High Rate of GERD Recurrence After Antireflux Surgery

Jennifer Garcia

September 12, 2017

Nearly 18% of patients who undergo primary laparoscopic antireflux surgery will experience recurrent gastroesophageal reflux disease (GERD) requiring long-term medication or a secondary surgery. These findings were published online September 12 in JAMA.

"Laparoscopic antireflux surgery was associated with a relatively high rate of recurrent [GERD] requiring treatment, diminishing some of the benefits of the operation," write John Maret-Ouda, MD, from Karolinska University, Stockholm, Sweden, and colleagues.

Researchers retrospectively evaluated national registry data from 2655 patients in Sweden who underwent primary laparoscopic antireflux surgery between January 1, 2005, and December 31, 2014. The median age of patients in the cohort was 51.0 years, and sex distribution was even. Patients were followed for a median of 5.6 years.

The researchers found that 470 (17.7%) of the patients experienced a recurrence of their reflux after primary laparoscopic antireflux surgery. The authors defined recurrence as the use of antireflux medications for at least 6 months or the need for a second antireflux surgery. Among the patients with recurrent GERD, 83.6% required long-term treatment with proton pump inhibitors or histamine2 receptor antagonists, whereas 16.4% underwent secondary antireflux surgery.

In addition, the researchers found that female patients, those who were at least 61 years of age, and patients with a Charlson comorbidity index score of 1 or higher had the greatest risk for reflux recurrence after surgery. Hospital volume of antireflux surgery, in contrast, was not found to be associated with the risk for reflux recurrence.

The authors note that although previously published clinical trials report similar recurrence rates to the present study, similar cohort studies have reported higher rates. They postulate that the lower rates reported in the present study may be a result of the larger sample size or relate to patient selection and higher quality of surgery.

The authors acknowledge study limitations such as the lack of a control group and the inability to account for use of over-the-counter antireflux medication, which may have led to underestimation of GERD recurrence.

In an accompanying editorial, Stuart J. Spechler, MD, from Baylor University Medical Center, Dallas, Texas, writes: "the observation that more than 80% of patients did not restart antireflux medications after laparoscopic antireflux surgery suggests that the operation provided long-lasting relief of GERD symptoms for most patients."

Dr Spechler goes on to point out that antireflux medications are often inappropriately prescribed for reasons that may have nothing to do with GERD, so basing recurrence on prolonged use of antireflux medication may have overestimated the recurrence rate.

Ultimately, Dr Spechler notes, the clinician's decision to recommend antireflux surgery will depend on individual patient concerns, disease severity, and associated risk for recurrence.

"The study by Maret-Ouda et al suggests that laparoscopic antireflux surgery might be an especially appealing option for young and otherwise healthy men, who seem to have the lowest rate of GERD recurrence after antireflux surgery and who otherwise would likely require decades of [proton pump inhibitor] treatment without the operation," concluded Dr Spechler.

Funding for the study was provided by the Swedish Research Council. The study authors and editorialist have disclosed no relevant financial relationships.

JAMA. 2017;318:913-915, 939-946. Article abstract, Editorial extract

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