INTRODUCTION — Gastroesophageal reflux disease (GERD) is defined according to the Montreal consensus as "a condition which develops when the reflux of stomach contents causes troublesome symptoms and/or complications" [1]. It is manifested by a spectrum of nonspecific symptoms, including heartburn, regurgitation, dysphagia, laryngitis, dental problems, adult-onset asthma, and/or aspiration pneumonia. The prevalence of GERD is high and increasing, particularly in developed countries (eg, 20 percent in the United States) [2].
Lifestyle modification and medications are the first-line treatment for GERD. Surgical management is generally reserved for patients who have persistent symptoms or develop complications despite optimal medical therapy [3]. Additionally, patients who are unable to tolerate, noncompliant with, or unwilling to take lifelong medications are also surgical candidates.
Surgical management of GERD focuses on restoring a physiologic equivalent to the normal lower esophageal sphincter (LES). Manometric studies correlate GERD with a lower mean LES pressure, shorter mean intra-abdominal LES length, and shorter overall sphincter length [4]. Each of these problems can be corrected by specific surgical procedures.
The surgical management of adult patients with GERD is reviewed in this topic. The pathophysiology, diagnosis, medical management, and complications of GERD are discussed elsewhere:
●(See "Pathophysiology of reflux esophagitis".)
●(See "Clinical manifestations and diagnosis of gastroesophageal reflux in adults".)
●(See "Medical management of gastroesophageal reflux disease in adults".)
●(See "Approach to refractory gastroesophageal reflux disease in adults".)
●(See "Non-acid reflux: Clinical manifestations, diagnosis, and management".)
●(See "Complications of gastroesophageal reflux in adults".)
●(See "Gastroesophageal reflux and asthma".)
●(See "Radiofrequency treatment for gastroesophageal reflux disease".)
Management of GERD in neonates, infants, or pediatric patients is discussed separately:
●(See "Gastroesophageal reflux in premature infants".)
●(See "Gastroesophageal reflux in infants".)
●(See "Management of gastroesophageal reflux disease in children and adolescents".)
INDICATIONS FOR OPERATION — Antireflux surgery is most often performed to control gastrointestinal symptoms (eg, heartburn and regurgitation) that are refractory to medical therapy. It may also be performed for nongastrointestinal symptoms (eg, chronic cough, laryngeal disease, and asthma) when there is solid objective evidence to attribute such symptoms to reflux. The gastrointestinal symptoms are also referred to as typical symptoms and the nongastrointestinal symptoms as atypical symptoms.
Gastrointestinal indications
Failed medical management — The most frequent indication for antireflux surgery is moderate-to-severe gastroesophageal reflux disease (GERD) incompletely controlled by optimal medical therapy, which consists of both drug therapy and lifestyle modifications [5]. Ten to 40 percent of patients continue to have substantial symptoms of "reflux" despite elimination of the heartburn component of their GERD and may wish to consider operation on this basis alone [6].
There is consensus that patients with documented pathologic acid reflux who have complete or partial response to proton pump inhibitors (PPIs) are good candidates for one of the antireflux procedures if continued medical therapy is not desired. The choice of procedure depends on whether a clinically significant hiatal hernia is present (laparoscopic fundoplication [LF] or magnetic sphincter augmentation [MSA]) or absent (LF, MSA, or transoral incisionless fundoplication [TIF]). (See 'Choice of procedure' below.)
However, there is less agreement on whether patients with documented pathologic acid reflux who do not respond to maximal PPI therapy should be offered any antireflux procedures [7]. As an example, an expert panel of 14 gastroenterologists recommended impedance testing for all PPI nonresponders and LF or MSA only for patients with elevated esophageal acid exposure time or those with a positive symptom-reflux association for regurgitation and a large hiatal hernia; TIF was not recommended for any PPI nonresponders [6]. By contrast, another expert panel of eight foregut surgeons and seven interventional gastroenterologists recommended LF for all PPI nonresponders with a large hiatal hernia, TIF for all PPI nonresponders without a large hiatal hernia, and MSA for any PPI nonresponders with regurgitation-predominant symptoms [8].
At a minimum, continued symptoms despite adequate acid suppression with double-dose PPIs for over three months should serve as a warning that symptoms may not be due to excess esophageal acid exposure but to another diagnosis, such as reflux hypersensitivity, functional heartburn, a malignancy, or extraesophageal disease. Consequently, such patients should be properly assessed before antireflux surgery. Those patients who fail to meet objective criteria such as hypotensive lower esophageal sphincter (LES) or objectively elevated acid exposure should most likely not be offered a surgical procedure in this setting. (See 'Preoperative evaluation' below and "Approach to refractory gastroesophageal reflux disease in adults", section on 'Diagnostic strategies and initial management'.)
Intolerance of or noncompliance with medical therapy — Such patients may opt for antireflux surgery due to quality of life considerations despite successful medical management of GERD [9]. These include patients who respond to but experience complications with PPI therapy and young patients with a hypotensive sphincter who do not want to take medications for the rest of their lives [10].
Complications of GERD — Complications of GERD, such as severe esophagitis (usually defined as Los Angeles class C or D) or benign peptic stricture, are diagnosed endoscopically and may be indications for antireflux surgery if patients fail medical therapy [9].
Surgical intervention for asymptomatic Barrett's esophagus is controversial. It remains to be established whether surgery is beneficial for preventing esophageal adenocarcinoma in Barrett's esophagus patients [11,12]. Patients with either Barrett-associated dysplasia or carcinoma should not undergo antireflux surgery before the lesion has been eradicated histologically by endoscopic therapy. (See "Barrett's esophagus: Surveillance and management", section on 'Management of dysplasia or intramucosal carcinoma'.)
Volume regurgitation — Patients with high-volume reflux may have typical gastrointestinal symptoms (eg, regurgitation) or atypical, nongastrointestinal symptoms (eg, cough or asthma due to aspiration, dental erosions). Such patients often fail PPI therapy because of persistent reflux of weakly acidic or alkaline gastric contents through an incompetent LES [10]. Surgical correction of the incompetent LES may alleviate their symptoms. Preoperative evaluation of high-volume or nonacidic reflux patients is more complicated and usually requires specialized pH testing before surgery. (See "Non-acid reflux: Clinical manifestations, diagnosis, and management", section on 'Diagnostic evaluation' and 'Esophageal pH testing' below.)
High-volume reflux should be distinguished from rumination, which is effortless regurgitation of food. Heartburn may be associated with rumination, causing even more confusion with GERD. Rumination often responds to behavioral therapy. (See "Rumination syndrome".)
