Choosing the right patient for laparoscopic fundoplication: a narrative review of preoperative predictors

Objective: To determine the best preoperative predictors for a successful outcome after primary laparoscopic fundoplication. Background: Anti-reflux surgery is a proven treatment modality for patients with debilitating reflux symptoms, or those with breakthrough symptoms or an intolerance to medical therapy. Studies show that 3-6% of patients undergoing primary anti-reflux surgery will ultimately need a revisional procedure, and this carries a higher morbidity and mortality rate than primary surgery. Given the risks associated with laparoscopic revisional fundoplication, it is imperative to select the right patient for a primary laparoscopic fundoplication. Methods: A literature search was conducted of MEDLINE, Embase, Cochrane and ClinicalKey databases using the search terms "fundoplication", "recurrent reflux", "predictors of success" with "AND" and "OR" selected. English-written papers published between 1995 to 2020 were included. Abstracts and case reports of patients less than 18 years of age were excluded. Only studies with laparoscopic fundoplication were included. Open, endoscopic and revisional fundoplication studies were excluded, as well as any paper discussing hiatus hernias greater than 5 cm in size. Conclusions: Best predictors for a good outcome after anti-reflux surgery include: male gender, BMI under 30 kg/m2, typical reflux symptoms, responders to anti-reflux medication, and abnormal reflux on 24-hour pH monitoring with positive symptom indices.