Surgical fundoplication in laryngopharyngeal reflux unresponsive to aggressive acid suppression: a controlled study.
OBJECTIVE
In patients with persistent laryngeal symptoms despite aggressive proton pump inhibitor therapy, gastroesophageal reflux disease (GERD) continues to be implicated. The role of surgical fundoplication as the definitive therapy for these patients is uncertain.


METHODS
In this prospective concurrent controlled study, 72 patients with suspected GERD-related laryngeal symptoms received aggressive acid-suppressive therapy. Four-month symptomatic nonresponders (<50% improvement) with continued laryngeal inflammation and normalized esophageal acid exposure were offered laparoscopic Nissen fundoplication. The primary outcome was symptom improvement/resolution at 1 year after surgery.


RESULTS
Twenty-five of 72 (35%) patients remained unresponsive after 4 months of acid-suppressive therapy. Ten patients (40%) underwent surgical fundoplication (median age, 54 y; men, 4) and 15 patients (60%) continued medical therapy (median age, 52; men, 4). The most common laryngeal symptoms were sore throat, hoarseness, and cough. pH studies at 3 and 12 months were normal in all patients after fundoplication (median % time pH < 4, .0% and .3%; respectively). One of 10 (10%) patients in the surgery group reported improvement of laryngeal symptoms at 1 year compared with 1 of 15 in the control group (6.7%) (P = 1.0). Treatment of causes other than GERD improved symptoms in an additional 2 of 10 (20%) patients in the surgical group, and 10 of 15 (66%) patients in the nonsurgical cohort.


CONCLUSIONS
Surgical fundoplication does not improve laryngeal symptoms reliably in patients unresponsive to aggressive proton pump inhibitor therapy. The argument of low volume or intermittent reflux as the cause of persistent laryngeal symptoms needs to be replaced with evaluation and therapy for other potential non-GERD causes.
Swoger
Jason
J
Department of Gastroenterology and Hepatology, Center for Swallowing and Esophageal Disorders, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
Ponsky
Jeff
J
Hicks
Douglas M
DM
Richter
Joel E
JE
Abelson
Tom I
TI
Milstein
Claudio
C
Qadeer
Mohammed A
MA
Vaezi
Michael F
MF
D000328:Adult; D000368:Aged; D000897:Anti-Ulcer Agents / Q000627:therapeutic use; D005260:Female; D005500:Follow-Up Studies; D018662:Fundoplication; D005764:Gastroesophageal Reflux / Q000188:drug therapy / Q000473:pathology / Q000601:surgery*; D006801:Humans; D007013:Hypopharynx; D007828:Laryngoscopy; D008297:Male; D008365:Manometry; D008875:Middle Aged; D011446:Prospective Studies
D000897:Anti-Ulcer Agents