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Association Between Laparoscopic Antireflux Surgery and Recurrence of Gastroesophageal Reflux

Educational Objective
To understand risk factors for reflux recurrence after laparoscopic antireflux surgery.
1 Credit CME
Key Points

Question  What is the recurrence rate of gastroesophageal reflux after primary laparoscopic antireflux surgery?

Findings  In this retrospective cohort study of 2655 patients who underwent primary laparoscopic antireflux surgery for gastroesophageal reflux disease in 2005-2014, reflux recurrence occurred in 17.7% (83.6% requiring long-term treatment with proton pump inhibitors or histamine2 receptor antagonists, 16.4% undergoing secondary antireflux surgery).

Meaning  Laparoscopic antireflux surgery was associated with a relatively high rate of recurrent gastroesophageal reflux disease requiring long-term medication or secondary antireflux surgery, diminishing some of the benefits of the operation.

Abstract

Importance  Cohort studies, mainly based on questionnaires and interviews, have reported high rates of reflux recurrence after antireflux surgery, which may have contributed to a decline in its use. Reflux recurrence after laparoscopic antireflux surgery has not been assessed in a long-term population-based study of unselected patients.

Objectives  To determine the risk of reflux recurrence after laparoscopic antireflux surgery and to identify risk factors for recurrence.

Design and Setting  Nationwide population-based retrospective cohort study in Sweden between January 1, 2005, and December 31, 2014, based on all Swedish health care and including 2655 patients who underwent laparoscopic antireflux surgery according to the Swedish Patient Registry. Their records were linked to the Swedish Causes of Death Registry and Prescribed Drug Registry.

Exposures  Primary laparoscopic antireflux surgery due to gastroesophageal reflux disease in adults (>18 years).

Main Outcomes and Measures  The outcome was recurrence of reflux, defined as use of antireflux medication (proton pump inhibitors or histamine2 receptor antagonists for >6 months) or secondary antireflux surgery. Multivariable Cox regression was used to assess risk factors for reflux recurrence.

Results  Among all 2655 patients who underwent antireflux surgery (median age, 51.0 years; interquartile range, 40.0-61.0 years; 1354 men [51.0%]) and were followed up for a median of 5.6 years, 470 patients (17.7%) had reflux recurrence; 393 (83.6%) received long-term antireflux medication and 77 (16.4%) underwent secondary antireflux surgery. Risk factors for reflux recurrence included female sex (hazard ratio [HR], 1.57 [95% CI, 1.29-1.90]; 286 of 1301 women [22.0%] and 184 of 1354 men [13.6%] had recurrence of reflux), older age (HR, 1.41 [95% CI, 1.10-1.81] for age ≥61 years compared with ≤45 years; recurrence among 156 of 715 patients and 133 of 989 patients, respectively), and comorbidity (HR, 1.36 [95% CI, 1.13-1.65] for Charlson comorbidity index score ≥1 compared with 0; recurrence among 180 of 804 patients and 290 of 1851 patients, respectively). Hospital volume of antireflux surgery was not associated with risk of reflux recurrence (HR, 1.09 [95% CI, 0.77-1.53] for hospital volume ≤24 surgeries compared with ≥76 surgeries; recurrence among 38 of 266 patients [14.3%] and 271 of 1526 patients [17.8%], respectively).

Conclusions and Relevance  Among patients who underwent primary laparoscopic antireflux surgery, 17.7% experienced recurrent gastroesophageal reflux requiring long-term medication use or secondary antireflux surgery. Risk factors for recurrence were older age, female sex, and comorbidity. Laparoscopic antireflux surgery was associated with a relatively high rate of recurrent gastroesophageal reflux disease requiring treatment, diminishing some of the benefits of the operation.

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Article Information

Corresponding Author: John Maret-Ouda, MD, Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, 171 76 Stockholm, Sweden (john.maret.ouda@ki.se).

Accepted for Publication: July 25, 2017.

Author Contributions: Dr Lagergren had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Maret-Ouda, El-Serag, Lagergren.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Maret-Ouda.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Maret-Ouda, Wahlin.

Obtained funding: Lagergren.

Supervision: Lagergren.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Funding/Support: This study was funded by the Swedish Research Council (grant D0547801).

Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

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