Postoperative objective outcomes for upright, supine, and bipositional reflux disease following laparoscopic Nissen fundoplication

Hypothesis: Traditionally, patients with gastroesophageal reflux disease fall into 3 categories based on 24-hour pH testing and the clinical occurrence of their acid exposure. Patients with upright reflux are believed to do worse following surgery compared with supine or bipositional reflux patients. We assessed objective postoperative outcomes for patients with upright, supine, and bipositional reflux following laparoscopic Nissen fundoplication to determine if there is a category of refluxing patient who should be counseled against antireflux surgery. Design: Retrospective analysis of prospectively collected data. Setting: Esophageal physiology laboratory at a tertiary care teaching hospital. Patients: A total of 225 patients (supine, 45; upright, 92; bipositional, 88) with preoperative and postoperative 24-hour pH measurements, manometry results, and standardized symptom assessment forms were included in the study. Interventions: A Nissen fundoplication was performed based on 24-hour pH and manometry result. Esophageal manometry was performed with a water-perfused system, and 24-hour pH was measured with a digital capture device. Main Outcome Measures: Preoperative and postoperative symptom correlation, 24-hour pH, and manometric variables. Results: There was a significant difference in preoperative symptom correlation between groups. Patients with bipositional reflux disease have significantly worst reflux disease (percentage of time with a pH <4, total number of reflux episodes, longest reflux episode, and Johnson-DeMeester score) and the weakest preoperative lower esophageal sphincter pressure. Postoperative symptom correlation was low among all 3 groups. There was no significant difference in postoperative 24-hour pH or manometry among groups. Success following surgery was achieved in 73.3% with supine reflux, 80.4% with upright reflux, and 75.0% with bipositional reflux. Conclusions: Patients with bipositional reflux have the most severe disease. Supine, upright, and bipositional reflux patients perform equally well following laparoscopic fundoplication as defined by objective outcome criteria.