Predicting preoperatively the outcome of respiratory symptoms of gastroesophageal reflux

Abstract

The fact that bronchopulmonary symptoms remain unchanged in about 15% of patients after successful operation for gastroesophageal reflux (GER) with respiratory tract disease (RTD) makes surgical indications uncertain and warrants further research into preoperative prognostic predictors. This problem has been adressed in infants by demonstrating that those most likely to be cured by antireflux procedures have long nocturnal episodes of GER and/or temporal coincidence between drops in pH levels and respiratory episodes. In an attempt to validate these predictors and, at the same time, to search for other reliable ones, we have retrospectively studied the charts, manometric studies, pH tracings, and pathology reports of 55 patients aged 48 ± 36 months (range, 2 to 170) who had Nissen funduplication for GER with RTD in the last 10 years. Forty-five children were cured or improved of their RTD symptoms after operation, but in 10 (18%) they were unchanged in spite of the control of GER. Patients with a former history of vomiting (n = 38) had better results than those (n = 17) without it (95% of RTD cure v 53%, P < .001). The success rate in children with recurrent obstructive airway disease (n = 20) was definitely lower than in those without it (n = 35) (70% v 89%, P < .05). Neither esophageal manometry nor mucosal biopsy provided any predictive clue, but pH studies confirmed that the mean duration of nocturnal episodes of reflux (ZMD) was definitely longer in patients responding favourably to surgical cure of GER than in those in whom this failed (12.2 ± 9.6 v 3.9 ± 2.8 minutes, P < .01). Patients with ZMD longer than 4.5 minutes had 95% chances of cure after funduplication. In addition, all cases in whom a temporal coincidence between GER and respiratory episodes could be documented were cured after surgery. Our results suggest that a thorough study of both the clinical history and the extended pH metering tracings may predict preoperatively which patients (infants and children of any age) are more likely to be relieved of their RTD by funduplication.