Surgical Options for Laryngopharyngeal Reflux (LPR)
Laparoscopic fundoplication is the most effective surgical intervention for LPR in patients with documented GERD who have failed appropriate medical management, but should only be considered in highly selected patients with concomitant heartburn/regurgitation, prior response to PPI therapy, and high acid exposure demonstrated by pH monitoring.
Patient Selection for Surgical Management
Surgical intervention should be considered only after:
Failure of conservative management including:
- Lifestyle modifications
- Adequate trial of PPI therapy (8-12 weeks of twice daily dosing)
- Dietary changes
Objective documentation of pathologic reflux through:
- Endoscopy
- 24-hour pH monitoring or pH-impedance testing
- Laryngoscopy showing reflux-related changes
Presence of favorable predictive factors:
- Concomitant typical GERD symptoms (heartburn/regurgitation)
- Prior positive response to PPI therapy
- High acid exposure time (>12%) on pH monitoring 1
Available Surgical Options
1. Laparoscopic Fundoplication
- Primary surgical option for LPR with documented GERD
- Success rate of 80-90% for symptom relief in properly selected patients 2
- Multiple studies demonstrate effectiveness in improving LPR symptoms (p<0.05) 3
- Most effective in patients who previously responded to PPI therapy 1
2. Upper Esophageal Sphincter (UES) Augmentation
- External UES compression device (newer technology)
- Applies 20-30 mmHg of cricoid pressure to enhance barrier to supraesophageal reflux
- May improve laryngeal symptoms when added to PPI therapy (symptom improvement increased from 31% to 55%) 1
- Not yet widely available for clinical use
3. Other Surgical Options
- Magnetic sphincter augmentation
- Transoral incisionless fundoplication 4
- Cricopharyngeal myotomy (for specific cases with upper esophageal sphincter dysfunction) 1
Evidence for Surgical Management
The evidence supporting surgical management for LPR is mixed:
- Systematic reviews show variable effectiveness of antireflux surgery for LPR symptoms 1
- No randomized controlled trials comparing antireflux surgery with medical therapy for LPR exist 1
- A 2022 review of 9 studies involving 287 fundoplications found that all studies demonstrated significant improvement in LPR symptoms after fundoplication (p<0.05) 3
- Professional voice users with refractory LPR showed high satisfaction rates (76-86%) after laparoscopic Nissen fundoplication, with 60% able to discontinue reflux medications postoperatively 5
Important Considerations and Caveats
- Poor PPI response predicts poor surgical response: Lack of response to PPI therapy predicts lack of response to anti-reflux surgery 1
- Objective testing is essential: Diagnosis should be confirmed with laryngoscopy before considering surgery 1
- Shared decision-making: Fundoplication should only be undertaken after careful consideration of benefits, risks, and alternatives 1
- Antireflux surgery is less predictable for extraesophageal symptoms than for typical GERD symptoms 1
- Common complications include tight wrap causing obstruction, slipped wrap, paraesophageal hernia (5-43%), delayed gastric emptying, and dumping syndrome 2
Surgical Management Algorithm
- First-line approach: Optimize medical therapy (8-12 weeks of twice daily PPI)
- If symptoms persist: Perform objective testing (pH monitoring, impedance studies)
- If high acid exposure confirmed: Consider surgical referral for patients with:
- Documented GERD
- Prior positive response to PPI
- Typical reflux symptoms alongside LPR symptoms
- Surgical option of choice: Laparoscopic fundoplication
- Post-surgical follow-up: Monitor for symptom improvement and complications
Remember that clinicians should not prescribe antireflux medications to treat isolated dysphonia attributed to suspected LPR without visualization of the larynx 1, and proper patient selection is critical for successful surgical outcomes.