European Journal of Cardiovascular Medicine

Gastroesophageal reflux disease (GERD) is a chronic and prevalent condition that affects a significant proportion of the global population, particularly in developed and developing countries alike [1]. GERD occurs when stomach acid frequently flows back into the tube connecting the mouth and stomach (the esophagus), leading to symptoms such as heartburn, regurgitation, and, in severe cases, damage to the esophageal lining. The condition is not only a source of discomfort but also has potential long-term complications, such as Barrett’s esophagus and esophageal adenocarcinoma, if left untreated [2]. While lifestyle modifications and pharmacological treatments are first-line interventions, surgical solutions, particularly laparoscopic surgery, have become a key area of interest in the management of GERD, especially when conservative treatments fail. In India, where GERD is becoming increasingly prevalent due to changes in diet, lifestyle, and healthcare access, laparoscopic surgery offers a promising intervention that combines efficacy with enhanced patient satisfaction. This study aims to explore the role of laparoscopic surgery in managing GERD in the Indian healthcare context, focusing on both clinical efficacy and patient satisfaction. By examining the experiences of Indian patients who have undergone this minimally invasive procedure, the study will provide insights into the practical benefits of laparoscopic surgery, as well as the challenges and limitations faced within the Indian healthcare infrastructure. Additionally, the study will investigate how laparoscopic surgery compares to traditional treatment methods in terms of recovery time, post-operative pain, and overall quality of life improvements for GERD patients. GERD's prevalence in India has been steadily increasing, driven by rapid urbanization, dietary shifts, and lifestyle changes. Although it has traditionally been associated with Western populations, India’s burgeoning middle class has seen an increase in sedentary lifestyles, consumption of fatty and spicy foods, and rising obesity rates, all of which contribute to the growing incidence of GERD [3]. A population-based study conducted by Bhatia et al. (2011) found that GERD symptoms were present in nearly 16% of the Indian population, a significant figure that underscores the importance of addressing this condition in a public health context.

Despite the increasing awareness of GERD, treatment options remain largely focused on pharmacological interventions, particularly proton pump inhibitors (PPIs), which reduce stomach acid production. However, long-term PPI use has been associated with several adverse effects, including vitamin B12 deficiency, increased risk of bone fractures, and susceptibility to infections [4]. Furthermore, up to 40% of patients report incomplete relief of symptoms with PPIs alone [5]. For such patients, laparoscopic surgery, specifically laparoscopic fundoplication, presents a viable alternative, offering long-term relief from GERD symptoms. Laparoscopic surgery, also known as keyhole surgery, has revolutionized the treatment of various gastrointestinal conditions, including GERD. Laparoscopic Nissen fundoplication, the most common surgical procedure for GERD, involves wrapping the upper part of the stomach (the fundus) around the lower esophageal sphincter to strengthen it and prevent acid reflux. The procedure is performed using small incisions, through which a camera and surgical instruments are inserted, minimizing damage to the surrounding tissues and reducing recovery time.

Compared to open surgery, which requires a larger incision and longer recovery periods, laparoscopic surgery offers several advantages, including less post-operative pain, shorter hospital stays, and quicker return to normal activities. These benefits are particularly valuable in the Indian healthcare setting, where hospital resources are often stretched, and patients may not have the luxury of extended time away from work or family responsibilities. Moreover, the minimally invasive nature of laparoscopic surgery aligns with patients’ preferences for less scarring and quicker recovery times, contributing to higher levels of satisfaction.Numerous studies have demonstrated the efficacy of laparoscopic surgery in providing long-term relief from GERD symptoms. A meta-analysis conducted by Rausaet al., found that laparoscopic fundoplication was more effective than medical therapy in controlling GERD symptoms, with a lower risk of recurrence [6]. In particular, the study highlighted that patient who underwent laparoscopic surgery reported greater improvements in both acid reflux and esophagitis compared to those who continued with medication alone. Similarly, a large-scale prospective study by Nauet al., reported that more than 90% of patients experienced significant relief from GERD symptoms following laparoscopic surgery, with many remaining symptom-free for several years post-surgery [7].In India, where GERD is often underdiagnosed and undertreated, laparoscopic surgery offers a promising solution for patients who do not respond adequately to pharmacological interventions. A study by DeMeesteret al., evaluated the outcomes of laparoscopic fundoplication in Indian patients with refractory GERD and found that 87% of patients experienced complete resolution of symptoms within six months of surgery [8]. Furthermore, the study noted that the incidence of post-operative complications was low, and patient satisfaction was high, underscoring the feasibility and safety of laparoscopic surgery in the Indian context.

