Patients with Upright Reflux Have Less Favorable Postoperative Outcomes Following Laparoscopic Antireflux Surgery (LARS) Than Those with Supine Reflux
Abstracts
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Aims: To compare the symptomatic outcomes of LARS in patients with upright vs. supine reflux. Methods: A prospective database was used to assess clinical outcome in relation to patterns of reflux in 117 patients with GERD (documented by pH testing) who underwent LARS. Patients with abnormal acid exposure time in one position but not the other were classified as being refluxers in that position. Patients were surveyed (yes/no) regarding specific symptoms postoperatively, with any degree of symptomatology recorded as "yes." P values were calculated using chi-square, Fischer's exact, and Student's t-tests. Results: Predominantly supine reflux (SR) was present in 31%, upright (UR) in 24%, and the remaining 44% of patients had bipositional reflux (BR). Preoperatively, there were no differences in frequency of symptoms (heartburn, regurgitation, chest pain, aspiration, dysphagia, odynophagia) between groups. Postoperatively, a subgroup of patients underwent surveillance pH testing with normalization of acid exposure in 97%. There was only one patient with a surgical failure (SR); she underwent reoperation for an intrathoracic wrap. At mean follow-up of 19?12 months, there were striking differences in symptoms between groups. The UR group noted significantly (p=.03) more heartburn than the SR group (18% vs. 3%). Chest pain was present in 32% of the UR group compared to only 5% of the SR group (p=.004). The UR group also experienced significantly more bloating (50% vs. 27%, p=.05) and odynophagia (11% vs. 0%, p=.04) than the SR group. By visual analog scales, patients with upright reflux expressed less overall satisfaction with their operative results. The UR group had more symptoms ascribed to the esophagus (24 vs. 4 mm, p=.03) and stomach (30 vs. 4 mm, p=.002) Although all patients reported improvement, the extent of the relief from preoperative symptoms was less in the UR group (89 vs. 98 mm, p=.05). When asked if in retrospect they favored operative therapy, the upright refluxers were less enthusiastic (24 vs. 4 mm, p=.03). Conclusions: LARS eliminates reflux in nearly all patients, but postoperative symptomatic outcome is related to the preoperative pattern of reflux. Although all patients experienced symptomatic improvement, the extent of that improvement was significantly less in patients with upright reflux. In this subgroup, both surgeons and patients should have realistic expectations preoperatively regarding the symptomatic outcomes after LARS. |
