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Objective: To determine the long-term symptom control after laparoscopic fundoplication for gastroesophageal reflux disease (GERD), and possible prognostic factors.
Design, setting and patients: A cohort of 271 patients, operated at a university hospital from 1996 through 2002, was eligible for evaluation after a median interval of 102 months (range, 12 to 158).
Main outcome measures: The time between operation and recurrence of reflux symptoms (i.e. time to treatment failure) served as the end point for statistical analysis. Putative risk factors for symptom recurrence were analyzed by univariate analysis and by using Cox's multiple hazards regression. Results: According to Kaplan-Meier estimates the rate of reflux symptom recurrence was 15% after 108 months, 11% in cases without intestinal metaplasia, but 43% in patients with long-segment (33cm) Barrett's esophagus (BE; p<0.0001). Reflux symptoms recurred in 22% of cases with a hiatal hernia (HH) 33 cm before operation, but only in 7% with smaller or absent HH (p=0.005). Multivariate analysis revealed a relative risk of 6.6 (CI 3.0) for long-segment BE and of 3.0 (CI 1.7) for HH 33 cm. A strong statistical interaction was found between HH 33 cm and long-segment BE: the small group (n=18) of cases exhibiting both risk factors revealed an exaggerated recurrence rate of 72% at 108 months.
Conclusions: Laparoscopic fundoplication for symptomatic GERD provided a long-lasting abolition of reflux symptoms in 231 of 271 (85%) patients. HH 33 cm and long-segment BE materialized as independent prognostic factors favoring recurrence.

Univariate analysis of putative risk factors for symptom recurrence

Variable	n	% recurrence after 36 months	% recurrence after 108 months	p-Value (log-rank test)
All patients	271	7%	15%
Mode of fundoplication				0.49
	Total (Nissen) n=197	7%	16%
	Partial (Toupet) n=74	7%	14%
Intestinal metaplasia				<0.001
	Absent n=199	3%	11%
	Short segment BE n=43	12%	16%
	Long segment BE n=29	28%	43%
DeMeester's score	<50 n=209	5%	10%	0.001
	>/= 50 n=62	15%	28%
Hiatal hernia	< 3cm n=93	5%	7%	0.005
	>3cm n=153	10%	22%
Contraction amplitudes	<62mmHg n=131	10%	19%	0.07
	>62 n=138	6%	12%

Gender, age, LES pressure and operation time period were not significant.

Multivariate analysis (Cox’s multiple hazards model) of prognostic factors for time to symptom recurrence.

Variable	Risk Ratio	Lower CL	Upper CL	p-Value
HH>/= 3cm	3.8	1.7	10.2	<0.001
BE>/= 3cm	6.6	3.1	13.5	<0.001
Nissen vs. Toupet	1.0	0.7	1.5	0.91
Propensity score	0.97	0.6	1.2	0.85