To the Editor: Dr. Bowrey and colleagues reviewed the effects of medical antireflux therapy and fundoplication and concluded that “fundo- plication has been constantly shown to ameliorate reflux-induced asthma; results are superior to the published results of antisecre- tory therapy.” 1 I believe that it is premature to arrive at this conclusion. Published studies of the relationship between gastro- esophageal reflux (GER) and asthma, and the effects of antireflux therapy on asthma are conflicting. 2–4 Although some reports have concluded that antireflux therapy improves asthma control, others were unable to demonstrate any benefit. 3,4 Critical review of the literature on both the effects of medical antireflux therapy and fundoplication demonstrates that the literature is conflicting and a clear consensus is not evident. 3,4 Further blinded, randomized, placebo-controlled clinical trials of both the effects of medical and surgical antireflux therapy in asthma patients are required to an- swer these important questions. Many studies have not confirmed that GER or acid perfusion of the esophagus worsens asthma, or that treating GER improves asthma. 5–7 Moreover, the Cochrane collaboration recently con- cluded that the available data did not support the hypothesis that treating GER improved asthma. 8 We recently published critical reviews of the effects of both medical and surgical antireflux therapy; both seem to improve asthma symptoms but do not improve pulmonary function. 3,4 A major problem with conducting asthma therapy trials is the large placebo or “benefit of entering a trial” effect. Patients in the placebo arm of asthma therapy trials generally experience a 30 to 40% improvement. 9 –10 The placebo effect is due to several factors including the benefits of patient education, proper asthma medication delivery device technique, adherence to prescribed drug regimens, and regular medical fol- low-up that asthma patients receive while participating in research trials. 3 Unless the trial design includes a placebo-controlled group for comparison, it is unclear whether improvement is due to the treatment or to the benefits of participating in the trial. Only two of surgical studies included control groups. 11–12 The others were uncontrolled case series or retrospective reviews and were subject to the limitations already noted. 4 Conclusions about some of the reports are limited, since pulmonary function was not measured nor was the presence of GER confirmed objectively either pre or post operatively. 4 There are reasons why the antireflux therapy studies may have failed to show more impressive effects on asthma control. Asth- matics have different sensitivities to different triggers. 13 Some respond to certain allergens or to exercise whereas others do not. The inclusion of asthma patients who are insensitive to GER in study cohorts might mask a potential benefit. Continuing asthma medications during the antireflux therapy trials may have blunted potential changes due to GER. Many asthma patients have normal or near normal lung function between asthma attacks and antire- flux therapy would not be expected to improve pulmonary function indices. There are also statistical factors to consider. Generally the sample sizes in the studies were small and type two error cannot be excluded. 3 Both medical and surgical antireflux therapies have a role in asthma patients with symptomatic GER that requires therapy. The evidence does not support the notion that fundoplication is supe- rior to medical antireflux therapy for asthma control. 3,4 Currently, there is no evidence for a role for treating asymptomatic GER in asthma. Although unproven, there may be a minority of patients with difficult-to-control asthma who would benefit from antireflux therapy. Other more common causes of poor asthma control such as ongoing exposure to allergens or cigarette smoke, inadequate antiinflammatory therapy, improper inhaler use, and noncompli- ance to prescribed drug regimens need to be excluded in patients with difficult-to-control-asthma. Other conditions that can mas- querade as poorly controlled asthma such as vocal cord dysfunc- tion also have to be excluded. In summary, I believe that it is premature to recommend fun- doplication as the preferred option for asthma control in asthmatics with GER. Further properly powered, controlled trials are needed to understand the relationship between GER and asthma, and the roles of proton pump inhibitors and fundoplication in these patients. STEPHEN K. FIELD, MD, CM, FRCPC Clinical professor Division of Respiratory Medicine University of Calgary Medical School References 1. Bowrey DJ, Peters JH, DeMeester TR. Gastroesophageal reflux dis- ease in asthma. Effects of medical and surgical antireflux therapy on asthma control. Ann Surg 2000; 231:161–72. 2. Field SK. A critical review of the studies of the effects of simulated or real gastroesophageal reflux on pulmonary function in asthmatic adults. Chest 1999; 115:848 –56. 3. Field SK, Sutherland LR. Does medical antireflux therapy improve asthma in asthmatics with gastroesophageal reflux? A critical review of the literature. Chest 1998; 114:275– 83. 4. Field SK, Gelfand GAJ, McFadden SD. The effects of antireflux surgery on asthmatics with gastroesophageal reflux. Chest 1999; 116: 766 –74. 5. Ekstrom T, Tibbling L. Gastro-oesophageal reflux and triggering of bronchial asthma: a negative report. Eur J Respir Dis 1987; 71:177– 80. 6. Wesseling G, Brummer RJ, Wouters EF, et al. Gastric asthma? No change in respiratory impedance during intraesophageal acidification in adult asthmatics. Chest 1993; 104:1733–36. 7. Ford GA, Oliver PS, Prior JS, et al. Omeprazole in the treatment of asthmatics with nocturnal symptoms and gastro-oesophageal reflux: a placebo-controlled cross-over study. Postgrad Med 1994; 70:350 –54. 8. Gibson PG, Henry RL, Coughlan JL. The effect of treatment for gastro-oesophageal reflux on asthma in adults and children. Cochrane Review, latest version 10 Feb 1999. In: The Cochrane Library. Oxford: Update Software. 9. Lofdahl CG, Reiss TF, Leff JA, et al. Randomized, placebo controlled trial of effect of a leukotriene receptor antagonist, montelukast, on tapering inhaled corticosteroids in asthmatic patients. BMJ 1999; 319:87–90. 10. Erzurum SC, Leff JA, Cochran, et al. Lack of benefit of methotrexate in severe, steroid-dependent asthma. Ann Intern Med 1991; 114:353– 60. ANNALS OF SURGERY Vol. 234, No. 1, 130–134 © 2001 Lippincott Williams & Wilkins, Inc. LETTERS TO THE EDITOR 130