Comorbidity of aerophagia in GERD patients: outcome of laparoscopic antireflux surgery.

BACKGROUND: While there is evidence that physiological data correlate poorly with quality-of-life data or patient-perceived symptom severity, most outcome studies of antireflux surgery still refer physiologic criteria. The aim of this prospective study was to establish whether concomitant aerophagia in GERD (gastroesophageal reflux disease) patients might influence the surgical outcome of laparoscopic 'floppy' Nissen fundoplication.
METHODS: A total of 112 patients were divided into 2 subgroups: group 1 comprising GERD patients without aerophagia (n = 94; 84%); group 2 of GERD patients with concomitant aerophagia (n = 28; 16%). In all patients, requirements for surgery included an evaluation of symptoms (list of 17 symptoms; patients' grading from no--mild to moderate--severe), quality of life (Gastrointestinal Quality of Life Index: GIQLI), esophagogastroduodenoscopy, esophageal manometry and 24-h pH monitoring. Additionally, we asked for any potential stress relations to GERD symptoms. Surgical outcome was assessed 3 months and 1 year postoperatively.
RESULTS: In group 2 patients before surgery, we found a significantly higher percentage with a mild impairment of esophageal motility, with a subjectively and objectively dominant reflux in the upright position, with a lower grading of esophagitis or Barrett esophagus, and with a stronger belief that stress was in any relation to perceived symptoms compared with group 1 patients. Additionally, these patients perceived typical and untypical symptoms more intensively. Factors such as DeMeester score and lower esophageal sphincter pressure did not differ preoperatively, the same as after antireflux surgery. Both groups profit significantly from surgery-a continuous reduction of symptom severity and quality-of-life improvement was found. Group 1 patients showed an improvement in mean GIQLI from 93.4+/-8.3 points preoperatively to 123.1+/-7.3 and 122.9+/-9.0 points 3 months and 1 year postoperatively, whereas group 2 patients demonstrated a lower outcome, from 82.2+/-9.1 points to 112.4+/-8.1 and 116.8+/-7.9 points postoperatively. This lesser improvement is the result of preoperative symptoms such as belching, bloating or flatulence, which many patients had after surgery. In addition, some of the group 2 patients suffered from subjective mild to moderate heartburn or dysphagia, but without any objective correlation.
CONCLUSION: GERD patients with concomitant aerophagia demonstrated less symptomatic relief than patients without aerophagia. Moreover, patients with aerophagia showed less quality-of-life improvement after laparoscopic antireflux surgery. There were no significant differences in physiological outcome data between groups. Surgery in GERD patients with symptoms relating to aerophagia should be approached with great care. An additional psychological intervention in these patients might improve surgical outcome.