Systematic review: laparoscopic fundoplication for gastroesophageal reflux disease in partial responders to proton pump inhibitors

Abstract

Aim: To assess laparoscopic fundoplication (LF) in partial responders to proton pump inhibitors (PPIs) for gastroesophageal reflux disease (GERD).

Methods: We systematically searched PubMed and Embase (1966-Dec 2011) for articles reporting data on LF efficacy in partial responders. Due to a lack of randomized controlled trials, observational studies were included. Of 558 articles screened, 17 were eligible for inclusion. Prevalence data for individual symptoms were collated across studies according to mutually compatible time points (before and/or after LF). Where suitable, prevalence data were presented as percentage of patients reporting symptoms of any frequency or severity.

Results: Due to a lack of standardized reporting of symptoms, the proportion of patients experiencing symptoms was recorded across studies where possible. After LF, the proportion of partial responders with heartburn was reduced from 93.1% (5 studies) to 3.8% (5 studies), with similar results observed for regurgitation [from 78.4% (4 studies) to 1.9% (4 studies)]. However, 10 years after LF, 35.8% (2 studies) of partial responders reported heartburn and 29.1% (1 study) reported regurgitation. The proportion using acid-suppressive medication also increased, from 8.8% (4 studies) in the year after LF to 18.2% (2 studies) at 10 years. In the only study comparing partial responders to PPI therapy with complete responders, higher symptom scores and more frequent acid-suppressive medication use were seen in partial responders after LF.

Conclusion: GERD symptoms improve after LF, but subsequently recur, and acid-suppressive medication use increases. LF may be less effective in partial responders than in complete responders.

Keywords: Gastroesophageal reflux disease; Laparoscopic fundoplication; Partial response, Proton pump inhibitors; Systematic review.

Figure 1

Search strategy.

Figure 2

Proportion of patients reporting heartburn, regurgitation and dysphagia symptoms during preoperative proton pump inhibitor treatment and at follow-up after laparoscopic fundoplication. Superscript numbers indicate individual studies. A: Heartburn; B: Regurgitation; C: Dysphagia.

Figure 3

Effects of laparoscopic fundoplication on esophageal acid exposure (assessed by ambulatory 24-h H measurement) and resting lower esophageal sphincter pressure (assessed by esophageal manometry). Data are shown for before and after laparoscopic fundoplication (LF) (follow-up period: 0.25-1 year). A: Esophageal acid exposure [baseline taken during proton pump inhibitors (PPIs) treatment]; B: Lower esophageal sphincter pressure (LESP) (baseline taken during PPI abstinence).

Figure 4

Proportion of patients using acid-suppressive medication (A) and requiring surgical reintervention (B) after laparoscopic fundoplication.