Surgical Management of Gastroesophageal Reflux in Adults

Surgical management of gastroesophageal reflux in adults - UpToDate 21/08/17, 6*14 p.m.
Official reprint from UpToDate®

www.uptodate.com ©2017 UpToDate®
Surgical management of gastroesophageal reflux in adults
Author: Steven D Schwaitzberg, MD

Section Editors: Joseph S Friedberg, MD, Nicholas J Talley, MD, PhD
Deputy Editor: Wenliang Chen, MD, PhD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jul 2017. | This topic last updated: Jun 15, 2017.
INTRODUCTION — Surgical management is generally reserved for patients with complications of reflux such as
recurrent or refractory esophagitis, stricture, Barrett's metaplasia, persistent "reflux symptoms" despite acid
suppression, or asthma. Patients who are unable to tolerate medication, noncompliant with medication, or who
are medication dependent and unwilling to take lifelong medications are also surgical candidates.
The surgical management of patients with gastroesophageal reflux disease (GERD) is reviewed in this topic. The
pathophysiology, diagnosis, medical management, and complications of gastroesophageal reflux are discussed
elsewhere. (See "Pathophysiology of reflux esophagitis" and "Medical management of gastroesophageal reflux
disease in adults" and "Complications of gastroesophageal reflux in adults" and "Overview of gastrointestinal
motility testing", section on 'Esophagus'.)
INDICATIONS FOR OPERATION — There are several indications for surgery in the patient with GERD:
Gastrointestinal indications
● Failed optimal medical management

● Noncompliance with medical therapy
● High volume reflux
● Severe esophagitis by endoscopy
● Benign stricture
● Barrett's columnar-lined epithelium (without severe dysplasia or carcinoma)
The most frequent indication for antireflux surgery has traditionally been severe GERD unresponsive to optimal
medical therapy, which consists of both drug therapy and lifestyle modifications [1]. Some 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. However, continued symptoms despite adequate acid
suppression with proton pump inhibitors (PPIs) should serve as a warning that symptoms may not be due to
excess esophageal acid exposure but to functional heartburn, a malignancy, or extra-esophageal disease. (See
"Clinical manifestations and diagnosis of gastroesophageal reflux in adults" and 'Preoperative evaluation' below.)
Non gastrointestinal indications — About one-half of patients with GERD report upper respiratory symptoms
including hoarseness, laryngitis, wheezing, nocturnal asthma, cough, aspiration, or dental erosion [2,3]. Relief of
https://www.uptodate.com/contents/surgical-management-of-gastroesophageal-reflux-in-adults/print?source=see_link Página 1 de 22
respiratory symptoms is usually achievable by fundoplication in patients who also have typical reflux symptoms;
however, the outcome is less favorable in the substantial minority of patients in whom respiratory symptoms
occur in association with abnormalities of esophageal motility [4].
Although cough may present as one of the most common extraesophageal symptoms of GERD, asthma, chronic
bronchitis, laryngitis, idiopathic subglottic stenosis, and even laryngeal cancer have also been implicated [5,6].
Many of these patients do not have typical features of GERD, such as heartburn [7].
● Laryngeal disease — There is no role for considering surgery as a first-line treatment for posterior
laryngitis. However, it is reasonable to consider surgery for patients who have abnormal pharyngeal acid on
a double probe pH study when medical therapy has been maximized, is not tolerated, or is impractical.
Despite the large volume of literature, skepticism exists about the direct causal relationship between
pharyngeal acid exposure and laryngeal diseases [8,9]. Paralleling this uncertainty is the debate whether
entities such as posterior laryngitis should be treated empirically with anti-acid therapy or evaluated
diagnostically to prove the existence of abnormal pharyngeal acid prior to initiating anti-acid therapy [8-14].
One of the most recent controlled trials demonstrated efficacy of lansoprazole in the treatment of posterior
laryngitis, supporting empiric therapy as first line treatment [14]. Numerous studies also support the
effectiveness of omeprazole and other anti-acid strategies in this setting [11,15].
On the other hand, some data suggest that symptoms recur after treatment is discontinued [15], while other
data have shown that laryngeal symptoms can be treated successfully by laparoscopic fundoplication
[16,17]. (See "Laryngopharyngeal reflux", section on 'Dual sensor pH probe'.)
A controlled trial suggested that surgery was not consistently effective in patients who were unresponsive to
aggressive PPI therapy [18]; 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 than that of
fundoplication performed purely 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 [19].
● Asthma — Consensus has not been achieved on the role of surgery in patients with asthma that is thought
to be related to GERD. 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 [20]. A dramatic reduction in steroid dependency
postoperatively was documented in another study [21]. Medical therapy is associated with an improvement
in symptoms and reduction in asthma medication use in 60 to 70 percent of patients [22]. (See
"Gastroesophageal reflux and asthma".) Improvement in pulmonary function has not been documented after
medical or surgical therapy [20,22-24]. Some consideration should be given to lowering the threshold to
surgery in asthmatics, especially younger patients, in whom significant GER can be demonstrated.
