Symptomatic Outcomes and Side Effects Following Fundoplication According to Gastroesophageal Junction Integrity

Max Schumm, BS, Matt Frelich, MS, M Goldblatt, MD, J Wallace, MD, PhD, A Kastenmeier, MD, J Gould, MD. Medical College of Wisconsin

Background Gastroesophageal reflux disease (GERD) is an extremely common condition. Laparoscopic fundoplication, for medically refractory cases is widely underutilized – partly due to concerns about potential side effects such as bloating, belching, and dysphagia. The severity of these side effects may vary depending on preoperative variables, namely the integrity of the gastroesophageal junction (GEJ). This study seeks to determine if patients with a normal lower esophageal sphincter (normal LES pressure, total length, and abdominal length) experience more side effects or a decreased disease-specific quality of life when compared to patients with a disrupted GEJ prior to and following fundoplication for GERD.

Methods This study is a retrospective review of prospectively maintained data. All patients underwent primary laparoscopic fundoplication for GERD at Froedtert Hospital from June 2014- May 2014. Preoperative clinical information including high-resolution esophageal manometry was entered into an IRB-approved clinical data registry. Patients were dichotomously grouped based on manometry: 1) competent defined by normal LES pressure, abdominal and total length, 2) incompetent with/without hiatal hernia (one or more abnormalities of LES compared to group 1). Symptomatic outcomes were collected up to one year using the Gastrointestinal Quality of Life Index (GIQLI) and GERD-Health Related Quality of Life (GERD-HRQL) questionnaires.

Results A total of 34 patients underwent primary fundoplication during the study interval. Thirty-two Nissen (94%) and two (6%) Toupet fundoplications were included. Patient characteristics did not differ significantly between the groups (age, sex, BMI, ethnicity, esophagitis, DeMeester Score). In the different groups, no significant difference in GIQLI or GERD-HRQL was detected preoperatively or postoperatively (Table 1). There were no intraoperative complications.

Table 1.Quality of Life

GERD-HRQL(Score, 0-50)

GIQLI(Score, 0-144)

Preop 2wk 2mo 6mo Preop 2wk 2mo 6mo

Competent

(n=8)

33.25

(8.8)

4.9

(2.0)

2.0

(2.0)

9.0

(8.7)

75.5

(19.5)

99.8

(11.4)

105.2

(8.6)

94.5

(36.9)

Incompetent

(n=26)

27.5

(8.5)

9.6

(8.2)

9.0

(9.6)

10.8

(10.5)

73.8

(19.6)

92.3

(16.7)

86.4

(26.7)

91.0

(24.2)

p-value 0.24 0.23 0.24 0.80 0.88 0.36 0.26 0.85

Conclusion In this small retrospective review, patients with an intact gastroesophageal junction at the time of fundoplication for GERD experience similar outcomes/side effects as patients with a disputed GEJ. We believe that an intact GEJ in the presence of medically refractory symptoms in patients with proven GERD (positive pH, esophagitis) is not a contraindication to surgery and that these patients do just as well following antireflux surgery.

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