The preoperative reflux pattern as prognostic indicator for long-term outcome after Nissen fundoplication

We set out to investigate the impact of the preoperative reflux pattern on long-term outcome after Nissen fundoplication. Recent studies disagree on whether patients with pathological upright reflux should be discouraged from undergoing surgery.

A total of 338 patients underwent Nissen fundoplication. Of these, 234 of 289 patients had pathological acid exposure on preoperative 24-h esophageal pH monitoring and their reflux was classified as pathological upright (n=81), supine (n=55), or bipositional (n=98). Clinical outcomes and results of endoscopy, manometry, and 24-h pH monitoring were compared before surgery, and at 3 months and 5 years after surgery.

Patients with pathological upright and supine reflux had similar preoperative reflux parameters. In patients with pathological bipositional reflux, however, preoperative total acid exposure was higher than that in patients with upright or supine reflux (18.3% vs. 10.7 and 7.5%; P<0.001 and P<0.001). Prevalence of esophagitis was higher in patients with bipositional reflux than in those with upright reflux, both before (64.0 vs. 45.6%; P=0.035) and 3 months after surgery (16.0 vs. 3.5%; P=0.018). Before surgery, mean lower esophageal sphincter (LES) pressure was lower compared with the upright and supine reflux groups (1.0 vs. 1.5 and 1.6 kPa; P=0.007 and 0.005, respectively). The increase in quality of life, reduction of symptoms, use of acid-suppressing drugs, total acid exposure, and esophagitis were independent of reflux pattern at 3 months and 5 years after surgery (all P<0.05). Prevalence of recurrent pathological acid exposure was higher in the bipositional group than in the upright group (40.9 vs. 10.7%; P=0.013). Surgical reintervention was significantly more common in bipositional reflux patients (20.0 vs. 8.9% for upright and 4.1% for supine).

All three pathological reflux patterns respond favorably to Nissen fundoplication in the long term. Patients with pathological bipositional reflux, however, suffer from more severe disease with higher chance of recurrence and reoperation.