Introduction With the increasing use of antireflux surgery since the widespread dissemination of the laparoscopic approach, preoperative indicators to predict success could reduce the number of patients with a poor outcome. The aim of this study was to identify if poorer outcomes could be predicted in patients with upright reflux alone vs mixed upright and supine reflux, in the presence of a positive DeMeester score.
Methods This was a retrospective cohort study of all patients undergoing antireflux surgery from 2001 to 2009 in a tertiary centre under a single surgeon. Patients undergoing fundoplication and/or repair of paraoesophageal hernias were included. Patients underwent preoperative assessment by means of endoscopy, oesophageal manometry and 24 h oesophageal pH monitoring. Patients were grouped on the basis of their 24 h pH profile into upright refluxers (daytime increased oesophageal acid exposure) and mixed refluxers (night-time increased oesophageal acid exposure +/− daytime reflux). Primary outcomes included if the patient had stopped PPIs following surgery and the incidence of postoperative dysphagia, vomiting and reflux symptoms. Secondary outcomes included if the patients deemed the operation a success.
Results 120 patients were included, with a median age of 49 years (range 24–81) at time of surgery. 53% (n=63) were male and 93% were laparopscopic procedures. 100 patients (83.3%) had Nissen fundoplication and 13% had a combination of fundoplication and paraoesophageal hernia repair. A DeMeester score >15 was present in 97.8% (n=88) patients, with 21% (n=19) patients having upright reflux and 68.5% (n=63) having mixed reflux symptoms on pH studies. Mixed refluxers were nearly twice as likely to have significant oesophagitis (grade B+) and or Barrett's oesophagus on preoperative endoscopy (mixed reflux 57.1% vs 31% upright reflux; p=0.051). Those patients with mixed reflux symptoms were significantly more likely to stop PPIs postoperatively (mixed reflux 96%, n=48 vs 75% n=12, upright reflux; p=0.01). Further, the incidence of significant post operative dysphagia was doubled in the upright reflux group (upright reflux 53.3% vs mixed reflux 26.7%; p=0.058). Overall, 83.5% (n=76) deemed the operation to have been a success, 7.7% (n=7) a partial success and 8.8% (n=8) considered that surgery had failed to improve their symptoms.
Conclusion In addition to the DeMeester score for predicting outcomes in antireflux surgery, the presence of reflux only in the upright position may indicate a poorer outcome.
Competing interests None declared.
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