Gastroesophageal reflux disease: A review of surgical decision making

Abstract

Gastroesophageal reflux disease (GERD) is a very common disorder with increasing prevalence. It is estimated that up to 20%-25% of Americans experience symptoms of GERD weekly. Excessive reflux of acidic often with alkaline bile salt gastric and duodenal contents results in a multitude of symptoms for the patient including heartburn, regurgitation, cough, and dysphagia. There are also associated complications of GERD including erosive esophagitis, Barrett’s esophagus, stricture and adenocarcinoma of the esophagus. While first line treatments for GERD involve mainly lifestyle and non-surgical therapies, surgical interventions have proven to be effective in appropriate circumstances. Anti-reflux operations are aimed at creating an effective barrier to reflux at the gastroesophageal junction and thus attempt to improve physiologic and mechanical issues that may be involved in the pathogenesis of GERD. The decision for surgical intervention in the treatment of GERD, moreover, requires an objective confirmation of the diagnosis. Confirmation is achieved using various preoperative evaluations including: ambulatory pH monitoring, esophageal manometry, upper endoscopy (esophagogastroduodenoscopy) and barium swallow. Upon confirmation of the diagnosis and with appropriate patient criteria met, an anti-reflux operation is a good alternative to prolonged medical therapy. Currently, minimally invasive gastro-esophageal fundoplication is the gold standard for surgical intervention of GERD. Our review outlines the many factors that are involved in surgical decision-making. We will review the prominent features that reflect appropriate anti-reflux surgery and present suggestions that are pertinent to surgical practices, based on evidence-based studies.

Keywords: Gastroesophageal reflux disease; Decision-making; Fundoplication

Core tip: Gastroesophageal reflux disease (GERD) is a common disorder with increasing prevalence. Excessive reflux of acidic gastric contents has a multitude of symptoms for the suffering patient including heartburn, regurgitation, cough, and dysphagia. Surgical intervention is often necessary in those who fail medical therapy, are non-compliant or wish to discontinue long-term medical therapy, have complications secondary to GERD, or present with extra-esophageal symptoms. There are various types of anti-reflux operations that are successful in treating GERD. Laparoscopic fundoplication is the gold standard for surgical treatment. Robotic Nissen fundoplication is also advantageous with good outcomes.