Skip to main content

Advertisement

SpringerLink
Log in

Clinical outcomes of atypical extra-esophageal reflux symptoms following laparoscopic antireflux surgery

  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Introduction

While it is well established that antireflux surgery is effective in relieving typical gastroesophageal reflux disease (GERD) symptoms such as heartburn and regurgitation, it is currently unclear whether atypical symptoms (cough, hoarseness, wheeze) foreshadow a less satisfactory outcome following laparoscopic antireflux surgery (LARS). The purpose of this study is to critically analyze the clinical outcomes of atypical symptoms in patients undergoing LARS.

Methods

Patients scheduled for LARS for GERD were prospectively enrolled over a 7-year period; all subjects underwent preoperative high-resolution manometry (HRM) and had evidence of GERD on ambulatory pH study. Cough, wheeze, and hoarseness were considered atypical symptoms. During preoperative and postoperative examinations, patients completed detailed foregut symptomatology questionnaires, using both 5-point Likert and 10-point visual analog scales (VAS) to document typical as well as atypical symptoms. Atypical symptom burden was calculated as a sum of VAS for the three atypical symptoms, termed the atypical score (ATS). HRM patterns were grouped into normal, spastic, and hypomotile. Statistical significance (p < 0.05) was determined using paired t-test, and analysis of variance with post hoc least significant difference (LSD).

Results

One hundred thirteen patients (age 49 ± 1.26 years, range 20–84 years, M:F 47:66) with mean follow-up of 28 ± 2.31 months (range 1–92 months) fulfilled inclusion criteria, having mean modified DeMeester score of 45.5 ± 2.78. Heartburn was noted in 84.1%, while atypical symptoms of some degree were reported by 92.0% (104 patients). Heartburn improved from a preoperative score of 7.1 ± 0.54 to 0.9 ± 0.24 after LARS, and ATS improved from 8.9 ± 0.71 to 2.2 ± 0.42. Significant improvements were noted for all atypical symptoms analyzed (p < 0.0001 for each). Improvement in atypical symptoms was least in the presence of hypomotility features on HRM (21.7% improvement), compared with normal motility (72.4%) and spastic features (83.9%). Preoperative atypical score (p < 0.0001) and esophageal hypomotility (p = 0.04) demonstrated a linear relationship with postoperative atypical score.

Conclusions

In an unselected cohort of patients undergoing LARS, atypical GERD symptoms improved as significantly as typical symptoms. Symptom improvement was significantly lower in the presence of esophageal hypomotility and with higher symptomatic state. Therefore, patients with severe atypical symptoms or hypomotile esophagus may not achieve the same clinical satisfaction from LARS.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Spechler SJ et al (2001) Long-term outcome of medical and surgical therapies for gastroesophageal reflux disease: follow-up of a randomized controlled trial. JAMA 285(18):2331–2338

    Article  PubMed  CAS  Google Scholar 

  2. Peters JH et al (1998) The treatment of gastroesophageal reflux disease with laparoscopic Nissen fundoplication: prospective evaluation of 100 patients with “typical” symptoms. Ann Surg 228(1):40–50

    Article  PubMed  CAS  Google Scholar 

  3. Oelschlager BK et al (2008) Long-term outcomes after laparoscopic antireflux surgery. Am J Gastroenterol 103(2):280–287 (quiz 288)

    Article  PubMed  Google Scholar 

  4. Gee DW, Andreoli MT, Rattner DW (2008) Measuring the effectiveness of laparoscopic antireflux surgery: long-term results. Arch Surg 143(5):482–487

    Article  PubMed  Google Scholar 

  5. Fein M et al (2008) Ten-year outcome of laparoscopic antireflux surgery. J Gastrointest Surg 12(11):1893–1899

    Article  PubMed  CAS  Google Scholar 

  6. Power C, Maguire D, McAnena O (2004) Factors contributing to failure of laparoscopic Nissen fundoplication and the predictive value of preoperative assessment. Am J Surg 187(4):457–463

    Article  PubMed  Google Scholar 

  7. Chin KF et al (2008) Symptoms experienced during 24-h pH monitoring and their relationship to outcome after laparoscopic total fundoplication. Dis Esophagus 21(5):445–451

    Article  PubMed  Google Scholar 

  8. Velanovich V, Mahatme A (2004) Effects of manometrically discovered nonspecific motility disorders of the esophagus on the outcomes of antireflux surgery. J Gastrointest Surg 8(3):335–341

    Article  PubMed  Google Scholar 

  9. Laine S et al (1997) Laparoscopic vs conventional Nissen fundoplication. A prospective randomized study. Surg Endosc 11(5):441–444

    Article  PubMed  CAS  Google Scholar 

  10. Richardson WS, Trus TL, Hunter JG (1996) Laparoscopic antireflux surgery. Surg Clin North Am 76(3):437–450

    Article  PubMed  CAS  Google Scholar 

  11. Richter JE (2005) Review article: extraoesophageal manifestations of gastro-oesophageal reflux disease. Aliment Pharmacol Ther 22 Suppl 1:70–80

