SAN DIEGO—Patients with a diagnosis of gastroesophageal reflux disease may receive completely different treatment paths depending on whether they visit with a gastroenterologist or a surgeon for symptom analysis and management, according to a study presented at DDW 2025.
Investigators analyzed three sets of GERD treatment recommendations: the American Gastroenterological Association (AGA) guideline (Clin Gastroenterol Hepatol 2022;20[5]:984-994), the American College of Gastroenterology (ACG) guideline (Am J Gastroenterol 2022;117[1]:27-56) and a multi-society consensus (MSC) guideline, which incorporated representation from several surgical societies and the American Society for Gastrointestinal Endoscopy (Surg Endosc 2023;37[2]:781-806).
The research used to support the AGA and ACG guidelines was overwhelmingly representative of gastroenterologists, whereas the literature in the MSC document largely reflected input from surgeons of varying specialties, albeit with ASGE representation. The 325 studies evaluated by the ACG panel were authored exclusively by gastroenterologists and the 55 evaluated by the AGA panel were authored mainly by GIs (91%, 9% foregut surgeons); and the 189 evaluated by the MSC panel were authored by a blend of general (53.6%), cardiothoracic (14.3%), foregut (10.7%), colorectal (3.6%) and pediatric (3.6%) surgeons, as well as gastroenterologists (14.3%) and other specialists (9%).
PPI Duration and Criteria For Surgery Vary
Faraz Jafri, MD, MBA, a resident physician at Broward Health in Houston, who presented the findings at the meeting, assessed how the three sets of guidelines differed with respect to PPI use and duration, escalation of therapy, and criteria for surgery (Table).
| Table. Treatment Approach to GERD by Various Societies | |||
| ACG guideline (325 references) | AGA clinical practice update (55 references) | Multi-society consensus (189 references) | |
|---|---|---|---|
| Recommended length of PPI trial in patients without alarm features | 8 weeks (strong recommendation, moderate level of evidence) | 4-8 weeks (best-practice advice) | No recommendation on PPI length |
| Recommendation for medical, endoscopic or surgical treatment of GERD | Maintenance PPI indefinitely or anti-reflux surgery (strong recommendation, moderate level of evidence) | Indefinite long-term PPI therapy and/or an invasive anti-reflux procedure (best-practice advice) | MSA, fundoplication, TIF and Stretta procedures are superior to continued PPI use (conditional recommendations, moderate level of evidence) |
| Journal focus of reference source (n, %) | Gastroenterology (170, 52%) Surgery (39, 12%) Othera (116, 36%) | Gastroenterology (49, 52%) Surgery (1, 12%) Othera (5, 36%) | Gastroenterology (26, 13.8%) Surgery (148, 78.3%) Othera (15, 7.9%) |
| a Other categories consisted of cardiology, pulmonology, renal, and other medicine subspecialty and pharmacology journals. ACG, American College of Gastroenterology; AGA, American Gastroenterological Association; GERD, gastroesophageal reflux disease; MSA, magnetic sphincter augmentation; PPI, proton pump inhibitor; TIF, transoral incisionless fundoplication. Based on Am J Gastroenterol 2022;117(1):27-56, Clin Gastroenterol Hepatol 2022;20(5):984-994 and Surg Endosc 2023;37(2):781-806. | |||
Dr. Jafri and his co-investigators found that based on these guidelines, patients will receive very different recommendations depending on the clinician they see. The MSC recommends surgery sooner than the other guidelines from gastroenterologists, he said.
“With GI guidelines, they’ll trial PPI, and if it fails, [they’ll] generally recommend trying another course of PPI before jumping into an anti-reflux surgical procedure,” Dr. Jafri said.
For example, the ACG guideline recommends eight weeks of PPI use, and the AGA guideline recommends four to eight weeks. The MSC did not have any recommendations on PPI use or duration for GERD symptoms. The ACG panel recommends longer durations of PPIs if no results were found after initial use, and the AGA recommends indefinite PPI use followed by an invasive anti-reflux procedure, such as magnetic sphincter augmentation (MSA) or transoral incisionless fundoplication. However, the MSC does not offer a recommendation for length of PPI therapy, recommending MSA, TIF and other procedures as superior to long-term PPI use.
“The MSC consensus, in general, [recommends] more invasive procedures, … whereas GIs want more PPI for longer before jumping into surgery,” which represents “a more cautious approach [from GIs],” Dr. Jafri said.
He concluded that treatment bias exists for GERD patients depending on the literature their doctors pull from, and that the next step would be for leaders from the GI and surgeon communities to work together and develop more consensus on balanced recommendations that take into account both gastroenterologist and surgeon perspectives.
An algorithm to map that patient’s treatment path if they go to a GI or a surgeon with GERD symptoms would be helpful. Points of analysis could be the cost, risks and timeline for surgery.
Tailoring Therapy To Each Patient
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Michael Vaezi, MD, PhD, the clinical director of the Division of Gastroenterology and director of the Center for Swallowing and Esophageal Disorders at Vanderbilt University Medical Center, in Nashville, Tenn., told Gastroenterology & Endoscopy News that he was not surprised by the literature analysis. “GIs will always lean towards treatment with medication while surgical colleagues often assess what surgical intervention may help patients with continued symptoms, despite therapy,” he said. “I think there is a role for both.”
Dr. Vaezi said he works primarily to evaluate patients who have not responded to continual PPI use or are only partially responsive. Noting that PPI treatment will never fix what is deemed to be a mechanical esophageal defect, such as a hiatal hernia, he said he refers about 10% of his patients to surgical fundoplication follow-up. But he stressed that he is “very selective” in tailoring this intervention to the right patient. The key, he said, is being mindful of what patient is best suited for what intervention.
—Karen Fischer
Dr. Jafri reported no relevant financial disclosures. Dr. Vaezi reported financial relationships with Diversatek, IsoThrive, Phathom and Sanofi.
This article is from the August 2025 print issue.