Patient satisfaction after laparoscopic antireflux surgery: community achievement.

Gastroesophageal reflux disease (GERD) is a common problem, with up to 40% of the population having reflux symptoms during their lives. Fortunately for most, symptoms are either mild and infrequent or can be successfully managed with anti-acid medications such as histamine receptor-2 ([H.sub.2]) antagonists or proton pump inhibitors. However, some patients with severe disease fail to respond to medical therapy and will potentially benefit from surgery. With the advent of less invasive laparoscopic surgery, patients with moderate-to-severe disease controlled by medication, but who do not wish to take medication for the rest of their lives, are also considered for surgery. (1)

The aim of surgery is to create a mechanical barrier to stop reflux of gastric content into the esophagus. This is normally achieved by either partially or fully wrapping the fundus of the stomach around the esophagus. Among surgeons, debate exists as to whether a total fundoplication such as the traditional Nissen fundoplication is better than partial fundoplication techniques such as the Toupet or anterior fundoplication. Some believe that the side effects of fundoplication, such as dysphagia, gas-bloat, and increased flatulence, may be minimized by partial fundoplication. (2) Others believe that a total fundoplication is more durable and offers better control of reflux. Although some evidence exists to support both of these arguments, the differences are relatively small, and overall, patient satisfaction reaches 90% or above in most reports. (3,4)

Although laparoscopic fundoplication was initially performed predominantly in academic centers, community surgeons have either acquired the necessary advanced laparoscopic skills or trained in academic centers where these procedures were initiated, such that they may competently perform these advanced laparoscopic procedures routinely. In this issue of the Southern Medical Journal, Tucker et al (5) describe the results of laparoscopic fundoplications performed in a community setting. Most long-term studies of antireflux surgery report success rates of 90% with regard to control of reflux symptoms. (3,4) Typically, two thirds of these patients will have no reflux, whereas the remainder will have occasional reflux but are significantly improved in comparison to preoperative symptoms. The qualitative postoperative reflux results from the current study mirror those published from academic centers in that 78% of patients had no postoperative heartburn, whereas 5% of patients had daily heartburn. Thus, 22% of patients had some remaining heartburn, and, interestingly, 21.8% of patients required postoperative proton pump inhibitor therapy, albeit not all for GERD symptoms. Therefore, in terms of qualitative acid reflux control, surgery in the community has achieved excellent standards.

Despite the majority of patients being well satisfied after surgery, up to 10% of patients would not recommend the procedure to others. Reasons for dissatisfaction include prolonged dysphagia, gas-bloat symptoms, or recurrent reflux. Postoperative dysphagia is generally short-lived, and few patients have long-term dysphagia, as described in the current publication. However, nearly 40% of patients in this series had "some" postoperative dysphagia of unknown duration. This appears to be a high percentage of patients with dysphagia that may be related to operative techniques such as applying total fundoplication to all patients rather than using a stratified approach that uses partial fundoplication for patients with decreased esophageal motor function. Other operative factors that may influence postoperative dysphagia include an overly tight crural repair, a long (>2 cm) fundoplication performed over a small bougie (<50F), or a non-floppy fundus. Continued quantitative follow-up and correlation with refinement in techniques may decrease postoperative dysphagia rates.

Some patients, however, do not have an identifiable cause for persistent postoperative symptoms. Certain characteristics of these individuals have been identified and include a relatively poor indication for surgery (mildly abnormal pH study without erosive esophagitis), coexisting psychiatric diagnoses such as depression or anxiety, and chronic pain syndromes such as fibromyalgia. (6) In both the community and academic settings, these patients should not be offered laparoscopic fundoplication because of a high likelihood of persistent postoperative symptoms.

Tucker et al should be applauded for their diligent follow-up of patients that are too frequently "lost" to subsequent analysis. This study shows that laparoscopic fundoplication can be performed well in the community setting, and that a high rate of follow-up can be attained. The challenge for academic and community centers alike is to select appropriate patients for surgical therapy of GERD, and to make continued quality improvement assessments by quantitative methods.

There are only two ways to live your life. One is as though nothing is a
miracle. The other is as though everything is a miracle.
--Albert Einstein

Accepted October 20, 2004.

References

1. Watson DI, Jamieson GG. Antireflux surgery in the laparoscopic era. Br J Surg 1998;85:1173-1184.

2. Watson DI, Jamieson GG. Pike GK, et al. A prospective double blind trial between laparoscopic Nissen fundoplication and anterior partial fundoplication. Br J Surg 1999;86:123-130.

3. Booth MI, Jones L, Stratford J, et al. Results of laparoscopic Nissen fundoplication at 2-8 years after surgery. Br J Surg 2002;89:476-481.

4. Lafullarde T, Watson DI, Jamieson GG, et al. Laparoscopic Nissen fundoplication: five year results and beyond. Arch Surg 2001;136:180-184.

5. Tucker LE, Blatt C, Richardson NL, et al. Laparoscopic Nissen fundoplication in a community hospital: patient satisfaction survey. South Med J 2005;98:441-443.

6. Velanovich V. The effect of chronic pain syndromes and psychoemotional disorders on symptomatic and quality of life outcomes of antireflux surgery. J Gastrointest Surg 2003;7:53-58.

Michael France, MD, and Kevin E. Behrns, MD

From the Division of Gastrointestinal Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC.

Reprint requests to Dr. Kevin E. Behrns, University of North Carolina, 320 Medical School Wing E, Campus Box 7081, Chapel Hill, NC 27599-7081. Email: [e-mail]