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Medical Meeting Reports

American College of Surgery Clinical Congress

October 10-15, 1999

font=>By Paul Recchia, Ph.D.

Despite the moderate success of medicinal therapy for reflux, antireflux surgery is often the better choice for select patients, according to this panel of experts moderated by Jeffrey Peters, MD, University of Southern California.

Indications for Laparoscopic Fundoplication

Ronald Hinder, MD, St. Luke's Hospital, Jacksonville, FL, explained that over 80% of patients with chronic reflux would relapse after going off medication. Particularly for the young, antireflux surgery can often be a better option, lowering disease activity permanently. According to a study in the Journal of Gastrointestinal Surgery earlier this year, a good response in patients receiving medicinal therapy was a positive predictor for good laparoscopic antireflux surgery outcome. Furthermore, according to another study, antireflux laparoscopic surgery improves pulmonary symptoms in 86% of patients. Dr. Hinder suggests that surgeons can predict positive surgical outcome when the patient in question is young and responds well to 24 hour pH testing, has typical reflux symptoms, and shows positive response to medical therapy.

Indications for Open Fundoplication

Steven DeMeester, MD, University of Southern California, spoke up against the popular tide of minimally invasive surgery by citing a Swedish study that found that patients do not care about the size of the scar(s), but do care about the removal of presurgical symptoms. According to Dr. DeMeester, there are circumstances where open surgery is advantageous. Some resurgery may be due to inappropriate laparoscopic surgery. For example, laparoscopic antireflux surgery on patients with short esophagus often fails. Considering that 25% of patients having laparoscopic antireflux surgery require resurgery, surgeons may want to consider open antireflux surgery in certain circumstances. Obesity is an independent factor that negatively effects antireflux laparoscopic surgery, and may warrant open antireflux surgery.

Outcome Following Fundoplication

David Rattner, MD, Harvard University, claims the most important antireflux surgery outcome measure is the patient perception of whether the problem was fixed. Relief of the primary symptom appears to be high (75% with laparoscopic antireflux surgery) for patients with the well-defined characteristics mentioned by Dr. Hinder, above, but lower for more advanced cases, such as Barrette's Esophageal disease. A trend that should be monitored is that many patients are being referred for antireflux surgery, but if the patient has asthma or pulmonary symptoms, surgery may not help. Therefore, patient selection is very important. Dr. Rattner feels that 24-hour pH reading is the primary predictor. Furthermore, a double probe designed to read high and low 24-hour pH within the esophagus is best because a positive proximal probe reading is highly predictive of antireflux surgery success. One negative outcome of antireflux surgery verses medicinal therapy is the high rate of bloating after antireflux surgery. Postsurgical patients should be followed up for 3 months before the benefits of the operation become apparent.

For professional correspondence, please contact Dr. Peters at jhpeters@hsc.usc.edu or Dr. Rattner at rattner.david@mgh.harvard.edu.

Ortho Biotech

Funded through an unrestricted educational grant by Ortho Biotech.

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