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Personalized anti-reflux surgery: connecting GERD phenotypes in 690 patients to outcomes

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Abstract

Background

Anti-reflux operations are effective treatments for GERD. Despite standardized surgical techniques, variability in post-operative outcomes persists. Most patients with GERD possess one or more characteristics that augment their disease and may affect post-operative outcomes—a GERD “phenotype”. We sought to define these phenotypes and to compare their post-operative outcomes.

Methods

We performed a retrospective review of a prospective gastroesophageal database at our institution, selecting all patients who underwent an anti-reflux procedure for GERD. Patients were grouped into different phenotypes based on the presence of four characteristics known to play a role in GERD: hiatal or paraesophageal hernia (PEH), hypotensive LES, esophageal dysmotility, delayed gastric emptying (DGE), and obesity. Patient-reported outcomes (GERD-HRQL, dysphagia, and reflux symptom index (RSI) scores) were compared across phenotypes using the Wilcoxon rank-sum test.

Results

690 patients underwent an anti-reflux procedure between 2008 and 2022. Most patients underwent a Nissen fundoplication (302, 54%), followed by a Toupet or Dor fundoplication (205, 37%). Twelve distinct phenotypes emerged. Non-obese patients with normal esophageal motility, normotensive LES, no DGE, with a PEH represented the most common phenotype (134, 24%). The phenotype with the best post-operative GERD-HRQL scores at one year was defined by obesity, hypotensive LES, and PEH, while the phenotype with the worst scores was defined by obesity, ineffective motility, and PEH (1.5 ± 2.4 vs 9.8 ± 11.4, p = 0.010). There was no statistically significant difference in GERD-HRQL, dysphagia, or RSI scores between phenotypes after five years.

Conclusions

We have identified distinct phenotypes based on common GERD-associated patient characteristics. With further study these phenotypes may aid surgeons in prognosticating outcomes to individual patients considering an anti-reflux procedure.

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Funding

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Authors and Affiliations

  1. Department of Surgery, NorthShore University HealthSystem, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA

    Christopher J. Zimmermann, Kristine Kuchta, Stephanie Joseph, Simon Che, H. Mason Hedberg & Michael Ujiki

  2. Surgery, UCHealth Northern Colorado, Fort Collins, USA

    Christopher J. Zimmermann

  3. Department of Surgery, University of Chicago, Chicago, IL, USA

    Julia R. Amundson & Vanessa N. VanDruff

Authors
  1. Christopher J. Zimmermann
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  2. Kristine Kuchta
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  5. Stephanie Joseph
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  6. Simon Che
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Corresponding author

Correspondence to Christopher J. Zimmermann.

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Disclosures

Dr Michael B Ujiki is a scientific advisory board member for Boston Scientific and Apollo, a consultant and speaker for WL Gore and Associates and a speaker for Medtronic. Christopher J. Zimmermann, Kristine Kuchta, Julia R. Amundson, Vanessa N. VanDruff, Stephanie Joseph, Simon Che, and H. Mason Hedberg all have no conflicts of interest to disclose.

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Zimmermann, C.J., Kuchta, K., Amundson, J.R. et al. Personalized anti-reflux surgery: connecting GERD phenotypes in 690 patients to outcomes. Surg Endosc 38, 3273–3278 (2024). https://doi.org/10.1007/s00464-024-10756-4

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  • DOI: https://doi.org/10.1007/s00464-024-10756-4

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