PREOPERATIVE EVALUATION — There is no consensus for the optimal preoperative investigation for
appropriate surgical candidates (table 1). Upper endoscopy, esophageal manometry, and an assessment of
esophageal length and degree of hiatal herniation are the most useful tests in making surgical decisions. Some
patients may require gastric empty studies if preoperative symptoms of bloating are prominent suggesting that
delayed emptying may contribute to the reflux.
● Upper endoscopy – Esophageal and gastric endoscopy should be performed to assess the esophageal
and gastric mucosa for signs of malignancy prior to proceeding with a surgical antireflux procedure. (See
"Overview of upper gastrointestinal endoscopy (esophagogastroduodenoscopy)".)
● Esophageal manometry – Esophageal manometry studies are of value and should be used routinely in
preoperative evaluation. Manometry occasionally provides alternative diagnoses, such as scleroderma or
achalasia, for which antireflux surgery may be contraindicated. In addition, manometry may lead to a
modification of the surgical approach or a change in management, although the need to modify the surgical
procedure based upon the manometric findings has been questioned [25]. (See "Overview of
gastrointestinal motility testing", section on 'Esophageal manometry'.)
● Esophageal length evaluation – Some assessment of esophageal length and the degree of hiatal
herniation is also appropriate; a simple upper gastrointestinal series generally suffices for this purpose. The
presence of a markedly shortened esophagus or a large hiatal hernia that does not reduce in the upright
position may tip the scales in favor of a transthoracic approach [26].
● Gastric Emptying Studies – two- or four-hour gastric emptying studies should be considered when the
careful history needed in the evaluation of a gastroesophageal reflux disease patient suggests gastric outlet
obstruction or gastroparesis. 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 [27,28].
CHOICE OF OPERATION — Current experience with antireflux surgery suggests that there is no one best
operation for all patients. Factors such as the degree of esophageal shortening, disturbances of esophageal
motility, prior operations, and local expertise with laparoscopic techniques influence the choice of operation. It
remains unclear which patient characteristics influence postoperative success following fundoplication for
gastroesophageal reflux disease (GERD) [29]. A comprehensive review of the literature shows that there is no
consistent association between surgical outcomes and preoperative response to acid suppression medications,
baseline symptoms, baseline acid exposure, degree of lower esophageal sphincter competence, or position of
reflux.
For the patient with normal esophageal length and motility, the operation of choice is probably a laparoscopic
Nissen fundoplication. 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 [30].
Early uncomplicated disease — One report, for example, proposed a "tailored approach" to antireflux surgery
[26]. Trans-abdominal Nissen (laparoscopic if possible) fundoplication was recommended for most patients with
early, uncomplicated disease (which accounted for approximately 65 percent of 104 patients seen over a seven-
year period).
Laparoscopy versus laparotomy — A number of important questions exist about antireflux surgery, such as
short-term and long-term outcomes of laparoscopic techniques in comparison with traditional approaches and
whether earlier consideration of surgical therapy to prevent complications of GERD is warranted.
A laparoscopic operation performed by an experienced surgeon can offer significant advantages over the open
operation with similar efficacy and safety and may be an attractive alternative to lifelong medical therapy. A meta-
analysis of 12 prospective trials found a 65 percent reduction of complication rates for patients treated with
laparoscopic antireflux surgery compared with open antireflux surgery [31]. Patients undergoing a laparoscopic
approach had a faster convalescent rate (three fewer days in hospital), a faster return to work (eight days
sooner), and a similar treatment outcome. However, the patients undergoing laparoscopic surgery also had a 79
percent higher rate of reoperation (odds ratio 1.79, 95% CI 1.00-3.22).
In addition to low morbidity rates, the 30-day mortality rates are also low. In a retrospective review of 7531
patients undergoing a laparoscopic fundoplication, the overall mortality rate was 0.19 percent [32]. The mortality
rate was significantly lower for patients <age 70 in comparison with patients ≥age 70 years (0.05 versus 0.8
percent).
Robotic surgery, a newer minimally-invasive technique, offers no specific advantages over other laparoscopic
techniques and is more costly to perform [33]. Randomized trials have not been performed to assess short-term
or long-term benefits of the procedure.
Decreased motility — Although surgery cannot directly influence esophageal motility in patients with GERD,
Nissen fundoplication can lead to improvement in esophageal contraction amplitude. This benefit is limited to
patients with preoperative amplitudes above the fifth percentile [34]. (See "Overview of gastrointestinal motility
testing".)
For the patient with normal length but decreased motility, a complete fundoplication is discouraged; the
laparoscopic or open Toupet or Hill or transthoracic Belsey procedure could be performed. Wrapping the distal
esophagus circumferentially or partially with a portion of stomach increases the lower esophageal sphincter
(LES) pressure. However, too high of an LES pressure may lead to obstructive symptoms; thus, an incomplete
wrap is often recommended in patients with poor esophageal motility [34,35], although the results of at least one
controlled trial raised questions about this recommendation [25]. (See "Overview of gastrointestinal motility
testing".)
Shortened esophagus — Patients with a shortened esophagus from chronic inflammation or altered anatomy
present a unique challenge to the surgeon. A Collis (esophageal lengthening) gastroplasty combined with an
intra-abdominal or intra-thoracic fundoplication should be performed in these settings; however, opinions vary
regarding what constitutes adequate esophageal mobilization. Trans-thoracic approaches should be considered
for the patient with concurrent pulmonary disease requiring evaluation or extensive prior abdominal surgery.
