In a recent retrospective study (JT Krill et al. Clin Gastroenterol Hepatol 2017; 15: 675-81), the authors reinforce the notion that surgery works best for reflux patients whose symptoms respond best to medical therapy.
Background: In this study, 196 patients with normal anatomy were identified, though 81 had inadequate follow-up at 1 year. This left 115 patients (median age ~52). This study examined patients with typical reflux symptoms (regurgitation, heartburn) (n=79 of 115, 68.7%) and extraesophageal symptoms, like cough, hoarseness, and throat clearing (n=36 of 115, 31.3%). It is noted that 2/3rds of those with extraesophageal symptoms had coexisting typical GERD symptoms. Most patients had a Nissen fundoplication but some underwent a Toupet fundoplication.
- 91.5% of those with typical reflux symptoms (who had responded to medical therapy) were in remission at 1 year; in comparison, only 33.3% (P <.01) of those with extraesophageal symptoms along with poor response to acid suppression therapy exhibited remission following fundoplication.
- “The severity of acid reflux on pH monitoring and larger hiatal hernia size were associated with a more favorable outcome at 12 months.” All patients had either abnormal pH monitoring or endoscopic esophagitis prior to surgery. Only those with severe reflux had increased likelihood of response to surgery.
Limitations: retrospective study, 81 of 196 patients were excluded due to lack of followup
My take: This study is consistent with other studies in suggesting that reflux surgery is less effective in those who do not respond to medical therapies and who have atypical symptoms.
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