2017-05-17 05:07:25 UTC

What Factors Associate With Symptom Recurrence After Anti-reflux Surgery for GERD?

The most reliable factors associated with symptom recurrence after anti-reflux surgery for patients with gastroesophageal reflux disease (GERD) are a primary complaint of extraesophageal reflux symptoms and lack preoperative response to acid-suppression therapy, researchers report in the May issue of Clinical Gastroenterology and Hepatology.

Approximately 10% of the US population has daily symptoms of GERD. Anti-reflux surgery reduces symptoms on more than 90% of patients with typical reflux (heartburn, regurgitation). It is an option for patients whose symptoms are not controlled with lifestyle modification or acid-suppression therapy, or when complications develop.

Guidelines state that anti-reflux surgery should be considered for patients with typical esophageal reflux symptoms who are responsive to, but intolerant of, proton pump inhibitor (PPI) therapy; typical reflux symptoms considered troublesome (especially regurgitation) despite PPI therapy; typical reflux symptoms who prefer a more definitive option; or extra-esophageal symptoms when reflux etiology has been established.

However, it is difficult to predict the response to anti-reflux surgery for patients with extra-esophageal symptoms (cough, asthma/wheezing, hoarseness, or throat clearing).

Joseph T. Krill et al investigated patient features and test results associated with symptom recurrence after anti-reflux surgery. They performed a retrospective analysis to compare symptom recurrence after surgery for 36 patients with primary extra-esophageal reflux symptoms (cough, hoarseness, asthma/wheezing, throat clearing) and 79 patients with typical GERD manifestations (heartburn, regurgitation).

Time to primary symptom recurrence by primary symptom and preoperative response to acid-suppressive therapy. Hb, heartburn; reg, regurgitation; extra, extraesophageal

The median time to recurrence of symptoms in entire group was 68 months. The median time to symptom recurrence in patients with extra-esophageal symptoms was 11.5 months, compared to more than 132 months in patients with typical GERD.

Symptom recurrence after anti-reflux surgery was associated with having primarily extraesophageal symptoms (adjusted hazard ratio, 2.34) and poor preoperative response to acid-suppression therapy (hazard ratio, 3.85).

Patients with primary extra-esophageal symptoms who had a full or partial preoperative response to acid-suppressive therapy were less likely to have symptom recurrence than patients with poor response to acid-suppressive therapy. Severity of acid reflux on pH testing, symptom indices, severity of esophagitis, and hiatal hernia size were not associated with symptom response.

Krill et al state that the findings fill a gap in our understanding of physiologic testing and response to therapy, and provide prognostic factors that can guide selection of patients for anti-reflux surgery.

Limitations of the study include its retrospective design, single-center cohort, and somewhat homogenous patient population (predominantly Caucasian and obese). A multi-center prospective study of a diverse study population, using a standardized assessment tool, is needed to fully determine the utility of the variables discussed in this study.

 

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