A. D. Jalilvand1, S. E. Martin Del Campo1, J. W. Hazey1, K. A. Perry1 1Ohio State University,Columbus, OH, USA
Background: Laparoscopic Nissen fundoplication (LNF) is the gold standard for surgical reflux control in patients with objective evidence of gastroesophageal reflux disease (GERD). Symptom association probability (SAP) score is used with pH testing to correlate symptoms to reflux events, with scores above 95% implying a high correlation to reflux exposure. It is unclear whether these scores impact the outcomes of laparoscopic anti-reflux surgery. We hypothesize that a negative SAP score for typical GERD symptoms in the setting of a positive pH test is not associated with persistent symptoms after LNF.
Methods: We reviewed all patients undergoing LNF for objectively confirmed GERD between May 2011 and June 2016. Patients without pH testing due to complicated GERD or who did not have SAP scores were excluded from this analysis. SAP scores >95% were considered positive and those <95% were considered negative. Reflux symptoms and quality of life were assessed using the Gastroesophageal Reflux Symptom Scale (GERSS) and Gastroesophageal Reflux Disease Health-Related Quality of Life (GERD-HRQL) questionnaires. Baseline and post-operative data were collected in the clinic setting. Data are presented as incidence (%), mean ± SD, or median (IQ range) as appropriate, and a p-value of <0.05 was considered statistically significant.
Results: LNF was performed in 142 patients during the study period with an average age of 48.5 ± 13.5 years, BMI of 31.3 ± 5.6, and 78% (n=111) were female. Median preoperative DeMeester score was 38.5 (28.0-54.4), baseline GERSS was 37.5 (26.0-51.0) and GERD-HRQL was 32 (22.0-37.5). Patient characteristics and baseline symptoms did not differ between positive and negative SAP scores. Positive SAP scores were reported in 63% of patients for heartburn, 64.4% for regurgitation, and 40.9% for chest pain. Compared to baseline, GERSS improved from 36 (26-50) to 8 (2-16, p<0.001) in those with positive SAP for heartburn and 39 (28-54) to 8 (0-13, p<0.001) with negative SAP. GERD-HRQL scores improved from 31.5 (22-37) to 4 (2-8, p<0.001) and 34 (22-39) to 4 (1-11, p<0.001) respectively. Postoperative GERSS (p=0.923) and GERD-HRQL (p=0.600) scores did not differ between groups. Complete resolution of HB was achieved in 86.8% of patients with positive SAP compared to 66.7% of patients with negative SAP for HB (p=0.065). There were no significant differences in postoperative GERSS, GERD-HRQL, or symptom resolution following LNF for patients with positive and negative SAP for regurgitation or chest pain.
Conclusion: LNF achieves excellent symptom control and improves disease-specific quality of life in patients with symptomatic GERD confirmed by pH testing. Negative SAP scores for typical GERD symptoms are not associated with higher GERD symptom scores or reduced disease-specific quality of life following LNF and should not be used to select patients for laparoscopic anti-reflux surgery in this setting.