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The Clinical Significance of Routine Postoperative 24-Hour pH Studies in Nissen Fundoplication
Jason T. Wong, Legacy Health System Minimally Invasive Surgery Division, Portland, OR; Yashodhan S. Khajanchee, Legacy Health System Division of Minimally Invasive Surgery, Portland, OR; Lee L. Swanstrom, Legacy Minimally Invasive Surgery Division, Portland, OR
Gastroesophageal reflux disease (GERD) is growing in prevalence in the Western World. Surgery has been shown to be a safe and effective method of treating GERD. Although the role of pH testing prior to antireflux surgery has been well established, there is some controversy regarding the need for routine postoperative 24 hour pH testing. We offer routine objective testing to all of our patients after antireflux surgery. While this is a useful to clarify complaints of patients who remain symptomatic after surgery, as many as 15% of patients have objective evidence of ongoing reflux (defined as a DeMeester score > 14.7 on 24-hour pH testing) but remain asymptomatic. The natural history of these patients' reflux is not known. This aim of this study is to reevaluate the late outcomes of this patient population.
Methods: from January 1995 to November 2004, 255 patients underwent laparoscopic Nissen fundoplication for gastroesophageal reflux disease and subsequently returned for postoperative 24 hour pH testing six months after their procedure. Of these patients, 28 patents had a complete resolution of their symptoms but continued to demonstrate reflux on objective testing (defined as DeMeester score > 14.7). Patients were reassessed clinically at a mean of 52 months by symptom score questionnaire and repeat 24-hour pH testing or upper endoscopy. Results:We were able to contact 21 patients for review, representing 75% of the study population. The mean followup for this group was 52 months (standard deviation 25.2 months).14 patients (73.7%) remained asymptomatic, while 5 patients (23.8%) developed new symptoms of GERD – 2 patients with heartburn, 2 patients with reflux, and 1 patient with both.5 patients (23.8%) were on acid suppression therapy, but only 3 on a regular basis.2 patients (10.5%) required subsequent endoscopic reinforcement and 1 patient (5.3%) required a redo fundoplication.17 patients (80.9%) have had followup 24 pH study and or upper endoscopy. Conclusions: We have shown in the past that as many as 12% of asymptomatic post-fundoplication patients will continue to have acid reflux on postoperative pH studies. The natural history of this ‘silent refluxers' has not been described. We show that the majority (74%) will continue to be asymptomatic and that the incidence of reflux complications is very low. Aggressive treatment of these silent refluxing patients may not be warranted but they should be carefully followed.
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