Endoluminal Treatments For Gastroesophageal Reflux Disease (GERD)
Publication Date: February 1, 2010
Last Updated: March 14, 2022
Recommendations
Diagnosis
Based on the available evidence, the diagnosis of GERD can be confirmed if at least one of the following conditions exists: a mucosal break seen on endoscopy in a patient with typical symptoms, Barrett’s esophagus on biopsy, a peptic stricture in the absence of malignancy, or positive pH-metry. (, A)
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A newer test to objectively document gastroesophageal reflux is multichannel intraluminal esophageal impedance but the available evidence is insufficient to provide firm recommendations.
Medical Versus Surgical Treatment
Surgical therapy for GERD is an equally effective alternative to medical therapy and should be offered to appropriately selected patients by appropriately skilled surgeons. (, A)
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Surgical therapy effectively addresses the mechanical issues associated with the disease and results in long-term patient satisfaction. (, A)
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For surgery to compete with medical treatment, it has to be associated with minimal morbidity and cost.
Surgical Technique, Learning Curves, and their Influence on Outcome
The standardization of antireflux surgery technique is highly desirable, as it has been shown to lead to good postoperative patient outcomes. (, A)
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Like any other surgical procedure, laparoscopic antireflux surgery is subject to a learning curve, which may impact patient outcomes. Therefore, surgeons with little experience in advanced laparoscopic techniques and fundoplication in particular should have expert supervision during their early experience with the procedure to minimize morbidity and improve patient outcomes. (, B)
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On the other hand, reoperative antireflux surgery should be performed in a high-volume center by an experienced foregut surgeon. (, B)
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Laparoscopic Versus Open Treatment of GERD
Based on the available evidence that is of high quality (level I), laparoscopic fundoplication should be preferred over its open alternative as it is associated with superior early outcomes (shorter hospital stay and return to normal activities, and fewer complications) and no significant differences in late outcomes (failure rates). (, A)
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Nevertheless, antireflux surgeons should be aware that laparoscopic fundoplication takes longer to perform and has a higher incidence of reoperations at least in the short term. (, A)
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Further study is needed to identify ways to minimize the incidence of reoperations after laparoscopic fundoplication.
Partial Versus Total Fundoplication
Based on the available evidence that is of high quality (level I), partial fundoplication is associated with less postoperative dysphagia, fewer reoperations, and similar patient satisfaction and effectiveness in controlling GERD compared with total fundoplication up to five years after surgery. (, A)
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Furthermore, a tailored approach to esophageal motility appears unwarranted. (, B)
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Nevertheless, the paucity of long-term follow-up data that compare the effectiveness of the procedures makes it hard to recommend one type of fundoplication over the other especially in an era where the long-term effectiveness of surgical treatment for GERD is questioned.
- It should also be noted that a body of literature suggests that anterior partial fundoplication may be less effective in the long term
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- and retrospective data suggests that partial fundoplication may not be as effective as total in the long run.
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- Nonetheless, the evidence suggests that surgeons appropriately trained in minimally invasive techniques that perform surgery for GERD may minimize postoperative dysphagia by choosing a partial fundoplication
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- or a short total fundoplication (1 to 2 cm) over a large bougie (56 French)
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- and maximize the effectiveness of the procedure by choosing a a total fundoplication
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- or a longer (at least 3 cm) posterior fundoplication
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It should also be noted that there are regional differences in expert opinion and practice in the choice of fundoplication type for GERD with most North American experts choosing a total fundoplication due to concerns for the long term effectiveness of the procedure. Controlled studies that take into account these guidelines are needed.
Other Technical Aspects That May Influence Outcomes
SHORT GASTRIC VESSEL DIVISION
When the fundus can be wrapped around the esophagus without significant tension, no division of the short gastrics seems necessary. (, A)
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Division should be undertaken when a tension-free fundopliaction cannot be accomplished. (, B)
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It should also be noted that expert opinion in North America advocates for the routine division of the short gastric vessels to minimize tension. (, C)
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CRURAL CLOSURE
Crural closure should be strongly considered during fundoplication when the hiatal opening is large and mesh reinforcement may be beneficial in decreasing the incidence of wrap herniation. (, B)
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Anterior crural closure may be associated with less postoperative dysphagia, but additional evidence is needed to provide a firm recommendation. (, C)
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ROBOTIC SURGERY
While robotic assistance can be safely and effectively used for fundoplication, its higher cost compared with conventional laparoscopy and similar short-term patient outcomes make it a less than ideal initial choice. (, B)
Nevertheless, further study regarding learning curves and surgeon workload with the robotic technique are needed before stronger recommendations can be made.