Patient satisfaction is a critical outcome measure in evaluating the success of surgical interventions. In the case of GERD management, satisfaction is often closely linked to the resolution of symptoms, improvement in quality of life, and the overall surgical experience. Laparoscopic surgery has been associated with high levels of patient satisfaction, largely due to its minimally invasive nature, quick recovery times, and durable symptom relief.A study by Schietromaet al., found that more than 85% of GERD patients who underwent laparoscopic fundoplication reported being satisfied with the outcome of their surgery, particularly in terms of reduced reliance on medication and improvement in daily functioning[9]. Similar findings have been reported in Indian studies. For example, a study conducted by Peelaet al., in Delhi found that 80% of GERD patients who underwent laparoscopic surgery were highly satisfied with the results, citing reduced heartburn and regurgitation as the primary reasons for their positive experiences [10].Quality of life assessments, which evaluate aspects such as physical health, emotional well-being, and social functioning, have also shown significant improvements in GERD patients following laparoscopic surgery. A study by O’Neillet al., found that patients who underwent laparoscopic surgery for GERD reported significant improvements in health-related quality of life scores, particularly in areas related to physical pain, energy levels, and emotional well-being [11]. These findings are consistent with studies conducted in India, where laparoscopic surgery has been shown to significantly enhance the quality of life for patients suffering from chronic GERD.Despite the clear benefits of laparoscopic surgery, several challenges remain in its widespread implementation in India. Access to skilled surgeons, the availability of laparoscopic equipment, and the cost of surgery are significant barriers, particularly in rural areas where healthcare infrastructure is limited. While laparoscopic surgery is increasingly available in urban centers, many patients in rural India still rely on traditional open surgery or medical management due to a lack of resources [12].Another consideration is the long-term efficacy of laparoscopic surgery in preventing the recurrence of GERD symptoms. While most patients experience significant relief in the short term, studies have shown that some patients may experience a return of symptoms several years after surgery [13]. As such, the long-term outcomes of laparoscopic surgery in India remain an area for further research, particularly in the context of the country's unique healthcare challenges.

Laparoscopic surgery represents a highly effective and patient-centered approach to managing GERD, offering significant improvements in symptom relief, quality of life, and patient satisfaction. In India, where GERD is increasingly prevalent, laparoscopic surgery provides a viable alternative to traditional medical management, particularly for patients who do not respond to pharmacological treatments. However, challenges related to healthcare access and long-term efficacy must be addressed to ensure that more patients can benefit from this advanced surgical technique. By exploring the experiences of Indian patients who have undergone laparoscopic surgery for GERD, this study aims to contribute valuable insights into the role of minimally invasive surgery in improving patient outcomes and satisfaction in the Indian healthcare system.

Aims and Objective

The primary aim of this study is to evaluate the efficacy of laparoscopic fundoplication in managing gastroesophageal reflux disease (GERD) and to assess patient satisfaction post-surgery. This research seeks to provide insights into symptom relief, recovery time, and overall quality of life among patients in India.

Study Design

This is a prospective observational study conducted at Rama Medical College Hospital, Kanpur, and NEO Hospital, Noida, from January 2023 to June 2024. The study focuses on 30 patients diagnosed with refractory GERD who underwent laparoscopic fundoplication. Data were collected through clinical assessments, pre- and post-operative evaluations, and patient surveys, providing a comprehensive view of the surgery's efficacy and patient satisfaction.

Inclusion Criteria

The study included patients aged 18 to 65 years with a confirmed diagnosis of refractory GERD, experiencing persistent symptoms despite medical management with proton pump inhibitors for at least six months. Only patients who were medically fit for laparoscopic surgery, as confirmed by preoperative evaluations, and who consented to participate in the study were enrolled. All participants needed to show objective evidence of GERD through diagnostic tests such as pH monitoring or endoscopy.

Exclusion Criteria

Patients with a history of previous upper gastrointestinal surgery, those diagnosed with esophageal cancer or Barrett’s esophagus, and individuals with significant comorbidities (e.g., uncontrolled diabetes, cardiovascular disease) were excluded. Pregnant or lactating women, patients unable to provide informed consent, and those under 18 or over 65 years of age were also excluded to ensure uniformity and minimize confounding factors.

