An important limitation of antireflux surgery is a 5%-10% failure rate. We investigated the correlation between various diaphragm stressors and failure of antireflux surgery. Forty-one study cases who underwent a reoperative antireflux operation from 1997 to 2001 and 50 control patients who had undergone a successful laparoscopic Nissen
fundoplication during the same period without clinical or symptomatic evidence of failure were randomly selected for comparison. A retrospective analysis was conducted utilizing a standardized diaphragm stressor questionnaire, addressing the period between the primary and secondary operation. Stressors considered in the study included height, body mass index (BMI), postoperative
gagging,
vomiting, weight lifting (greater than 100 pounds), coughing, hiccuping,
motion sickness, retching,
belching,
antidepressant use, smoking, preoperative grade of
esophagitis, size of
hiatal hernia, lower esophageal sphincter pressure, esophageal body pressures, and preoperative response to
proton pump inhibitors. Of the potential stressors investigated, the following were significantly associated with surgical failure after adjusting for other variables through multivariate analysis:
gagging (P = 0.005),
belching (P = 0.02), and
hernia size greater than 3 cm (P = 0.04; Table 1). Other potential risk factors show trends as obvious in Fig. 2.
Vomiting was significant (P = 0.01) in the earlier models but lost significance when logistic regression was applied. Patients with postoperative
gagging and an intraoperative
hiatal hernia (greater than 3 cm) have a poorer outcome, whereas patients with postoperative
belching have a better long-term outcome.