Nongastrointestinal indications — About one-half of patients with GERD report upper respiratory symptoms, such as chronic cough, hoarseness, laryngitis, wheezing, asthma, chronic bronchitis, aspiration, or dental erosion [13,14]. In addition, idiopathic subglottic stenosis and even laryngeal cancer have also been implicated [15,16].
For patients whose respiratory symptoms are accompanied by typical reflux symptoms and positive esophageal pH testing, relief of respiratory symptoms might also be achieved by antireflux surgery. However, the outcome is less favorable for a minority of patients who either only have respiratory symptoms [17] or have abnormal esophageal motility [18]. In such patients, careful patient selection by objective esophageal testing and with multidisciplinary input (otolaryngology, pulmonary, and allergy specialists) can increase the likelihood of positive results [3,19,20]. (See 'Preoperative evaluation' below.)
Chronic cough — After a thorough, objective medical workup to document proximal esophageal exposure, patients with chronic cough associated with GERD can have an excellent rate of resolution (77 to 81 percent) and quality-of-life outcomes with antireflux surgery [21,22].
Laryngeal disease — A direct causal relationship between pharyngeal acid exposure and laryngeal diseases remains controversial [23,24]. As such, antireflux surgery is not to be used as the first-line treatment for posterior laryngitis. However, it is reasonable to consider surgery for patients who have abnormal pharyngeal acid exposure on a double probe pH study when medical therapy has been maximized, is not tolerated, or is impractical [25]. (See "Laryngopharyngeal reflux in adults: Evaluation, diagnosis, and management".)
While some data have shown that laryngeal symptoms can be treated successfully by laparoscopic fundoplication [26,27], others have suggested that surgery was not consistently effective in patients who were unresponsive to aggressive PPI therapy [28]; thus, failure to respond to a PPI should serve as a warning that symptoms may not be relieved with surgery.
Documented response rates for airway diseases are less favorable than those for fundoplication performed for typical gastroesophageal symptoms. Approximately 70 percent of patients will experience symptom improvement, while approximately 33 percent of patients may remain on medication but often at a far reduced dosage [29].
Asthma — Gastroesophageal reflux is common among patients with asthma. Reciprocally, respiratory symptoms, including those associated with asthma, are increased among patients with GERD. However, consensus has not been reached on the role of antireflux surgery in patients with asthma that is thought to be related to GERD. (See "Gastroesophageal reflux and asthma".)
A systematic review that included 24 reports (mostly case series and uncontrolled trials) suggested that surgery improved asthma symptoms, asthma medication use, and pulmonary function in 79, 88, and 27 percent of patients, respectively [30]. A dramatic reduction in steroid dependency postoperatively was documented in another study [31]. However, improvement in pulmonary function has not been documented after either medical or surgical therapy [30,32-34].
PREOPERATIVE EVALUATION — Symptoms of gastroesophageal reflux disease (GERD) are highly prevalent. As such, symptoms alone, with or without response to proton pump inhibitor (PPI) therapy, are not specific enough to diagnose GERD. Before antireflux surgery, objective data from esophageal testing are required to anatomically and physiologically evaluate the presence and severity of GERD and determine the indication and best operative approach for each patient.
A consensus panel recommended that upper endoscopy, standard pH testing, esophageal manometry, and barium esophagram be performed for all patients before antireflux surgery. Nonstandard pH testing or gastric emptying study may be required for some patients (table 1):
Upper endoscopy — Esophageal and gastric endoscopy should be performed to assess the esophageal and gastric mucosa for signs of malignancy prior to proceeding with an antireflux procedure. Patients with endoscopic findings of severe (Los Angeles grade C or D) esophagitis, biopsy-proven Barrett's esophagus ≥1 cm, or a benign peptic stricture may forego pH testing as these criteria establish the diagnosis of pathologic GERD [35]. (See "Clinical manifestations and diagnosis of gastroesophageal reflux in adults", section on 'Upper gastrointestinal endoscopy'.)
Esophageal pH testing — Patients with typical (gastrointestinal) symptoms of GERD should undergo standard pH testing. Patients with atypical (nongastrointestinal) symptoms may require nonstandard pH testing, such as one with dual pH probe or impedance in order to document proximal and/or nonacidic reflux.
Standard pH testing — Ambulatory pH testing is the gold standard for diagnosing pathologic GERD. Prior to antireflux surgery, all patients with nonerosive GERD, including those with Los Angeles grade A or B (mild) esophagitis and those with short-segment (<1 cm) Barrett's esophagus, should undergo standard pH testing to document abnormal distal esophageal acid exposure. An abnormal pH test in a PPI-dependent patient with typical symptoms predicts successful outcomes with antireflux surgery [36].
Standard pH testing can be done via a transnasal catheter for 24 hours or a wireless pH system for 48 hours after the patient has been off acid suppression for seven days. Esophageal acid exposure is considered pathological if acid exposure time (AET) is >6 percent [35]. (See "Clinical manifestations and diagnosis of gastroesophageal reflux in adults", section on 'Ambulatory esophageal pH monitoring'.)
MII (impedance) testing — Multichannel intraluminal impedance (MII) is a catheter-based method to detect intraluminal bolus movement within the esophagus. MII is performed in combination with manometry or pH testing. Combined MII and pH (MII-pH) testing can detect both acid and nonacid gastroesophageal reflux. It should be recognized that this testing is somewhat controversial and interpretation is operator dependent.
MII is indicated to document weakly acidic or nonacidic reflux in patients who are refractory to PPI, have high-volume regurgitation, or have nongastrointestinal symptoms. This test can also help exclude rumination (effortless regurgitation), which may be confused with volume reflux, or supragastric belching, which may induce reflux. (See "Esophageal multichannel intraluminal impedance testing".)
Dual pH probe — A dual pH probe test is usually performed in patients with suspected laryngopharyngeal reflux (LPR) to document proximal (laryngeal) reflux events [20]. (See "Laryngopharyngeal reflux in adults: Evaluation, diagnosis, and management", section on 'LPR testing'.)
Symptom association — A correlation between a patient's symptoms and reflux events can be calculated by computer software, which associates a symptom with a reflux event if the symptom occurs within two minutes of the reflux event. Symptom association is usually presented as either the symptom index (SI) or symptomatic association probability (SAP). An SI >50 percent or an SAP >95 percent is considered positive.
Symptom association scores are most useful in determining if a particular symptom (eg, cough) is associated with acid reflux. In surgical practice, SI, and especially SAP, are primarily used in patients who have atypical but no typical symptoms. For those with typical symptoms and a positive acid exposure time, SI or SAP is hardly relevant.
Decisions to proceed with antireflux surgery, however, should not be made on the basis of a positive SI or SAP alone. The calculation of SI and SAP is performed by the computer software (of standard and MII pH testing) without manual reading of the tracings and is highly dependent on the number of symptoms provided by the patient during the testing period. Additionally, SI and SAP have only been validated for acid reflux, not nonacid reflux (as detectable by MII) [37].
