The influence on outcome of indications for antireflux surgery

Background: Patients with gastroesophageal reflux referred for fundoplication present with different symptom patterns. Previous studies have not analyzed the clinical outcome after fundoplication in patients stratified according to symptom patterns. Methods: Five hundred eighteen patients undergoing laparoscopic fundoplication were stratified according to reflux symptom patterns: group 1, regurgitation; group 2, poorly controlled reflux; group 3, regurgitation and poor reflux control (combination of 1 and 2); and group 4, symptoms well controlled but patient does not want to continue taking medication. Clinical outcomes (heartburn control, dysphagia, satisfaction) were assessed prospectively using a standardized questionnaire at early (6 months to 2 years) and late (3–5 years) follow-up intervals. Results: Preoperative demographic data for the four groups were similar, except for age and the frequency of esophagitis (patients in group 4 were younger and more likely to have esophagitis). Perioperative morbidity was similar for the four groups. Eighty-seven percent of the overall study group was satisfied at early follow-up and 88% at late follow-up. Early clinical outcomes were similar for all subgroups, except dysphagia scores were higher in early follow-up in groups 1 and 3 (P = 0.001). At late clinical follow-up, there were no significant differences in clinical outcome between any groups. Conclusions: At early follow-up (6 months to 2 years), patients who had reported regurgitation as the primary indication for surgery had a less favorable clinical outcome for the side effect dysphagia. However, at later follow-up, the type of preoperative reflux symptoms did not influence the clinical outcome.Urs Zingg, Lorelle Smith, Nicky Carney, David I. Watson and Glyn G. Jamieso

Use of antireflux medication after antireflux surgery

The original publication can be found at www.springerlink.comIntroduction It is claimed that a substantial number of patients who undergo antireflux surgery use antireflux medication postoperatively. This study was aimed to determine the prevalence and underlying reasons for antireflux medication usage in patients after surgery. Materials and Methods A questionnaire on the usage of antireflux medication was sent to 1,008 patients identified from a prospective database of patients who had undergone a laparoscopic antireflux procedure. Results A total of 844 patients (84%) returned the questionnaire. Mean follow-up was 5.9 years after surgery. A single or combination of medications was being taken by 312 patients (37%): 82% proton pump inhibitors, 9% H2-blockers and 34% antacids. Fifty-two patients (17%) had never stopped taking medication, whereas 260 patients (83%) restarted medication at a mean of 2.5 years after surgery. Return of the same (31%) or different (49%) symptoms were the commonest reasons for taking medication, whereas 20% were asymptomatic or had other reasons for medication use. Postoperative 24-hour pH studies were abnormal in 16/61 patients (26%) on medication and in 5/78 patients (6%) not taking medication. Conclusions Antireflux medication is frequently taken by many patients for various symptoms after antireflux surgery. Symptomatic patients should be properly investigated before antireflux medications are prescribed.Bas P. L. Wijnhoven, Carolyn J. Lally, John J. Kelly, Jennifer C. Myers and David I. Watso

A modified Nissen fundoplication: subjective and objective midterm results

Purpose: The failure rate of laparoscopic anti-reflux surgery is approximately 10\u201320%. The aim of our prospective study was to investigate whether a modified Nissen fundoplication (MNF) can improve reflux symptoms and prevent surgical treatment failure in the midterm. Methods: The MNF consisted of (1) suturing the esophagus to the diaphragmatic crura on each side using four non-absorbable stitches, (2) reinforcing clearly weak crura with a tailored Ultrapro mesh, and (3) fixing the upper stitch of the valve to the diaphragm. Forty-eight consecutive patients experiencing typical gastroesophageal reflux disease (GERD) symptoms at least three times per week for 6 months or longer were assessed before and after surgery using validated symptom and quality of life (GERD-HRQL) questionnaires, high-resolution manometry, 24-h impedance-pH monitoring, endoscopy, and barium swallow. Results: Mortality and perioperative complications were nil. At median follow-up of 46.7 months, the patients experienced significant improvements in symptom and GERD-HRQL scores. One patient presented with severe dyspepsia and another complained of dysphagia requiring a repeat surgery 12 months after the first operation. Esophageal acid exposure (8.8 vs 0.1; p < 0.0001), reflux number (62 vs 8.5; p < 0.0001), and symptom-reflux association (19 vs 0; p < 0.0001) significantly decreased postoperatively. The median esophagogastric junction contractile integral (EGJ-CI) from 31 cases (8.2 vs 21.2 mmHg cm; p = 0.0003) and the abdominal length of the lower esophageal sphincter (LES) (0 vs 16 mm; p = 0.01) increased postoperatively. Conclusions: Our data demonstrate that the MNF is a safe and effective procedure both in the short term and midterm. \ua9 2018, Springer-Verlag GmbH Germany, part of Springer Nature