Postoperative symptoms and failure after antireflux surgery

Background: Outcomes in patients having surgery for gastroesophageal reflux disease are most commonly determined by symptomatic assessment. Objective testing is usually, reserved for symptomatic patients. Hypothesis: To evaluate the relationship between symptomatic and objective outcomes after antireflux surgery. Design: Retrospective analysis of prospectively collected data. Setting: A tertiary, care teaching hospital with a comprehensive esophageal physiology laboratory. Interventions: A 360degrees (Nissen) fundoplication or a 270degrees (Toupet) posterior fundoplication was performed based on esophageal motility,. Twenty-four-hour pH monitoring was used as a gold standard for assessing postoperative acid reflux. Patients: Two hundred nine consecutive patients with preoperative and postoperative symptomatic and objective testing performed between January, 1, 1996, and June 15, 2001. Main Outcome Measures: Data on preoperative and postoperative symptoms, DeMeester scores, and esophageal motility, were prospectively collected. Objective testing was performed after at least 6 months. Results: The preoperative median DeMeester score was 50.0 (interquartile [IQ] range, 30.3-87.0). One hundred eighth, patients had a Nissen and 29 patients had a Toupet fundoplication, After a median postoperative interval of 7.7 months (IQ range, 6.7-9.5 months), 174 patients (83.3%) had normal DcMeester scores (median, 2.2 IQ range, 0.8-5.0; P<.001). Of 58 patients (27.7%) who had reflux symptoms after surgery, only 17 (29.3%) had abnormal DeMeester scores (median, 36.9; IQ range, 748.4-20.0; P=.001). Eighteen (11.9%) of the 151 asymptomatic patients had abnormal DeMeester scores (median, 32.5 IQ range, 22.2-57.5; P=.006). Conclusions: There is poor correlation between postoperative reflux symptoms and actual reflux (abnormal DeMeester scores). Surgeons must be careful to define their terms when reporting success or failure rates after antireflux surgery,. Routine use of medical therapy, for suppressing postoperative gastroesophageal reflux disease symptoms is not supported by these data, and postoperative therapy should be based on objective testing only,