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Postoperative Symptoms and Failure After Antireflux Surgery
Yashodhan S. Khajanchee, MBBS, MS;
Robert W. O'Rourke, MD;
Barbara Lockhart, RN;
Emma J. Patterson, MD;
Paul D. Hansen, MD;
Lee L. Swanstrom, MD
Arch Surg. 2002;137:1008-1014.
Background Outcomes in patients having surgery for gastroesophageal reflux disease are most commonly determined by symptomatic assessment. Objective testing is usually reserved for symptomatic patients.
Hypothesis To evaluate the relationship between symptomatic and objective outcomes after antireflux surgery.
Design Retrospective analysis of prospectively collected data.
Setting A tertiary care teaching hospital with a comprehensive esophageal physiology laboratory.
Interventions A 360° (Nissen) fundoplication or a 270° (Toupet) posterior fundoplication was performed based on esophageal motility. Twenty-four–hour pH monitoring was used as a gold standard for assessing postoperative acid reflux.
Patients Two hundred nine consecutive patients with preoperative and postoperative symptomatic and objective testing performed between January 1, 1996, and June 15, 2001.
Main Outcome Measures Data on preoperative and postoperative symptoms, DeMeester scores, and esophageal motility were prospectively collected. Objective testing was performed after at least 6 months.
Results The preoperative median DeMeester score was 50.0 (interquartile [IQ] range, 30.3-87.0). One hundred eighty patients had a Nissen and 29 patients had a Toupet fundoplication. After a median postoperative interval of 7.7 months (IQ range, 6.7-9.5 months), 174 patients (83.3%) had normal DeMeester scores (median, 2.2; IQ range, 0.8-5.0; P<.001). Of 58 patients (27.7%) who had reflux symptoms after surgery, only 17 (29.3%) had abnormal DeMeester scores (median, 36.9; IQ range, 748.4-20.0; P = .001). Eighteen (11.9%) of the 151 asymptomatic patients had abnormal DeMeester scores (median, 32.5; IQ range, 22.2-57.5; P = .006).
Conclusions There is poor correlation between postoperative reflux symptoms and actual reflux (abnormal DeMeester scores). Surgeons must be careful to define their terms when reporting success or failure rates after antireflux surgery. Routine use of medical therapy for suppressing postoperative gastroesophageal reflux disease symptoms is not supported by these data, and postoperative therapy should be based on objective testing only.
From the Department of Minimally Invasive Surgery and Surgical Research, Legacy Health System, Portland, Ore.
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