Choice of long-term strategy for the management of patients with severe esophagitis: A cost-utility analysis

Heudebert, GR; Marks, Robert D.; Wilcox, C. Mel; Rm, Centor

doi:10.1016/s0016-5085(97)70118-5

Cited by 138 publications

(64 citation statements)

References 2 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…The utility of NSRS state was derived from two studies that reported QOL weights for patients with gastroesophageal reflux disease and achalasia (0.72 [0.64 -0.75]). 15,16 According to the time required for recovery, a disutility was assigned to each of the various short-term postoperative health states. The utilities and the total QOL weight for each year a patient undergoes an operation was calculated using the formula:…”

Section: Appendix Bmentioning

confidence: 99%

Paraesophageal Hernias: Operation or Observation?

Stylopoulos¹,

Gazelle²,

Rattner³

2002

Annals of Surgery

366

208

View full text Add to dashboard Cite

ObjectiveTo examine the hypothesis that elective laparoscopic repair should be routinely performed on patients with asymptomatic or minimally symptomatic paraesophageal hernias. Summary Background DataThe management of asymptomatic paraesophageal hernias is a controversial issue. Most surgeons believe that all paraesophageal hernias should be corrected electively on diagnosis, irrespective of symptoms, to prevent the development of complications and avoid the risk of emergency surgery. MethodsA Markov Monte Carlo decision analytic model was developed to track a hypothetical cohort of patients with asymptomatic or minimally symptomatic paraesophageal hernia and reflect the possible clinical outcomes associated with two treatment strategies: elective laparoscopic paraesophageal hernia repair (ELHR) or watchful waiting (WW). The input variables for ELHR were estimated from a pooled analysis of 20 published studies, while those for WW and emergency surgery were derived from the 1997 HCUP-NIS database and surgical literature published from 1964 to 2000. Outcomes for the two strategies were expressed in quality-adjusted lifeyears (QALYs). ResultsAnalysis of the HCUP-NIS database showed that published studies overestimate the mortality of emergency surgery (17% vs. 5.4%). The mortality rate of ELHR was 1.4%. The annual probability of developing acute symptoms requiring emergency surgery with the WW strategy was 1.1%. For patients 65 years of age, ELHR resulted in reduction of 0.13 QALYs (10.78 vs. 10.65) compared with WW. The model predicted that WW was the optimal treatment strategy in 83% of patients and ELHR in the remaining 17%. The model was sensitive only to alterations of the mortality rates of ELHR and emergency surgery. ConclusionsIf ELHR is routinely recommended, it would be more beneficial than WW in fewer than one of five patients. WW is a reasonable alternative for the initial management of patients with asymptomatic or minimally symptomatic paraesophageal hernias, and even if an emergency operation is required, the burden of the procedure is not as severe as was thought in the past.The need for surgical correction of asymptomatic paraesophageal hernias is controversial. Many surgeons, citing the influential studies of Belsey 1 and Hill, 2 advocate elective repair of all paraesophageal hernias irrespective of symptoms. The rationale for this approach is prophylactic; that is, prevention of life-threatening complications such as obstruction and strangulation and avoidance of the significant morbidity and mortality of an emergency operation. The perception that laparoscopic techniques offer a less morbid approach to surgical correction of paraesophageal hernias is cited as an additional reason to support the elective repair of paraesophageal hernias. However, beliefs held by the surgical community about the natural history of paraesophageal hernias and the morbidity and mortality of both elective and emergency operations are based on relatively small patient series and anecdotal case reports. Several recent ...

show abstract

Section: Appendix Bmentioning

confidence: 99%

Paraesophageal Hernias: Operation or Observation?

Stylopoulos¹,

Gazelle²,

Rattner³

2002

Annals of Surgery

366

208

View full text Add to dashboard Cite

show abstract

“…The scientific attempts to elucidate the problem have hitherto been limited to either retrospective studies or studies in which computer-based modeling has been used [58][59][60][61]. Although some information of clinical value can be obtained from such studies they suffer from inherent and well-known methodological weaknesses.…”

Section: Cost-effectiveness Of Antireflux Surgerymentioning

confidence: 99%

Surgery of Gastroesophageal Reflux Disease: A Competitive or Complementary Procedure?

