| Detailed clinical history and physical examination to determine: | Rationale |
| Clinically significant GERD | Antireflux surgery is most often performed to control typical gastrointestinal symptoms (eg, heartburn or regurgitation). |
| Atypical GERD | Antireflux procedures may also be performed for nongastrointestinal symptoms (eg, chronic cough, hoarseness, laryngitis, wheezing, asthma, chronic bronchitis, aspiration, or dental erosion) when there is objective evidence to attribute such symptoms to reflux. |
| Medical treatment failure | Continued symptoms despite double-dose proton pump inhibitors for over six months should serve as a warning that symptoms may not be due to excess esophageal acid exposure. Consequently, such patients should be properly assessed before antireflux surgery. Older patients should undergo upper endoscopy to exclude esophageal malignancy; younger patients would benefit from esophageal studies such as pH testing and manometry to establish the diagnosis and etiology of their reflux symptoms. |
| Medication intolerance/Noncompliance/Prospect of lifelong medical therapy | Despite successful medical management, patients who are intolerant of, noncompliant with, or do not wish to continue lifelong medical therapy may opt for antireflux surgery due to quality of life considerations. |
| Routine esophageal testing for most patients seeking antireflux surgery | Rationale |
| Upper endoscopy | Esophageal and gastric endoscopy should be performed to assess the esophageal and gastric mucosa for signs of malignancy, esophagitis, stricture, or intestinal metaplasia (Barrett's esophagus). |
| Standard pH testing | Ambulatory pH testing is the gold standard for diagnosing pathologic GERD. Prior to antireflux surgery, all patients with nonerosive GERD should undergo standard pH testing to document abnormal distal esophageal acid exposure. |
| Esophageal manometry | Esophageal manometry is the most reliable way to assess lower esophageal sphincter competence and esophageal peristalsis. It can diagnose scleroderma or achalasia, for which antireflux surgery may be contraindicated. Manometric findings may influence the approach of antireflux surgery (eg, partial instead of complete fundoplication for those with weak peristalsis). Additionally, manometry is also used to determine the precise location of the gastroesophageal junction for accurate pH catheter placement. |
| Barium esophagram | Barium esophagram can demonstrate esophageal length, presence and size of any hiatal hernia, presence of any esophageal diverticulum or stricture, and the extent of reflux with provocation. |
| Optional additional evaluations | Rationale |
| Gastric emptying study for suspected gastric outlet obstruction or gastroparesis | A four-hour gastric emptying study should be performed when the history suggests gastric outlet obstruction or gastroparesis (eg, significant nausea, vomiting, bloating, or retained food in the stomach after overnight fast). |
| Multichannel intraluminal impedance (MII) study for patients who are refractory to PPI, have high-volume regurgitation, or have predominantly nongastrointestinal symptoms | Combined MII and pH (MII-pH) testing can detect both acid and nonacid gastroesophageal reflux. |
| Dual pH probe study for suspected laryngopharyngeal reflux | Dual probe pH study can document proximal (laryngeal) reflux events. |