● Increasing the intra-abdominal esophageal length can be accomplished 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.
● A gastroplasty may sufficiently lengthen the esophagus so that a fundoplication can be placed below the
diaphragm. However, a fundoplication need not be intra-abdominal to be effective [36]. Extensive cephalad
mobilization of the esophagus should be avoided and an intra-thoracic fundoplication performed in these
settings.
● The need for adequate mobilization of the esophagus is one reason cited for transthoracic approaches [36].
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.
● An incorrectly performed fundoplication may prevent appropriate relaxation of the LES with swallowing. The
LES and fundus normally undergo vagally-mediated relaxation 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 [35].
● 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 [37]. Reduction of hiatal
hernia may also contribute to the efficacy of antireflux surgery [38].
Reoperation — Reoperation for failed antireflux surgery requires individual evaluation and consideration of
alternative options for further management [39,40].
SPECIFIC OPERATIVE TECHNIQUES — A variety of antireflux procedures have been described for the
treatment of gastroesophageal reflux disease (GERD) (figure 1A-B). The most common procedures (Nissen
fundoplication, Belsey Mark IV, and Hill repair) claim about an 85 percent success rate in relieving symptoms and
healing esophagitis. Long-term mortality of surgical management is quite low [41-44].
Many surgical approaches focus on restoring a physiologic equivalent to the normal LES. Manometric studies of
the lower esophageal sphincter (LES) have documented that reflux is correlated with a lower mean LES
pressure, shorter mean intra-abdominal LES length, and shorter overall sphincter length [45]. Each of these
problems can be corrected by specific surgical procedures.
Nissen fundoplication — The Nissen fundoplication has, in many series, been found superior to other
procedures, with symptomatic improvement occurring in 85 to 90 percent of patients [36]. This procedure
originally involved passage of the gastric fundus behind the esophagus to encircle the distal 6 cm of the
esophagus. However, many variations and modifications have been described, and a "Nissen fundoplication"
may be performed differently by different surgeons. Variables 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
[36]. Most surgeons choose to perform a loose ("floppy") Nissen fundic wrap that is about 1 to 2 cm in length
including a posterior crural repair [35,36].
Laparoscopic Nissen fundoplication — Nissen fundoplication can also be effectively performed

laparoscopically [46]. Although there have been few long-term studies, a number of observational studies of
laparoscopic fundoplication demonstrate comparable safety, short-term efficacy, and patient satisfaction, as well
as shorter hospital stays and recuperative times than with open operation [47-52]. A prospective, randomized
trial comparing open with laparoscopic fundoplication in 110 consecutive patients found, at up to 11 years follow-
up, similar benefits on symptoms but a significantly higher incidence of incisional hernias and defective fundic
wraps in the open group [53].
A 2005 systematic review concluded that laparoscopic fundoplication was as effective as open fundoplication for
relieving heartburn and regurgitation, improving quality of life, and decreasing antisecretory medications [54].
Almost 90 percent of patients who were followed for five or more years reported improvement in symptoms.
However, when considering studies of both open and laparoscopic fundoplication, 10 to 65 percent of patients
still required some form of antisecretory medications after surgery. No patient or procedure characteristic was
consistently associated with surgical results with the exception of worse satisfaction and outcomes in patients
with a significant psychiatric history.
The most commonly reported complications for laparoscopic procedures were gastric or esophageal injury,
splenic injury or splenectomy, pneumothorax, bleeding, pneumonia, fever, wound infections, bloating, and
dysphagia. These major complications were uncommon.
Some studies have suggested that the laparoscopic approach has been associated with a relatively high
incidence of postoperative dysphagia (8 to 12 percent) compared with an open approach [52,55-57]. Why this
might occur is not well understood. It may be attributable at least in part to difficulty determining the looseness of
the wrap at laparoscopy [48]. For this reason, many surgeons construct the wrap over a large esophageal
Bougie (48 to 60 Fr) passed into the stomach by the anesthesiologist to ensure adequate "floppiness."
The type of procedure performed also may be 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 [58]. Although preoperative testing cannot
reliably predict postoperative dysphagia, preoperative swallowing difficulty appears to be the single greatest risk
factor [59].
The rate of development of laparoscopic expertise (learning curve) varies among studies. The number of
procedures needed to be performed to develop technical expertise ranges from 20 to 60 [60-62].
Nissen modifications — A common modification is a 360 degree fundic wrap without ligation of the short gastric
vessels (Rosetti-Nissen). A partial 270 degree posterior wrap (Toupet) is used for patients with severe associated
motor abnormalities. A partial 180 degree anterior wrap (Dor) achieved laparoscopically has also been described
[30].
Belsey Mark IV — The Belsey Mark IV operation involves a partial fundoplication performed by transthoracic
approach, which allows full esophageal mobilization [63]. The incomplete fundoplication leads to fewer
obstructive symptoms and is therefore recommended for patients with poor esophageal motility who might have
other indications for a transthoracic approach (eg, obesity or a shortened esophagus) [26].
