What Effect Does Treating GERD Surgically Have on Reflux Cough?

What effect does treating GERD surgically have on reflux cough?

Source / Sample size / Study design / Diagnosis of reflux cough/selection of patients / Length of follow up / Intervention / Outcome(s) / Main finding(s)
Hoppo 2013 / 36 / Retrospective cohort / 1) persistent cough >= 8 weeks, 2) no ACEi or seasonal allergies, 3) no known pulmonary disease / 0.5-13 months / Nissen (10), Dor (2), Toupet (1), esophagojejunostomy (3) / Improvement in cough symptoms / 13 of 16 (81%) patients with abnormal proximal refluxate exposure on MII-pH had resolution of cough, while the other 3 had significant improvement (19%)
Zhang 2012 / 198 / Retrospective cohort / 1) coughing, asthma, wheezing, shortness of breath, or choking, 2) GERD diagnosed on esophageal pH monitoring with DeMeester score >= 14.7 / 12 months / Laparoscopic Nissen (197), laparoscopic converted to open Nissen (1) / Improvement in Reflux Diagnostic Questionnaire / Mean cough scores improved from 7.23 to 2.79 (p < 0.01) after ARS.
Koch 2012 / 100 / Randomized comparative effectiveness / 1) persistent or recurrent GERD despite medical treatment and a) DeMeester score >= 14.7 and b) symptom correlation >= 50% or reflux episodes > 73 during MII-pH / 1 year / Laparoscopic floppy Nissen (50) or Toupet fundoplication (50) / Change in symptom questionnaire score / 98 patients were available at 3-month follow-up. Mean cough score improved 2.46 in the Nissen group and 1.77 in the Toupet group, both of which were significant changes from baseline (p < 0.001 and p = 0.001, respectively).
89 patients were available at 1 year follow-up. Mean cough score improved 1.74 in the Nissen group and 2.14 in the Toupet group, both of which were significant changes from baseline (p = 0.007 and 0.004, respectively).
There were no statistically significant differences in improvement of cough scores between the two procedures.
van der Westhuizen 2011 / 244 / Retrospective cohort / Patients who underwent antireflux surgery for reflux / Unclear / Nissen / Reported change in symptom intensity / > 50% improvement in symptom intensity was reported by 84 of 135 (62%) patients who reported chronic cough preoperatively.
Brown 2011 / 113 / Prospective cohort / 1) GERD diagnosed on esophageal pH monitoring, 2) underwent laparoscopic Nissen / Mean 28 months / Laparoscopic Nissen / Change in VAS symptom score / Mean cough score decreased from 3.78 to 0.95 (p < 0.0001) after surgery.
Francis 2011 / 27 / Retrospective cohort / 1) chief complaint of atypical symptom, 2) without improvement after 12 weeks of bid PPI therapy, 3) with abnormal esophageal acid exposure on bid PPI therapy, 4) who underwent antireflux surgery / Median 33 months / Antireflux surgery / Resolution or > 50% improvement in primary atypical symptom / 12 patients presented with cough and 7 with asthma/wheezing. No significant difference in response to surgery was found according to the specific presenting atypical complaint.
After 1 year of follow-up, 59% of patients reported improvement (11%) or complete resolution (48%) of their presenting atypical symptom.
Patients with concomitant heartburn or with > 12% acid exposure time had greater likelihood of symptom resolution after fundoplication than patients without heartburn (OR 6.6, p = 0.05; OR 10.5, p = 0.02).
Patients without concomitant heartburn and acid exposure time < 12% resolved their symptoms after fundoplication 8.5% of the time, while patients with both factors resolved their symptoms 90.7% of the time.
Iqbal 2009 / Retrospective cohort / 1) underwent ARS, 2) predominance of extraesophageal symptoms before surgery / Mean 53.3 months / Open (9) or laparoscopic (31) Nissen (33) or partial (7) fundoplication / Change in cough symptoms / 32 of 40 (80%) patients reported cough preoperatively. 17 (53%) reported their cough cured, 10 (32%) reported it improved, 4 (13%) reported no change, and 1 (3%) reported worsened cough.
Oelschlager 2008 (same cohort as Oelschlager 2002) / 288 / Retrospective cross-section / Underwent ARS between 1993 and 1999 for reflux indication / Median 69 months / Laparoscopic Nissen / Reported resolution or improvement in cough symptoms / 88 of 288 (31%) of patients reported cough preoperatively. 40% reported symptom resolution, another 29% reported symptom improvement.