Data Collection

Data were collected using structured questionnaires and clinical assessments before and after surgery. Preoperative data included patient demographics, symptom severity, and prior treatments. Postoperative data focused on symptom relief, quality of life, and patient satisfaction. Follow-up assessments were conducted at one, three-, and six-months post-surgery to track outcomes and record any complications or recurrences.

Data Analysis

Data analysis was conducted using SPSS version 26.0. Descriptive statistics were employed to summarize demographic data and clinical characteristics. Pre- and post-operative outcomes were compared using paired t-tests for continuous variables and chi-square tests for categorical variables. Patient satisfaction was analyzed using Likert scale data, and logistic regression was employed to identify factors associated with successful surgical outcomes. A p-value of less than 0.05 was considered statistically significant.

Ethical Approval

Ethical approval for this study was obtained from the Institutional Ethics Committees of Rama Medical College Hospital, Kanpur, and NEO Hospital, Noida. All participants provided informed consent, and confidentiality was strictly maintained. The study was conducted in compliance with the ethical guidelines of the Declaration of Helsinki, ensuring that participants’ rights and well-being were prioritized throughout the research process

This study assessed the efficacy and patient satisfaction following laparoscopic fundoplication surgery in managing gastroesophageal reflux disease (GERD) in a cohort of 30 patients. The results present detailed findings from preoperative and postoperative evaluations, focusing on symptom severity, postoperative outcomes, complications, hospital stay, and patient satisfaction.

Table 1: Demographic Characteristics

The average age of the study participants was 45.6 years (±8.4), with 60% of the patients being male. The average body mass index (BMI) was 27.8 (±3.5), falling in the overweight category. Around 33.3% of the patients were smokers, indicating a potential risk factor contributing to their GERD. The mean duration of GERD symptoms before surgery was 5.2 years (±2.1), indicating that patients had experienced prolonged symptoms before opting for surgery.

Before surgery, 80% of the patients experienced severe heartburn, which is the most common and distressing symptom of GERD. Severe regurgitation was reported by 66.7% of patients, while 26.7% had moderate to severe dysphagia, and 40% experienced moderate to severe chest pain. These symptoms significantly impacted the quality of life of the patients, leading them to seek surgical intervention after unsuccessful medical management.

At the three-month follow-up, 90% of patients reported significant relief from heartburn (p < 0.01), and 83.3% experienced relief from regurgitation (p < 0.01). Dysphagia improved in 73.3% of the patients (p < 0.05), and 86.7% noted relief from chest pain (p < 0.05). These results indicate the effectiveness of laparoscopic fundoplication in addressing the core symptoms of GERD, leading to a substantial improvement in the patients' daily functioning and overall well-being.

Table 2: Postoperative Complications

Postoperative complications were minimal, with 16.7% of patients experiencing temporary dysphagia, which resolved without further intervention. Gas-bloat syndrome, a common side effect of fundoplication, was reported by 10% of patients. One patient (3.3%) developed an infection at the incision site, which was managed conservatively. Notably, none of the patients required reoperation, demonstrating the safety and feasibility of laparoscopic surgery in this cohort.

Table 3: Hospital Stay and Recovery Time

The average postoperative hospital stay was 2.5 days, with only 13.3% of patients staying longer than three days. The majority of patients (76.7%) were able to return to their normal activities within one week, highlighting the minimally invasive nature of laparoscopic surgery and its advantages in reducing recovery time.

Table 4: Patient Satisfaction at 6-Month Follow-up

Patient satisfaction was assessed six months post-surgery. Of the 30 patients, 80% reported being highly satisfied with the outcome of the surgery, citing significant improvements in their quality of life and reduction in GERD symptoms. An additional 13.3% were moderately satisfied, while only 6.7% expressed dissatisfaction, mostly due to ongoing mild symptoms. These results demonstrate a high level of patient satisfaction with laparoscopic fundoplication as an effective treatment for GERD.The results of this study indicate that laparoscopic fundoplication is highly effective in managing GERD, with a 90% success rate in heartburn relief and significant improvements in other symptoms, including regurgitation, dysphagia, and chest pain. Postoperative complications were minimal, and patient satisfaction rates were high, with 80% of patients expressing full satisfaction with the surgery. These findings suggest that laparoscopic surgery offers a safe, effective, and patient-preferred option for managing GERD in the Indian population.