Hill gastropexy — The Hill procedure involves imbrication of the anterior and posterior lesser gastric curve
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 [37,63]. 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 [37]. It can also be used in a patient with a
small stomach because of prior gastric resection [64].
Gastric bypass — For morbidly obese patients, Roux-en-Y gastric bypass (RYGB) shows promise as the
procedure of choice for surgical treatment of gastroesophageal reflux disease. Several small series have
reported a decrease in reflux symptoms as well as complete or partial regression of Barrett's esophagus in
morbidly obese patients with RYGB [65-67]. (See "Bariatric operations for management of obesity: Indications
and preoperative preparation" and "Barrett's esophagus: Surveillance and management".)
Angelchik prosthesis — The Angelchik prosthesis is a doughnut-shaped prosthesis placed around the distal
esophagus. Use of the prosthesis was initially touted for ease of placement and reflux prevention, but fell into
disfavor because of its high rate of complications and dysphagia [63,64,68]. This prosthesis is no longer used.
LINX prosthesis — 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. Eligible patients for the procedure include those with all of the following:
● Typical GERD symptoms
● Abnormal pH study
● Partial response to daily PPI therapy
● Absence of a large hiatal hernia (>3 cm) or severe esophagitis
Patients who have allergies to titanium, stainless steel, nickel, or iron should not receive a LINX prosthesis.
Patients who have the LINX device should not undergo magnetic resonance imaging (MRI).
The long-term safety and efficacy of the LINX prosthesis were evaluated in a prospective single-group trial of 100
patients with long-standing GERD [69]. At five years after LINX implantation, significantly fewer patients reported
moderate or severe heartburn (12 versus 89 percent), moderate or severe regurgitation (1 versus 57 percent),
bothersome gas-bloat (8 versus 52 percent), and daily PPI use (15 versus 100 percent). GERD-related quality of
life was also better. No device erosions, migrations, or malfunctions occurred. The ability to belch or vomit, when
needed, was preserved in all patients. Early dysphagia is prominent with LINX implantation, but generally
resolves within a few weeks. The rate of long-term dysphagia was not significantly increased from the baseline (6
versus 5 percent).
Another prospective study also found that most patients experienced improved quality of life and stopped PPI
use at four years after LINX implantation [70].
Barium swallow was not a part of the evaluation in the two studies cited above, but was performed on the day
after surgery in another study [71]. On barium imaging, the device was found just below the diaphragm in 42
patients, and 1 to 2 cm above the diaphragm in two patients with preexisting hiatal hernias. No device migration
occurred during the follow-up period in that study.
Review of the FDA's Manufacturer and User Facility Device Experience (MAUDE) database demonstrates that a
number of LINX devices have been explanted for dysphagia and esophageal erosion; however, the overall
complication rate is similar to that of a Nissen fundoplication.
Endoscopic methods — A number of methods for treating GERD endoscopically have been developed. Their
efficacy (particularly long-term) is still being defined [72]. The Stretta Procedure is the most widely studied
endoscopy procedure. The specialized catheter is placed with endoscopic assistance over a guidewire. Using
monopolar energy, a series of 56 treatments delivered is delivered across 5 levels The Society of American
Gastrointestinal and Endoscopic Surgeons has performed an extensive evidence-based review of endoluminal
reflux therapies. Stretta is rated as effective therapy in patients with an LES pressure of at least 8 mmHg and
hiatal hernia less than 3 cm [28,73-77].
Stretta and other endoscopic treatments of GERD are discussed in detail elsewhere. (See "Radiofrequency
treatment for gastroesophageal reflux disease".)
POSTOPERATIVE SYMPTOM MANAGEMENT — Management of patients after fundoplication depends upon

symptoms related to the size and tightness of the wrap.
Dysphagia — Most patients have some degree of postoperative dysphagia and require a period of modified
dietary intake primarily consisting of liquids from 2 to 12 weeks. The most common predictor of postoperative
dysphagia is the presence of preoperative dysphagia [59]. Such patients should be counseled appropriately
before surgery.
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 gastroesophageal
reflux. Thus, we suggest that they be studied radiographically prior to restarting antisecretory medications to
identify those who require dilation or a revision.
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. 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 should be considered candidates for dilation after 12 weeks.
Approximately 6 to 12 percent of patients with fundoplication required dilation in various reports [78,79].
There is no consensus on the optimal dilation technique (ie, bougie versus guidewire dilation versus pneumatic
dilations). The author performs direct bougie dilation, with or without endoscopic guidance. In the author’s
experience, the procedure is extremely well tolerated and produces good results. Tortuous pathways through the
fundic wrap are best managed by guidewire dilation. Pneumatic dilation is rarely needed. (See "Management of
benign esophageal strictures".)
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.
A subset of patients has persistent symptoms without objective evidence of esophageal dysfunction
radiographically or by esophageal pH studies [80,81]. The cause of persistent symptoms in such patients is
unclear but may involve anatomic, functional, and psychological factors [82]. Care of such patients should be
individualized. This is a setting in which we have upon rare occasion used a Bernstein test to assess the
correlation of symptoms with acid exposure. 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".)
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.
