Swoger Jason, Ponsky Jeff, Hicks Douglas M, Richter Joel E, Abelson Tom I, Milstein Claudio, Qadeer Mohammed A, Vaezi Michael F
Department of Gastroenterology and Hepatology, Center for Swallowing and Esophageal Disorders, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
Clin Gastroenterol Hepatol. 2006 Apr;4(4):433-41. doi: 10.1016/j.cgh.2006.01.011.
BACKGROUND & AIMS: In patients with persistent laryngeal symptoms despite aggressive proton pump inhibitor therapy, gastroesophageal reflux disease (GERD) continues to be implicated. The role of surgical fundoplication as the definitive therapy for these patients is uncertain.
In this prospective concurrent controlled study, 72 patients with suspected GERD-related laryngeal symptoms received aggressive acid-suppressive therapy. Four-month symptomatic nonresponders (<50% improvement) with continued laryngeal inflammation and normalized esophageal acid exposure were offered laparoscopic Nissen fundoplication. The primary outcome was symptom improvement/resolution at 1 year after surgery.
Twenty-five of 72 (35%) patients remained unresponsive after 4 months of acid-suppressive therapy. Ten patients (40%) underwent surgical fundoplication (median age, 54 y; men, 4) and 15 patients (60%) continued medical therapy (median age, 52; men, 4). The most common laryngeal symptoms were sore throat, hoarseness, and cough. pH studies at 3 and 12 months were normal in all patients after fundoplication (median % time pH < 4, .0% and .3%; respectively). One of 10 (10%) patients in the surgery group reported improvement of laryngeal symptoms at 1 year compared with 1 of 15 in the control group (6.7%) (P = 1.0). Treatment of causes other than GERD improved symptoms in an additional 2 of 10 (20%) patients in the surgical group, and 10 of 15 (66%) patients in the nonsurgical cohort.
Surgical fundoplication does not improve laryngeal symptoms reliably in patients unresponsive to aggressive proton pump inhibitor therapy. The argument of low volume or intermittent reflux as the cause of persistent laryngeal symptoms needs to be replaced with evaluation and therapy for other potential non-GERD causes.
尽管进行了积极的质子泵抑制剂治疗，但仍有持续喉部症状的患者，胃食管反流病（GERD）仍被认为与之相关。手术胃底折叠术作为这些患者的确定性治疗方法，其作用尚不确定。
在这项前瞻性同期对照研究中，72例疑似GERD相关喉部症状的患者接受了积极的抑酸治疗。对4个月症状无改善（改善不足50%）、喉部持续炎症且食管酸暴露正常的患者，提供腹腔镜Nissen胃底折叠术。主要结局是术后1年症状改善/缓解。
72例患者中有25例（35%）在抑酸治疗4个月后仍无反应。10例患者（40%）接受了手术胃底折叠术（中位年龄54岁；男性4例），15例患者（60%）继续药物治疗（中位年龄52岁；男性4例）。最常见的喉部症状是咽痛、声音嘶哑和咳嗽。胃底折叠术后所有患者3个月和12个月时的pH值研究均正常（pH<4的中位时间百分比分别为0.0%和0.3%）。手术组10例患者中有1例（10%）报告1年后喉部症状改善，而对照组15例中有1例（6.7%）（P=1.0）。手术组另外2例（20%）患者和非手术组10例（66%）患者经治疗GERD以外的病因后症状改善。
对于对积极质子泵抑制剂治疗无反应的患者，手术胃底折叠术不能可靠地改善喉部症状。将持续喉部症状的原因归结为少量或间歇性反流的观点，需要被对其他潜在非GERD病因的评估和治疗所取代。