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ANTIREFLUX SURGERY IN THE MORBIDLY OBESE PATIENT
Due to concerns for higher failure rates after fundoplication in the morbidly obese patient (BMI >35 kg/m2) and the inability of fundoplication to address the underlying problem (obesity) and its associated comorbidities, gastric bypass should be the procedure of choice when treating GERD in this patient group. (, B)
The benefits in patients with BMI > 30 is less clear and needs further study.
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ESOPHAGEAL DILATORS
The placement of an esophageal dilator during the creation of laparoscopic fundoplication is advisable as it leads to decreased postoperative dysphagia but should be weighed against a small risk of esophageal injury. (, B)
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A 56 French bougie has been found to be effective but the evidence is limited. (, C)
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Predictors of Success
Surgeons should be aware that fundoplication in patients demonstrating poor compliance with PPI therapy preoperatively or with poor response to preoperative PPI treatment is associated with poorer outcomes. (, C)
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Age should not be considered a contraindication for antireflux surgery in otherwise acceptable operative candidates, as outcomes in this patient group are similar to outcomes of younger patients. (, C)
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Care should be taken to minimize early postoperative severe gagging, belching, and vomiting as weak evidence suggests that they may lead to anatomical failure of fundoplication. (, C)
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A partial wrap should be considered in patients with a preoperative diagnosis of major depression, as it may lead to better postfundoplication outcomes in this patient group that tends to have generally inferior outcomes. (, C)
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Revisional Surgery for Failed Antireflux Procedures
Laparoscopic reoperative antireflux surgery is feasible, safe, and effective but has higher complication rates compared with primary repair and should be undertaken only by experienced surgeons using a similar approach to primary fundoplication. (, B)
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Outcomes
Laparoscopic antireflux surgery is effective at restoring the mechanical barrier to reflux with significant improvements in the LES pressure and acid reflux exposure, can be performed safely with minimal perioperative morbidity and mortality, and leads to high patient satisfaction rates and improved quality of life. (, A)
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Laparoscopic antireflux surgery is an effective treatment strategy for typical symptoms of GERD with significant improvements in rates of dysphagia, heartburn, and regurgitation and should be considered in appropriately selected patients and be performed by appropriately trained surgeons. (, A)
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While atypical symptoms improve in a majority of patients after antireflux surgery, symptom persistence is higher compared with patients with typical symptoms and surgeons should therefore carefully select and counsel these patients preoperatively. (, B)
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Patients undergoing laparoscopic antireflux surgery should be counseled preoperatively about the reported rates of symptom relapse and resumption of acid reducing medications. (, A)
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BARRETT’S ESOPHAGUS AND ANTIREFLUX SURGERY
Detection of Barrett’s esophagus with adenocarcinoma involving the submucosa or deeper excludes the patient from anti-reflux surgery and demands comprehensive stage-specific therapy (esophagectomy, chemotherapy, and/or radiation therapy). (, A)
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- HGIN and IMC can be effectively treated with endoscopic therapy including PDT, EMR and RFA, alone or in combination.
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- Anti-reflux surgery can be performed after achieving complete histological eradication of the lesion with endoscopic therapy.
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Esophagectomy remains an option for HGIN and IMC, either as salvage in the case of endoscopic therapy failure or as primary therapy.
Antireflux surgery may be performed in a patient with non-neoplastic IM, IND and LGIN; with or without endoscopic therapy to eradicate the Barrett’s tissue. Specifically, RFA has been shown to be safe, clinically effective, and cost-effective in these disease states and may be performed in eligible patients before, during, or after anti-reflux surgery. (, B)
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Antireflux surgery does not alter the need for continued surveillance endoscopy in patients with Barrett’s esophagus. Patients who have undergone endoscopic ablative therapy and anti-reflux surgery should continue surveillance endoscopy according to their baseline grade of Barrett’s. (, A)
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The available evidence is inconclusive about the resolution or improvement of Barrett’s after antireflux surgery. (, )
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Recommendation Grading
Overview
Title
Endoluminal Treatments For Gastroesophageal Reflux Disease (GERD)
Authoring Organization
Society of American Gastrointestinal and Endoscopic Surgeons
Publication Month/Year
February 1, 2010
Last Updated Month/Year
July 26, 2023
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
The guidelines for the surgical treatment of gastroesophageal reflux disease (GERD) are a series of systematically developed statements to assist physicians and patient decisions about the appropriate use of laparoscopic surgery for GERD
Target Patient Population
Patients with GERD
Inclusion Criteria
Female, Male, Adolescent, Adult, Child, Older adult
Health Care Settings
Ambulatory, Hospital, Operating and recovery room, Outpatient
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Assessment and screening, Management, Treatment
Diseases/Conditions (MeSH)
D013903 - Thoracic Surgery, D005764 - Gastroesophageal Reflux, D016099 - Endoscopy, Gastrointestinal, D020776 - Endoscopes, Gastrointestinal
Keywords
surgery, gastroesophageal reflux disease (GERD), GERD