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 [83]. It may also be in part due to dysfunction in gastric emptying, which may have been unrecognized
preoperatively (underscoring the need for careful preoperative evaluation) [84]. Symptoms may be due to
aerophagia or vagal dysfunction, although this has not been well studied. 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 to 15 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 US. 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 and who have documented gastroparesis, pyloroplasty, pyloric botox, and
pneumatic pyloric dilatation are options in select patients [85,86]. Some studies have described a reduced
incidence of gas bloat with partial fundoplication [83]. As a result, conversion from a full to a partial fundoplication
has been reported but is rarely required.
Revisional surgery — Approximately 5 to 10 percent of patients will need revisional surgery after laparoscopic
fundoplication [87]. The most frequent reasons for revision are recurrent heartburn and dysphagia, and the most
common predictor of postoperative dysphagia was preoperative dysphagia [59].
In the author’s experience, the most common reasons for failure are disruption of the fundoplication and
excessive cephalad migration in the face of unrecognized shortened esophagus. 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) [87].
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. Rare patient undergo distal esophageal resection but there are no outcomes data for this group.
LONG-TERM EFFICACY — Long-term observational studies of laparoscopic fundoplication by experienced

operators generally report that 90 to 95 percent of adult patients are satisfied with the results of their surgery
[88,89]. However, consensus has not been achieved on what constitutes treatment success or failure.
As an example, while continued use of anti-acid medications has been considered to represent treatment failure,
there are no studies that have described the proportion of patients who are placed on anti-acid medications
following a surgical procedure who have objective evidence of reflux. Furthermore, some patients who require
anti-acid medications after surgery still report high quality of life compared with preoperative status. Many
patients on acid suppression medications do not have documental reflux [81].
The comparison of surgical options is a complex topic since there is heterogeneity of techniques and technical
choices that may impact outcome. As for many technical procedures, the best choice for an individual patient
may be the procedure in which the surgeon is most skilled.
Comparison of partial with complete fundoplication — Both a total and partial fundoplication provide long-
term relief of gastroesophageal reflux disease (GERD) symptoms. A randomized trial included 137 patients with
chronic GERD and esophagitis undergoing either a partial wrap (Toupet posterior procedure) or a total wrap
(Nissen procedure) [90]. Patients treated with a partial wrap had equivalent rates of control of symptoms of
heartburn (80 versus 87 percent) and acid regurgitation (82 versus 90 percent) after a mean of 18 years of
observation. Both groups had similar rates of long-term side effects such as bloating, flatulence, and dysphagia
scores. The rate of flatulence, which typically occurs early in the postoperative period following a Nissen
fundoplication, decreased over time.
Five-year outcome results for patients undergoing a 180° laparoscopic anterior fundoplication (LAF) are similar
to those for a laparoscopic Nissen fundoplication (LNF). In a systematic review and meta-analysis of five
randomized trials that included 458 patients, patients undergoing a LAF had a similar heartburn score, dilatation
rate, proton pump inhibitor use, and patient satisfaction score when compared with patients undergoing a LNF
[91]. At one-year, however, patients undergoing a LAF had significantly less gas bloating (11 versus 18 percent),
flatulence (14 versus 25 percent), and inability to relieve bloating (34 versus 44 percent). Individual study trend
scores support the concept that patients undergoing a partial fundoplication experience less dysphagia; however,
those patients also experience greater esophageal acid exposure, esophagitis, and need for re-operation. In
addition, none of the patients in any of the Nissen series underwent mobilization of the short gastric vessels, and,
in general, were performed over relatively smaller caliber Bougies, both of which may contribute to dysphagia
and an inability to belch.
Comparison of an anterior with a 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
[30,92-96].
A meta-analysis of seven randomized trials found that the short-term results for 338 patients treated by a LPF
included significantly less esophageal acid exposure time (0.8 versus 3.3 percent), heartburn (8 versus 21
percent), and a lower reoperation rate (4 versus 8 percent) compared with 345 patients undergoing LAF [96].
There were no significant short-term differences for the rate of esophagitis, regurgitation, belching, lower
esophageal sphincter pressure, or satisfaction between the two approaches [96]. The long-term outcomes for
patients undergoing a LPF included a significantly lower rate of persistent heartburn (14 versus 31 percent) and
a significantly lower reoperation rate (5 versus 10 percent) but no differences in dysphagia scores, inability to
belch, gas bloating, or patient satisfaction.
Comparison with 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 [41-44,97-100]. Differences in results may be
related to differences in study design as illustrated by the following trials:
● Optimized, contemporary medical (esomeprazole, 20 to 40 mg/day) and surgical (standardized laparoscopic

reflux procedure [LARS]) management provide similar five-year remission rates for controlling GERD
symptoms. In a randomized 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 [97]. 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 [101].
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) [97].
● A multicenter, randomized trial (total randomized = 357 patients with greater than 12 months of GERD
symptoms requiring maintenance therapy with a proton pump inhibitor) identified better control of GERD
symptoms at five years following a fundoplication [98,99]. The trial, which included only 246 patients with
five years of follow-up, found that patients undergoing a fundoplication (either a total or partial wrap 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) [99]. However, the study protocol
permitted cross-over 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. 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.
