20-years Later: Laparoscopic Fundoplication Durability

Benjamin J Robinson, Christy M Dunst, MD, Kevin M Reavis, MD, Ahmed Sharata, MD, Lee L Swanstrom, MD. Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic.

Introduction:
The objective of this study is to present long-term 20-year outcomes after laparoscopic fundoplication. In the early 1990’s, this advanced surgery for gastrointestinal reflux disease (GERD) started in highly selected institutions. Long-term outcomes studies are rare. The longest study to date showed a 73% success rate of the laparoscopic fundoplication procedure at 10-years.

Methods and Procedures:
A prospectively collected database was queried for all patients who underwent primary laparoscopic fundoplication procedures for GERD between 1991 and 1995. A single surgeon performed all procedures (LLS). Patients were contacted by phone and completed a 20-year follow up survey. Patients were asked whether they underwent a revision surgery, and a symptom questionnaire was administered. Symptomatic success of fundoplication was defined by lack of surgical re-intervention and a symptom score of 0-1 using a validated GERD symptom scoring system (0=never, 1=once a month, 2=once a week, 3=everyday, 4=continuous). Symptom scores were analyzed for heartburn, regurgitation, and dysphagia.

Results
One hundred ninety-three patients were identified as having had surgery between 1991-1995. Of these, 100 could not be contacted, 40 were deceased, and 2 declined to answer, leaving 51 patients who completed a standardized survey. Respondents had a median follow up of 19.4 years (inter quartile range 18.7-20 years). Overall, 63% (32/51) of patients were successful, being free of consistent GERD symptoms. Specifically, 94% (48/51) had no or rare regurgitation and 75% (38/51) had no or rare heartburn. Of all patients, 16% (8/51) of respondents had revision, and 45% (23/51) were on proton pump inhibitors (PPI). Furthermore, 26% (13/51) had dysphagia (5 patients with occasional, 8 patients with daily). Lastly, 10% (5/51) of respondents were unsatisfied with surgery, but 3 of them had one or more of the analyzed symptoms: heartburn, reflux, or dysphagia. The fourth was not happy to have to take PPI’s again, and the final patient was dissatisfied because of short-term post-op dysphagia.

Conclusion:
Laparoscopic fundoplication has a symptomatic success of 63% for regurgitation and heartburn at 20-year follow up. There is a relatively high rate of dysphagia (26%) at long-term follow up, but need for reparative surgery is relatively low (16%). A high percentage of patients (90%) are happy they underwent fundoplication.