Recurrent Heartburn after Laparoscopic Fundoplication is Not Always Recurrent Reflux
- 107 Downloads
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.
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.
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.
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).
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.
KeywordsLaparoscopic fundoplication Recurrent heartburn Recurrent reflux 24-h pH study
- 2.Jamieson GG, Duranceau A. What is a Nissen fundoplication? Surgery 1984;159:591–593.Google Scholar
- 5.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.PubMedCrossRefGoogle Scholar
- 8.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.PubMedCrossRefGoogle Scholar
- 9.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.Google Scholar
- 12.Maddern GJ. The reproducibility of esophageal manometry. Dis Esophagus 1991;4:95–99.Google Scholar
- 24.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.PubMedCrossRefGoogle Scholar
- 28.Gregersen H, Drewes AM. Functional findings in irritable bowel syndrome. World J Gastroenterol 2006;12:2830–2838.Google Scholar
- 31.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.PubMedCrossRefGoogle Scholar