Outcome of Surgical Fundoplication for Extraesophageal (Atypical) Manifestations of Gastroesophageal Reflux Disease in Adults: A Systematic Review

Abstract

Background: A significant proportion of patients with gastroesophageal reflux disease (GERD) present with atypical symptoms (extraesophageal reflux; EER). The effectiveness of surgical fundoplication in treating classical reflux symptoms is well documented, but the role of surgery in alleviating EER symptoms is less clear. The aim of this study was to review the published literature to determine whether surgical fundoplication is effective in controlling EER. Materials and Methods: A Medline, PubMed, and Cochrane database search was done to find articles on surgery for extraesophageal reflux (1991)(1992)(1993)(1994)(1995)(1996)(1997)(1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005)(2006). Articles on pediatric patients were excluded. The parameters looked at were patient selection, resolution of symptoms, change in the quality of life, and any adverse outcomes. Results: In 25 studies, a variable proportion (15-95%) of patients with various symptoms of EOR improved after surgical fundoplication. The percentage of patients with EER responding to surgery was less than that reported for classical GERD. Conclusions:The majority of patients in most studies seem to improve symptomatically after surgery. However, a small percentage remains unchanged or worsens. The reported studies are so disparate in their methodology that firm conclusions on the role of surgery are difficult. Further studies are needed. These should be large, multicenter, prospective trials comparing medical and surgical treatment with standardized diagnostic criteria for EER. Pre-and post-treatment assessment, the type of surgery performed, and follow-up should be standardized.

Determinants of reflux-induced chronic cough

“…We did find that the proximal extent correlated well with the volume clearance time, and this suggests that the volume of the refluxate is a determinant of the occurrence of cough bursts. Since volume rather than acidity seems to be important in patients with reflux-induced cough, this could explain why antireflux surgery seems to be more effective than medical treatment 28. However, it is important to note that differences in selection criteria might account for this and that the surgical trials lacked a sham control group 29–31.…”

Traditional reflux parameters and not impedance monitoring predict outcome after fundoplication in extraesophageal reflux

“…Reported effectiveness of fundoplication for EER symptoms varies from 15% to 95%4 and is largely attributable to disparate study design, patient selection, and outcome metrics. In our population limited to subjects with refractory reflux symptoms and objective evidence of GERD, 59% had EER symptom improvement after surgery.…”

“…However, the role of antireflux surgery for EER symptoms refractory to aggressive acid suppressive therapy is unclear. In a systematic review by Iqbal et al, 15% to 95% of patients with EER symptoms improved after fundoplication 4. This broad variability underscores our poor understanding of which patients with refractory EER symptoms might benefit from surgery.…”

Evolution and Outcome of Eight Patients Undergoing Treatment of Gastroesophageal Disease by Esophyx

“…The exclusion criteria were Hiatal hernia greater than 2 cm, severe erosive esophagitis (grade D in the Los Angeles classification), esophageal structures or varices, intestinal metaplasia and Barrett's esophagus, previous esophagogastric surgery, pregnancy, obesity with BMI >35 kg/m 2 at high anaesthesia risk (ASA class 3 or greater). The validated 10 question GERD-HRQL questionnaire was used to assess patient quality of life as primary endpoint and to evaluate patient satisfaction regarding heartburnrelated symptoms [8][9][10][11][12][13].…”