Assessment of diaphragmatic stressors as risk factors for symptomatic failure of laparoscopic nissen fundoplication.
An important limitation of antireflux surgery is a 5%-10% failure rate. We investigated the correlation between various diaphragm stressors and failure of antireflux surgery. Forty-one study cases who underwent a reoperative antireflux operation from 1997 to 2001 and 50 control patients who had undergone a successful laparoscopic Nissen fundoplication during the same period without clinical or symptomatic evidence of failure were randomly selected for comparison. A retrospective analysis was conducted utilizing a standardized diaphragm stressor questionnaire, addressing the period between the primary and secondary operation. Stressors considered in the study included height, body mass index (BMI), postoperative gagging, vomiting, weight lifting (greater than 100 pounds), coughing, hiccuping, motion sickness, retching, belching, antidepressant use, smoking, preoperative grade of esophagitis, size of hiatal hernia, lower esophageal sphincter pressure, esophageal body pressures, and preoperative response to proton pump inhibitors. Of the potential stressors investigated, the following were significantly associated with surgical failure after adjusting for other variables through multivariate analysis: gagging (P = 0.005), belching (P = 0.02), and hernia size greater than 3 cm (P = 0.04; Table 1). Other potential risk factors show trends as obvious in Fig. 2. Vomiting was significant (P = 0.01) in the earlier models but lost significance when logistic regression was applied. Patients with postoperative gagging and an intraoperative hiatal hernia (greater than 3 cm) have a poorer outcome, whereas patients with postoperative belching have a better long-term outcome.
Iqbal
Atif
A
Department of Surgery, Creighton University School of Medicine, Omaha, Nebraska, 68131, USA.
Kakarlapudi
Ganesh V
GV
Awad
Ziad T
ZT
Haynatzki
Gleb
G
Turaga
Kiran K
KK
Karu
Anouki
A
Fritz
Katie
K
Haider
Mumnoon
M
Mittal
Sumeet K
SK
Filipi
Charles J
CJ
D000293:Adolescent; D000328:Adult; D000368:Aged; D000928:Antidepressive Agents / Q000627:therapeutic use; D001827:Body Height / Q000502:physiology; D015992:Body Mass Index; D016022:Case-Control Studies; D003371:Cough / Q000503:physiopathology; D003964:Diaphragm / Q000503:physiopathology*; D004884:Eructation / Q000503:physiopathology; D004941:Esophagitis / Q000503:physiopathology; D005260:Female; D005500:Follow-Up Studies; D018662:Fundoplication / Q000379:methods*; D005683:Gagging / Q000502:physiology; D005764:Gastroesophageal Reflux / Q000601:surgery*; D006551:Hernia, Hiatal / Q000150:complications; D006606:Hiccup / Q000503:physiopathology; D006801:Humans; D010535:Laparoscopy / Q000379:methods; D008297:Male; D008875:Middle Aged; D009041:Motion Sickness / Q000503:physiopathology; D020250:Postoperative Nausea and Vomiting / Q000209:etiology; D012189:Retrospective Studies; D012307:Risk Factors; D012907:Smoking / Q000503:physiopathology; D017211:Treatment Failure
D000928:Antidepressive Agents