Ranson 2007 / 69 / Prospective cohort / Underwent ARS after GERD diagnosis by empiric PPI trial or esophageal pH monitoring / Mean 24.6 months / Laparoscopic Nissen / Improvement in modified Allen symptom score / 55 of 69 (80%) patients reported cough preoperatively. Their mean cough symptom score decreased from 1.2 to 0.5 (p < 0.01) after ARS. 35 (64%) reported their cough resolved, another 7 (10%) reported their cough improved, 6 (10%) reported no change, and 7 (13%) reported worsened cough.
Tutuian 2006 / 50 / Retrospective review / Patients with persistent cough on day of MII-pH monitoring while on bid PPI therapy with or without nighttime H2 blocker therapy / Median 17 months / Laparoscopic Nissen / Resolution of cough / 13 of 50 patients had positive non-acid SI for reflux-cough. 6 of these 13 underwent laparoscopic Nissen (1 lost to follow up). All patients reported complete resolution of cough at follow-up.
Rakita 2006 / 813 / Prospective cohort / 1) underwent laparoscopic Nissen, 2) had preoperative symptom scores of 4 or 5 on 5 point scale for extraesophageal symptoms (asthma [diagnosed by having symptoms of asthma and having been cared for by a physician for asthma], cough, gas/bloat, chest pain, odynophagia) / Mean 50 months / Laparoscopic Nissen / Improvement of symptoms / 132 patients presented with cough scores of 4-5. Mean cough score decreased from 4.3 to 2 (p < 0.0001).
Kaufman 2006 / 128 / Retrospective cohort / 1) Underwent laparoscopic Nissen, 2) experienced cough, hoarseness, or wheezing > once per week / Median 53 months / Laparoscopic Nissen (123) and Toupet (5) / Improvement of symptoms / 108 patients presented with cough. 80 (74%) patients reported improved cough. There was a statistically significant decrease in the frequency of cough (p < 0.001).
Allen 2004 / 209 / Prospective cohort / 1) underwent laparoscopic Nissen for GERD, 2) without evidence of post-nasal drip or having received treatment for it, 3) with negative methacholine inhalation challenge, 4) with primarily respiratory complaints / 5-years / Laparoscopic Nissen / Symptoms cured (score = 0), better (score improved > 2), no significant change (score change <= 2), or worse (score decreased 2 or more) / 79 of 209 (38%) patients with primarily respiratory complaints were available for 5-year follow-up. Mean cough score decreased 3.9. 36% of patients were cured, 35% were better, 24% had no significant change, and 5% were worse.
Brouwer 2003 / 28 / Prospective cohort / 1) underwent laparoscopic Nissen, 2) predominantly respiratory symptoms (cough, aspiration, voice changes) / Mean 650 days / Laparoscopic Nissen / Symptom score / Mean cough score decreased after ARS from 4.7 to 0.36 (p < 0.001)
Thoman 2002 / 129 / Retrospective cohort / 1) underwent laparoscopic ARS / Unclear / Laparoscopic Nissen or Toupet / Patient-reported resolution or significant improvement in cough symptoms / 37 of 129 patients complained of cough preoperatively. 24 (65%) patients reported their cough completely resolved (p = 0.002), while another 10 (27%) reported significant improvement.
Novitsky 2002 / 21 / Retrospective cohort / 1) cough > 8 weeks, normal CXR, non-smoker, no ACEi, no relief with treatment of post-nasal drip, no asthma, 2) failure of intensive medical therapy, 3) underwent ARS / 1 year / Laparoscopic Nissen (18), open Nissen (3) / Patient report of improvement, ACOS, SIP / 18 of 21 (86%) reported improved cough at 1-year follow-up, with 13 (62%) having complete resolution. ACOS improved from 15.1 to 5.8 (p < 0.01), SIP improved from 15 to 4.2 (p < 0.01).
Greason 2002 / 62 / Retrospective cohort / 1) underwent ARS, 2) reported wheezing, sputum production, cough, choking, hoarseness, or pneumonia / Median 65 months / Wide variety of open and laparoscopic antireflux operations / Patient-reported improvement in symptoms / 30 patients reported cough preoperatively, 10 after ARS.