Esophageal manometry — Esophageal manometry is the most reliable way to assess lower esophageal sphincter (LES) competence and esophageal peristalsis. Overall, the LES is incompetent in about 60 percent of patients with GERD [38], while transient relaxation of a competent LES is the cause of GERD in the remaining 40 percent [39].
Manometry assesses esophageal peristalsis as well and occasionally provides alternative diagnoses, such as scleroderma or achalasia, for which antireflux surgery may be contraindicated. Manometric findings may influence the surgical approach (eg, partial instead of complete fundoplication for those with weak peristalsis) or a change in management, although the need to modify the surgical procedure based upon the manometric findings has been questioned [40].
Additionally, manometry is also used to determine the precise location of the gastroesophageal junction for accurate pH catheter placement. (See "Overview of gastrointestinal motility testing", section on 'Esophageal manometry'.)
Barium esophagram — Barium esophagram (ie, upper gastrointestinal series) 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.
Although primarily an intraoperative decision, the presence of a markedly shortened esophagus or a large hiatal hernia that does not reduce in the upright position may alert the surgeon to the necessity of a Collis gastroplasty or a transthoracic approach [41]. (See 'Shortened esophagus' below.)
Gastric emptying study — A four-hour gastric emptying study should be performed when the history of a patient with GERD symptoms suggests gastric outlet obstruction or gastroparesis (eg, significant nausea, repeated vomiting, severe bloating or postprandial fullness, or retained food in the stomach after overnight fast).
A combination of antireflux procedure and significantly impaired gastric emptying will lead to bloating and discomfort. Some surgeons will choose to add a pyloroplasty to improve gastric emptying when serious dysfunction is revealed [42,43]. (See "Gastroparesis: Etiology, clinical manifestations, and diagnosis", section on 'Scintigraphic gastric emptying'.)
CHOICE OF PROCEDURE — There is no one best operation for all patients with gastroesophageal reflux disease (GERD). Currently available antireflux procedures include:
●Radiofrequency treatment (Stretta) – Endoscopic
●Transoral incisionless fundoplication (TIF) – Endoscopic
●Magnetic sphincter augmentation (MSA) – Surgical
●Laparoscopic Hill gastropexy – Surgical
●Laparoscopic partial fundoplication – Surgical
●Laparoscopic Nissen (complete) fundoplication – Surgical
These procedures vary by efficacy and durability on one hand and adverse effect profiles on the other. At one end of the spectrum, laparoscopic Nissen fundoplication is highly effective in relieving GERD symptoms and is the most durable amongst all the procedures; however, it is also associated with the greatest potential for adverse effects, such as dysphagia, difficulty in vomiting, and gas bloating. At the other end of the spectrum, endoscopic procedures such as Stretta and TIF are the most "physiologic" procedures and therefore the least likely to be associated with adverse effects. However, their efficacy and durability are not as good as those of a complete fundoplication. Partial fundoplications, Hill procedure, and LINX generally fall in the middle of the spectrum both in terms of efficacy/durability and adverse effect profile.
When the requisite surgical and endoscopic expertise is available, patients should ideally be offered a spectrum of rather than a single antireflux procedure. As such, patients can choose the procedure that affords the right combination of efficacy/durability and potential adverse effects/perturbation to gastrointestinal physiology to them. The shared decision-making process also sets the correct expectation for surgical outcomes.
In addition to patient preference, anatomic and patient/surgeon factors such as the degree of esophageal shortening, disturbances of esophageal motility, prior operations, and local expertise also influence the choice of operation:
Early uncomplicated disease — For patients with normal esophageal length and motility (ie, most patients with early, uncomplicated disease), the operation of choice in the United States is probably a laparoscopic Nissen fundoplication [44,45]. Studies comparing partial fundoplication to the 360 degree Nissen fundoplication have consistently reported less postoperative dysphagia with partial fundoplication but greater long-term durability with complete fundoplication [46]. (See 'Comparison of partial with complete fundoplication' below.)
Complicated disease — Fundoplication remains the standard of care for patients with GERD complicated by hiatal hernia >2 cm, severe (Los Angeles class C or D) erosive esophagitis, and/or Barrett's esophagus [47]. Such complications are contraindications to less invasive procedures such as TIF or MSA.
Decreased esophageal motility — For patients with normal esophageal length but decreased esophageal motility, a laparoscopic partial fundoplication (eg, Toupet) or Hill procedure, rather than a complete (Nissen) fundoplication, should be performed. While an incomplete wrap is often recommended in patients with poor esophageal motility [48,49], the results of at least one trial raised questions about this recommendation [40].
Shortened esophagus — Patients with a shortened esophagus from chronic inflammation or altered anatomy present a unique challenge. Although opinions vary regarding what constitutes adequate esophageal mobilization, it is generally accepted that increasing the intra-abdominal esophageal length can also be facilitated by reduction of hiatal hernia, approximation of the diaphragmatic crura, or tethering of the distal esophagus below the diaphragm. The bulk of a fundoplication may also keep the gastroesophageal junction within the abdomen.
In 311 consecutive patients undergoing minimally invasive surgery for GERD and/or hiatal hernia, the distance between the endoscopically localized gastroesophageal junction and the apex of the diaphragmatic hiatus after maximal thoracic esophagus mobilization was <1.5 cm in 31.8 percent of the patients who had "true" shortened esophagus [50].
If the intra-abdominal esophagus is <2 cm despite the surgeon's best efforts at esophageal mobilization, a Collis gastroplasty (esophageal-lengthening procedure) combined with a fundoplication should be performed. A survey of about 1000 patients reported that, at four years, those who underwent a laparoscopic Collis gastroplasty with fundoplication had similar symptom control, satisfaction, and quality of life to those who underwent fundoplication alone [51].
Shortened esophagus is discussed in detailed elsewhere as it is more commonly encountered during paraesophageal hernia repair than pure antireflux surgery. (See "Surgical management of paraesophageal hernia", section on 'Esophageal mobilization'.)
Patients with obesity — Obesity is associated with GERD. For patients with severe obesity, Roux-en-Y gastric bypass (RYGB) is the bariatric procedure of choice for surgical treatment of GERD. Several small series have reported a decrease in reflux symptoms as well as complete or partial regression of Barrett's esophagus with RYGB [52-54]. (See "Laparoscopic Roux-en-Y gastric bypass", section on 'Gastroesophageal reflux disease' and "Barrett's esophagus: Surveillance and management".)
