Background : Laparoscopic nissen fundoplication (LNF) is the gold standard for surgical treatment of gastroesophageal reflux disease (GERD) with majority of patients are younger adults. In recent era of aging population, many community surgeons are hesitant to perform this procedure in the elderly due to presumed higher morbidity and poorer surgical outcomes. Therefore this study is aimed to investigate long term subjective and objective outcomes of LNF based on age.
Methods : Retrospective review was performed in all patients undergoing LNF between 2001 and 2007 for reflux disorder. Patients were divided into 4 age groups (age65(D)) and compared for improvement in objective and subjective findings, medication use, complications, length of hospital stay and reoperation rate. Objective findings were measured by esophagogastroduodenoscopy (EGD) and upper gastrointestional contrast study (UGI) performed both pre and postoperatively. 24 h pH study and esophageal manometry performed prior to surgery were also recorded.
Results : Total of 277 patients undergoing LNF during the study period (Group A=11, B=98, C=131, D=37). Gender and BMI are comparable among all groups. Preoperative 24 h pH study revealed higher DeMeester score in patient >65 year of age compared to those in younger groups (66.34 vs 21.2-groupA, 51.61-groupB, 29.29-groupC; p=0.74). Similar pattern was seen on percentage of pH below 4 (13.92 vs 5.23-group A, 13.27-group B, 12.6-groupC; p=0.75). Preoperative manometry showed higher incidence of abnormal esophageal motility in patients >65 compared to those in younger groups (30% of patients vs 14.3%-groupA, 8.1%-groupB, 15.4%-groupC; p=0.12). Abnormally low lower esophageal sphincter pressure was found most frequently in patients age 25-45 (46.5%-group B vs 0%-group A, 35.3%-group C, 31.8%-groupD; p= 0.25). Following surgery, heartburn and regurgitation are 2 symptoms that were most significantly improved by LNF with patients >65 experienced the highest benefit among all groups (89%; p=0.300 and 81%; p=0.310 respectively). Majority of patients in all 4 groups were able to discontinue their H2 blocker, proton pump inhibitor and antacid postoperatively. Objective measurement with pre and postoperative EGD showed highest percentage of resolution of hiatal hernia in patients >65 compared to those in younger age groups (85% vs 55%-group A, 56%-groupB, 44%-group C; p=0.28). The most significant improvement of esophagitis was endoscopically seen in the youngest age group and at a lower frequency as the age increases ( 38%-group A vs 34%-groupB, 23%-group C, 12% group D; p=0.035). UGI that was performed pre and postoperatively trended toward similar results. Length of hospital stay was similar among all groups (1.1 day; p=0.980). Reoperation was required in 4 patients in group B (4/98), 4 in group C (4/131) and 1 in group D (1/37). No mortality found in this series.
Conclusions : Laparoscopic nissen fundoplication provides a comparable subjective and objective outcomes in the elderly patients to those in younger age. The more frequent anatomic and physiologic esophageal abnormalities found in the elderly patients do not preclude good surgical outcomes.
Program Number: P342