Abstracts
1997 Digestive Disease Week

Outcome after laparoscopic fundoplication is not dependent upon a structurally defective lower esophageal sphincter.

JH Peters, MP Ritter, PF Crookes, M Gadenstatter, RJ Mason, L Green, CG Bremner, TR DeMeester. USC Department of Surgery, Los Angeles, CA.

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.