Transthoracic procedure — In contemporary surgical practice, transthoracic antireflux procedures are rarely used except in patients with concurrent pulmonary disease requiring evaluation, extensive prior abdominal surgery, severe obesity, or a shortened esophagus [41]. The need for adequate mobilization of the esophagus is another reason cited for transthoracic approaches [55]. Transthoracic approaches for esophageal reflux are exceedingly rare, except occasionally in reoperative scenarios.
The Belsey Mark IV operation involves a partial fundoplication performed by transthoracic approach, which allows full esophageal mobilization [56]. The incomplete fundoplication leads to fewer obstructive symptoms and is therefore recommended for patients with poor esophageal motility who also have one of the indications for a transthoracic approach described above.
OPERATIVE TECHNIQUES — A variety of antireflux procedures have been described for the treatment of gastroesophageal reflux disease (GERD) (figure 1A-B).
Fundoplication procedures — The original fundoplication as described by Rudolph Nissen in 1956 involved passage of the gastric fundus behind the esophagus to encircle the distal 6 cm of the esophagus. Since that time, many variations and modifications have been described, and the same-named procedure may be performed differently by different surgeons.
Important variables of a fundoplication procedure include approach (transthoracic or abdominal), portion of stomach wall used (anterior and posterior or anterior only), combination with other procedures (eg, vagotomy or gastroplasty), the looseness of the wrap, the completeness of the wrap, and the length of the wrap [55].
In contemporary surgical practice, fundoplication is performed laparoscopically or robotically in most patients. Compared with open transabdominal or transthoracic fundoplication, laparoscopic or robotic fundoplication is endorsed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) [57] because it demonstrates comparable safety, efficacy in symptom relief [58], and patient satisfaction as well as shorter hospital stays and recuperative times [59-64] and fewer incisional hernias over time [65].
The reported learning curve of laparoscopic fundoplication varies among studies but ranges from 20 to 60 [66-68]. Although robotic antireflux surgery offers no specific advantages over other laparoscopic techniques and is more costly to perform [69], its use has increased from 5.4 to 26 percent from 2012 to 2018, according to data from the Michigan Surgical Quality Collaborative [70].
Nissen (360 degree or complete) fundoplication — Most surgeons choose to perform a loose ("floppy") Nissen fundic wrap that is about 2 to 3 cm in length, followed by a posterior crural repair [49,55]. Important technical points of a successful laparoscopic Nissen fundoplication include [10]:
●Extensive mediastinal dissection should be performed, especially when a hiatal hernia is present, to reduce >2 cm of esophagus to below the diaphragm without tension. Reduction of hiatal hernia may also contribute to the efficacy of antireflux surgery [71]. If the intra-abdominal esophagus is <2 cm despite the surgeon's best efforts at esophageal mobilization, a Collis gastroplasty should be performed. (See 'Shortened esophagus' above.)
●The short gastric vessels are typically transected to ensure a tension-free ("floppy") fundoplication. The Rosetti technique does not divide the short gastric vessels. (See 'Rosetti-Nissen fundoplication' below.)
●The lower esophageal sphincter (LES) and fundus normally undergo vagally mediated relaxation with swallowing. An incorrectly performed fundoplication may prevent appropriate relaxation of the LES with swallowing. It is therefore important that the fundus is the only part of the stomach used for reinforcing the LES; the wrap is placed around the esophagus, not the upper stomach, and the vagal nerves must not be injured during dissection [49].
●A posterior crural repair should be performed by approximating the right and left pillar of the right crus with sutures. Mesh placement is optional and controversial. A trial of 159 patients reported that, compared with suture repair alone, mesh reinforcement did not decrease the incidence of recurrent hiatal hernia rate but increased solid dysphagia rate at three years [72]. (See "Surgical management of paraesophageal hernia", section on 'Closure of hiatal defect'.)
●Advocates of the importance of the gastroesophageal valve support restoration of the angle of His (between the esophagus and gastric fundus) in order to improve the competence of the valve [73].
●A 50 to 60 French bougie should be placed in the stomach (along the lesser curvature) to calibrate the tightness of the fundoplication [74].
●The length of the overall sphincter can be affected by altering the length of a fundoplication; however, too long a fundoplication may lead to obstructive symptoms. Most surgeons would perform a wrap of 2 to 3 cm [74].
Nissen fundoplication is the most studied antireflux procedure. In many series, it has been found superior to other antireflux procedures, with symptomatic improvement occurring in 85 to 90 percent of patients [55].
A laparoscopic Nissen fundoplication can offer significant advantages over the open operation with similar efficacy and safety [75] and is considered the current gold standard of antireflux procedures against which all other procedures are benchmarked.
As an example, in the follow-up study to a randomized trial comparing laparoscopic with open Nissen fundoplication in the Netherlands, 90 and 95 percent of patients reported symptom relief at 17 years, with no differences in GERD symptoms or dysphagia [76]. Despite that, 43 and 49 percent of the patients used proton pump inhibitors (PPIs) after laparoscopic and open surgery, although the indication for the PPI use was not specified. Surgical reinterventions were more frequent after open surgery (18 versus 45 percent), mainly due to incisional hernia corrections (3 versus 14 percent).
In a prospective study of 150 patients followed for 15 years after laparoscopic Nissen fundoplication, symptom control was maintained in 80 percent of patients (Visick I to II), who also showed objective improvement according to endoscopy, esophageal manometry, and pH monitoring [77].
Rosetti-Nissen fundoplication — A common modification is a 360 degree fundic wrap without division of the short gastric vessels (Rosetti-Nissen). However, most surgeons in the United States prefer to divide the short gastric vessels to allow for greater freedom of mobilization and reduced concern about torque on the fundoplication (which is hard to measure) and also facilitate lower esophageal relaxation [74].
A randomized trial was conducted in the 1990s to compare division versus nondivision of short gastric vessels during laparoscopic Nissen fundoplication [78]. At 20 year follow-up, there were no significant differences in heartburn symptoms (mean analog scores 1.4 versus 2.1/10) and satisfaction scores (mean analog scores 8.1 versus 8.6/10) or medication use, while fewer patients in the nondivision group reported epigastric bloating (26 versus 50 percent) [79].
The 2021 SAGES guidelines recommended choosing between the standard Nissen fundoplication and the Rosetti modification based on the patient's values and preferences. Those who value resolution of reflux symptoms over the risk of potential gas bloat symptoms should choose division of the short gastric vessel as opposed to nondivision, and vice versa [57].
Partial fundoplications — A partial 270 degree posterior wrap (Toupet) is used for patients with severe associated motor abnormalities. A partial 180 degree anterior wrap (Dor) has also been described [46].