    Article  PubMed  CAS  Google Scholar 

  12. Allen CJ, Anvari M (2004) Does laparoscopic fundoplication provide long-term control of gastroesophageal reflux related cough? Surg Endosc 18(4):633–637

    Article  PubMed  CAS  Google Scholar 

  13. Pauwels A et al (2009) Cough and gastroesophageal reflux: from the gastroenterologist end. Pulm Pharmacol Ther 22(2):135–138

    Article  PubMed  CAS  Google Scholar 

  14. Tutuian R et al (2006) Nonacid reflux in patients with chronic cough on acid-suppressive therapy. Chest 130(2):386–391

    Article  PubMed  Google Scholar 

  15. Patterson N et al (2009) Nonacid reflux episodes reaching the pharynx are important factors associated with cough. J Clin Gastroenterol 43(5):414–419

    Article  PubMed  Google Scholar 

  16. Kushnir VM, Sayuk GS, Gyawali CP (2010) Abnormal GERD parameters on ambulatory pH monitoring predict therapeutic success in noncardiac chest pain. Am J Gastroenterol 105(5):1032–1038

    Article  PubMed  Google Scholar 

  17. Hersh MJ, Sayuk GS, Gyawali CP (2010) Long-term therapeutic outcome of patients undergoing ambulatory pH monitoring for chronic unexplained cough. J Clin Gastroenterol 44(4):254–260

    Article  PubMed  Google Scholar 

  18. Banos JE et al (1989) Acceptability of visual analogue scales in the clinical setting: a comparison with verbal rating scales in postoperative pain. Methods Find Exp Clin Pharmacol 11(2):123–127

    PubMed  CAS  Google Scholar 

  19. Ayazi S, Crookes PF (2009) High-resolution esophageal manometry: using technical advances for clinical advantages. J Gastrointest Surg

  20. DeMeester TR et al (1990) Chronic respiratory symptoms and occult gastroesophageal reflux. A prospective clinical study and results of surgical therapy. Ann Surg 211(3):337–345

    Article  PubMed  CAS  Google Scholar 

  21. Chen RY, Thomas RJ (2000) Results of laparoscopic fundoplication where atypical symptoms coexist with oesophageal reflux. Aust N Z J Surg 70(12):840–842

    Article  PubMed  CAS  Google Scholar 

  22. Farrell TM et al (2001) Response of atypical symptoms of gastro-oesophageal reflux to antireflux surgery. Br J Surg 88(12):1649–1652

    Article  PubMed  CAS  Google Scholar 

  23. Horvath KD et al (1999) Laparoscopic Toupet fundoplication is an inadequate procedure for patients with severe reflux disease. J Gastrointest Surg 3(6):583–591

    Article  PubMed  CAS  Google Scholar 

  24. Winslow ER et al (2003) Influence of spastic motor disorders of the esophageal body on outcomes from laparoscopic antireflux surgery. Surg Endosc 17(5):738–745

    Article  PubMed  CAS  Google Scholar 

Download references

Disclosures

Authors Brown, Gyawali, Melman, Jenkins, Bader, and Frisella have no conflicts of interest or financial ties to disclose relevant to this work. Author Eagon is a consultant for Ethicon Endosurgical. Author Brunt has received educational grants and research support from Ethicon Endosurgical, Karl Storz Endoscopy, Stryker Endoscopy, Lifecell, and an honorarium for speaking from Ethicon EndoSurgery. Author Matthews has received consulting fees from Atrium Medical, Ethicon EndoSurgery, and Muskuloskeletal Transplant Foundation, and an honorarium for speaking from W.L. Gore.

Author information

Authors and Affiliations

  1. Section of Minimally Invasive Surgery, Department of Surgery, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box #8109, St. Louis, MO, 63110, USA

    Shaun R. Brown, Lora Melman, Eric D. Jenkins, Julia Bader, Margaret M. Frisella, L. Michael Brunt, J. Christopher Eagon & Brent D. Matthews

  2. Division of Gastroenterology, Department of Internal Medicine, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box #8109, St. Louis, MO, 63110, USA

    C. Prakash Gyawali

Authors
  1. Shaun R. Brown
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. C. Prakash Gyawali
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Lora Melman
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Eric D. Jenkins
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Julia Bader
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Margaret M. Frisella
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. L. Michael Brunt
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. J. Christopher Eagon
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Brent D. Matthews
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Brent D. Matthews.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Brown, S.R., Gyawali, C.P., Melman, L. et al. Clinical outcomes of atypical extra-esophageal reflux symptoms following laparoscopic antireflux surgery. Surg Endosc 25, 3852–3858 (2011). https://doi.org/10.1007/s00464-011-1806-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-011-1806-y

Keywords

Search

Navigation