The rise and fall of antireflux surgery in the United States

Background: National rates of laparoscopic antireflux surgery grew steadily in the 1990s. Since then, a highly visible randomized trial has questioned the long-term effectiveness of antireflux surgery, several new endoscopic therapies have been developed, and proton pump inhibitors have become available over the counter. Whether these recent developments have had an impact on the use of antireflux surgery remains unknown. Methods: Using data from the Nationwide Inpatient Sample, this study identified all patients older than 18 years who underwent antireflux surgery between 1994 and 2003. Sampling weights were used to estimate the total number of procedures performed in the United States each year. Population-based rates were determined using denominators from U.S. census data. Results: Confirming the results of earlier studies, this study found that the annual number of antireflux procedures grew rapidly during the 1990s, peaking at 31,695 (15.7 cases per 100,000 adults) in 1999. After 1999, surgical rates declined steadily, falling approximately 30% by 2003 to 23,998 (11 cases per 100,000; p < 0.0001). Use of antireflux procedures fell more precipitously among younger patients (39% for 30- to 49-year-olds vs 12.5% for those older than 60 years; p < 0.0001) and at teaching hospitals (36% vs 23% at nonteaching hospitals; p < 0.0001). The proportion of cases managed laparoscopically remained stable after 1999. Conclusions: The use of antireflux surgery in the United States has declined substantially. Although other factors may be involved, this trend may reflect new questions about the long-term effectiveness of surgery and suggests the need for prospective randomized clinical trials assessing current therapies.