Based on currently available data, the choice of anterior versus posterior or partial versus complete (Nissen) fundoplication should be left to the individual surgeon. Many trials and meta-analyses have shown that a well-constructed partial fundoplication can result in similar reflux control to that of a well-performed complete fundoplication. (See 'Comparison of partial with complete fundoplication' below and 'Comparison of anterior with posterior fundoplication' below.)
Hill gastropexy — The Hill procedure involves imbrication of the anterior and posterior collar sling muscular fibers at the level of the gastroesophageal junction around the esophagus with tethering of the complex to the median arcuate ligament and closure of the diaphragm. Intraoperative manometry is used to achieve a desired LES pressure [56,73]. This operation has also been performed laparoscopically and is advocated by those who support reconstruction of the angle of His and the importance of the "gastroesophageal valve" for preventing reflux [73]. It can also be used in a patient with a small stomach because of prior gastric resection [80].
In a randomized trial, laparoscopic Hill gastropexy and laparoscopic Nissen fundoplication yielded similar and both excellent outcomes at one-year follow-up [81]. In a single-center retrospective study with a median follow-up of 18.5 years, 85 percent of patients who underwent Hill gastropexy reported good to excellent symptomatic outcomes and quality of life [82].
Magnetic sphincter augmentation (MSA) — In 2012, the US Food and Drug Administration (FDA) approved the LINX Reflux Management System as a treatment for GERD. The device works by augmenting the LES with a ring made up of a series of rare earth magnets. The magnets have sufficient attraction to increase the LES closure pressure but permit food passage with swallowing. (See "Magnetic sphincter augmentation (MSA)".)
Eligible patients must have GERD confirmed by a pH study. In addition, the manufacturer of the LINX device also suggests that the patient have no large (>3 cm) or paraesophageal hiatal hernias, severe (Los Angeles class C or D) esophagitis, Barrett esophagus, obesity (body mass index >35 kg/m2), esophageal dysmotility, or prior upper gastrointestinal tract surgery. Patients who have allergies to titanium, stainless steel, nickel, or iron should not receive a LINX prosthesis. Patients who have the MSA device can undergo magnetic resonance imaging in a system up to 1.5 Tesla (1.5 T).
MSA is implanted laparoscopic or robotically. The techniques are discussed in another topic. (See "Magnetic sphincter augmentation (MSA)", section on 'Implantation technique'.)
MSA implantations have consistently demonstrated reduced GERD symptoms and improved GERD-related quality of life scores, cessation of PPI use, and substantial normalization of objective GERD measurements in the majority of patients [83]. (See "Magnetic sphincter augmentation (MSA)", section on 'Clinical improvements'.)
Dysphagia can occur early or late (>30 days) after MSA implantation by different mechanisms and is treated differently. Device erosion occurs in 0.3 percent of patients at four years; between 3 and 7 percent of the MSA devices are explanted by combined endoscopic and laparoscopic means. (See "Magnetic sphincter augmentation (MSA)", section on 'Postoperative complications'.)
Endoscopic methods — A number of methods for treating GERD endoscopically have been developed. Their efficacy (particularly long-term) is still being defined [84].
Stretta — The Stretta procedure is the most widely studied endoscopic antireflux procedure. The specialized catheter is placed with endoscopic assistance over a guidewire. Using monopolar energy, a series of 56 treatments is delivered across five levels. SAGES has performed an extensive evidence-based review of endoluminal reflux therapies [85]. Stretta is rated as effective therapy in patients with an LES pressure of at least 8 mmHg and hiatal hernia less than 3 cm [43,86-89].
Stretta and other endoscopic treatments of GERD are discussed in detail elsewhere. (See "Radiofrequency treatment for gastroesophageal reflux disease".)
Transoral incisionless fundoplication — Transoral incisionless fundoplication (TIF) is an endoscopic procedure performed under general anesthesia to create a full-thickness serosa-to-serosa plication that is 3 to 5 cm in length and 200 to 300 degrees in circumference (partial fundoplication).
TIF can be performed in patients with typical GERD symptoms, no or only low-grade erosive esophagitis (grades A and B), and no or only small hiatal hernia (≤2 cm). TIF is contraindicated in patients with high-grade erosive esophagitis, Barrett's esophagus, atypical and extraesophageal symptoms of GERD, scleroderma, or other esophageal pathology or surgery [90].
TIF has been compared with PPI therapy in several randomized trials [91]. In the latest trial (TEMPO), 63 patients with GERD refractory to PPI received TIF versus maximum standard dose PPI therapy [92]. At six months, both regurgitation and extraesophageal symptoms were eliminated in more TIF than PPI patients (62 versus 5 percent); 90 percent of TIF patients were off PPIs. After six months, all patients in the PPI (control) group elected to cross over to TIF. At three years, 90 and 88 percent of patients reported elimination of troublesome regurgitation and all atypical symptoms, respectively [93]. At five years, troublesome regurgitation was eliminated in 80 percent of patients; 34 percent were on daily PPI therapy, and the average total GERD health-related quality of life score improved from 22.2 (baseline) to 6.8 [94].
Although TIF is associated with fewer postoperative adverse effects such as gas bloating and dysphagia compared with surgical fundoplication [95], the durability of TIF is less certain than that of surgery. In a meta-analysis of five randomized trials and 13 prospective studies, PPI use after TIF increased over time (albeit at a reduced dose); the satisfaction rate was 69 percent at six months [96]. This meta-analysis has been criticized for mixing results from the first and second (current) generation of TIF devices.
The Esophyx device has been CE marked for the European market (2006) and FDA approved for the United States market (2009) for TIF procedures. In 2017, the FDA issued an updated clearance to include patients with hiatal hernias >2 cm when a laparoscopic hiatal hernia repair reduces the hernia to ≤2 cm [97]. In 2016, the American Medical Association (AMA) issued a specific CPT code for TIF. However, many private payers still consider the TIF procedure experimental, making reimbursement challenging.
POSTOPERATIVE SYMPTOMS AND MANAGEMENT — Typical symptoms after fundoplication include dysphagia and gas bloating, which occurred in 11 and 40 percent of patients, respectively, in one trial [98]. Management of patient symptoms after fundoplication depends upon duration of the symptoms as well as the size and tightness of the wrap.
In a systematic review and meta-analysis of eight randomized trials, prevalence of postoperative dysphagia, gas bloating, inability to belch, dilatation for dysphagia, and reoperation were higher after Nissen fundoplication than Toupet fundoplication, but subgroup analyses showed that differences with respect to dysphagia disappeared over time [99]. In a retrospective study of 441 patients who underwent Nissen or a partial fundoplication, persistent postoperative dysphagia occurred in approximately one-quarter of patients at a median follow-up of three years but did not differ between the type of fundoplication [100].
