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The relationship between gastroesophageal junction integrity and symptomatic fundoplication outcomes

  • 2019 SAGES Oral
  • Published:
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Abstract

Background

The majority of patients who undergo a laparoscopic fundoplication for gastroesophageal reflux disease (GERD) have a structural (hiatal hernia, shortened lower esophageal sphincter [LES]) or functional (weak LES) defect of the gastroesophageal junction (GEJ). We hypothesized that the symptomatic outcomes of fundoplication in patients with a competent GEJ prior to surgery are inferior to those with an incompetent GEJ.

Methods

This is a retrospective review of prospectively maintained data on subjects who underwent primary laparoscopic fundoplication (Nissen or Toupet) for medically refractory and confirmed GERD. Three esophageal manometry variables were used to determine GEJ competency: (1) hiatal hernia (normal = no hernia), (2) total lower esophageal sphincter length (normal ≥ 2.43 cm), and (3) lower esophageal sphincter pressure (normal = 15.0–43.7 mmHg). Patients in the competent group had normal values for all 3 variables. Symptomatic outcomes were assessed with the GERD Health-Related Quality of Life (HRQL) survey administered pre- and postoperatively, and then compared both intragroup, intergroup, and by procedure.

Results

A total of 78 patients met inclusion criteria—17 competent GEJ and 61 incompetent GEJ patients. GERD-HRQL scores improved in the incompetent cohort at all intervals out to 2 years postoperatively. GERD-HRQL improved in the competent cohort at 2 months, with no difference at 6 months or 2 years postoperatively compared to preoperative scores. Competent GEJ patients receiving a Nissen fundoplication had a higher rate of additional procedures (endoscopy with or without dilation, pH studies) following surgery to address recurrent or persistent GERD symptoms compared to Toupet.

Conclusions

GERD patients with a competent GEJ report a lower GERD-HRQL with more frequent and severe reflux symptoms up to 2 years post-fundoplication. Competent GEJ patients receiving a Nissen fundoplication are more likely to have additional procedures to address symptoms following surgery. Surgeons should approach patients with a competent GEJ and medically refractory GERD with caution.

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Authors and Affiliations

  1. Division of General Surgery, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd, HUB 6th Floor, Milwaukee, WI, 53226, USA

    Brexton Turner, Melissa Helm, Emily Hetzel, Max Schumm & Jon C. Gould

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  1. Brexton Turner
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  2. Melissa Helm
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  3. Emily Hetzel
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  4. Max Schumm
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  5. Jon C. Gould
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Correspondence to Jon C. Gould.

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Dr. Gould is a consultant for Torax/Ethicon. Dr. Schumm, Mr. Turner, and Ms. Helm and Hetzelhave no conflicts of interest or financial ties to disclose.

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Turner, B., Helm, M., Hetzel, E. et al. The relationship between gastroesophageal junction integrity and symptomatic fundoplication outcomes. Surg Endosc 34, 1387–1392 (2020). https://doi.org/10.1007/s00464-019-06921-9

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  • DOI: https://doi.org/10.1007/s00464-019-06921-9

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