Gastroesophageal reflux disease includes a wide spectrum of patients only a
portion of which have a structurally defective lower esophageal sphincter (LES).
It is these patients that have been traditionally referred for antireflux
surgery, although patients with normal resting sphincter characteristics may be
equally symptomatic. The relationship of resting sphincter charactaristics to
the outcome after fundoplication is unknown, and formed the basis of this study.
The study population consisted of 101 patients undergoing laparoscopic
Nissen fundoplication between 1992 and 1996. All patients had increased
esophageal acid exposure on 24h esophageal pH monitoring. Patients were divided
into those with normal (n=31) and structurally defective LES (n=70), based on
LES resting pressure (normal > 6mmHg), overall length (normal > 2cm) and
abdominal length (normal > 1cm). The two groups were further divided into
patients pesenting with "typical" (heartburn, regurgitation or
dysphagia) and "atypical" (respiratory, chest pain) symptoms of
gastroesophageal reflux disease. Symptomatic outcome was assessed via a detailed
questionnaire at a median follow-up period of 18 months after surgery. The
outcome was considered excellent in asymptomatic patients, good when the primary
symptom was relieved but minor GI symptoms remained, and poor when symptoms were
equal to or worse than before surgery.
Typical reflux symptoms were present in the majority of patients (88/101,
87%) Laparoscopic fundoplication was highly successful in relieving typical
symptoms of gastroesophageal reflux irrespective of the resting status of the
LES (table). Atypical symptoms were significantly more common in patients with a
normal LES (29%), than those with a structurally defective LES (5.7%; p<0.01
Fishers exact test) and were less likely to be relieved by antireflux surgery.
Primary symptom Excellent / good outcome
"Normal LES" (n=31) "Defective LES" (n=70)
Typical 95% (21/22) 97% (64/66)
Atypical 44% (4/9)* 75% (3/4)
*p<0.01 vs typical primary symptom normal / defective LES
Laparoscopic antireflux surgery is highly successful and not dependent on
the status of the resting LES in patients presenting with increased esophageal
acid exposure and "typical" symptoms of gastroesophageal reflux. The
outcome is not as predictable however in patients with atypical symptoms, in
whom antireflux surgery should be applied carefully.
