Hiatal hernia, Barrett’s esophagus, and long-term symptom control after laparoscopic fundoplication for gastroesophageal reflux

Surgical Endoscopy, 06/08/2012

Laparoscopic fundoplication for symptomatic GERD provided a long–lasting abolition of reflux symptoms in 231 of 271 (85 %) patients. HH ≥ 3 cm and long–segment BE were shown as independent prognostic factors favoring recurrence.

Methods

  • A cohort of 271 patients, operated on at a university hospital from 1996 through 2002, was eligible for evaluation after a median interval of 102 months (range = 12–158).
  • The time between surgery and recurrence of reflux symptoms (i.e., time to treatment failure) served as the end point for statistical analysis.
  • Putative risk factors for symptom recurrence were analyzed by univariate analysis and by using Cox’s multiple–hazards regression.

Results

  • According to Kaplan–Meier estimates, the rate of reflux symptom recurrence was 15 % after 108 months, 11 % in cases without intestinal metaplasia, but 43 % in patients with long–segment ≥3 cm) Barrett’s esophagus (BE; p < 0.0001).
  • Reflux symptoms recurred in 22 % of cases with a hiatal hernia (HH) ≥3 cm before operation, but only in 7 % with smaller or absent HH (p = 0.005).
  • Multivariate analysis revealed a relative risk of 6.6 (CI = 3.0–13.0) for long–segment BE and 3.0 (CI = 1.7–10.1) for HH ≥ 3 cm.
  • A strong statistical interaction was found between HH ≥3 cm and long–segment BE: the small group (n = 18) of cases exhibiting both risk factors had an exaggerated recurrence rate of 72 % at 108 months.

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