Upper gastrointestinal surgeons comment on NICE dyspepsia guidelines

Editor—We believe that the recent dyspepsia management guidelines of the National Institute for Clinical Excellence (NICE) were poorly researched and that the recommendations are unsubstantiated.¹

The guidelines committee comprised six primary care doctors, two gastroenterologists, one pharmacist, one patient representative, and one methodologist. No surgeons were represented, and the Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland was not registered as a stakeholder. This is surprising as upper gastrointestinal surgeons treat most patients with gastro-oesophageal cancer.

The guidelines advise primary care doctors (and community pharmacists) that endoscopy is indicated only as a primary investigation of dyspepsia for patients with “alarm” symptoms. All other patients should receive an empirical trial of antisecretory drugs or eradication treatment for Helicobacter pylori (if colonised). The message to the public is that dyspepsia can be ignored.

The survival of patients with gastrooesophageal cancer is related to the stage of the cancer. The guidelines seem not to understand this, quoting the overall poor outcome in the United Kingdom without mentioning the superior outcome achieved in Japan and certain Western centres, where a greater proportion of “early” gastric cancers are diagnosed.²,³

The guidelines suggest endoscopy for patients with alarm symptoms, which are invariably associated with advanced disease beyond the realms of curative surgery.⁴ There is little point in fast tracking endoscopy for such patients whose disease is amenable only to palliative treatments.

The guidelines completely undervalue the importance of endoscopy in identifying benign diagnoses such as oesophagitis, gastroduodenal ulceration, and Barrett's oesophagus. Furthermore, a normal result reassures both practitioner and patient.

Antireflux surgery is not recommended, although randomised studies of antireflux surgery v antisecretory drugs have shown that the two are equivalent.⁵ w1 ^{Furthermore, good health economic data indicate the superiority of antireflux surgery in younger patients.w2 w3} This is the standard of care in many west European countries, North America, and Australia.

The two operations most commonly performed in the United Kingdom for reflux disease are reported as the Nissen fundoplication and the Hill gastropexy. There is no evidence that any surgeons in the United Kingdom are performing Hill gastropexy. The quoted mortality for antireflux surgery relates to old data on open surgery, not more recent figures for laparoscopic antireflux surgery.

A mortality of 1 in 2000 for endoscopy is high and misleading. Series confined to diagnostic endoscopy alone show appreciably lower mortality. Series that combine diagnostic and therapeutic endoscopy obviously have higher mortality, principally from oesophageal perforation after dilatation.

The guidelines ignore the potential medicolegal implications of delayed and missed diagnoses of gastro-oesophageal cancer.

In conclusion, the answer to the logistic implications of screening large numbers of patients with dyspepsia is to allocate resources appropriately. Until and unless the evidence is accurately assessed and full consultation achieved, the advice to primary care doctors should be to continue to recommend diagnostic endoscopy for patients with dyspepsia.