title: Who will fail laparoscopic Nissen fundoplication? Preoperative prediction of long-term outcomes.
abstract: BACKGROUND
  A small but significant percentage of patients are considered failures after laparoscopic Nissen fundoplication (LNF). We sought to identify preoperative predictors of failure in a cohort of patients who underwent LNF more than 10 years ago.
  
  
  METHODS
  Of 312 consecutive patients undergoing primary LNF between 1992 and 1995, recent follow-up was obtained from 166 patients at a mean of 11.0 +/- 1.2 years. Eight additional patients who underwent reoperation were lost to follow-up but are included. Failure is broadly defined as any reoperation, lack of satisfaction, or any severe symptoms at follow-up. Potential predictors evaluated included sex, age, body-mass index (BMI), response to acid reducing medications (ARM), psychiatric history, typical versus atypical symptoms, manometry, esophageal pH, and others. Logistic regression was used to assess significance of predictors in univariate analysis.
  
  
  RESULTS
  Of 174 known outcomes, 131 were classified as successful (75.3%), while 43 were failures (24.7%): 26 reoperations, 13 unsatisfied, and 13 with severe symptoms. Response and lack of response to ARM were associated with 77.1% and 56.0% success rates respectively (P = 0.035). Eighty five percent of patients with typical symptoms had a successful outcome, compared to only 41% with atypical symptoms (P < 0.001). Preoperative morbid obesity (BMI > 35 kg/m2) was associated with failure (P = 0.036), while obesity (BMI 30-34.9 kg/m2) was not. A history of psychiatric illness trended toward significance (P = 0.06).
  
  
  CONCLUSIONS
  In a cohort with 11 years follow-up after LNF, factors predictive of a successful outcome include preoperative response to ARM, typical symptoms, and BMI < 35 kg/m2. Patients with atypical symptoms, no response to ARM, or morbid obesity should be informed of their higher risk of failure. Some patients in these groups do have successful outcomes, and further research may clarify which of these patients can benefit from LNF.
authors.affiliation: Endosurgery Unit, Department of Surgery, Emory University School of Medicine, 1364 Clifton Road NE, Suite H-124, Atlanta, Georgia 30322, USA.
authors.forename: Craig B
authors.initials: CB
authors.lastname: Morgenthal
authors.forename: Edward
authors.initials: E
authors.lastname: Lin
authors.forename: Matthew D
authors.initials: MD
authors.lastname: Shane
authors.forename: John G
authors.initials: JG
authors.lastname: Hunter
authors.forename: C Daniel
authors.initials: CD
authors.lastname: Smith
mesh_terms: D000293:Adolescent; D000328:Adult; D017677:Age Distribution; D000368:Aged; D015992:Body Mass Index; D002648:Child; D015331:Cohort Studies; D015897:Comorbidity; D005260:Female; D018662:Fundoplication / Q000706:statistics & numerical data*; D005764:Gastroesophageal Reflux / Q000453:epidemiology / Q000601:surgery*; D005845:Georgia / Q000453:epidemiology; D006551:Hernia, Hiatal / Q000453:epidemiology; D006801:Humans; D010535:Laparoscopy / Q000706:statistics & numerical data*; D008137:Longitudinal Studies; D008297:Male; D001523:Mental Disorders / Q000453:epidemiology; D008875:Middle Aged; D009767:Obesity, Morbid / Q000453:epidemiology; D010043:Outcome and Process Assessment, Health Care; D017060:Patient Satisfaction / Q000706:statistics & numerical data; D012086:Reoperation / Q000706:statistics & numerical data; D012307:Risk Factors; D017678:Sex Distribution; D017211:Treatment Failure