title: Association Between Response to Acid-Suppression Therapy and Efficacy of Antireflux Surgery in Patients With Extraesophageal Reflux.
abstract: OBJECTIVE
  The effectiveness of antireflux surgery (ARS) varies among patients with extraesophageal manifestations of gastroesophageal reflux disease (GERD). By studying a cohort of patients with primary extraesophageal symptoms and abnormal physiologic markers for GERD, we aimed to identify factors associated with positive outcomes from surgery, and compare outcomes to those with typical esophageal manifestations of GERD.
  
  
  METHODS
  We performed a retrospective cohort study to compare adult patients with extraesophageal and typical reflux symptoms who underwent de novo ARS from 2004 through 2012 at a tertiary care center. All 115 patients (79 with typical GERD and 36 with extraesophageal manifestations of GERD) had evidence of abnormal distal esophageal acid exposure based on pH testing or endoscopy. The principle outcome was time to primary symptom recurrence after surgery, based on patient reports of partial or total recurrence of symptoms at follow-up visits. Patients were followed up for a median duration of 66 months (interquartile range, 52-77 mo).
  
  
  RESULTS
  The median time to recurrence of symptoms in the overall cohort was 68 months (11.5 months in the extraesophageal cohort vs >132 months in the typical cohort). Symptom recurrence after ARS was associated with having primarily extraesophageal symptoms (adjusted hazard ratio, 2.34; 95% confidence interval, 1.31-4.17) and poor preoperative symptom response to acid-suppression therapy (AST) (hazard ratio, 3.85; 95% confidence interval, 2.05-7.22). Patients with primary extraesophageal symptoms who had a full or partial preoperative AST response experienced lower rates of symptom recurrence compared to patients with poor AST response (P < .01). The rate of symptom recurrence was lowest among patients with primary typical reflux symptoms who had a partial or full symptom response to AST (P < .01). The severity of acid reflux on pH testing, symptom indices, severity of esophagitis, and hiatal hernia size were not associated with symptom response.
  
  
  CONCLUSIONS
  In a retrospective study, we found the effectiveness of ARS to be less predictable in patients with extraesophageal symptoms of GERD than in patients with typical GERD. Response to AST before surgery was associated with ARS effectiveness in patients with extraesophageal reflux symptoms. Caution should be exercised when advocating ARS for patients with extraesophageal symptoms that do not respond to AST.
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee.
authors.forename: Joseph T
authors.initials: JT
authors.lastname: Krill
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee.
authors.forename: Rishi D
authors.initials: RD
authors.lastname: Naik
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee.
authors.forename: Tina
authors.initials: T
authors.lastname: Higginbotham
authors.affiliation: Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee.
authors.forename: James C
authors.initials: JC
authors.lastname: Slaughter
authors.affiliation: Department of General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.
authors.forename: Michael D
authors.initials: MD
authors.lastname: Holzman
authors.affiliation: Vanderbilt Voice Center, Vanderbilt University Medical Center, Nashville, Tennessee.
authors.forename: David O
authors.initials: DO
authors.lastname: Francis
authors.affiliation: Vanderbilt Voice Center, Vanderbilt University Medical Center, Nashville, Tennessee.
authors.forename: C Gaelyn
authors.initials: CG
authors.lastname: Garrett
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee. Electronic address: Michael.vaezi@vanderbilt.edu.
authors.forename: Michael F
authors.initials: MF
authors.lastname: Vaezi
mesh_terms: D000328:Adult; D000863:Antacids / Q000627:therapeutic use*; D005260:Female; D005500:Follow-Up Studies; D005764:Gastroesophageal Reflux / Q000188:drug therapy* / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012008:Recurrence; D012189:Retrospective Studies; D013514:Surgical Procedures, Operative / Q000379:methods*; D062606:Tertiary Care Centers; D016896:Treatment Outcome
chemical_list: D000863:Antacids
keywords: Acid-Suppression Therapy; Fundoplication; Gastroesophageal Reflux; Laryngopharyngeal Reflux