Association between laparoscopic antireflux surgery and recurrence of gastroesophageal reflux
Author: Maret-Ouda, John; Wahlin, Karl; El-Serag, Hashem B; Lagergren, Jesper
Department: Inst för molekylär medicin och kirurgi / Dept of Molecular Medicine and Surgery
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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 outcomewas 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.
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 outcomewas 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.
Institution:
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
- Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, USA
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- School of Cancer Sciences, King’s College London, London, United Kingdom
Citation: JAMA. 2017 Sep 12;318(10):939-946.
Citation DOI: 10.1001/jama.2017.10981
Citation PMID: 28898377
Citation ISI: 000410487100015
Publishing journal: Journal of the American Medical Association
Eprint status: Peer Reviewed
Version: Published
Issue date: 2018-03-09
Sponsorship: Swedish Research Council, D0547801
Rights:
Article is made available in accordance with the publisher's policy and may be subject to copyright law. Please refer to the publisher's site for terms of use.
Publication year: 2017
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