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Surgical Treatment for Laryngopharyngeal Reflux DiseaseA Systematic Review

Educational Objective
To determine whether surgical approaches, particularly fundoplication, are associated with effective control of both signs and symptoms that have been attributed to laryngopharyngeal reflux disease.
1 Credit CME
Key Points

Question  What is the efficacy of fundoplication in controlling signs and symptoms associated with laryngopharyngeal reflux?

Findings  This systematic review of 34 studies comprising 2190 patients with laryngopharyngeal reflux found that 83.0% of patients have shown partial relief of symptoms and 67.0% of patients have shown complete relief of symptoms, but these rates vary significantly between studies because of a high level of methodological heterogeneity according to method of diagnosis, exclusion criteria, and outcomes used to assess the efficacy of fundoplication. Many usual signs and symptoms associated with laryngopharyngeal reflux were not taken into consideration in the clinical outcomes.

Meaning  The heterogeneity among studies makes it impossible to establish clear consensus about the definition of laryngopharyngeal reflux or reliable conclusions about the effectiveness of fundoplication in controlling symptoms and signs associated with laryngopharyngeal reflux disease.

Abstract

Importance  Laryngopharyngeal reflux (LPR) is a prevalent disease that is usually treated with diet, lifestyle modifications, and proton pump inhibitor therapy. However, nearly 10% to 30% of patients do not achieve adequate acid suppression even with high doses of proton pump inhibitors. For these patients with resistant disease, fundoplication may be recommended but the success rate of fundoplication surgery on laryngopharyngeal symptoms and findings remains uncertain.

Objective  To determine whether fundoplication is associated with control of signs and symptoms in patients with LPR.

Evidence Review  A literature search was conducted on PubMed, Cochrane Library, and Scopus according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline to identify studies published between 1990 and 2018 about the efficacy of fundoplication on clinical outcomes of LPR. Three investigators screened publications for eligibility and exclusion based on predetermined criteria. Study design, patient characteristics, diagnostic method, exclusion criteria, treatment characteristics, follow-up, and quality of the outcome assessment were evaluated.

Findings  Of the 266 studies identified, 34 met the inclusion criteria, accounting for 2190 patients with LPR (1270 women and 920 men; mean [SD] age at the time of surgery, 49.3 [6.3] years). A weighted mean of 83.0% of patients (95% CI, 79.7%-86.3%) experienced improvement and a weighted mean of 67.0% of patients (95% CI, 64.1%-69.9%) experienced a disappearance of symptoms, but there is a high level of methodological heterogeneity among studies according to diagnostic method, exclusion criteria, and outcomes used to assess the efficacy of fundoplication. A pH study without impedance study was used in most studies but with various inclusion criteria. According to results of an a priori assessment, the clinical outcomes used were overall poor, excluding many symptoms and findings associated with LPR.

Conclusion and Relevance  The reported studies of fundoplication in LPR disease have important heterogeneity in method of diagnosis, exclusion criteria, symptoms, and signs assessed as therapeutic outcomes; therefore, this systematic review was nonconclusive regarding whether surgery for LPR disease is associated with effective control of sight and symptoms. Otolaryngologists, gastroenterologists, and surgeons must establish a diagnostic criterion standard, clear indications for surgery, and future clinical outcomes to precisely assess the effectiveness of treatment.

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: February 11, 2019.

Corresponding Author: Jérôme R. Lechien, MD, PhD, MS, Laboratory of Anatomy and Cell Biology, Faculty of Medicine, University of Mons Research Institute for Health Sciences and Technology, University of Mons, Avenue du Champ de Mars, 6, B7000 Mons, Belgium (jerome.lechien@umons.ac.be).

Published Online: May 2, 2019. doi:10.1001/jamaoto.2019.0315

Author Contributions: Drs Lechien and Saussez had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Saussez and Fisichella contributed equally to this work and should be regarded as co–last authors.

Concept and design: Dapri, Dequanter, Rodriguez Ruiz, Marechal, De Marrez, Saussez.

Acquisition, analysis, or interpretation of data: Lechien, De Marrez, Saussez, Fisichella.

Drafting of the manuscript: Lechien, Saussez.

Critical revision of the manuscript for important intellectual content: Dapri, Dequanter, Rodriguez Ruiz, Marechal, De Marrez, Saussez, Fisichella.

Statistical analysis: Fisichella.

Administrative, technical, or material support: Marechal, De Marrez.

Supervision: Lechien, Dequanter, Rodriguez Ruiz, Saussez.

Conflict of Interest Disclosures: None reported.

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