Although studies show that the short-term outcomes of laparoscopic antireflux surgery (LARS) for the treatment of GERD are good, the long-term results are variable. LNF provides effective management of reflux symptoms, achieving long-term relief including heartburn and regurgitation in 84–97 % of patients [20]. Recent data demonstrates excellent heartburn and regurgitation control 5 years after standardized laparoscopic Nissen fundoplication [31] (Figs. 24.1 and 24.2). After 10 years, control of reflux symptoms was observed in 89.5 % of LNF patients, with PPI antacid medications being used by only 8.4 % of patients [32]. Long-term outcomes from the University of Washington revealed that the majority of patients showed a maintained improvement or resolution of symptoms including heartburn (90 %), regurgitation (92 %), and dysphagia (75 %) at 69 months, however lesser improvements were observed with symptoms of hoarseness (69 %) and cough (69 %) [33].

A long-term post-surgical analysis conducted by Luostarinen et al. [34] found good results in patients 20 years after open antireflux surgery in most patients, with positive outcomes dependent on the condition of the fundic wrap. A reflux symptom resolution rate of 60 % was reported, with the incidence of dysphagia and heartburn being directly correlated with defective wraps, which were found in 28 % of patients [34] (Table 24.2).

While short-term outcomes of LARS are good, with an average of 85–95 % of patients experiencing excellent control of GERD symptoms [36, 37], long-term evidence suggests that these benefits diminish over time [3, 4]. A study evaluating LARS outcomes found better results at 5 years with resolution of significant reflux symptoms in 93 % of the patients, while at 10 years, 89.5 % of the patients were symptom free [32]. Valiati et al. [24] similarly revealed a short-term reflux recurrence rate of 3–4 % within 2 years of laparoscopic fundoplication, and 8 % long-term rate within 7 years.

Patient-reported outcomes assess the patient’s experience and are reported in terms of health-related quality of life, current health state, and patient satisfaction. A high rate of patient satisfaction is reported following laparoscopic fundoplication, ranging from 80 [31] to 96.5 % [20]. A randomized trial found a high satisfaction rate for LARS of 90 % [20], similarly, a 15 year RCT found a rate of 91.7 % [75].

When surgical treatment is compared to pharmacological therapy, an RCT using the VAS score to report overall patient satisfaction found significant improved symptom control at 3 years for the surgical group, whereas the medical group reported maintained scores (82.60–81.95 for the PPI group versus 81.79–92.67, P = 0.0072 for the LNF group) [39]. Contini and Scarpignato [41] highlight that patient satisfaction is correlated with improvement in quality of life and resolution of symptoms, while the use of antireflux medication does not influence the rate of satisfaction significantly. Broeders et al. [27] found that quality of life scores increased following LNF with a mean increase of 25.8 % at 10 years. It is understood that numerous patient-related factors can contribute to and affect quality of life and satisfaction scores following LARS, however subjective degree of symptoms is not a reliable indicator of objective reflux.

The use of PPIs is the primary treatment for GERD [42], however many patients still experience recurrent symptoms, with a failure rate of up to 40 % [43]. The need for antireflux medication following fundoplication is often used as an outcome measure for success. Some studies show an increase of acid-suppressing medication use following antireflux surgery to a rate of 15–22 % [24, 27, 44–47].

Conversely, some long-term trials have found a large percentage of LNF patients achieving relief of reflux symptoms no longer requiring acid-suppressing medications (72.2 %) [27]. A study by Papasavas et al. [48] found the use of PPI medication decreased from 84.4 % preoperatively to 18.7 with 82.7 % free of routine pharmacological treatment (PPIs, H-2 receptor blockers, and antacids for GERD symptoms) at 2 years follow-up. Draaisma et al. [49] indicate similar results at 5 years follow-up, with 13.9 % LNF patients requiring continued use of antireflux medications.

The reasons for frequent use of antireflux medication postoperatively must be explored, as abnormal esophageal acid is not always correlated with postoperative pharmacotherapy [49–51]. Antireflux medications are frequently prescribed in our current health care system, for a variety of GI presentations. Salminen [20] found that although 18.7 % of patients were taking PPI medication at 2 years post-surgery, GERD symptoms scores, as assessed using the Jamieson symptom scoring system, revealed that 82 % of patients improved from severe to mild reflux symptoms. Papasavas et al. [48] found that at 2 years LNF, PPI therapy was required by 10 % of patients for typical GERD symptoms, and 8.7 % were using PPIs for other reasons, such as Barrett’s esophagus, “sensitive” stomach, and irritable bowel syndrome. A study by Oelschlager et al. [33] withdrew antireflux medications from post antireflux surgery patients for 2 weeks to investigate GERD symptoms, and found that symptoms did not change significantly during the absence of medication (as cited in Oelschlager et al. [33]). The use of pharmacotherapy for alternate or unnecessary reasons after fundoplication can distort results when outcomes of surgical failure are analyzed by medication use; therefore it is not an efficient measure for procedure efficacy.

The success of antireflux surgery depends heavily on patient selection. Patients with a good response to medical therapy without complicated disease have been shown to have superior outcomes following antireflux surgery [60, 61]. Patients who have been identified with clinical testing as having pathological acid reflux are more likely to respond well to surgical treatment than those with unknown or complicated diagnoses. Campos et al. [61] conducted a multivariate analysis to analyze predictive factors of LNF outcomes, finding three predictive factors of successful outcome: an abnormal 24-h pH score, the presence of typical symptoms of gastroesophageal reflux, and a significant improvement in symptoms with acid suppression therapy prior to surgery.

When predicting successful long-term outcomes of reflux surgery, sex, age, obesity, history of psychiatric illness and the presence of dysphagia pre-surgery are all indicators. Although symptoms of dysphagia often improve after fundoplication, the incidence of pre-surgical dysphagia negatively influences clinical outcome. Univariate regression analysis conducted by Oeschlager et al. [33] found that male patients, of younger age, presenting with heartburn, were much more likely to have successful outcomes of LARS, whereas preoperative dysphagia, airway manifestations, bloating, and defective esophageal motility were negative predictive factors. A study by Morgenthal et al. [62] found that preoperative morbid obesity (BMI > 35 kg/m²) was associated with LNF failure, while obesity was not (BMI 30–34.9 kg/m²). A history of psychiatric illness trended toward a failed outcome, but did not reach statistical significance (P = 0.06) [62]. Similarly a regression analysis completed by Irino et al. [63] concluded that a BMI > 25 kg/m² and age >60 years were significant factors negatively affecting scores of postoperative GERD specific QOL.

Many authors have suggested clinical presentations of large hiatal hernias, atypical symptoms, the presence of Barrett’s esophagus and esophagitis, and a defective LES lead to increased failure rates and poor outcomes of fundoplication, though these opinions are not expressed consistently throughout the literature [19, 62]. Procedural variations such as division of the SGVs, degree of the wrap, and technology may play a minimal role in the success of surgical treatment (Table 24.3).