Dysphagia — Most patients will have some degree of postoperative dysphagia after fundoplication and require a period of modified dietary intake primarily consisting of liquids for 2 to 12 weeks.
The type of procedure performed is a determinant of postoperative dysphagia. One report found that dysphagia was more frequent with the laparoscopic Rosetti-Nissen procedure (11 percent) than with either the laparoscopic Nissen (2 percent) or Toupet (2 percent) procedure [101]. Although preoperative testing cannot reliably predict postoperative dysphagia, the most common predictor of postoperative dysphagia is the presence of preoperative dysphagia [102]. Thus, patients with preoperative dysphagia should be counseled appropriately before surgery. One must also consider the crural closure as a potential source of dysphagia in the postoperative setting [103].
Dysphagia that persists for more than 12 weeks requires evaluation, which typically begins with a barium swallow to assess the anatomic placement of the fundoplication.
Small migration of the fundoplication in a cephalad direction may result from inadequate esophageal mobilization or an unrecognized shortened esophagus. However, it is not clear whether these findings are associated with symptoms and thus can account for the dysphagia. An asymptomatic patient can be followed expectantly. Patients with symptoms of dysphagia or perceived reflux should undergo manometry, pH testing, and endoscopy in order to understand the impact, if any, of cephalad migration of the fundoplication.
At the time of the barium swallow, patients should be asked to swallow a 13 mm barium tablet. Patients with dysphagia in whom the 13 mm barium tablet passes slowly through the esophagus and who had normal motility preoperatively are candidates for dilation. Approximately 2 to 12 percent of patients required dilation after fundoplication [104-107].
There is no consensus on the optimal dilation technique (ie, bougie versus guidewire dilation). The author performs direct bougie dilation, with or without endoscopic guidance. In the author's experience, the procedure is well tolerated and produces good results. Tortuous pathways through the fundic wrap are best managed by guidewire dilation. Pneumatic dilation is very rarely needed. (See "Endoscopic interventions for nonmalignant esophageal strictures in adults".)
Patients who have a 360 degree fundoplication may be candidates for revision to a partial fundoplication if dysphagia persists and effective barium tablet passage cannot be established despite dilation.
Some patients describe a "sticking" sensation in their lower or mid chest that they mistakenly attribute to recurrent gastroesophageal reflux disease (GERD). Such patients often resume antisecretory medications. However, it is unlikely that patients whose fundoplication is functionally intact have persistent GERD. Thus, we suggest that they be objectively studied prior to restarting antisecretory medications to identify those who require dilation or a revision.
A subset of patients have persistent symptoms without objective evidence of esophageal dysfunction radiographically or by esophageal pH studies [108,109]. The cause of persistent symptoms in such patients is unclear but may involve anatomic, functional, and psychological factors [110]. Care of such patients should be individualized. Historically, this would have been a setting where a Bernstein test could have been used, but this is rarely performed today. Esophageal pH impedance studies may add diagnostic information in the setting of apparent surgical failure and help direct next steps (eg, adding a proton pump inhibitor). Medical therapy aimed at treating esophageal spasm can provide relief in some patients. (See "Clinical manifestations and diagnosis of gastroesophageal reflux in adults".)
Gas bloat syndrome — Symptoms of gas bloat syndrome (a sensation of intestinal gas with the inability to belch) can be elicited in a significant number of patients after fundoplication. The pathogenesis is not well understood, although it was seen more frequently in the past when longer and tighter fundoplications were created [111]. Symptoms may be due to aerophagia or vagal dysfunction, although this has not been well studied. It may also be in part due to dysfunction in gastric emptying, which may have been unrecognized preoperatively or occur secondarily to vagal damage [112]. The author performs a solid phase gastric emptying study to confirm the diagnosis of long-term gastric emptying dysfunction. (See "Gastroparesis: Etiology, clinical manifestations, and diagnosis", section on 'Scintigraphic gastric emptying'.)
In patients with only mild symptoms, we suggest empiric trials of chewable simethicone tablets or charcoal caplets. We also instruct patients not to drink with a straw or ingest carbonated beverages until symptoms resolve, although there is no evidence that these strategies are effective. Although there are no randomized trials, an empiric trial with metoclopramide (10 mg four times daily) may be helpful. Short courses of two to three months are typical, but some patients may require long-term treatment, placing them at risk for complications including irreversible tardive dyskinesia (especially in older patients). Domperidone is an alternative to consider and is available under an investigation new device (IND) program from compounding pharmacies in the United States. Erythromycin can be considered as an alternative; however, some patients experience significant gastric distress forcing discontinuation.
Symptoms tend to lessen over time in most patients. In patients with severe persistent symptoms despite the above treatment approaches, pyloroplasty, pyloric Botox injection, and pneumatic pyloric dilatation are options in select patients who have documented gastroparesis [113,114]. Some studies have described a reduced incidence of gas bloat with partial fundoplication [111]; conversion from a full to a partial fundoplication has been reported but is rarely required.
MORBIDITY AND MORTALITY — Long-term mortality of laparoscopic fundoplications is very low [115-119]. The reported 30 day surgical mortality rate of laparoscopic fundoplication is less than 0.1 to 0.2 percent [120].
The most commonly reported acute complications for laparoscopic fundoplications are gastric or esophageal injury, splenic injury or splenectomy, pneumothorax, bleeding, pneumonia, fever, wound infections, bloating, and dysphagia. Major acute complications are uncommon. In a study of 2655 patients, 4.1 percent had a complication within 30 days of surgery, including 1.1 percent infection, 0.9 percent bleeding, and 0.9 percent esophageal perforation [121].
Long-term complications could be caused by structural problem of the fundoplication (eg, malposition of the wrap) or functional abnormalities [122]. Up to 30 percent of laparoscopic fundoplications could be affected by a structural problem [121], which could negatively impact the patient's quality of life [123]. Some of these long-term problems require reoperative intervention. (See 'Revisional surgery' below.)
Failure — Antireflux surgery has a failure rate of 10 to 15 percent [124]. Operative failure is usually defined as persistent, recurrent, or new-onset symptoms. The main symptoms of operative failure are recurrent reflux symptoms and/or dysphagia. (See 'Dysphagia' above.)
Consensus has not been achieved on what constitutes treatment success or failure. As an example, while continued use of antisecretory medications may be considered treatment failure, many patients on acid suppression medications do not have documented pathologic reflux [109]. Furthermore, some patients who require antisecretory medications after surgery still report high quality of life compared with preoperative status.