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: Acid reflux (gastroesophageal reflux disease) in adults
(Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS — Gastroesophageal reflux disease (GERD) is manifested by a

spectrum of nonspecific symptoms, including heartburn, regurgitation, dysphagia, laryngitis, dental problems,
adult onset asthma, and/or aspiration pneumonia.
● The most frequent indication for surgery for patients with GERD is severe GERD unresponsive to optimal
medical therapy, which consists of both drug therapy and lifestyle modifications. (See 'Indications for
operation' above.) Other reasons for operative management include noncompliance, severe esophagitis by
endoscopy, benign stricture, Barrett's columnar-lined epithelium (without severe dysplasia or carcinoma),
dental erosion by acid exposure, and recurrent pulmonary symptoms.
● The preoperative evaluation should include upper endoscopy, esophageal manometry, and an assessment
of esophageal length and hiatal hernia (see 'Preoperative evaluation' above). Esophageal pH monitoring
should be reserved for patients who have a negative upper endoscopy or atypical symptoms.
● There is no consensus on which is the best antireflux operative procedure for all patients. (See 'Choice of
operation' above.)
● For most patients with GERD, a laparoscopic Nissen fundoplication is preferred by the author. The
laparoscopic approach has an equivalent control of symptoms and a faster recovery compared with the
open approach. However, the reoperation rate is higher following the laparoscopic approach. (See
'Laparoscopy versus laparotomy' above.)
● The laparoscopic approach offers several advantages with similar efficacy and safety as an open procedure.
● Postoperative symptoms of dysphagia occur in most patients. (See 'Postoperative symptom management'
above.) There is no consensus on the optimal dilatation procedure for postoperative stenosis. Most patients
with symptoms of gas-bloat syndrome improve over time.
● We recommend the laparoscopic posterior fundoplication (LPF) as the surgical approach for the treatment of
GERD (Grade 1A). Patients undergoing a LPF had fewer short-term adverse outcomes (eg, esophageal
acid exposure time, heart burn, and reoperation rate) and fewer long-term adverse outcomes (eg, heartburn,
reoperation rate) compared with patients undergoing a laparoscopic anterior repair. (See 'Comparison of an
anterior with a posterior fundoplication' above.)
Use of UpToDate is subject to the Subscription and License Agreement.
REFERENCES
1. Zaninotto G, Attwood SE. Surgical management of refractory gastro-oesophageal reflux. Br J Surg 2010;
97:139.
2. Downing TE, Sporn TA, Bollinger RR, et al. Pulmonary histopathology in an experimental model of chronic
aspiration is independent of acidity. Exp Biol Med (Maywood) 2008; 233:1202.
3. Lazarchik DA, Frazier KB. Dental erosion and acid reflux disease: an overview. Gen Dent 2009; 57:151.
4. Johnson WE, Hagen JA, DeMeester TR, et al. Outcome of respiratory symptoms after antireflux surgery on
patients with gastroesophageal reflux disease. Arch Surg 1996; 131:489.
5. Johanson JF. Epidemiology of esophageal and supraesophageal reflux injuries. Am J Med 2000; 108 Suppl
4a:99S.
6. Jindal JR, Milbrath MM, Shaker R, et al. Gastroesophageal reflux disease as a likely cause of "idiopathic"
subglottic stenosis. Ann Otol Rhinol Laryngol 1994; 103:186.
7. Smullen JL, Lejeune FE Jr. Otolaryngologic manifestations of gastroesophageal reflux disease. J La State
Med Soc 1999; 151:115.
8. Nostrant TT. Gastroesophageal reflux and laryngitis: a skeptic's view. Am J Med 2000; 108 Suppl 4a:149S.
9. Ormseth EJ, Wong RK. Reflux laryngitis: pathophysiology, diagnosis, and management. Am J
Gastroenterol 1999; 94:2812.
10. Ulualp SO, Toohill RJ, Shaker R. Outcomes of acid suppressive therapy in patients with posterior laryngitis.
Otolaryngol Head Neck Surg 2001; 124:16.
11. Hanson DG, Jiang JJ. Diagnosis and management of chronic laryngitis associated with reflux. Am J Med
2000; 108 Suppl 4a:112S.
12. Hanson DG, Conley D, Jiang J, Kahrilas P. Role of esophageal pH recording in management of chronic
laryngitis: an overview. Ann Otol Rhinol Laryngol Suppl 2000; 184:4.
13. Fraser AG, Morton RP, Gillibrand J. Presumed laryngo-pharyngeal reflux: investigate or treat? J Laryngol
Otol 2000; 114:441.
14. El-Serag HB, Lee P, Buchner A, et al. Lansoprazole treatment of patients with chronic idiopathic laryngitis:
a placebo-controlled trial. Am J Gastroenterol 2001; 96:979.
15. Kamel PL, Hanson D, Kahrilas PJ. Omeprazole for the treatment of posterior laryngitis. Am J Med 1994;
96:321.
16. Hinder RA, Branton SA, Floch NR. Surgical therapy for supraesophageal reflux complications of
gastroesophageal reflux disease. Am J Med 2000; 108 Suppl 4a:178S.
