CLINICAL | GASTROENTEROLOGY
Medical vs surgical
Treatment for refractory heartburn Antireflux surgery may be beneficial for refractory gastro-oesophageal reflux disease (GORD), but only for a highly selected group of patients, according to a New England Journal of Medicine study.
H
EARTBURN THAT PERSISTS despite proton-pump inhibitor (PPI) treatment is a frequent clinical problem with multiple potential causes. Treatments for PPI-refractory heartburn are of unproven efficacy and focus on controlling gastroesophageal reflux with refluxreducing medication or antireflux surgery or on dampening visceral hypersensitivity with neuromodulators. Roughly 370 Veterans Affairs patients with heartburn refractory to proton-pump inhibitors were enrolled, but 288 were excluded for various reasons (eg, testing revealed non-GORD causes of heartburn). Ultimately, 78 patients were randomised to receive either laparoscopic fundoplication, medical treatment (omeprazole, baclofen, desipramine), or control medication (omeprazole plus placebo). At 12 months, the proportion of patients who had treatment success (at least a 50% improvement in the GORD Health-Related Quality of Life score) was significantly higher in the surgery group (67% vs. 28% for active medication and 12% for control medication). An editorialist cautions: "The findings should not translate into more patients with refractory heartburn being offered surgery without each case being judiciously evaluated on its merits, and only after extended trials of medical therapy." METHODS Patients who were referred to Veterans Affairs (VA) gastroenterology clinics for PPI-refractory heartburn received 20mg of omeprazole twice daily for two weeks, and those with persistent heartburn underwent endoscopy, oesophageal biopsy, oesophageal manometry, and multichannel intraluminal impedance–pH monitoring. If patients were found to have reflux-related heartburn, we randomly assigned them to receive surgical treatment (laparoscopic Nissen fundoplication), active medical treatment (omeprazole plus baclofen, with desipramine added depending on symptoms), or control medical treatment (omeprazole plus placebo). The primary outcome was treatment success, defined as a decrease of 50% or more in the GORD– Health Related Quality of Life score (range, 0 to 50, with higher scores indicating worse symptoms) at one year. RESULTS A total of 366 patients (mean age, 48.5 years; 280 men) were enrolled. Prerandomisation procedures excluded 288 patients: 42 had relief of their heartburn during the two-week omeprazole trial, 70 did not complete trial procedures, 54 were excluded for other reasons, 23 had nonGORD oesophageal disorders, and 99 had
functional heartburn (not due to GORD or other histopathologic, motility, or structural abnormality). The remaining 78 patients underwent randomisation. The incidence of treatment success with surgery (18 of 27 patients, 67%) was significantly superior to
Y E A RS
T WENT Y
SADAG
that with active medical treatment (seven of 25 patients, 28%; P=0.007) or control medical treatment (three of 26 patients, 12%; P<0.001). The difference in the incidence of treatment success between the active medical group and
the control medical group was 16% points (95% confidence interval, −5 to 38; P=0.17).
References available on request.
MENTAL HEALTH FACT SHEET
LIFE-TIME PREVALENCE OF MENTAL DISORDERS IN SA Compared with 14 other countries in the WMH Survey, South Africa is the:
2nd highest for substance abuse disorders (13.3%) 6th highest for anxiety disorders (15.8%) 7th highest for mood disorders (9.8%) PATIENT ADHERENCE AT A GOVERNMENT HOSPITAL
MENTAL HEALTH IN SOUTH AFRICA • 3rd biggest contributor to the burden of disease • 7.7% reduction in mental hospital beds across all provinces • 11% of all non-natural death in SA is due to suicide • 16.5% of South Africans suffer from common mental health problems • 43.7% of people with HIV/AIDS have a mental health condition • 75% of clinic staff does not have a caring attitude • South Africa is in the bottom 4 countries providing mental health treatment
Only 15.4% of patients take their meds as suggested by their dr 1 in 3 patients do not attend their dr’s appointments • Most common reasons are +/- 6 mil South African suffers from PTSD • Forgetfulness 28.6% +/- 8000 South Africans commit suicide each year • Lack of Support 24.2% • Adverse reactions 13% 82.1% cannot afford private health care • Unavailability 11% > 1% of health budget devoted to mental health
SOCIAL BURDEN FOR MENTAL HEALTH PATIENTS
Can’t take care of dependants
Separated/ Divorced
Lost friends
Negative Family Relationships
17%
26%
47%
49%
SEEKING TREATMENT FOR MENTAL HEALTH
RESOURCES FOR MENTAL HEALTH Per 100,000 of the population there are: 9.72 Nurses 0.4 Social workers 0.27 Psychiatrists 0.32 Psychologists 2.8 beds for in-patients 1% beds for children
Research compiled by SADAG – References: DoH, 2012; WHO, 2012, SASH, 2009; MHaPP, 2007; Freeman, 2007; MRC, 2006; ALLERS, 2009; Janse van Rensburg, 2013
MEDICAL CHRONICLE | MAY 2020 33