In a Swedish population-based study of 2655 patients who underwent antireflux surgery, 470 patients (17.7 percent) were assumed to have developed recurrent reflux by long-term (six-month) antacid medication use (393 patients [83.6 percent]) or repeat antireflux surgery (77 patients [16.4 percent]) at a median follow-up of 5.6 years [121]. Risk factors for developing recurrent reflux included female sex (hazard ratio [HR] 1.57, 95% CI 1.29-1.90), older age (HR 1.41, 95% CI 1.10-1.81 for age ≥61 years compared with ≤45 years), and comorbidity (HR 1.36, 95% CI 1.13-1.65 for Charlson comorbidity index score ≥1 compared with 0). The recurrence rate is likely underestimated due to the fact that patients with recurrent reflux who did not take antacid medications consistently or underwent repeat surgery would have been missed.
Revisional surgery — Approximately 5 to 10 percent of patients will need revisional surgery after laparoscopic fundoplication [106,125]. The reoperation rate increases with time: in a national registry study of over 4000 contemporary antireflux operations (including hiatal hernia), the 1, 5, 10 and 15 year rates of repeat antireflux surgery were 3.1, 9.3, 11.7, and 12.8 percent, respectively [107]. In a series of 109 patients who underwent revisional surgery after a median time of 26 months, the indications for revisional surgery were dysphagia (48 percent), reflux (33 percent), paraesophageal herniation (15 percent), and atypical symptoms (4 percent) [125].
Recurrence of reflux symptoms after a fundoplication requires a thorough workup before reoperation [126,127] as fundoplication usually fails because of either the wrong indication for surgery, flawed or insufficient preoperative workup, or technical mistakes in executing the operation [10]. In the author's experience, the most common technical reasons for failed antireflux surgery are disruption of the fundoplication and excessive cephalad migration in the face of unrecognized shortened esophagus.
A reoperative fundoplication is the most commonly performed salvage procedure for failed fundoplication if additional medical therapy fails [128]. However, the success rate for revisional surgery is lower than primary surgery, and about 10 percent of patients will continue to complain of reflux or dysphagia after revisional surgery. Medical therapy remains the only option at that point. Patients with obesity may consider Roux-en-Y gastric bypass, which is an extremely effective antireflux operation. Rare patients undergo distal esophageal resection, but there are no outcomes data for this group.
LONG-TERM EFFICACY — Long-term observational studies of laparoscopic fundoplication performed by experienced operators generally report that 90 to 95 percent of adult patients are satisfied with the results of their surgery [129,130].
Surgical versus medical therapy — The comparison of operative management with medical management in controlled trials has identified mixed long-term results, with some studies finding comparable control of symptoms and others reporting better control by a fundoplication [98,116-119,131-133]. As examples:
●Optimized, contemporary medical (esomeprazole, 20 to 40 mg/day) and surgical (standardized laparoscopic reflux procedure [LARS]) management provides similar five-year remission rates for controlling gastroesophageal reflux disease (GERD) symptoms. In the LOTUS trial, patients who underwent LARS had a slightly lower estimated five-year remission rate compared with those treated medically (85 versus 92 percent); this difference was not statistically significant after controlling for the effects of study dropout [98]. Dysphagia, bloating, and flatulence were more common in patients treated with LARS (11 versus 5 percent, 40 versus 28 percent, 57 versus 40 percent, respectively), but acid regurgitation was less common (2 versus 13 percent). Although patients who underwent LARS had lower residual 24 hour esophageal acid exposure than patients treated medically (0.7 versus 2.1 percent at six months, and 0.7 versus 1.9 at five years), pH parameters did not predict treatment success or failure [134].
LARS has not been shown to halt the progression from intestinal metaplasia (Barrett's esophagus) to dysplasia; the presence of intestinal metaplasia is not an indication for LARS. At the beginning of this trial, endoscopic findings of intestinal metaplasia were present in 11.1 and 10.5 percent of patients in the LARS and esomeprazole groups, respectively, and the prevalences at five years remained stable in both groups (13.6 percent LARS; 9.3 percent esomeprazole) [98].
●A multicenter randomized trial (total randomized = 357 patients with greater than 12 months of GERD symptoms requiring maintenance therapy with a proton pump inhibitor [PPI]) identified better control of GERD symptoms at five years following a fundoplication [131,132]. The REFLUX trial, which included only 246 patients with five years of follow-up, found that patients undergoing a fundoplication (either a total or partial fundoplication per surgeon preference, n = 127) were less likely to require antireflux medication at five years compared with patients managed by medical therapy alone (44 versus 82 percent) [132]. However, the study protocol permitted crossover after randomization, and only 63 percent originally randomized to a fundoplication had undergone the procedure, and 13 percent randomized to medical management had undergone a fundoplication.
●In a trial conducted in Veterans Affairs (VA) gastroenterology clinics, 366 patients with PPI-refractory heartburn who failed to respond to a two-week course of double-dose omeprazole underwent a systematic workup including endoscopy, esophageal biopsy, esophageal manometry, and multichannel intraluminal impedance-pH monitoring (on PPI therapy) [135]. After excluding those who did not have objective evidence for reflux-related heartburn, 78 patients (21 percent) were randomly assigned to laparoscopic Nissen fundoplication, active medical management (omeprazole plus baclofen with or without desipramine), or control medical management (omeprazole plus placebo). At one year, more patients who underwent surgery (67 percent) achieved a ≥50 percent decrease in gastroesophageal reflux disease-health related quality of life score compared with those who received medical treatments (28 percent active medical management, 12 percent control). In a prespecified subgroup analysis, patients with esophageal visceral hypersensitivity (symptom association probability [SAP] of >95 percent alone) responded to surgery as well as those with acid reflux (acid reflux alone or with SAP of >95 percent).
Differences in results may be related to differences in study design. While the perfect trial has still yet to be performed, these studies lend credence to the concept that the optimal outcome achievable when fundoplication is performed by qualified surgeons is at least as good as medical therapy and possibly somewhat better at five years.
A 2015 Cochrane review of four trials found that, in the short and medium term, laparoscopic fundoplication was associated with better GERD-specific quality of life and fewer heartburn or reflux symptoms but a higher risk of adverse events (eg, dysphagia) compared with medical therapy [133]. However, all of the trials were at high risk of bias; the overall quality of evidence was low or very low, and none of the trials reported long-term quality-of-life data.
The 2013 American College of Gastroenterology (ACG) practice guidelines stated that "surgical therapy is as effective as medical therapy for carefully selected patients with chronic GERD when performed by an experienced surgeon" [136]. The 2021 Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guidelines suggested "managing adult patients with confirmed chronic or chronic refractory gastroesophageal reflux with surgical fundoplication rather than continued medical treatment (conditional recommendation based on very low certainty in the evidence of effects)" [57]. (See "Approach to refractory gastroesophageal reflux disease in adults", section on 'Subsequent management'.)
