2005 Abstracts: Assessment of Diaphragmatic Stressors As Risk Factors for Failure of Laparoscopic Nissen Fundoplication and Postoperative Hiatal Hernia Formation
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Assessment of Diaphragmatic Stressors As Risk Factors for Failure of Laparoscopic Nissen Fundoplication and Postoperative Hiatal Hernia Formation
Atif Iqbal, Ganesh V. Kakarlapudi, Creighton University, Omaha, NE; Ziad T. Awad, University of Missouri, Columbia, MO; Gleb Haynatzki, Creighton University, Omaha, NE; Kiran Turaga, Resident, Creighton University, Omaha, NE; Mumnoon Haider, Research fellow, Creighton University, Omaha, NE; Sumeet K. Mittal, Creighton University, Omaha, NE; Charles J. Filipi, Professor of Surgery,, Omaha, NE
Background: An important limitation of antireflux surgery is a 5-10% failure rate. We investigated the correlation between various diaphragm stressors and failure of antireflux surgery.
Methods: Forty-one study cases who underwent a re-operative antireflux surgery from 1997 to 2001 and 50 control patients who had undergone a successful laparoscopic Nissen fundoplication during the same period without clinical or symptomatic evidence of failure were randomly selected for comparison. A retrospective analysis was conducted utilizing a standardized diaphragm stressor questionnaire, addressing the period between the primary and secondary operation. Stressors considered in the study included height, BMI, postoperative gagging, vomiting, weight lifting (>100 lbs), coughing, hiccoughing, motion sickness, retching, belching, anti-depressant use, smoking, preoperative grade of esophagitis, size of hiatal hernia, lower esophageal sphincter pressure, esophageal body pressures and preoperative response to proton pump inhibitors. Results: Of the potential stressors investigated, the following were significantly associated with surgical failure after adjusting for other variables through multivariate analysis: gagging (p=0.005), belching (p=0.02) and hernia size >3 cm (p=0.04) [Table 1]. Other potential risk factors show trends as obvious in Figure 2. Vomiting was significant (p=0.01) in the earlier models but lost significance when logistic regression was applied. Conclusion: Patients with postoperative gagging and an intra-operative hiatal hernia (>3 cm) have a poorer outcome whereas patients with postoperative belching have a better long-term outcome. Table 4: Logistic regression model.| Variable | Odds ratio | p-value |
| (95% CI) | ||
| Gagging/week | 10.4 (2.0-54.0) | 0.005* |
| Hernia size >3cm | 3.17 (1.04-9.69) | 0.04* |
| Belching/week | 0.22 (0.06-0.82) | 0.02* |
| Grade of Esophagitis (0-4) | 0.93 (0.62-1.42) | 0.76 |
| Smoking Status (Smoker, ex-smoker, non-smoker) | 0.58 (0.25-1.38) | 0.22 |
| Weight (kg) | 1.02 (0.98-1.07) | 0.33 |
All changes are non-significant but trends are obvious. Vertical lines display the 95% confidence interval for each group. Poor rPPI, Poor clinical response to PPI's. Good rPPI, Good clinical response to PPI's.
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