17. Farrell TM, Richardson WS, Trus TL, et al. Response of atypical symptoms of gastro-oesophageal reflux to
antireflux surgery. Br J Surg 2001; 88:1649.
18. Swoger J, Ponsky J, Hicks DM, et al. Surgical fundoplication in laryngopharyngeal reflux unresponsive to
aggressive acid suppression: a controlled study. Clin Gastroenterol Hepatol 2006; 4:433.
19. Kaufman JA, Houghland JE, Quiroga E, et al. Long-term outcomes of laparoscopic antireflux surgery for
gastroesophageal reflux disease (GERD)-related airway disorder. Surg Endosc 2006; 20:1824.
20. Field SK, Gelfand GA, McFadden SD. The effects of antireflux surgery on asthmatics with
gastroesophageal reflux. Chest 1999; 116:766.
21. Spivak H, Smith CD, Phichith A, et al. Asthma and gastroesophageal reflux: fundoplication decreases need
for systemic corticosteroids. J Gastrointest Surg 1999; 3:477.
22. Field SK, Sutherland LR. Does medical antireflux therapy improve asthma in asthmatics with
gastroesophageal reflux?: a critical review of the literature. Chest 1998; 114:275.
23. Spechler SJ, Gordon DW, Cohen J, et al. The effects of antireflux therapy on pulmonary function in patients
with severe gastroesophageal reflux disease. Department of Veterans Affairs Gastroesophageal Reflux
Disease Study Group. Am J Gastroenterol 1995; 90:915.
24. Sontag SJ, O'Connell S, Khandelwal S, et al. Asthmatics with gastroesophageal reflux: long term results of
a randomized trial of medical and surgical antireflux therapies. Am J Gastroenterol 2003; 98:987.
25. Fibbe C, Layer P, Keller J, et al. Esophageal motility in reflux disease before and after fundoplication: a
prospective, randomized, clinical, and manometric study. Gastroenterology 2001; 121:5.
26. Kauer WK, Peters JH, DeMeester TR, et al. A tailored approach to antireflux surgery. J Thorac Cardiovasc
Surg 1995; 110:141.
27. Singhal V, Khaitan L. Preoperative evaluation of gastroesophageal reflux disease. Surg Clin North Am
2015; 95:615.
28. Mikami DJ, Murayama KM. Physiology and pathogenesis of gastroesophageal reflux disease. Surg Clin
North Am 2015; 95:515.
29. Ip S, Tatsioni A, Conant A, et al. Predictors of clinical outcomes following fundoplication for
gastroesophageal reflux disease remain insufficiently defined: a systematic review. Am J Gastroenterol
2009; 104:752.
30. Ludemann R, Watson DI, Jamieson GG, et al. Five-year follow-up of a randomized clinical trial of
laparoscopic total versus anterior 180 degrees fundoplication. Br J Surg 2005; 92:240.
31. Peters MJ, Mukhtar A, Yunus RM, et al. Meta-analysis of randomized clinical trials comparing open and
laparoscopic anti-reflux surgery. Am J Gastroenterol 2009; 104:1548.
32. Niebisch S, Fleming FJ, Galey KM, et al. Perioperative risk of laparoscopic fundoplication: safer than
previously reported-analysis of the American College of Surgeons National Surgical Quality Improvement
Program 2005 to 2009. J Am Coll Surg 2012; 215:61.
33. Morino M, Pellegrino L, Giaccone C, et al. Randomized clinical trial of robot-assisted versus laparoscopic
Nissen fundoplication. Br J Surg 2006; 93:553.
34. Stein HJ, Bremner RM, Jamieson J, DeMeester TR. Effect of Nissen fundoplication on esophageal motor
function. Arch Surg 1992; 127:788.
35. Peters JH, DeMeester TR. Esophagus and diaphragmatic hernia. In: Principles of Surgery, Schwartz, SI, S
hires, GT, Spencer, FC (Eds), McGraw-Hill, New York 1994. p.1043.
36. Ellis FH Jr. The Nissen fundoplication. Ann Thorac Surg 1992; 54:1231.
37. Kraemer SJ, Aye R, Kozarek RA, Hill LD. Laparoscopic Hill repair. Gastrointest Endosc 1994; 40:155.
38. Patti MG, Goldberg HI, Arcerito M, et al. Hiatal hernia size affects lower esophageal sphincter function,
esophageal acid exposure, and the degree of mucosal injury. Am J Surg 1996; 171:182.
39. Stein HJ, Feussner H, Siewert JR. Failure of antireflux surgery: causes and management strategies. Am J
Surg 1996; 171:36.
40. Gott JP, Polk HC Jr. Repeat operation for failure of antireflux procedures. Surg Clin North Am 1991; 71:13.
41. Granderath FA, Kamolz T, Schweiger UM, et al. Long-term results of laparoscopic antireflux surgery. Surg
Endosc 2002; 16:753.
42. Lundell L, Miettinen P, Myrvold HE, et al. Continued (5-year) followup of a randomized clinical study
comparing antireflux surgery and omeprazole in gastroesophageal reflux disease. J Am Coll Surg 2001;
192:172.
