An improved evaluation of treatment regimens?.  Scand J Gastroenterol. 1993;  28 681-687
  • 2 Locke G R, 3rd, Talley N J, Fett S L. et al . Prevalence and clinical spectrum of gastroesophageal reflux: a population-based study in Olmsted County, Minnesota.  Gastroenterology. 1997;  112 1448-1456
  • 3 Revicki D A, Sorensen S, Maton P N, Orlando R C. Health-related quality of life outcomes of omeprazole versus ranitidine in poorly responsive symptomatic gastroesophageal reflux disease.  Dig Dis. 1998;  16 284-291
  • 4 el-Serag H B, Sonnenberg A. Opposing time trends of peptic ulcer and reflux disease.  Gut. 1998;  43 327-333
  • 5 Kennedy T, Jones R. The prevalence of gastro-oesophageal reflux symptoms in a UK population and the consultation behaviour of patients with these symptoms.  Aliment Pharmacol Ther. 2000;  14 1589-1594
  • 6 Voutilainen M, Sipponen P, Mecklin J P. et al . Gastroesophageal reflux disease: prevalence, clinical, endoscopic and histopathological findings in 1,128 consecutive patients referred for endoscopy due to dyspeptic and reflux symptoms.  Digestion. 2000;  61 6-13
  • 7 Lagergren J, Bergstrom R, Lindgren A, Nyren O. Symptomatic gastroesophageal reflux as a risk factor for esophageal adenocarcinoma.  N Engl J Med. 1999;  340 825-831
  • 8 Klinkenberg-Knol E C, Festen H P, Jansen J B. et al . Long-term treatment with omeprazole for refractory reflux esophagitis: efficacy and safety.  Ann Intern Med. 1994;  121 161-167
  • 9 Vigneri S, Termini R, Leandro G. et al . A comparison of five maintenance therapies for reflux esophagitis.  N Engl J Med. 1995;  333 1106-1110
  • 10 Spechler S J, Lee E, Ahnen D. et al . Long-term outcome of medical and surgical therapies for gastroesophageal reflux disease: follow-up of a randomized controlled trial.  JAMA. 2001;  285 2331-2338
  • 11 Lundell L. Laparoscopic fundoplication is the treatment of choice for gastro-oesophageal reflux disease. Protagonist.  Gut. 2002;  51 468-471
  • 12 Hetzel D J, Dent J, Reed W D. et al . Healing and relapse of severe peptic esophagitis after treatment with omeprazole.  Gastroenterology. 1988;  95 903-912
  • 13 McDougall N I, Johnston B T, Kee F. et al . Natural history of reflux oesophagitis: a 10 year follow up of its effect on patient symptomatology and quality of life.  Gut. 1996;  38 481-486
  • 14 Donahue P E, Samelson S, Nyhus L M, Bombeck C T. The floppy Nissen fundoplication. Effective long-term control of pathologic reflux.  Arch Surg. 1985;  120 663-668
  • 15 DeMeester T R, Bonavina L, Albertucci M. Nissen fundoplication for gastroesophageal reflux disease. Evaluation of primary repair in 100 consecutive patients.  Ann Surg. 1986;  204 9-20
  • 16 Thor K B, Silander T. A long-term randomized prospective trial of the Nissen procedure versus a modified Toupet technique.  Ann Surg. 1989;  210 719-724
  • 17 Dallemagne B, Weerts J M, Jehaes C. et al . Laparoscopic Nissen fundoplication: preliminary report.  Surg Laparosc Endosc. 1991;  1 138-143
  • 18 Fuchs K H, Feussner H, Bonavina L. et al . Current status and trends in laparoscopic antireflux surgery: results of a consensus meeting. The European Study Group for Antireflux Surgery (ESGARS).  Endoscopy. 1997;  29 298-308
  • 19 Lafullarde T, Watson D I, Jamieson G G. et al . Laparoscopic Nissen fundoplication: five-year results and beyond.  Arch Surg. 2001;  136 180-184
  • 20 Pelissier E P, Ottignon Y, Deschamps J P, Carayon P. Fundoplication avoiding complications of the Nissen procedure: prospective evaluation.  World J Surg. 1997;  21 611-616; discussion 616-617
  • 21 Wetscher G J, Glaser K, Wieschemeyer T. et al . Tailored antireflux surgery for gastroesophageal reflux disease: effectiveness and risk of postoperative dysphagia.  World J Surg. 1997;  21 605-610
  • 22 Bais J E, Bartelsman J F, Bonjer H J. et al . Laparoscopic or conventional Nissen fundoplication for gastro- oesophageal reflux disease: randomised clinical trial. The Netherlands Antireflux Surgery Study Group.  Lancet. 2000;  355 70-174
  • 23 Pessaux P, Arnaud J P, Ghavami B. et al . Morbidity of laparoscopic fundoplication for gastroesophageal reflux: a retrospective study about 1470 patients.  Hepatogastroenterology. 2002;  49 447-450
