Abstract
Introduction
A small cohort of patients present after antireflux surgery complaining of recurrent heartburn. Many of these patients have been empirically recommenced on proton pump inhibitors.
Objective
The aim of this study was to determine whether patients with symptoms that suggest recurrent reflux had objective evidence of reflux, and to determine predictors of recurrent reflux.
Methods
We identified all patients from an existing database who had undergone pH monitoring for “recurrent heartburn” after fundoplication. These patients were then cross-referenced to another database, which recorded the outcomes for patients who had undergone a laparoscopic fundoplication. Patients complaining of dysphagia or other problems without heartburn were excluded from analysis.
Results
Seventy-six patients were identified who met the inclusion criteria. Fifty-six (74%) of these had a normal 24-h pH study. Thirty-five patients (63%) with a normal pH study were on medication for heartburn at the time of referral. Three factors were found to be associated with an abnormal 24-h pH study: a partial fundoplication (P = 0.039), onset of symptoms 6 months or more after surgery (P < 0.001), and a good symptom response when antireflux medication was recommenced (P = 0.015).
Conclusions
Not all patients complaining of recurrent heartburn after fundoplication have evidence of abnormal reflux. Objective evidence of abnormal esophageal acid exposure should be confirmed before recommencing antireflux medication.
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References
Stylopoulos N, Rattner DW. The history of hiatal hernia surgery: from Bowditch to laparoscopy. Ann Surg 2005;241:185–193.
Jamieson GG, Duranceau A. What is a Nissen fundoplication? Surgery 1984;159:591–593.
Smith CD, McClusky DA, Rajad MA, Lederman AB, Hunter JG. When fundoplication fails: redo? Ann Surg 2005;241:861–871.
Eubanks TR, Omelanczuk P, Richards C, Pohl D, Pellegrini CA. Outcomes of laparoscopic antireflux procedures. Am J Surg 2000; 179:391–395.
Spechler SJ, Lee E, Ahnen D, Goyal RK, Hirano I, Ramirez F, Raufman JP, Sampliner R, Schnell T, Sontag S, Vlahcevic ZR, Young R, Williford W. Long-term outcome of medical and surgical therapies for gastroesophageal reflux disease: follow-up of a randomized controlled trial. JAMA 2001;285(18):2331–2338.
Galvani C, Fisichella PM, Gorodner MV, Perretta S, Patti MG. Symptoms are a poor indicator of reflux status after fundoplication for gastroesophageal reflux disease. Arch Surg 2003;138:514–519.
Khajanchee YS, O’Rourke RW, Lockhart B, Patterson EJ, Hansen PD, Swanstrom LL. Postoperative symptoms and failure after antireflux surgery. Arch Surg 2002;137:1008–1014.
Lord RVN, Kaminski A, Oberg S, Bowrey DJ, Hagen JA, DeMeester SR, Sillin LF, Peters JH, Crookes PF, DeMeester TR. Absence of gastroesophageal reflux disease in a majority of patients taking acid suppression medications after Nissen fundoplication. J Gastrointest Surg 2002;6:3–10.
Ollyo JB, Lang F, Fontolle CH, et al. Savary’s new endoscopic grading of reflux esophagitis: a simple, reproducible, logical, complete and useful classification. Gastroenterology 1990;89:A100.
Ludemann R, Watson DI, Jamieson GG, et al. Five-year follow-up of a randomized clinical trial of laparoscopic total versus anterior 180° fundoplication. Br J Surgery 2005;92:240–243.
Watson DI, Jamieson GG, Pike GP, et al. Prospective randomized double-blind trial between laparoscopic Nissen fundoplication and anterior partial fundoplication. Br J Surg 1999;86:123–130.
Maddern GJ. The reproducibility of esophageal manometry. Dis Esophagus 1991;4:95–99.
Jamieson JR, Stein HJ, DeMeester TR, Bonavina L, Schwizer W, Hinder RA, Albertucci M. Ambulatory 24-h esophageal pH monitoring: normal values, optimal thresholds, specificity, sensitivity, and reproducibility. Am J Gastroenterol 1992;87:1102–1111.
Bredenoord AJ, Weusten BL, Smout AJ. Symptom association analysis in ambulatory gastro-esophageal reflux monitoring. Gut 2005;54:1810–1817.