Allen 2002 / 483 / Prospective cohort / Underwent laparoscopic Nissen / 6 months / Laparoscopic Nissen / Change in cough score / 287 of 483 patients presented with cough. Mean cough score decreased from 35.1 to 13.2 (p < 0.0001). Patients with a positive esophageal acid infusion test were significantly more likely to respond to ARS (p = 0.02).
Patti 2000 / 340 / Prospective cohort / 1) underwent laparoscopic Nissen, 2) complaint of heartburn and/or regurgitation / Median 28 months / Laparoscopic NIssen / Patient-reported resolution of symptoms / 39 of 340 (11%) patients had cough or wheezing attributed to GERD on clinical grounds. All 39 complained of cough preoperatively. Cough resolved in 74%.
Ekstrom 2000 / 24 / Prospective cohort / 1) severe GERD refractory to maximal medical therapy, 2) simultaneous asthma (according to American Thoracic Society criteria) or chronic cough / 12 months / Open (20) or laparoscopic (4) Nissen / Improvement in symptoms by patient diary, FEV1, FVC, / 11 patients had chronic cough. 12 months post-operatively all had significant improvement in FEV1, FVC, cough day score, cough night score, hoarseness score, and expectoration score (p < 0.01 - < 0.05).

What effect does treating GERD surgically have on chronic laryngitis/LPR?

Source / Sample size / Study design / Diagnosis of LPR/selection of patients / Length of follow up / Intervention / Outcome(s) / Main finding(s)
Koch 2012 / 100 / Randomized comparative effectiveness / 1) persistent or recurrent GERD despite medical treatment and a) DeMeester score >= 14.7 and b) symptom correlation >= 50% or reflux episodes > 73 during MII-pH / 1 year / Laparoscopic floppy Nissen (50) or Toupet fundoplication (50) / Change in symptom questionnaire score / 98 patients were available at 3-month follow-up. Mean hoarseness score improved 0.76 (p = 0.004) in the Nissen group and nonsignificantly in the Toupet group.
89 patients were available at 1-year follow-up. Mean hoarseness score improved 1.35 (p = 0.034) in the Nissen group and 1.11 (p = 0.003) in the Toupet group.
There were no statistically significant differences in improvement of asthma scores between the two procedures.
Johannessen 2012 / 243 / Matched (age, sex, geographic location, follow-up time, degree of esophagitis, presence of hiatal hernia, and presence of Barrett esophagus) cross-sectional / GERD diagnosed endoscopically or on esophageal pH monitoring / Mean 6-6.3 years / Laparoscopic or open fundoplication versus medical therapy / Mean RASQ items and subscale for laryngopharyngitis / Mean score for globus sensation (0.76 vs 1.11, p = 0.01) and sore throat (0.86 vs 1.13, p = 0.04) and the laryngopharyngitis subscale (1.06 vs 1.27, p = 0.04) were significantly lower in the ARS group than the medically treated group.
van der Westhuizen 2011 / 244 / Retrospective cohort / Patients who underwent antireflux surgery for reflux / Unclear / Nissen / Reported change in symptom intensity / > 50% improvement in symptom intensity was reported by 99 of 140 (71%) patients who reported sore throat preoperatively, 86 of 124 (69%) who reported lump in throat preoperatively, 96 of 139 (69%) who reported dysphagia preoperatively, and 89 of 162 (55%) who reported repetitive throat clearing preoperatively.
Brown 2011 / 113 / Prospective cohort / 1) GERD diagnosed on esophageal pH monitoring, 2) underwent laparoscopic Nissen / Mean 28 months / Laparoscopic Nissen / Change in VAS symptom score / Mean hoarseness score decreased from 3.16 to 0.82 (p < 0.0001) after surgery.
Iqbal 2009 / Retrospective cohort / 1) underwent ARS, 2) predominance of extraesophageal symptoms before surgery / Mean 53.3 months / Open (9) or laparoscopic (31) Nissen (33) or partial (7) fundoplication / Change in globus sensation symptoms / 29 of 40 (73%) patients reported globus sensation preoperatively. 12 (41%) reported globus cured, 7 (24%) reported it improved, 7 (24%) reported no change, and 3 (10%) reported worsened globus.
31 of 40 (78%) reported throat clearing, mucous, or post-nasal drip. 16 (51%) reported these symptoms cured, 10 (32%) reported them improved, 4 (13%) reported no change, and 1 (3%) reported worsened symptoms.
