Pre-operative clinical and instrumental factors as antireflux surgery outcome predictors

Abstract

Gastroesophageal reflux disease (GERD) is nowadays a highly prevalent, chronic condition, with 10% to 30% of Western populations affected by weekly symptoms. Many patients with mild reflux symptoms are treated adequately with lifestyle modifications, dietary changes, and low-dose proton pump inhibitors (PPIs). For those with refractory GERD poorly controlled with daily PPIs, numerous treatment options exist. Fundoplication is currently the most commonly performed antireflux operation for management of GERD. Outcomes described in current literature following laparoscopic fundoplication indicate that it is highly effective for treatment of GERD; early clinical studies demonstrate relief of symptoms in approximately 85%-90% of patients. However it is still unclear which factors, clinical or instrumental, are able to predict a good outcome after surgery. Virtually all demographic, esophagogastric junction anatomic conditions, as well as instrumental (such as presence of esophagitis at endoscopy, or motility patterns determined by esophageal high resolution manometry or reflux patterns determined by means of pH/impedance-pH monitoring) and clinical features (such as typical or atypical symptoms presence) of patients undergoing laparoscopic fundoplication for GERD can be factors associated with symptomatic relief. With this in mind, we sought to review studies that identified the factors that predict outcome after laparoscopic total fundoplication.

Keywords: Gastroesophageal reflux disease; Antireflux surgery; Outcome predictors; Fundoplication; Nissen; Laparoscopy; High resolution manometry; Impedance-pH monitoring

Core tip: Fundoplication is currently the most commonly performed antireflux operation for management of gastroesophageal reflux disease (GERD). Outcomes described in current literature following laparoscopic fundoplication indicate that it is highly effective for treatment of GERD. However it is still unclear which factors, clinical or instrumental, are able to predict a good outcome after surgery. Anatomical conditions seem to not be a risk factor for poor outcome. The predictability of success following laparoscopic fundoplication seems to be directly proportional to the degree of certainty that gastroesophageal reflux is the underlying cause of the patient’s complaints. Thus, performing an accurate pre-operative clinical and instrumental evaluation is mandatory.