Background: Gastroesophageal reflux disease (GERD) presents with typical and atypical symptoms, making diagnosis and treatment more complex. Currently, our understanding of the differences in characteristics and outcomes of patients with typical and atypical symptoms undergoing anti-reflux surgery (ARS) is limited. Our study addresses this gap by comparing peri-operative characteristics and postoperative outcomes in these subgroups.
Method: A database of patients who underwent robotic ARS from January 2012 to November 2023 was reviewed. Patients with preoperative GERD symptoms were categorized into three groups: typical only, atypical only, and a combination of both. Perioperative characteristics, patient-reported symptoms, GERD-HRQL questionnaire data, and intra-operative impedance planimetry results were compared among the 3 symptom groups.
Results: Of the 705 patients, 334 (47.37%) had only typical symptoms, 98 (13.90%) had only atypical symptoms, and 273 (38.72%) had mixed symptoms preoperatively. Baseline characteristics were comparable. Following ARS, atypical symptoms resolved in 71.67% of patients with only atypical symptoms and 71.34% with mixed symptoms. Typical symptoms resolved in 80.00% of patients with only typical symptoms and 81.71% with mixed symptoms. Pre-operative HRQL scores differed significantly among the groups: 24.00 (IQR 8.00-33.00) in atypical, 34.00 (IQR 23.25-48.00) in mixed, and 34.50 (IQR 21.50-49.25) in typical (p=0.003). Following surgery, though HRQL score improvements were lower for patients with only atypical symptoms (17.00, IQR6.00-26.00) compared to typical (26.00,IQR 5.50-38.25) and both symptoms (26.00, IQR13.00-38.00), differences were not significant (p=0.127). Impedance planimetry revealed no significant differences in pre- and post-operative cross-sectional area, distensibility, and post-operative high-pressure zone (HPZ) between the groups. However, significant variations were observed in the pre-repair pressure (atypical: 19.75 mmHg (IQR16.53-25.88), mixed: 21.60 mmHg (IQR17.40-27.20), and typical: 22.50 mmHg (IQR17.70-28.90), p=0.047). Post-repair, pressure improved in all groups but remained varied significantly (p=0.044). HPZ improvement during surgery was notably higher in patients with typical symptoms (atypical: 1.00 cm (IQR0.50-1.50), typical: 1.50 cm (IQR1.00-2.00), and mixed: 1.50 cm (IQR1.00-2.00), p=0.016).
Conclusion: Individuals with atypical GERD symptoms tend to experience less postoperative improvement compared to those with typical symptoms, although both groups respond well to surgical intervention with dramatic symptom improvement. Clear differences in impedance planimetry measurements were identified. Further investigation is needed to correlate these findings with reflux. These insights emphasize the challenges in achieving optimal surgical outcomes for patients with atypical symptoms.

Benjamin Greenspun

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