Ranson 2007 / 69 / Prospective cohort / Underwent ARS after GERD diagnosis by empiric PPI trial or esophageal pH monitoring / Mean 24.6 months / Laparoscopic Nissen / Improvement in modified Allen symptom score / 47 (68%), 41 (59%), and 60 (87%) of 69 patients preoperatively reported hoarseness, sore throat, and throat clearing, respectively. Their mean hoarseness symptom score decreased from 1.2 to 0.6 (p < 0.01) after ARS. 22 (47%) reported their hoarseness resolved, another 11 (23%) reported their hoarseness improved, 6 (13%) reported no change, and 8 (17%) reported worsened hoarseness. Their mean sore throat symptom score decreased from 0.9 to 0.4 (p < 0.01) after ARS. 25 (61%) reported their sore throat resolved, another 6 (15%) reported their sore throat improved, 2 (5%) reported no change, and 8 (20%) reported their sore throat worsened. 26 (43%) reported their throat clearing resolved, another 14 (23%) reported their throat clearing improved, 12 (20%) reported no change, and 8 (13%) reported worsened throat clearing.
Swoger 2006 / 72 / Prospective cohort / 1) chronic laryngeal signs and symptoms (cough, throat clearing, sore/burning throat, hoarseness, or globus sensation), 2) treated with omeprazole 40 mg bid or lansoprazole 60 mg bid for 4 months with < 50% symptomatic improvement, 3) abnormal esophageal pH monitoring or evidence of reflux on barium esophagram off PPI therapy, 4) with normal esophageal acid exposure parameters on bid PPI therapy / 1 year / Laparoscopic Nissen / Symptom resolution or improvement on symptom score questioinnaire / 25 of 75 (35%) patients were unresponsive to bid PPI therapy. 10 chose to have surgery while 15 refused.
At 1 year follow-up, 1 of 10 (10%) ARS patients and 1 of 15 (7%) medical patients had resolved laryngeal symptoms.
Kaufman 2006 / 128 / Retrospective cohort / 1) Underwent laparoscopic Nissen, 2) experienced cough, hoarseness, or wheezing > once per week / Median 53 months / Laparoscopic Nissen (123) and Toupet (5) / Improvement of symptoms / 82 patients presented with hoarseness. 54 (66%) patients reported improved hoarseness. There was a statistically significant decrease in the frequency of hoarseness (p < 0.001).
41 patients presented with sore throat. 29 (70%) patients reported improved sore throat. There was a statistically significant decrease in the frequency of sore throat (p = 0.001).
Fernando 2005 / 74 / Prospective cohort / 1) primary complaint of heartburn, regurgitation, or water brash, 2) pulmonary symptoms of bronchospasam, hoarseness, aspiration, or laryngitis, 3) underwent laparoscopic Nissen / Median 12 months / Laparoscopic fundoplication / Resolution of laryngeal symptoms / 46 patients complained of hoarseness before the operation. 33 (72%) had complete resolution after the operation (p < 0.01). Patients did not report significantly less laryngitis after ARS.
Greason 2002 / 62 / Retrospective cohort / 1) underwent ARS, 2) reported wheezing, sputum production, cough, choking, hoarseness, or pneumonia / Median 65 months / Wide variety of open and laparoscopic antireflux operations / Patient-reported improvement in symptoms / 17 patients reported hoarseness preoperatively, 11 after ARS.
Patti 2000 / 340 / Prospective cohort / 1) underwent laparoscopic Nissen, 2) complaint of heartburn and/or regurgitation / Median 28 months / Laparoscopic Nissen / Patient-reported resolution of symptoms / 13 of 340 (4%) patients had hoarseness attributed to GERD on clinical grounds. Hoarseness resolved in 82% of patients.
Lindstrom 2002 / 29 / Retrospective cohort / Underwent Nissen for extraesophageal manifestations of GERD / 6-108 months / Laparoscopic Nissen (n = 28) or open Nissen (n = 1) / Reported resolution of symptoms on chart review? / 27 of 29 patients reported near-total relief of extraesophageal symptoms.
2 patients had wrap breakdown after 2 years, 1 from abdominal trauma.
1 patient with persistent symptoms had both typical and atypical manifestations of GERD: typical symptoms resolved while atypical symptoms persisted. Was diagnosed with cricopharyngeal muscle myositis caused by Lyme disease.
1 patient with chronic cough did not improve after Nissen.

What effect does treating GERD surgically have on reflux asthma?