Lundell

2004

Dig Dis

View full text Add to dashboard Cite

The management of chronic gastroesophageal reflux disease (GERD) has both been simplified and immensely improved by the development of modern medical therapies. These are built entirely on the concept of profound acid inhibition, which is very successful in a substantial proportion of GERD patients. Despite the efficacy of proton pump inhibitors (PPIs) some failures are unavoidable, and some patients experience incomplete control of major GERD symptoms on ordinary dosing of PPIs. Although the safety profile of PPIs is very reassuring, some people express some concern about the safety of drug treatment extending beyond 10 years especially when alternative therapeutic strategies are available. Some patients complain of alleged respiratory complications to severe reflux, and in those situations as well as in cases with e.g. Barrett’s esophagus, a complete control of reflux also incorporating the duodenal components in the refluxate may be warranted. In all those situations antireflux surgery can be considered indicated for the treatment of chronic GERD and thus be looked upon as complementary to medical therapy. Furthermore, some patients who have their GERD symptoms under control on PPIs still want to have an operation to avoid dependency on drugs. Hence in none of these clinical situations does antireflux surgery play a competitive role in relation to medical therapy. However, in the very few randomized clinical trials in which a head-to-head comparison has been completed between medical and surgical therapy, the latter has been found to be somewhat more effective in terms of reflux control. The other side of the coin is that antireflux surgery has some side effects that signify the importance of this surgery being performed in specialized centers.

show abstract

“…The estimated cost per year from each strategy was: $1,230 for H 2 RA, $1,411 for PPI, $1,598 for UGI series, and $2,159 for endoscopy. 77 From these adult studies, it is reasonable to extrapolate evidence supporting empiric treatment of pediatric patients with GERD without alarm signs, and a rational choice would be to use PPIs for more severe symptoms and use H 2 RAs for mild to moderate symptoms. With moderate to severe GERD not responsive to empiric PPI therapy, the dose of PPIs may be increased, but referral to the gastroenterologist is warranted to eliminate causes other than GERD and evaluate the need for possible surgical treatment.…”

Section: Treatment Approachmentioning

confidence: 99%

Clinical Management of Infants and Children with Gastroesophageal Reflux Disease

Whitworth¹,

Christensen

2004

The Journal of Pediatric Pharmacology and Therapeutics

View full text Add to dashboard Cite

Gastroesophageal reflux refers to the passage of gastric contents including food, acid, and digestive enzymes up into the esophagus. Reflux is most commonly recognized in infants when it is associated with regurgitation, known as “spitting up,” and it is usually a self-limited, benign process that has little or no effect on normal weight gain or development. Adults and adolescents may also have reflux, which is usually either asymptomatic or recognized as dyspepsia or “heartburn.” Gastroesophageal reflux disease (GERD) is defined as symptoms or complications that result from reflux. Most evidence suggests the mechanism of reflux is due to transient relaxations of the lower esophageal sphincter at inappropriate times. The diagnosis of suspected GERD in infants and children depends on the age and the presenting symptoms. A thorough history, physical examination, and growth charts are sufficient for the evaluation and diagnosis of GERD in most infants with recurrent vomiting or children with regurgitation and heartburn. Additional evaluation may include an upper gastrointestinal series, esophageal pH monitoring, or endoscopy. The goals of GERD management are eliminating symptoms, healing esophagitis, preventing complications, promoting normal weight gain and growth, and maintaining remission. Therapeutic options include lifestyle changes, pharmacologic therapy, and anti-reflux surgery. Currently available pharmacologic agents for the treatment of GERD include antacids, mucosal protectants, prokinetic agents, and acid suppressants.

show abstract

Choice of long-term strategy for the management of patients with severe esophagitis: A cost-utility analysis

Cited by 138 publications

References 2 publications

Paraesophageal Hernias: Operation or Observation?

Paraesophageal Hernias: Operation or Observation?

Surgery of Gastroesophageal Reflux Disease: A Competitive or Complementary Procedure?

Clinical Management of Infants and Children with Gastroesophageal Reflux Disease

Contact Info

Product

Resources

About