Applying Long-term Follow-up to Improve Patient Selection in Laparoscopic Anti-reflux Surgery

Aim To use registry-based data and long-term quality of life follow up after anti-reflux surgery to quantify efficacy of treatment and to propose a clinically applicable tool to improve patient selection for surgery.

Background Treatment of GERD consists of anti-secretory drugs, mainly proton pump inhibitors, or anti-reflux surgery. Laparoscopic anti-reflux surgery is considered standard of care in surgical treatment of gastro-esophageal reflux disease and with careful patient selection based on thorough preoperative workup; symptom control and patient satisfaction are high compared to medical therapy).

Despite a tailored approach, laparoscopic anti-reflux surgery is not without risks of adverse effects, most notably disruption of the fundoplication, post-fundoplication dysphagia and gas-bloat-syndrome, in some cases leading to reoperation. Furthermore non-surgical factors such as pre-existing anxiety or depression disorders can influence postoperative satisfaction and symptom relief when compared to patients without concomitant psychological disorders.

Although few studies conclude that medical and surgical treatment of GERD have similar effectiveness, disease-specific quality of life generally improves after anti-reflux surgery and patient satisfaction is high. Depending on surgical procedure, the postoperative quality of life, ranges from significantly increased compared to preoperative measurements, to "normal" values as found in subjects devoid of GERD. 73-98% are satisfied with their condition after surgery and would choose surgery again.

Follow-up of randomized clinical trials have demonstrated, that anti-reflux surgery patients use acid suppressing drugs, primarily proton pump inhibitor (PPI) therapy at postoperative follow-up. Use have been considered minimal with <20% using PPI-therapy and 27-44% using PPI at five-year follow-up. A recent register-based study, demonstrated a greater number of redeemed prescriptions of proton pump inhibitor after primary anti-reflux surgery, than previously known. Five-, 10- and 15-year risks of long-term PPI use were 29.4%, 41.1% and 56.6%. However, this register-based study could not examine whether patients had objective recurrence of reflux disease and also did not examine indication for treatment as well as prescribing physician. From 2001 to 2011, 94,4% of PPI where prescribed in primary care and it is unknown why post-fundoplication patients are prescribed PPI. It has previously been demonstrated, that the use of acid suppressing drugs after anti-reflux surgery does not necessarily correlate with abnormal acid exposure to the esophagus . In general, the use of PPI has increased rapidly in Denmark, rising 243% from 2001 to 2011 despite more restrictive guidelines and changes in reimbursement . It must also be taken under consideration that although PPIs are a safe group of drugs, there are possible side effects such as increased risk of fractures, interaction with platelet inhibitor Clopidogrel, increased risk of kidney failure, pneumonia and hypomagnesaemia. As the majority of proton pump inhibitors are prescribed by general practitioners and not by the surgical centers, surgeons have very little knowledge of this aspect of life following anti-reflux surgery.