  • 24 Van Den Boom G, Go P M, Hameeteman W. et al . Cost effectiveness of medical versus surgical treatment in patients with severe or refractory gastroesophageal reflux disease in the Netherlands.  Scand J Gastroenterol. 1996;  31 1-9
  • 25 Swain C P, Brown G J, Gong F, Mills T N. An endoscopically deliverable tissue-transfixing device for securing biosensors in the gastrointestinal tract.  Gastrointest Endosc. 1994;  40 730-734
  • 26 Filipi C J, Lehman G A, Rothstein R I. et al . Transoral, flexible endoscopic suturing for treatment of GERD: a multicenter trial.  Gastrointest Endosc. 2001;  53 416-422
  • 27 Mahmood Z, McMahon B P, Arfin Q. et al . Endocinch therapy for gastro-oesophageal reflux disease: a one year prospective follow up.  Gut. 2003;  52 34-39
  • 28 Tam W C, Holloway R H, Dent J. et al . Impact of endoscopic suturing of the gastroesophageal junction on lower esophageal sphincter function and gastroesophageal reflux in patients with reflux disease.  Am J Gastroenterol. 2004;  99 195-202
  • 29 Ponchon T, Boyer J, Grimaud J C. et al . A prospective multicenter phase II study to evaluate endocinch suturing system for the treatment of GERD.  Gastrointest Endosc. 2004;  60 AB15
  • 30 Triadafilopoulos G, Dibaise J K, Nostrant T T. et al . Radiofrequency energy delivery to the gastroesophageal junction for the treatment of GERD.  Gastrointest Endosc. 2001;  53 407-415
  • 31 Triadafilopoulos G, DiBaise J K, Nostrant T T. et al . The Stretta procedure for the treatment of GERD: 6 and 12 month follow-up of the U.S. open label trial.  Gastrointest Endosc. 2002;  55 149-156
  • 32 Corley D A, Katz P, Wo J M. et al . Improvement of gastroesophageal reflux symptoms after radiofrequency energy: a randomized, sham-controlled trial.  Gastroenterology. 2003;  125 668-676
  • 33 Tam W C, Schoeman M N, Zhang Q. et al . Delivery of radiofrequency energy to the lower oesophageal sphincter and gastric cardia inhibits transient lower oesophageal sphincter relaxations and gastro-oesophageal reflux in patients with reflux disease.  Gut. 2003;  52 479-485
  • 34 Mason R J, Hughes M, Lehman G A. et al . Endoscopic augmentation of the cardia with a biocompatible injectable polymer (Enteryx) in a porcine model.  Surg Endosc. 2002;  16 386-391
  • 35 Deviere J, Pastorelli A, Louis H. et al . Endoscopic implantation of a biopolymer in the lower esophageal sphincter for gastroesophageal reflux: a pilot study.  Gastrointest Endosc. 2002;  55 335-341
  • 36 Johnson D A, Ganz R, Aisenberg J. et al . Endoscopic, deep mural implantation of Enteryx for the treatment of GERD: 6-month follow-up of a multicenter trial.  Am J Gastroenterol. 2003;  98 250-258
  • 37 Johnson D A, Ganz R, Aisenberg J. et al . Endoscopic implantation of enteryx for treatment of GERD: 12-month results of a prospective, multicenter trial.  Am J Gastroenterol. 2003;  98 1921-1930
  • 38 Johansson J, Johnsson F, Joelsson B. et al . Outcome 5 years after 360 degree fundoplication for gastro-oesophageal reflux disease.  Br J Surg. 1993;  80 46-49
  • 39 Carlson M A, Frantzides C T. Complications and results of primary minimally invasive antireflux procedures: a review of 10,735 reported cases.  J Am Coll Surg. 2001;  193 428-439
  • 40 Flum D R, Koepsell T, Heagerty P, Pellegrini C A. The nationwide frequency of major adverse outcomes in antireflux surgery and the role of surgeon experience, 1992-1997.  J Am Coll Surg. 2002;  195 611-618
  • 41 Velanovich V, Ben Menachem T. Laparoscopic Nissen fundoplication after failed endoscopic gastroplication.  J Laparoendosc Adv Surg Tech A. 2002;  12 305-308
  • 42 El Nakadi I, Closset J, De Moor V. et al . Laparoscopic Nissen fundoplication after failure of Enteryx injection into the lower esophageal sphincter.  Surg Endosc. 2004;  18 818-820
  • 43 Mahmood Z, McMahon B, O"Morain C, Weir D G. Innovations in gastro-intestinal endoscopy: endoscopic antireflux therapies for gastro-oesophageal reflux disease.  Dig Dis. 2002;  20 182-190
  • 44 Harewood G C, Gostout C J. Cost analysis of endoscopic antireflux procedures: endoluminal plication vs. radiofrequency coagulation vs. treatment with a proton pump inhibitor.  Gastrointest Endosc. 2003;  58 493-499

K. Caca, M. D.

Department of Medicine II, University of Leipzig

Philipp-Rosenthal-Straße 27 · 04103 Leipzig · Germany

Fax: + 49-341-9712239

eMail: caca@medizin.uni-leipzig.de