Acid reflux relief: Outcomes following surgery

Studies of long-term outcome following both open and laparoscopic fundoplication document the ability of laparoscopic fundoplication to relieve typical reflux symptoms (heartburn, regurgitation, and dysphagia). Laparoscopic fundoplication results in a significant increase in LES pressure and length, generally restoring these values to normal. Postoperative pH studies indicate that the pH tracings of more than 90% of patients will normalize. The results of laparoscopic fundoplication compare favorably with those of open fundoplication. They also indicate the less predictable outcome of atypical reflux symptoms (cough, asthma, laryngitis) after surgery being relieved in only two thirds of patients. Some patients have symptoms after Nissen fundoplication severe enough to warrant evaluation with 24-hour ambulatory esophageal pH monitoring. Heartburn and regurgitation were the only symptoms that were significantly associated with an abnormal pH study. Most patients using acid-suppression medications after surgery for acid reflux relief do not have abnormal esophageal acid exposure. Objective evidence of reflux should be obtained in patients who complain of postoperative symptoms.
The goal of surgical treatment for GERD is to relieve the symptoms of reflux by reestablishing the GE barrier. The challenge is to accomplish this without inducing dysphagia or other untoward side effects. Dysphagia or difficulty in swallowing that existed prior to surgery usually improves following laparoscopic fundoplication. Temporary dysphagia is common after surgery and generally resolves within 3 months. Dysphagia persisting beyond 3 months has been reported in up to 10% of patients. There is some improvement in postoperative dysphagia with time. Induced dysphagia is usually mild, does not require dilatation, and is temporary. It can be induced by technical misjudgments, but this explanation does not hold in all instances. In experienced hands, its prevalence should be less than 3% at 1 year. Other side effects common to surgery for acid reflux relief include the inability to vomit and increased flatulence. Most patients cannot vomit through an intact wrap, though this is rarely clinically relevant. Hyperflatulence is a common and noticeable problem, likely related to increased air swallowing that is present in most patients with reflux disease.
Quality-of-life analyses have become an important part of surgical outcome assessment, with both generic and disease-specific questionnaires in use, in an attempt to quantitate quality of life before and after surgical intervention. In general, these measures relate the effect of disease management to the overall well-being of the patient. Most studies have utilized the Short Form 36 (SF-36) instrument, because it is rapidly administered and well validated. This questionnaire measures 12 different health-related quality-of-life parameters encompassing mental and physical well-being. Data from Los Angeles indicate significant improvements in scores for the area of bodily pain and in a portion of the general health index. Some investigators have also reported improvement in quality of life following surgery for acid reflux relief. Utilizing the Psychological General Well Being Index and the Gastrointestinal Symptom Rating Scale to evaluate quality of life in patients following laparoscopic surgery for acid reflux relief. Scores with both instruments were improved following surgery for acid reflux relief and better than in untreated patients. Of particular note was that scores were as good as or better than those of patients receiving optimal medical therapy. Others using a 10-item health-related quality-of-life questionnaire specific for GERD, have also shown an improvement in quality of life following surgery for acid reflux relief. The quality of life after antireflux surgery has been compared with nonoperative management for severe GERD. Follow-up quality of life was measured using the SF-36, and heartburn severity was measured using the Health Related Quality of Life (QOL) scale. Detailed outcomes were reviewed for both surgical and medical patients. Mean QOL scores were better in the surgical group. More of the medical patients were dissatisfied with therapy. SF-36 scores were better in six of eight domains for surgical patients. These data support the notion that surgery for acid reflux relief, performed on properly selected patients, can significantly improve quality of life and may outperform medical therapy in this regard.