Papasavas PK, Keenan RJ, Yeaney WW, Caushaj PF, Gagne DJ, Landreneau RJ. Effectiveness of laparoscopic fundoplication in relieving the symptoms of gastroesophageal reflux disease (GERD) and eliminating antireflux medical therapy. Surg Endosc 2003;17:1200–1205.
Madan A, Minocha A. Despite high satisfaction, majority of gastro-esophageal reflux disease patients continue to use proton pump inhibitors after antireflux surgery. Aliment Pharmacol Ther 2006;23:601–605.
Klauser AG, Schindlbeck NE, Muller-Lissner SA. Symptoms in gastro-esophageal reflux disease. Lancet 1990;335:205–208.
Costantini M, Crookes PF, Bremner RM, Hoeft SF, Ehsan A, Peters JH, Bremner CG, DeMeester TR. Value of physiologic assessment of foregut symptoms in a surgical practice. Surgery 1993;114:780–786.
Fraser J, Watson DI, O’Boyle CJ, Jamieson GG. Obesity and its effect on outcome of laparoscopic Nissen fundoplication. Dis Esophagus 2001;14:50–53.
D’Alessio MJ, Arnaoutakis D, Giarelli N, Villadolid DV, Rosemurgy AS. Obesity is not a contraindication to laparoscopic fundoplication. J Gastrointest Surg 2005;9:949–954.
Anvari M, Bamehriz F. Outcome of laparoscopic Nissen fundoplication in patients with body mass index ≥ 35. Surg Endosc 2006;20:230–234.
Patterson EJ, Davis DG, Khajanchee Y, Swanstrom LL. Comparison of objective outcomes following laparoscopic Nissen fundoplication versus laparoscopic gastric bypass in the morbidly obese with heartburn. Surg Endosc 2003;17:1561–1565.
Spence GM, Watson DI, Jamieson GG, Lally CJ, Devitt PG. Single center prospective randomized trial of laparoscopic Nissen versus anterior 90° fundoplication. J Gastrointest Surg 2006;10:698–705.
Watson DI, Jamieson GG, Lally C, Archer S, Bessell JR, Booth M, Cade R, Cullingford G, Devitt PG, Fletcher DR, Hurley J, Kiroff G, Martin CJ, Martin IJ, Nathanson LK, Windsor JA. Multicenter prospective double blind randomized trial of laparoscopic Nissen versus anterior 90 degree partial fundoplication. Arch Surg 2004;139:1160-1167.
Spechler SJ. The management of patients who have “failed” antireflux surgery. Am J Gastroenterol 2004;99:552–561.
Boyce PM, Talley NJ, Burke C, Koloski NA. Epidemiology of the functional gastrointestinal disorders diagnosed according to Rome II criteria: an Australian population-based study. Int Med J 2006;36:28–36.
Quigley EMM. Changing face of irritable bowel syndrome. World J Gastroenterol 2006;12:1–5.
Gregersen H, Drewes AM. Functional findings in irritable bowel syndrome. World J Gastroenterol 2006;12:2830–2838.
Gwee K, Chua ASB. Functional dyspepsia and irritable bowel syndrome, are they different entities and does it matter? World J Gastroenterol 2006;12:2708–2712.
Vaezi MF, Richter JE. Role of acid and duodenogastroesophageal reflux in gastroesophageal reflux disease. Gastroenterology 1996; 111:1192–1199.
Shay S, Tutuian R, Sifrim D, Vela M, Wise J, Balaji N, Zhang X, Adhami T, Murray J, Peters J, Castell D. Twenty-four hour ambulatory simultaneous impedance and pH monitoring: a multicenter report of normal values from 60 healthy volunteers. Am J Gastroenterol 2004;99:1037–1043.
Acknowledgment
We would like to thank Carolyn Lally for all her help in managing the Royal Adelaide Hospital fundoplication database.
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Thompson, S.K., Jamieson, G.G., Myers, J.C. et al. Recurrent Heartburn after Laparoscopic Fundoplication is Not Always Recurrent Reflux. J Gastrointest Surg 11, 642–647 (2007). https://doi.org/10.1007/s11605-007-0163-6
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DOI: https://doi.org/10.1007/s11605-007-0163-6