Laparoscopic fundoplication for symptomatic but physiologic gastroesophageal reflux |
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Authors: | Reginald C W Bell MD Philip Hanna MD Sandy Brubaker BS |
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Institution: | (1) Departments of Surgery and Medicine, Swedish Medical Center, Englewood, Colo.;(2) Boulder Community Hospital, Boulder, Colo.;(3) SurgOne PC., 499 East Hampden Ave., Suite 450, 80110 Englewood, CO |
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Abstract: | Esophageal pH monitoring identifies some patients who have physiologic amounts of esophageal acid exposure but have a strong
correlation between symptoms of esophageal reflux events. These patients with symptomatic physiologic reflux probably have
enhanced sensory perception of reflux events and may be difficult to control with acid-suppressive therapy. Little is known
about the role of fundoplication in such patients. Patients with no endoscopic evidence of gastroesophageal reflux disease
and a normal 24-hour pH composite score (<22.4 in our laboratory), but a symptom index (SI = number of symptoms with pH <4/total
number of symptoms) greater than 50% were offered laparoscopic fundoplication if acid-suppressive therapy was unsatisfactory.
This group comprised 18 (4%) of 459 patients undergoing fundoplication at our institution. Heartburn, dysphagia, and reflux
symptoms were scored on a scale of 0 to 10 with patients on and off medicine preoperatively, and at a mean of 7.2 months (range
1 to 32 months) postoperatively. The 18 patients with symptomatic physiologic reflux (6 males and 12 females) had heartburn
as a major complaint. Preoperative response to proton pump inhibitors for heartburn was 72% and for all symptoms was 60%.
The group had a mean pH composite score of 14 (range 4 to 22). The symptom used to calculate the symptom index was heartburn
in 12 patients, regurgitation in three, chest pain in two, and cough in one. An average of 18 symptoms (range 2 to 56) were
recorded. The mean symptom index was 82 % (range 50% to 100%). A Nissen fundoplication was performed in nine patients and
a Toupet fundoplication in nine. Surgery was successful (>90%) in alleviating reflux symptoms in 14 patients and partially
successful (>75%) in three of the remaining four patients. Gas bloat and dysphagia were seen in one patient each. Fundoplication
is effective at relieving reflux symptoms in carefully selected patients with symptomatic physiologic reflux, with minimal
side effects.
Presented at the Forty-First Annual Meeting of The Society for Surgery of the Alimentary Tract, San Diego, Calif., May 21–24,
200O (poster presentation). |
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Keywords: | GERD physiologic reflux fundoplication symptom index |
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