ANTIREFLUX SURGERY’S LIFESPAN: 20 YEARS AFTER LAPAROSCOPIC FUNDOPLICATION

Background: Gastroesophageal reflux disease (GERD), with or without hiatal hernia (HH), affects millions of individuals worldwide, with a significant economic impact and loss of health-related quality of life. Laparoscopic fundoplication is the surgical technique of choice for treating GERD, but only few studies report a follow-up beyond 15 years. In order to determine the best treatment option, it is important to assess the long-term outcome of LARS. The aim of this study was to evaluate the results at least 20 years after LARS performed for GERD and/or large HH at a single referral center for esophageal diseases.
Methods: We prospectively collected data on a cohort of consecutive patients who underwent LARS between 1992 and 2001 at our department. Patients were divided into two groups: a GERD group, comprising patients with pathological esophageal acid exposure, and large hiatal hernia (HH), including patients with >3 cm type I HH and types II-IV hiatal hernias. The study population flowchart is shown on Figure 1. Patients were followed up for at least 20 years using a symptom score (SS), endoscopy, barium-swallow, esophageal manometry, and 24-hour pH-monitoring. LARS was judged to have failed in any of the following cases: a) GERD symptom recurrence (SS >10); b) recurrence of esophagitis; c) HH recurrence or slipped-fundoplication; d) pathological 24-hour pH-monitoring; e) BE progression or onset of adenocarcinoma.
Results: The study population consisted of 137 patients: 107 in the GERD group and 30 in the HH group. The characteristics of patients in the two groups are shown on Figure 2. Conversion to open surgery proved necessary in 8 patients (5.8%), and intraoperative and perioperative complications were recorded in 9 patients (6.5%). At a median follow-up of 22 years, the outcome was positive in 84.1% of the GERD patients, and 63.3% of the HH patients. Revisional surgery was necessary in 9 (6.5%) patients (4 GERD and 5 HH patients). Indications for revisional surgery were a slipped fundoplication or hernia recurrence in 6 cases, a pH-detected abnormal acid reflux and esophagitis resistant to medical therapy in 2 cases, and the herniation of the stomach inside the fundoplication (telescoping) in one case. Overall, GERD patients had a better failure-free survival rate than HH patients (p=0.02). Two decades after LARS, 88.8% of GERD patients and 86.7% of HH patients were satisfied with the procedure.
Conclusion: The present study concerns one of the largest populations of patients who had undergone LARS to have been followed up for more than 20 years at a single center. The findings showed that laparoscopic antireflux surgery is effective and durable (for >20 years) in patients with uncomplicated GERD and, to a lesser extent, in those with a large hiatal hernia. The satisfaction rate more than 20 years after surgery almost reached 90%.