Different Outcome of GERD and NERD Patients after Laparoscopic Nissen Fundoplication.

INTRODUCTION: “Anatomic” or “organic” GERD is cured with antireflux Nissen fundoplication. Patients with symptom of “heartburn” but without erosive esophagitis or NERD are classified as “symptomatic GERD”. In our experience the outcome of patients with GERD and patients with NERD following laparoscopic Nissen fundoplication (LNF) was quite different.
METHODS: Since Jan1993, one of us (C.V.) has performed LNF on 509 patients. All patients had been on daily PPI for more than a year. Most patients requested surgery because they did not want to take medications for life. Some also suffered from long segment Barrett’s, and some from severe regurgitation. Four hundred and fifty patients were operated in the State of Massachusetts. In the year 2005, GERD related QOL questionnaires were mailed to the patients. Since 2005 fifty nine patients have been treated with LNF in Tehran, Iran.Ninety four percent (480 patients) had suffered from organic GERD, with more than one of these findings; regurgitation, nocturnal symptoms, heartburn, history of erosive esophagitis, hiatal hernia, widened GE junction on retroflexed endoscopic view, Barrett’s mucosa, and a clearly abnormal DeMeester score.seven patients (6%) suffered only from severe chronic heartburn, without history of erosive esophagitis. Cardia in these patients remained competent on retroflection view.Any patient whose heartburn did not improve after surgery underwent full investigation to exclude mechanical failure.
RESULTS: Responses of patients with “organic” GERD and “symptomatic” NERD to LNF were different. Ninety six percent of patients with GERD, considered the result of surgery as good to excellent. Interestingly 4 patients in whom the disease had recurred because of wrap disruption, years after surgery, all voluntarily requested to be reoperated.But only 7% of 27 patients with NERD have been pleased with the result of surgery. Although fundoplication wrap had remained intact and there were no hiatal hernias, the patients continued to have epigastric pain, “heartburn”, bloating and dyspeptic symptoms. All 25 patients had resumed taking PPI, in addition to anti anxiety or anti depressant medications.
CONCLUSION: Although patients with NERD suffer from chronic “heartburn”, majority of them do not benefit from antireflux surgery. We recommend that before surgery, patients with “functional” reflux to be differentiated from patients with “organic” GERD.

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Program Number: P248

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