GERD may recur after laparoscopic antireflux surgery

Last Updated: 2017-09-12

By Megan Brooks

NEW YORK (Reuters Health) - About 18% of patients who have laparoscopic antireflux surgery will suffer recurrent gastroesophageal reflux disease (GERD) requiring long-term medication or another surgery, according to a large Swedish study.

"Laparoscopic antireflux surgery was associated with a relatively high rate of recurrent GERD requiring long-term treatment, diminishing some of the benefits of the operation," the investigators write in JAMA online September 12.

Patients with severe erosive GERD have only two options: taking a proton pump inhibitor (PPI) indefinitely or, in patients with inadequate response to pharmacotherapy, having antireflux surgery with fundoplication. Until now, reflux recurrence after surgery has not been assessed in a long-term population-based study of unselected patients, Dr. John Maret-Ouda, of the Karolinska Institutet in Stockholm and colleagues note in their paper.

Using the Swedish patient registry, they identified 2,655 patients who had laparoscopic antireflux surgery from 2005 through 2014. They defined recurrence of reflux as the postoperative use of antireflux medication for more than six months or repeat antireflux surgery.

During a median follow-up of 5.6 years, 470 patients (17.7%) had recurrence of reflux: 393 used antireflux medication, and 77 had repeat surgery. Reflux recurrence was significantly more common in women (hazard ratio, 1.57), older patients (HR, 1.41, for age 61 or older vs. 45 or younger), and people with comorbid conditions (HR, 1.36, for Charlson comorbidity index score of 1 or higher, versus zero).

In an email to Reuters Health, Dr. Maret-Ouda noted that the risk of reflux recurrence after surgery was "especially low among young and otherwise healthy individuals. Furthermore, the procedure was associated with a low risk of complications. Considering this, antireflux surgery might be an underused treatment option in current clinical practice, especially among young and healthy individuals with severe reflux, patients who otherwise often require long-term, sometimes even life-long, medication."

Commenting on the results in a JAMA editorial, Dr. Stuart Spechler, of the Center for Esophageal Disease, Baylor University Medical Center at Dallas says, "How patients and physicians view the 17.7% recurrence rate is a matter of perspective. Clearly, antireflux surgery is not the permanent cure for GERD in all patients, as it was sometimes promoted to be in the 1980s and 1990s. On the other hand, most patients seem to obtain long-lasting benefit, especially men who are young and otherwise healthy."

"Whether the greater than 80% possibility of long-term freedom from PPIs and their associated risks warrants the 4% risk of acute surgical complications and the 17.7% risk of GERD recurrence is a decision that individual patients should make after a detailed discussion of these risks and benefits with their physicians," writes Dr. Spechler.

The study findings suggest that laparoscopic antireflux surgery might be "an especially appealing option for young and otherwise healthy men, who seem to have the lowest rate of GERD recurrence after antireflux surgery and who otherwise would likely require decades of PPI treatment without the operation. Although the study did not identify low hospital volume of laparoscopic antireflux surgeries as a risk factor for GERD recurrence, antireflux surgery should be performed only by a skilled surgeon who is highly experienced with the procedure," Dr. Spechler concludes.

SOURCES: http://bit.ly/2wmGAcO and http://bit.ly/2gZBPUy

JAMA 2017.