Outcomes of anti-reflux surgery in GERD patients refractory to maximal medical treatment

Radu Pescarus, MD, Christy M Dunst, MD, Mark M Levin, MD, Eran Shlomovitz, MD, Ahmed Sharata, MD, Kevin M Reavis, MD, Lee L Swanstrom, MD. Providence Cancer Center, Portland, Oregon.

INTRODUCTION

Proton pump inhibitors (PPI) have become the gold standard medical treatment of GERD. Unfortunately, 10-40% of patients with typical symptoms (heartburn and regurgitation) remain symptomatic despite maximal PPI treatment. Traditionally, these refractory patients have been considered to be relatively poor surgical candidates. Our hypothesis is that a carefully selected population of GERD patients with typical symptoms unresponsive to medical treatment will have a good clinical response to laparoscopic anti-reflux surgery.

METHODS

A retrospective analysis of all patients referred to our foregut service with diagnosis of GERD (ICD-9 530.81) at the initial visit from 08/2011 to 11/2012 was performed. All patients had standard symptom assessment forms that were completed at each visit. The forms were queried for symptoms and PPI use. Patients were classified as refractory if they had daily breakthrough symptoms (regurgitation or heartburn) despite maximal PPI therapy. All patients underwent extensive evaluation to determine the etiology of their symptoms (upper endoscopy, pH study, esophageal manometry and gastric emptying study). Patients found to have other concomitant foregut disorders were excluded from the final analysis. The remaining patients make up the study cohort: patients with persistent daily heartburn and/or regurgitation despite PPIs who were treated with isolated anti-reflux surgery.

RESULTS

Two hundred three out of 420 GERD patients were classified as refractory to PPIs. One hundred nine patients were excluded (72 patients did not have surgery for multiple reasons, 12 had Heller myotomy, 12 had pyloroplasty, 2 had gastric bypass, 11 had other procedures). Ninety-four patients were found to have straight forward regurgitation and/or heartburn refractory to PPI and were treated with antireflux surgery alone. Forty-five (48%) completed 6-month objective follow up.

Heartburn and regurgitation completely resolved in 36/45 (80%) of patients at 6 month follow up. Five (11%) patients reported heartburn or regurgitation once or twice a month and 4 (9%) patients had persistent weekly symptoms. Despite reporting daily refractory heartburn and/or regurgitation, 17(38%) patients reported a different symptom as their chief complaint (dysphagia, epigastric pain, cough etc). Regardless, the chief complaint was completely resolved for 38 (85%) patients, improved in 5 (11%) and unchanged in 2 patients (4%). Objectively, the post-operative acid exposure was normalized in 44/45 (98%) patients with an average DeMeester score of 3.8 ± 12.1. The patient with an increased acid exposure score denies any regurgitation or heartburn.

CONCLUSION

Laparoscopic anti-reflux surgery is an effective treatment for typical GERD symptoms in patients that are refractory to medical treatment when other confounding disorders have been excluded. A comprehensive evaluation to rule out other foregut pathologies is imperative prior to proceeding with anti-reflux surgery as up to 50% of patients require a different approach.
 

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