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Thématique :
- Intestin/Nutrition/Troubles fonctionnels
Originalité :
Réexamen
Solidité :
Intermédiaire
Doit faire évoluer notre pratique :
Dans certains cas
 
 
Nom du veilleur :
Professeur Frank ZERBIB
Coup de coeur :
 
 
Journal of the American Medical Association (JAMA)
  2017/09  
 
  2017 Sep ;318(10):939-946.  
  doi: 10.1001/jama.2017.10981.  
 
  ASSOCIATION BETWEEN LAPAROSCOPIC ANTIREFLUX SURGERY AND RECURRENCE OF GASTROESOPHAGEAL REFLUX  
 
  Maret-Ouda J, Wahlin K, El-Serag HB, Lagergren J  
  https://www.ncbi.nlm.nih.gov/pubmed/28898377  
 
 

Abstract

IMPORTANCE:

Cohort studies, mainly based on questionnaires and interviews, have reported high rates of reflux recurrence after antireflux surgery, which may have contributed to a decline in its use. Reflux recurrence after laparoscopic antireflux surgery has not been assessed in a long-term population-based study of unselected patients.

OBJECTIVES:

To determine the risk of reflux recurrence after laparoscopic antireflux surgery and to identify risk factors for recurrence.

DESIGN AND SETTING:

Nationwide population-based retrospective cohort study in Sweden between January 1, 2005, and December 31, 2014, based on all Swedish health care and including 2655 patients who underwent laparoscopic antireflux surgery according to the Swedish Patient Registry. Their records were linked to the Swedish Causes of Death Registry and Prescribed Drug Registry.

EXPOSURES:

Primary laparoscopic antireflux surgery due to gastroesophageal reflux disease in adults (>18 years).

MAIN OUTCOMES AND MEASURES:

The outcome was recurrence of reflux, defined as use of antireflux medication (proton pump inhibitors or histamine2 receptor antagonists for >6 months) or secondary antireflux surgery. Multivariable Cox regression was used to assess risk factors for reflux recurrence.

RESULTS:

Among all 2655 patients who underwent antireflux surgery (median age, 51.0 years; interquartile range, 40.0-61.0 years; 1354 men [51.0%]) and were followed up for a median of 5.6 years, 470 patients (17.7%) had reflux recurrence; 393 (83.6%) received long-term antireflux medication and 77 (16.4%) underwent secondary antireflux surgery. Risk factors for reflux recurrence included female sex (hazard ratio [HR], 1.57 [95% CI, 1.29-1.90]; 286 of 1301 women [22.0%] and 184 of 1354 men [13.6%] had recurrence of reflux), older age (HR, 1.41 [95% CI, 1.10-1.81] for age ≥61 years compared with ≤45 years; recurrence among 156 of 715 patients and 133 of 989 patients, respectively), and comorbidity (HR, 1.36 [95% CI, 1.13-1.65] for Charlson comorbidity index score ≥1 compared with 0; recurrence among 180 of 804 patients and 290 of 1851 patients, respectively). Hospital volume of antireflux surgery was not associated with risk of reflux recurrence (HR, 1.09 [95% CI, 0.77-1.53] for hospital volume ≤24 surgeries compared with ≥76 surgeries; recurrence among 38 of 266 patients [14.3%] and 271 of 1526 patients [17.8%], respectively).

CONCLUSIONS AND RELEVANCE:

Among patients who underwent primary laparoscopic antireflux surgery, 17.7% experienced recurrent gastroesophageal reflux requiring long-term medication use or secondary antireflux surgery. Risk factors for recurrence were older age, female sex, and comorbidity. Laparoscopic antireflux surgery was associated with a relatively high rate of recurrent gastroesophageal reflux disease requiring treatment, diminishing some of the benefits of the operation.

 
 
Question posée
 
Quel est le taux de récidive du reflux après fundoplicature laparoscopique ?
 
Question posée
 
Le taux de récidive est de 17.7% à 5 ans, principalement chez les femmes, les personnes âgées et avec comorbidités.
 
Commentaires

Le taux de 17,7% à 5 ans est élevé mais plus faible que dans les études précédentes. Large étude scandinave à partir de données de l’assurance maladie, donc assez solide. Le diagnostic de récidive ne repose que sur la consommation d’antisécrétoires et la reprise chirurgicale. La prise de traitement en automédication est toujours possible. D’un autre côté, la prise de traitement n’est pas forcément en rapport avec un RGO. Ces résultats sont tout de même intéressants et donnent une idée assez nette du risque de récidive après chirurgie. 

 
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