By Scott Baltic
NEW YORK (Reuters Health) - 3/5/2019
"Patients with chronic cough are among the most desperate, lowest-quality-of-life folks you'll ever encounter in clinic," Dr. Adrian Park of Anne Arundel Medical Center in Annapolis, Maryland, told Reuters Health by email. "To be able to offer a carefully selected subset of them significant improvement in their cough/symptoms from this surgery will be transformative to their health."
Dr. Park and his colleagues reviewed records for patients over 18 who underwent minimally invasive surgery for gastroesophageal reflux disease (GERD) or hiatal hernia between 2012 and 2018 at their center. The records, from a prospectively maintained database, included both operative and quality-of-life outcomes with up to three years of follow-up.
The procedure used was predominantly fundoplasty, mostly Nissen fundoplication.
Chronic cough was defined as more than eight weeks of troublesome cough symptoms, as reported on a patient self-assessment. The researchers note that chronic cough arising from gastroesophageal reflux disease (GERD) "is postulated to be secondary to recurrent irritation by the gastric refluxate," although "the exact causal relationship between reflux episodes and extraesophageal manifestations remains to be defined."
The database review identified 232 patients (185 women) who presented with chronic cough attributed to gastroesophageal reflux. Their mean was age 61 and mean BMI was 28.9 kg/m2, and most (87%) were taking antireflux medication. Comorbidities were common, including hypertension (51.7%) and hyperlipidemia (49.0%).
Postoperative complications included oral intolerance (being slow to tolerate oral intake, usually because of postoperative swelling or poor esophageal function) in 1.7% of patients, a need for antibiotic therapy in 1.3% and prolonged ileus in 1.3%.
During follow-up averaging 31 months, about 77% of patients reported complete resolution of chronic cough. In addition, 72% of those who had been taking antireflux medication stopped doing so.
"Robust operative volume, thorough and complete workup before operative therapy, and proper selection of patients with GERD-induced cough are paramount to achieving good outcomes," the authors conclude.
Dr. Brant Oelschlager, director of surgical specialties at the University of Washington Medicine Center for Esophageal and Gastric Surgery, in Seattle, told Reuters Health by email that the study is worthwhile for confirming, with a larger patient cohort and good follow-up, what many other, smaller studies have found: That in a well-screened patient population, managed with pulmonologists and otolaryngologists, patients with chronic cough will show improvement following LARS 60% to 75% of the time.
"Surgeons must confirm significant GERD before operating, but should not try to manage this disease in isolation," added Dr. Oelschlager, who was not involved in the research. "The pulmonologist and otolaryngologist should have a particular interest in cough, GERD and related problems, as generalist members of the team may miss subtle contributors."
Dr. Paul Singh, director of minimally invasive surgery and bariatric surgery at Albany Medical Center, in Albany, New York, told Reuters Health by phone that appropriate diagnosis and workup are crucial.
Chronic cough is sometimes seen as an atypical symptom of reflux, he said, but instead indicates pneumonia or another pulmonary issue, for example.
Part of this study's value is that it comes from a high-volume program, with established surgical protocols, not from the experience of just one or two surgeons, noted Dr. Singh, who also was not involved in the work. "It reduces a lot of the variability of the outcomes."
This study is also important in that it links causation and therapy, he said. "If reflux is the cause, and there's a good workup, there will be a good outcome" with LARS, Dr. Singh said.