ANZ J. Surg. 2003; 73: 189–193 ORIGINAL ARTICLE ORIGINAL ARTICLE IMPROVEMENT OF RESPIRATORY SYMPTOMS FOLLOWING LAPAROSCOPIC NISSEN FUNDOPLICATION RICHARD BROUWER AND GEORGE K. KIROFF Department of Clinical and Biomedical Science, University of Melbourne, and Division of Surgery, St John of God Health Care, Geelong Hospital, Geelong, Victoria, Australia Background: Laparoscopic fundoplication has become the standard of care for the management of symptomatic gastro- oesophageal reflux disease (GORD). Although atypical and respiratory symptoms are frequently described in standard texts in asso- ciation with reflux, the response of respiratory symptoms to management of GORD has not been extensively studied. Methods : Herein is reported a prospective series of 29 patients who presented with predominantly respiratory symptoms. Typical and respiratory symptoms were graded according to a standard scale. All patients had preoperative investigations confirming GORD. These patients were treated by a laparoscopic Nissen fundoplication and followed up for a minimum of 14 months (range: 14–48 months). Patients were contacted and interviewed by an independent observer. Results : Conversion to open surgery was necessary in three patients. There were four significant complications. Ultimately control of typical reflux symptoms was achieved in 88%. Cough was completely relieved in 81% and improved in a further 13%. Wheeze and nocturnal bronchospasm was completely relieved in 50% and improved in the balance. Dysphagia remains a significant problem, with only 42% of patients completely free of trouble. Conclusions : Overall the respiratory symptoms were improved in the majority of patients, with cough responding somewhat better than wheeze. Appropriate patient selection remains the greatest challenge when a patient with cough or wheeze that is considered to be due to GORD is referred for surgery. Key words: cough, fundoplication, gastro-oesophageal reflux, laparoscopy. Abbreviations: GORD, gastro-oesophageal reflux disease; LNF, laparoscopic Nissen fundoplication; PPI, proton pump inhibitor; RS, respiratory system. INTRODUCTION Gastro-oesophageal reflux disease (GORD) is a common con- dition. The prevalence of symptomatic reflux in western society is approximately 10%. A subset of patients with GORD suffer from predominately respiratory symptoms such as cough, gross aspiration, wheeze or hoarse voice. Furthermore, 10–21% of patients with a chronic or persistent cough will have GORD as the cause of their symptoms. 1–3 Surgery for GORD has an excel- lent outcome with regard to the control of heartburn and dyspep- tic symptoms. Although standard texts frequently cite respiratory symptoms as associated with GORD, the use of anti-reflux surgery to manage these non-gastrointestinal symptoms has not often been evaluated in the medical literature. Medical manage- ment of these respiratory symptoms, with either H2 antagonists or a proton-pump inhibitor (PPI) has been shown to be of benefit in some patients. 4,5 The advent of laparoscopic Nissen fundopli- cation (LNF), first reported in 1991, 6 has had excellent results for the conventional symptoms of reflux disease, 7–9 and has made surgery for these atypical symptoms more attractive. The present study evaluates the results of LNF for patients with GORD char- acterized by predominantly respiratory symptoms. METHODS A prospective study was undertaken. One hundred and two patients underwent LNF for GORD between 1997 and 2000. Of these, 29 were identified as having predominantly respiratory symptoms as the manifestation of their disease during their pre- operative evaluation. These patients were either referred by a res- piratory physician or complained of cough, aspiration or voice change in addition to typical reflux symptoms. They were asked to grade their typical GORD and respiratory symptoms according to frequency and severity. The severity was classified as (0), not at all; (1), mild; (2), moderate; and (3), severe. The frequency was graded as (0), symptom absent; (1), once a month; (2), weekly; (3) 2–4 times per week; and (4), daily. The product of severity and frequency yielded a score of 0–12 for each symptom. Patients There were 15 female and 14 male patients. The mean age was 53 years (range: 26–79 years). All patients had a trial of, or were still taking PPI therapy. All patients were interviewed preopera- tively and all had endoscopy. Sixteen patients had preoperative pH and manometry studies. Twenty-four-hour oesophageal pH studies were performed using a single channel recorder with an antimony electrode located 5 cm above the lower oesophageal sphincter as determined by prior manometry. All those who underwent surgery without pH studies had evidence of oesopha- gitis or Barrett’s epithelium on endoscopy. Barrett’s epithelium was defined as 3 cm of columnar epithelium with intestinal metaplasia on biopsy. The details of preoperative pH and man- ometry studies between patients with typical reflux symptoms R. Brouwer MB BS; G. K. Kiroff MS, FRACS. Correspondence: Dr G. Kiroff, Suite 4, Level 3 Geoffrey Royal Wing, St John of God Hospital, Myers Street, Geelong 3220, Australia. Email: george@barwonsurgicalgroup.com Accepted for publication 28 November 2002.