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Long-Term Patient Outcomes After Laparoscopic Anti-Reflux Procedures

  • 2013 SSAT Plenary Presentation
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background

Laparoscopic anti-reflux surgery with or without large hiatal hernia has been shown to have good short-term outcomes. However, limited data are available on long-term outcomes of greater than 5 years. The aim of this study is to review functional and symptomatic outcomes of anit-reflux surgery in a large tertiary referral medical center.

Methods

Two hundred ninety-seven patients who underwent anti-reflux surgery at the University of Nebraska Medical Center between 2002 and 2013 were included in this study. Patient data including pre- and post-operative studies and symptom questionnaires were prospectively collected and the database was used to analyze postoperative outcomes.

Results

A total of 297 Nissen fundoplications, 35 redo fundoplications and 22 Toupet procedures were performed. Mean BMI was 30.0 ± 6.2. The median follow-up was 70 (6–135) months. There were three reoperations (0.9 %) for recurrent symptoms. Mesh was used in 210 cases where hiatal hernia was larger than 2 cm. Median preoperative DeMeester score was 50.8 ± 46. There was a statistically significant improvement in composite heartburn score (83 % (CI 78.2, 87.7); p < 0.05), regurgitation (81.1 % (CI 76.1, 86.1); p < 0.05), and belching (63 % (CI 56.7, 69.3); p < 0.05). Atypical presentation such as pulmonary (e.g., aspiration (25.8 % (CI 20, 31.6), wheezing (20.3 % (CI 15, 25.6); p < 0.05), and throat symptoms (e.g., laryngitis 28 % (CI 22.1, 33.9); p < 0.05) also improved. Available radiographic studies for patients more than 3 years follow-up show an overall recurrence of 33.9 % (47.8 % in hiatal hernia > 5 cm repaired with mesh). Of those with recurrence, over 84 % were asymptomatic at follow-up.

Conclusions

This study shows that patients had excellent symptom control and low rates of complications and reoperations in long-term follow-up. We found that typical gastro intestinal symptoms responded better compared with atypical symptoms in spite of clear evidence of reflux on preoperative studies. Hiatal hernia was very commonly seen in our patient population and long-term radiographic follow-up suggest that asymptomatic recurrence may be high but rarely requires any surgical intervention. Anti-reflux surgery with correction of hiatal hernia if present is safe and effective in long-term follow-up.

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Authors and Affiliations

  1. Department of Surgery, University of Nebraska Medical Center, Omaha, NE, 68198, USA

    Anton Simorov, Ajay Ranade, Rachel Jones, Carl Tadaki, Valerie Shostrom, Eugene Boilesen & Dmitry Oleynikov

  2. 985126 Nebraska Medical Center, Omaha, NE, 68198-5126, USA

    Dmitry Oleynikov

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  1. Anton Simorov
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  2. Ajay Ranade
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Correspondence to Dmitry Oleynikov.

Additional information

Discussant

Dr. Vic Velanovich (Tampa, Florida): Dr. Oleynikov and colleagues should be congratulated on a thorough, honest long-term follow-up on their series of patients undergoing antireflux surgery. What they have demonstrated is that when the operation is done well, the symptomatic improvement is durable. But what this study also shows is the magnitude of this improvement. As someone who has been involved in measuring patient-centered outcomes for some time, the value in the routine use of validated symptom or quality of life instruments is not only in quantitating outcomes, but in using these quantified outcomes to counsel patients and educate referring physicians as to the magnitude of the improvement. What this study also shows is the fickleness of both PPI use and radiographs. It is my policy never to restart PPI’s until I know what the cause of the patient’s postoperative symptoms are, as we have previously published that only 25% of patients on PPI’s post-Nissen are helped by these medications.

Hence, my questions:

1. You report that many “asymptomatic” patients were taking PPI’s. How many of these patients were asymptomatic because of or despite of the PPI’s?

2. Although you did a great job documenting GERD-related symptomatic change, you did not report operation-related side effects like dysphagia, gas bloat or diarrhea. How often do these occur and what was their effect on patient satisfaction?

Lastly, your symptom scoring instrument is a Likert scale which provides ordinal data; these should be presented as medians with interquartile ranges and analyzed using non-parametric statistical techniques.

Closing Discussant

Dr. Dmitry Oleynikov: Dr. Vic Velanovich, Thank you very much for your review and comments.

In our study only 16% of patients actually reported the reflux symptoms and the remaining 84% did not have GI complains. We always ask our patients about symptoms as if they are off medications, or what happens if they miss their doses to get a better idea of true symptoms not masked by medications.

We have reviewed the operation-related side effects and we noted, that at six months and 12 months after the surgery less than 5 percent had persistent feelings of gas bloat and or dysphagia. We only saw one patient with new onset of diarrhea.

Thank you for your suggestion regarding the table, we will consider changing that in the paper.

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Simorov, A., Ranade, A., Jones, R. et al. Long-Term Patient Outcomes After Laparoscopic Anti-Reflux Procedures. J Gastrointest Surg 18, 157–163 (2014). https://doi.org/10.1007/s11605-013-2401-4

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  • DOI: https://doi.org/10.1007/s11605-013-2401-4

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