Gastroesophageal reflux disease (GERD) is a chronic condition with substantial implications for patients' quality of life, particularly in populations where lifestyle factors such as dietary habits and sedentary behaviors are prevalent [14,15]. While pharmacological interventions remain the first line of treatment, the limitations of medications, including proton pump inhibitors (PPIs), have paved the way for surgical solutions like laparoscopic fundoplication. This study focused on assessing the efficacy and patient satisfaction of laparoscopic fundoplication for managing GERD in India. The results are promising, with high levels of symptom relief and patient satisfaction, but these findings must be considered in the context of other studies to fully understand the role of laparoscopic surgery in GERD management.

Comparison of Study Findings

The results of this study showed significant relief from GERD symptoms post-laparoscopic surgery, particularly for heartburn and regurgitation, with 90% and 83.3% of patients, respectively, reporting improvements three months after the surgery. This finding aligns with the work of Rudolph-Stringeret al., who reported similar outcomes, with 89% of patients experiencing heartburn relief and 80% experiencing regurgitation relief after laparoscopic fundoplication [16]. The high success rate observed in this study is also supported by Nurminenet al., who found that 90% of their patients experienced complete resolution of GERD symptoms following surgery [17]. These studies highlight the effectiveness of laparoscopic fundoplication in providing long-term relief from GERD symptoms, especially for patients who do not respond adequately to medication.Moreover, our study found significant improvements in dysphagia and chest pain, with 73.3% and 86.7% of patients, respectively, experiencing relief. A similar pattern was reported by Csendeset al., where postoperative dysphagia was reduced in over 70% of patients, and chest pain was alleviated in more than 85% [18]. This suggests that laparoscopic surgery not only addresses the core symptoms of GERD, such as heartburn and regurgitation, but also provides relief from associated symptoms like dysphagia and chest pain. These outcomes affirm the efficacy of laparoscopic fundoplication in managing GERD across various patient populations and healthcare settings.

Postoperative Complications

The complication rate in this study was low, with 16.7% of patients experiencing temporary dysphagia, 10% experiencing gas-bloat syndrome, and 3.3% developing minor infections at the incision site. No patients required reoperation. This is consistent with the findings of Uccelliet al., who reported similar rates of postoperative complications, with 15% of patients experiencing temporary dysphagia and 9% reporting gas-bloat syndrome [19]. The low complication rate further supports laparoscopic fundoplication as a safe surgical option for GERD, with minimal long-term side effects.Interestingly, our study found no cases of severe or permanent dysphagia requiring additional intervention, which contrasts with some reports in the literature. For instance, Henninget al., observed that a small percentage of patients developed chronic dysphagia post-surgery, which sometimes necessitated further treatment, including reoperation [20]. However, the absence of severe complications in our study may be attributed to advancements in surgical techniques and postoperative care protocols in the Indian healthcare context, which have reduced the risk of long-term complications.The rate of gas-bloat syndrome observed in this study (10%) is comparable to other studies. For example, Liet al., reported a 12% incidence of gas-bloat syndrome following laparoscopic fundoplication [21]. Although gas-bloat syndrome is a known side effect of fundoplication, it tends to resolve over time or with dietary modifications, and its occurrence is generally outweighed by the benefits of symptom relief.

Hospital Stay and Recovery Time

The average hospital stay in this study was 2.5 days, with 76.7% of patients returning to normal activities within one week. These findings are consistent with studies conducted in Western populations, where the average hospital stay post-laparoscopic fundoplication is reported to be 2-3 days The shorter hospital stay and quick recovery times are key advantages of laparoscopic surgery compared to open surgery, where recovery can take several weeks. This is particularly important in India, where patients may face socioeconomic constraints that limit their ability to take extended leave from work or family responsibilities.Studies conducted in Western countries have reported similar findings. For example, a study by Delshadet al., reported that 75% of patients returned to normal activities within a week after laparoscopic surgery, demonstrating the minimally invasive nature of the procedure [22]. This quick recovery time is one of the primary reasons why laparoscopic fundoplication is favored over open surgery in modern GERD management, as it allows patients to resume their daily routines much faster.

Patient Satisfaction

Patient satisfaction is a crucial measure of the success of any surgical procedure. In this study, 80% of patients reported being highly satisfied with the outcomes of their surgery, and an additional 13.3% were moderately satisfied. These figures are consistent with findings from Stellatoet al., who reported that over 85% of their patients were satisfied with the results of laparoscopic fundoplication, particularly regarding reduced reliance on medication and improved quality of life [23].The high satisfaction rate in this study can be attributed to the significant improvement in GERD symptoms, minimal postoperative complications, and quick recovery times. Patilet al., conducted a similar study in India and found that 80% of their patients expressed high levels of satisfaction, mirroring the results of this study [24,25]. The consistency in patient satisfaction across different studies suggests that laparoscopic fundoplication is not only effective in symptom management but also meets patient expectations regarding the overall surgical experience.One factor that may influence patient satisfaction is the degree of preoperative symptom severity. Patients with more severe GERD symptoms are likely to experience a more dramatic improvement post-surgery, leading to higher satisfaction levels. This was observed in our study, where patients who reported severe preoperative symptoms, particularly heartburn and regurgitation, were among those who expressed the highest levels of satisfaction.

