Fundoplication success in laryngopharyngeal reflux hard to assess

Last Updated: 2019-05-08

By David Douglas

NEW YORK (Reuters Health) - The heterogeneity among studies makes it "impossible" to reliably estimate the effectiveness of fundoplication in controlling laryngopharyngeal reflux disease, according to a review of more than 30 studies.

As Dr. Jerome R. Lechien told Reuters Health by email, "The efficacy of fundoplication is not demonstrated in laryngopharyngeal reflux (LPR). This approach has to be only considered for patients who failed adequate diet and medical treatments."

In a May 2 online paper in JAMA Otolaryngology-Head & Neck Surgery, Dr. Lechien of the University of Mons, Belgium, and colleagues note that as many as 30% of patients have refractory disease and fundoplication may be recommended.

To examine clinical outcomes, the researchers reviewed 34 studies involving 2,190 patients. They found that 83% of patients exhibited significant improvement of symptoms after surgery and 67% of patients considered themselves cured.

Despite this apparent success, the investigators point out that the number of patients in each study ranged from 9 to 324 and "both rates of improvement and cure significantly differed between studies, varying from 10% to 98%."

Moreover, "Many usual signs and symptoms associated with laryngopharyngeal reflux were not taken into consideration in the clinical outcomes."

In addition, although most studies (31) used pH test results for the diagnosis, five different types of tests were employed, two studies used several types of pH tests and seven did not specify the system used. In four studies diagnosis was based on symptoms and laryngoscopic findings.

The investigators conclude, "Otolaryngologists, gastroenterologists, and surgeons must establish a diagnostic criterion standard, clear indications for surgery, and future clinical outcomes to precisely assess the effectiveness of treatment."

And, added, Dr. Lechien, "patients should be informed about the risk of failure of fundoplication."

Commenting by email, Dr. Michael F. Vaezi, co-author of an accompanying editorial, told Reuters Health that "the optimal strategy to treat patients with LPR is challenging. The role of surgical therapy in this group of patients should be critically assessed before embarking on life-long and at times life-altering anatomic alterations."

Dr. Vaezi of Vanderbilt University Medical Center, Nashville, Tennessee, went on to note that as highlighted by the study, "the current literature is fraught with heterogeneity and uncertainty. I recommend a thoughtful and cautious approach in first establishing reflux as the potential cause for patients' extraesophageal symptoms. This in large part can be established by response to medical therapy and presence of anatomic alterations such as hiatal hernia and physiologic testing showing significant esophageal acid exposure."

Dr. Vaezi concluded, "In patients without a hiatal hernia and no reflux or mild reflux by pH testing at baseline, I do not recommend surgical intervention since the short term response achieved post-surgery in many will be met with long-term disappointment."

SOURCE: http://bit.ly/2J88R1B and http://bit.ly/2J9R7TG

JAMA Otolaryngol Head Neck Surg 2019.