National trends in utilization and outcomes of antireflux surgery

Background: Studies examining the outcomes of surgery for gastroesophageal reflux disease (GERD) have consisted primarily of case series. We sought to assess trends in both utilization and outcomes of antireflux surgery from a national perspective. Methods: Using ICD-9 codes, we identified all antireflux procedures (N = 24,208) performed on adults from 1990 to 1997 in hospitals participating in the Nationwide Inpatient Sample, the largest all-payer inpatient care database in the United States. Using sampling weights and U. S. Census data, we then calculated the national population-based rate of antireflux surgery for each year and examined secular trends in utilization, in-hospital mortality, splenectomy (a technical complication), and length of hospital stay. Using a coding algorithm, we also assessed trends in the proportion of procedures performed via the laparoscopic, open abdominal, and thoracic approaches. Results: From 1990 to 1997, the population-based annual rate of antireflux surgery increased from 4.4 to 12.0 per 100,000 adults. A substantial increase in utilization was observed from 1993 to 1995, but annual rates before and after this period were relatively stable. Between 1990 and 1997, in-hospital surgical mortality decreased from 1.2% to 0.5% (p = 0.002), splenectomy rates decreased from 3.9% to 1.5% (p < 0.001), and median length of stay decreased from 7 to 2 days (p < 0.01). The proportion of antireflux procedures performed laparoscopically increased from 0.5% to 64% (p < 0.001), and the proportion of procedures performed using a thoracic approach decreased from 12% to 1% (p < 0.001). Conclusions: With the dissemination of the laparoscopic approach, the population-based rate of antireflux surgery has more than doubled. At the same time, operative mortality and splenectomy risks have diminished.