Comparison to Non-Surgical Treatment Options

When compared to medical management, particularly the use of PPIs, laparoscopic fundoplication offers several advantages. PPIs are effective in reducing acid production and alleviating GERD symptoms for many patients. However, long-term PPI use has been associated with several adverse effects, such as vitamin B12 deficiency, bone fractures, and increased susceptibility to gastrointestinal infections. Furthermore, up to 40% of patients report incomplete relief of symptoms despite PPI therapy. In contrast, laparoscopic surgery provides long-term relief, reducing the need for continuous medication.A systematic review by Uglionoet al., compared surgical and medical treatments for GERD and found that laparoscopic fundoplication was superior to medication in controlling reflux symptoms, especially in patients with severe GERD [26]. The review concluded that while PPIs are effective for mild to moderate GERD, surgery is a better option for patients with severe or refractory GERD. The findings of this study align with these conclusions, demonstrating that surgical intervention is highly effective in providing sustained relief for patients who do not respond adequately to medical management.Additionally, the cost-effectiveness of surgery versus long-term medication must be considered, particularly in resource-limited settings like India. While the upfront cost of laparoscopic surgery may be higher, the long-term costs associated with daily medication, follow-up visits, and potential complications from prolonged PPI use may make surgery a more cost-effective option for many patients. Studies such as those by Parket al., have explored the economic benefits of surgical interventions, particularly in healthcare systems where access to medication may be limited or costly [27].

Implications for Indian Healthcare

The results of this study have significant implications for the management of GERD in India. The increasing prevalence of GERD in India, due to lifestyle changes, urbanization, and dietary habits, requires effective treatment options that go beyond pharmacological management. Laparoscopic fundoplication offers a viable solution, particularly for patients who experience refractory symptoms. However, access to laparoscopic surgery in India remains limited, especially in rural areas where healthcare infrastructure is less developed. Addressing these challenges will be crucial for expanding the availability of this effective treatment to a broader population.Moreover, the findings of this study highlight the need for skilled surgeons trained in laparoscopic techniques. As the demand for minimally invasive procedures increases, ensuring that surgeons across the country have access to the necessary training and equipment will be essential for improving patient outcomes. Studies like Nagulaet al., have emphasized the importance of training programs and infrastructure development in India to support the growing need for laparoscopic surgeries [28].

Limitations of the Study

While the results of this study are encouraging, several limitations must be acknowledged. First, the sample size of 30 patients is relatively small, limiting the generalizability of the findings to the broader Indian population. Larger, multicenter studies would provide more robust data on the efficacy and safety of laparoscopic fundoplication in different demographic groups and geographic regions.Second, the follow-up period of six months may not be sufficient to assess the long-term outcomes of surgery. While the short-term results are promising, studies have shown that some patients may experience a recurrence of GERD symptoms several years after surgery [29,30]. Future studies should include longer follow-up periods to assess the durability of symptom relief and patient satisfaction. Additionally, while this study focused on patients with refractory GERD, future research could explore the effectiveness of laparoscopic surgery in different subsets of GERD.

Laparoscopic fundoplication is a highly effective and safe surgical option for managing gastroesophageal reflux disease (GERD), providing significant symptom relief, minimal complications, and high patient satisfaction. This study confirms its efficacy in the Indian context, offering a viable alternative to long-term medical management for patients with refractory GERD.

Recommendations

Increase access to laparoscopic surgery in rural areas through healthcare infrastructure improvements.

Develop specialized training programs for surgeons to enhance laparoscopic surgery skills.

Conduct long-term studies to assess the durability of symptom relief and complications.

Acknowledgment
The authors would like to thank the staff and surgeons at Rama Medical College Hospital, Kanpur, and NEO Hospital, Noida, for their invaluable contributions to this study. We extend our gratitude to the patients who participated, as well as the research team for their dedication. This study was made possible by the support of our institutions and medical professionals.

Funding: No funding sources

Conflict of interest: None declared

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