Comparison between surgical options — The comparison of surgical options is a complex topic since there is heterogeneity of techniques and technical choices that may impact outcome. As such, the best choice for an individual patient may be the procedure in which the surgeon is most skilled [10]. In Europe, the two preferred procedures are laparoscopic Nissen fundoplication and the posterior partial (Toupet) fundoplication [124]. In North America, laparoscopic Nissen fundoplication is most commonly performed [9].
Comparison of partial with complete fundoplication — Multiple randomized trials have compared laparoscopic Nissen (complete) fundoplication with laparoscopic partial (posterior or anterior) fundoplication. Although some randomized trials have shown that partial fundoplications have fewer adverse effects (eg, dysphagia, gas bloating) than complete fundoplication, the available trials are of limited quality and power due to significant heterogeneity [124].
●Laparoscopic Toupet (posterior partial) fundoplication was compared with laparoscopic Nissen (posterior complete) fundoplication in a systematic review and meta-analysis of seven trials [137]. Toupet and Nissen fundoplication resulted in similar reduction in esophageal acid exposure and reflux symptom control, but Toupet fundoplication was associated with fewer cases of postoperative dysphagia and dilation, gas-related symptoms, and reoperation. Another meta-analysis of 13 trials reached a similar conclusion [138].
●A 180° laparoscopic anterior fundoplication was compared with Nissen fundoplication in a 2017 systematic review and meta-analysis of six randomized trials [139]. Anterior and Nissen fundoplications were equivalent in reflux control and patient satisfaction. While anterior fundoplication resulted in a lower incidence of postoperative dysphagia, Nissen fundoplication required fewer reoperations for recurrent symptoms.
●Based on poor-quality studies, a 2014 systematic review and meta-analysis of two trials and 12 retrospective studies failed to demonstrate superiority of either complete or partial fundoplication [140].
The 2021 SAGES guidelines suggested choosing between a complete or partial fundoplication based on the patient's values and preferences. Those who value resolution of reflux symptoms over the risk of dysphagia should undergo a complete rather than partial fundoplication and vice versa [57].
Comparison of anterior with posterior fundoplication — The laparoscopic anterior fundoplication (LAF; 90 to 180° wrap) was proposed as an alternative to the laparoscopic posterior fundoplication (LPF; 180 to 360° wrap) to reduce postfundoplication symptoms but was reported to have higher rates of recurrence of reflux [46,141-145].
●A meta-analysis of nine randomized trials totaling 840 patients associated LPF with better heartburn control but LAF with lower risk of postoperative dysphagia [146]. Similar patient satisfaction scores and reoperation rates were associated with LAF and LPF.
Comparison of fundoplication with other surgical options — Newer minimally invasive antireflux procedures (eg, magnetic sphincter augmentation [MSA] or transoral incisionless fundoplication [TIF]) have not been around long enough to report long-term efficacy and adverse effect data. As such, there is insufficient evidence to recommend them as alternatives to fundoplication for severe GERD [3,124]. Nevertheless, such minimally invasive procedures may be suitable for patients who wish to avoid potential adverse effects of fundoplication (eg, dysphagia, gas bloating) but do not desire to continue lifelong medical therapy for GERD [85].
●MSA has not been compared with fundoplication in randomized trials. In a meta-analysis of seven observational studies, both procedures were safe and effective in symptom control with up to one year of follow-up [147]; MSA was associated with fewer gas bloat symptoms and increased ability to vomit and belch [148]. In a propensity score matched retrospective study, MSA and Toupet (partial) fundoplication had similar GERD control and side effect profiles [149]. (See "Magnetic sphincter augmentation (MSA)", section on 'MSA versus fundoplication'.)
●TIF has not been directly compared with fundoplication in any randomized trial either. In a network meta-analysis of TIF versus laparoscopic fundoplication versus PPI therapy, laparoscopic fundoplication was associated with greater sphincter augmentation than TIF. Quality-of-life improvement scores were actually higher with TIF, but the follow-up period was shorter [150].
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Gastroesophageal reflux in adults".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Hiatal hernia (The Basics)")
●Beyond the Basics topics (see "Patient education: Gastroesophageal reflux disease in adults (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Most authorities consider antireflux procedures an equally effective alternative to medical therapy for chronic gastroesophageal reflux disease (GERD) when offered to appropriately selected patients by appropriately skilled surgeons/endoscopists. (See 'Surgical versus medical therapy' above.)
•The most common indication for antireflux procedures is severe symptoms incompletely controlled by optimal medical therapy. However, continued symptoms despite double-dose proton pump inhibitors for over three 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. (See 'Failed medical management' above.)
•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 solid objective evidence to attribute such symptoms to reflux. However, the outcome is less favorable for those who either only have nongastrointestinal symptoms or have abnormal esophageal motility. (See 'Nongastrointestinal indications' above.)
•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. (See 'Intolerance of or noncompliance with medical therapy' above.)
●For most patients seeking an antireflux procedure, the preoperative evaluation should include upper endoscopy, standard pH testing, esophageal manometry, and barium esophagram (table 1). Specialized testing may be required for unusual symptoms. (See 'Preoperative evaluation' above.)
●Currently available antireflux procedures include:
•Radiofrequency treatment (Stretta) – Endoscopic
•Transoral incisionless fundoplication (TIF) – Endoscopic
•Magnetic sphincter augmentation (MSA) – Surgical
•Laparoscopic Hill gastropexy – Surgical
•Laparoscopic partial fundoplication – Surgical
•Laparoscopic Nissen (complete) fundoplication – Surgical
●For most patients undergoing surgical treatment for GERD, we suggest laparoscopic Nissen fundoplication (Grade 2C). This procedure appears to be the most effective and durable among all the procedures but is also associated with the greatest potential for dysphagia, difficulty in vomiting, and gas bloating. Patients with decreased esophageal motility or severe obesity may benefit from an alternative procedure. For an individual patient, the best procedure may be the procedure in which the surgeon is most skilled. (See 'Choice of procedure' above.)
●Postoperative symptoms of dysphagia and gas bloating occur in 11 and 40 percent of patients, respectively, after fundoplication. Dysphagia that persists for more than 12 weeks requires evaluation with barium esophagram. Patients in whom a 13 mm barium tablet passes slowly through the esophagus and who had normal motility preoperatively are candidates for dilation. Gas bloating is managed medically; most patients improve over time. (See 'Postoperative symptoms and management' above.)
●Antireflux surgery has a failure rate of 10 to 15 percent. The main symptoms of operative failure are recurrent reflux symptoms and/or dysphagia. Approximately 5 to 10 percent of patients will need revisional surgery after laparoscopic fundoplication. (See 'Morbidity and mortality' above.)
