Short summary

Gastroesophageal reflux disease (GERD) affects 10-20% of the Western population. Treatment consists of anti-secretory treatment or anti-reflux surgery. Worldwide, the prevalence of GERD is increasing however, it is unknown how patients with GERD are treated on a national level and whether the preferred method of treatment is changing.

The aim of this study is to examine rate of surgery with medical treatment in patients with newly diagnosed gastro-esophageal reflux disease in a nationwide population based cohort from 2000-2014.

Rationale

Gastroesophageal reflux disease (GERD) is episodic reflux of gastric contests to the esophagus accompanied by bothersome symptoms, typically heartburn, regurgitation or retrosternal pain and is a complex and multifaceted disease, affecting 10-20% of the Western population. Worldwide, the prevalence of GERD has been increasing.

Treatment of GERD consists of anti-secretory drugs, mainly proton pump inhibitors (PPI), or anti-reflux surgery Laparoscopic anti-reflux surgery is considered standard of care in surgical treatment of gastro-esophageal reflux disease and with careful patient selection based on thorough preoperative workup; symptom control and patient satisfaction are high compared to medical therapy.

Between 1990 and 1997 the frequency of anti-reflux surgery in USA rose from 4,4 per 100.000 inhabitants to 12 per 100.000 inhabitants. In the same period a trans-abdominal laparoscopic approach increased to 64% of cases and mortality as well as morbidity decreased. The operation rate peaked around 2000 with an increase of 260% to approximately 16.7 operations per 100.000 inhabitants. Complications fell to its lowest point around 2000 as well.

Hereafter, the frequency of anti-reflux surgery dropped by 40% between 2000 and 2006. Complications in the form of morbidity and mortality rates steadily rose again, but the patients having performed surgery were now older and have longer hospital stays and more comorbidity. A slight rise in frequency of anti-reflux surgery to 6,1 per 100.000 inhabitants was registered in 2010 and at this time length of stay, morbidity and mortality rates have decreased, probably illustrating an increased experience. Interesting to note is, that in the American data, use of laparoscopic approach does tend to plateau at 70-80%.

It is unknown whether anti-reflux surgery in Denmark has followed the same trend. There are important differences in the setup of surgical service that may affect the results, as open anti-reflux surgery never gained much popularity in Denmark. Also, significantly fewer centers offer the procedure. In a study of re-operative anti-reflux surgery based on data from 1997-2005, a primary anti-reflux surgery rate of 5.2 per 100.000 inhabitants was reported. However, we do not know how this rate has developed or was preceded.

Description of the cohort

Patient selection will be done through the Danish National Patient Register and the cohort includes all adult Danish patients diagnosed with GERD and GERD-related diagnosis between 2000-2014. Diagnosis must be given no later than three months after upper endoscopy. Patients with GERD-diagnosis within previous two years or with concomitant diagnosis requiring independent anti-secretory treatment will be excluded (DK25.0-9, DK26.0-9, DK27.0-9, DK22.7 & DE16.4B).

Data and biological material

From the National Patient Register, GERD-diagnosis (ICD-10 DK21.0-21.9B & DK20.9B), sex, age and Charlson Comorbidity Index will be identified as any gastroscopy (NOMESCO: KUJD02&05) or anti-reflux surgery within the same period using the procedure codes (NOMESCO: KJBC01, KJBC00, KJBC02)

Using the Danish National Prescription Register, use of H2-antagonists (A02BA), proton pump inhibitors (A02BC), prostaglandins A02BB and bismuth, alginate and sucralfate (A02BX) will be identified in daily doses within two years of GERD-diagnosis

From the National Civic Registry mortality in the cohort will be extracted.

Collaborating researchers and departments

Department of Surgery, Kolding Hospital

• PhD student Jonas Sanberg Jensen, MD

Department of Vascular Surgery, Kolding Hospital

• Professor Kim Christian Houlind, MD, PhD

OPEN - Odense Patient data Explorative Network, Department of Clinical Research, University of Southern Denmark

• Associate professor Katrine Hass Rubin, PhD, MHS

Department of Surgery, Odense University Hospital

• Jesper Durup, MD, PhD

Publications associated with the project