title: Clinical outcomes of atypical extra-esophageal reflux symptoms following laparoscopic antireflux surgery.
abstract: BACKGROUND
  While it is well established that antireflux surgery is effective in relieving typical gastroesophageal reflux disease (GERD) symptoms such as heartburn and regurgitation, it is currently unclear whether atypical symptoms (cough, hoarseness, wheeze) foreshadow a less satisfactory outcome following laparoscopic antireflux surgery (LARS). The purpose of this study is to critically analyze the clinical outcomes of atypical symptoms in patients undergoing LARS.
  
  
  METHODS
  Patients scheduled for LARS for GERD were prospectively enrolled over a 7-year period; all subjects underwent preoperative high-resolution manometry (HRM) and had evidence of GERD on ambulatory pH study. Cough, wheeze, and hoarseness were considered atypical symptoms. During preoperative and postoperative examinations, patients completed detailed foregut symptomatology questionnaires, using both 5-point Likert and 10-point visual analog scales (VAS) to document typical as well as atypical symptoms. Atypical symptom burden was calculated as a sum of VAS for the three atypical symptoms, termed the atypical score (ATS). HRM patterns were grouped into normal, spastic, and hypomotile. Statistical significance (p < 0.05) was determined using paired t-test, and analysis of variance with post hoc least significant difference (LSD).
  
  
  RESULTS
  One hundred thirteen patients (age 49 ± 1.26 years, range 20-84 years, M:F 47:66) with mean follow-up of 28 ± 2.31 months (range 1-92 months) fulfilled inclusion criteria, having mean modified DeMeester score of 45.5 ± 2.78. Heartburn was noted in 84.1%, while atypical symptoms of some degree were reported by 92.0% (104 patients). Heartburn improved from a preoperative score of 7.1 ± 0.54 to 0.9 ± 0.24 after LARS, and ATS improved from 8.9 ± 0.71 to 2.2 ± 0.42. Significant improvements were noted for all atypical symptoms analyzed (p < 0.0001 for each). Improvement in atypical symptoms was least in the presence of hypomotility features on HRM (21.7% improvement), compared with normal motility (72.4%) and spastic features (83.9%). Preoperative atypical score (p < 0.0001) and esophageal hypomotility (p = 0.04) demonstrated a linear relationship with postoperative atypical score.
  
  
  CONCLUSIONS
  In an unselected cohort of patients undergoing LARS, atypical GERD symptoms improved as significantly as typical symptoms. Symptom improvement was significantly lower in the presence of esophageal hypomotility and with higher symptomatic state. Therefore, patients with severe atypical symptoms or hypomotile esophagus may not achieve the same clinical satisfaction from LARS.
authors: Section of Minimally Invasive Surgery, Department of Surgery, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8109, St. Louis, MO 63110, USA.
authors: Shaun R
authors: SR
authors: Brown
authors: C Prakash
authors: CP
authors: Gyawali
authors: Lora
authors: L
authors: Melman
authors: Eric D
authors: ED
authors: Jenkins
authors: Julia
authors: J
authors: Bader
authors: Margaret M
authors: MM
authors: Frisella
authors: L Michael
authors: LM
authors: Brunt
authors: J Christopher
authors: JC
authors: Eagon
authors: Brent D
authors: BD
authors: Matthews
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002637:Chest Pain / Q000209:etiology; D003371:Cough / Q000209:etiology; D003680:Deglutition Disorders / Q000209:etiology; D005260:Female; D018662:Fundoplication / Q000379:methods*; D005764:Gastroesophageal Reflux / Q000150:complications / Q000601:surgery*; D006356:Heartburn / Q000209:etiology; D006801:Humans; D006863:Hydrogen-Ion Concentration; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008365:Manometry / Q000379:methods; D008875:Middle Aged; D018670:Monitoring, Ambulatory; D011446:Prospective Studies; D012135:Respiratory Sounds; D016896:Treatment Outcome; D055815:Young Adult