High recurrence of gastroesophageal reflux disease in patients treated with laparoscopic antireflux surgery

1. Among patients receiving laparoscopic antireflux surgery, 17.7% experienced recurrent GERD requiring medication or secondary antireflux surgery

2. Factors associated with recurrence included older age, female sex, and comorbidity.

Evidence Rating Level: 2 (Good)

Study Rundown: Gastroesophageal reflux disease (GERD) is a common diagnosis affecting 10 to 20% of adult patients in the Western world. Presenting often with the symptoms of heart burn, regurgitation, or dysphagia, it is commonly treated successfully with lifestyle modifications or medical therapy with proton pump inhibitors or histamine₂ receptor antagonists. In those refractory to medical treatment, laparoscopic antireflux surgery is an alternative treatment option and provides a mechanical barrier to stomach refluxate from entering the esophagus. Currently, there is mixed data on the benefit of antireflux surgery; some randomized controlled trials at referral centers have shown a low rate of recurrence while cohort studies have shown a higher rate of recurrence of GERD after antireflux surgery. In this retrospective cohort study, the rate of recurrence of GERD after primary laparoscopic antireflux surgery was investigated in a population of 2,655 patients (median age, 51 years; 51% male) that underwent antireflux surgery and were followed for 5.6 years on average. Overall, 470 (17.7%) patients had reflux recurrence, and of this group, 393 (83.6%) received long-term antireflux medication and 77 (16.4%) underwent secondary antireflux surgery. Risk factors associated with higher rate of recurrence included older age, female sex, and comorbidity. Overall, this study suggests that antireflux surgery for GERD is associated with a high rate of recurrence. Limitations to this study include variations in clinical practice regarding coding that may not have been fully captured in this study, as well as unmeasured confounders (body mass index, tobacco smoking) that were not available in the registries and may have affected the risk factor analysis.

Click to read the study, published today in JAMA

Relevant Reading: Analysis of the Causes of Failed Antireflux Surgery and the Principles of Treatment

In-Depth [retrospective cohort]: The current study is a nationwide retrospective cohort study conducted in Sweden. It assessed the recurrence of reflux in individuals with GERD who underwent primary laparoscopic antireflux surgery between January 1, 2005 and December 31, 2014. Three nationwide registries (Patient Registry, Causes of Death Registry, and Prescribed Drug Registry) were utilized to retrieve data. All patients coded to have undergone laparoscopic antireflux surgery were included in the study. The classification system used to code for the surgery did not differentiate between type of antireflux surgery, for instance, total or partial fundoplication. Main outcome of the study included recurrence of reflux. Markers of recurrence included at least 6 months of proton pump inhibitor or histamine₂ receptor antagonist use after the primary surgery, or a secondary antireflux surgery (both open and laparoscopic fundoplication). Secondary outcomes included risk factor analysis that predisposed the population to a higher recurrence rate. The study included 2,655 patients (median age, 51 years; 51% male) with GERD that underwent surgery during the defined period. Overall, 470 patients (17.7%) had recurrence; of these, 393 (83.6%) received long-term antireflux medication and 77 (16.4%) underwent a secondary antireflux surgery. Risk factors included female sex (HR 1.57, CI 1.29-1.90), older age (HR 1.41, CI 1.10-1.81) for age ≥61 years compared with ≤45 years, and comorbidity (HR 1.36, CI 1.13-1.65) for Charlson comorbidity index ≥1 compared with 0. Furthermore, hospital volume of antireflux surgery was not associated with risk of reflux recurrence.

Image: PD

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