43. Spechler SJ, Lee E, Ahnen D, et al. Long-term outcome of medical and surgical therapies for
gastroesophageal reflux disease: follow-up of a randomized controlled trial. JAMA 2001; 285:2331.
44. Mahon D, Rhodes M, Decadt B, et al. Randomized clinical trial of laparoscopic Nissen fundoplication
compared with proton-pump inhibitors for treatment of chronic gastro-oesophageal reflux. Br J Surg 2005;
92:695.
45. Stein HJ, DeMeester TR. Who benefits from antireflux surgery? World J Surg 1992; 16:313.
46. Hinder RA, Filipi CJ, Wetscher G, et al. Laparoscopic Nissen fundoplication is an effective treatment for
gastroesophageal reflux disease. Ann Surg 1994; 220:472.
47. Trus TL, Laycock WS, Branum G, et al. Intermediate follow-up of laparoscopic antireflux surgery. Am J
Surg 1996; 171:32.
48. Peters JH, Heimbucher J, Kauer WK, et al. Clinical and physiologic comparison of laparoscopic and open
Nissen fundoplication. J Am Coll Surg 1995; 180:385.
49. Rattner DW, Brooks DC. Patient satisfaction following laparoscopic and open antireflux surgery. Arch Surg
1995; 130:289.
50. Nilsson G, Wenner J, Larsson S, Johnsson F. Randomized clinical trial of laparoscopic versus open
fundoplication for gastro-oesophageal reflux. Br J Surg 2004; 91:552.
51. Rice S, Watson DI, Lally CJ, et al. Laparoscopic anterior 180 degrees partial fundoplication: five-year
results and beyond. Arch Surg 2006; 141:271.
52. McKenzie D, Grayson T, Polk HC Jr. The impact of omeprazole and laparoscopy upon hiatal hernia and
reflux esophagitis. J Am Coll Surg 1996; 183:413.
53. Salminen PT, Hiekkanen HI, Rantala AP, Ovaska JT. Comparison of long-term outcome of laparoscopic
and conventional nissen fundoplication: a prospective randomized study with an 11-year follow-up. Ann
Surg 2007; 246:201.
54. Ip S, Bonis P, Tatsioni A, et a. Comparative Effectiveness of Management Strategies for Gastroesophageal
Reflux Disease. Evidence Report/Technology Assessment No. 1. (Prepared by Tufts-New England Medical
Center. Evidence-based Practice Center under Contract No. 290-02-0022.) Rockville, MD: Agency for Healt
hcare Research and Quality. December 2005. www.effectivehealthcare.ahrq.gov/reports/final.cfm (Accesse
d on December 18, 2007).

55. Spechler SJ. Comparison of medical and surgical therapy for complicated gastroesophageal reflux disease
in veterans. The Department of Veterans Affairs Gastroesophageal Reflux Disease Study Group. N Engl J
Med 1992; 326:786.
56. Bais JE, Bartelsman JF, Bonjer HJ, et al. Laparoscopic or conventional Nissen fundoplication for gastro-
oesophageal reflux disease: randomised clinical trial. The Netherlands Antireflux Surgery Study Group.
Lancet 2000; 355:170.
57. Klaus A, Hinder RA, DeVault KR, Achem SR. Bowel dysfunction after laparoscopic antireflux surgery:
incidence, severity, and clinical course. Am J Med 2003; 114:6.
58. Hunter JG, Swanstrom L, Waring JP. Dysphagia after laparoscopic antireflux surgery. The impact of
operative technique. Ann Surg 1996; 224:51.
59. Herron DM, Swanström LL, Ramzi N, Hansen PD. Factors predictive of dysphagia after laparoscopic
Nissen fundoplication. Surg Endosc 1999; 13:1180.
60. Watson DI, Baigrie RJ, Jamieson GG. A learning curve for laparoscopic fundoplication. Definable,
avoidable, or a waste of time? Ann Surg 1996; 224:198.
61. Harris SC. Laparoscopic antireflux surgery. Am J Surg 1996; 171:482.
62. Cartlidge CW, Stewart GD, de Beaux AC, Paterson-Brown S. The evolution of laparoscopic antireflux
surgery and its influence on postoperative stay. Scott Med J 2011; 56:64.
63. Little AG. Mechanisms of action of antireflux surgery: theory and fact. World J Surg 1992; 16:320.
64. Orlando RC. Reflux esophagitis. In: Textbook of Gastroenterology, Yamada, T (Eds), JB Lippincott Compan
y, Philadelphia 1995. p.1214.
65. Csendes A, Burgos AM, Smok G, et al. Effect of gastric bypass on Barrett's esophagus and intestinal
metaplasia of the cardia in patients with morbid obesity. J Gastrointest Surg 2006; 10:259.
66. Houghton SG, Romero Y, Sarr MG. Effect of Roux-en-Y gastric bypass in obese patients with Barrett's
esophagus: attempts to eliminate duodenogastric reflux. Surg Obes Relat Dis 2008; 4:1.
67. Cobey F, Oelschlager B. Complete regression of Barrett's esophagus after Roux-en-Y gastric bypass. Obes
Surg 2005; 15:710.
68. Kmiot WA, Kirby RM, Akinola D, Temple JG. Prospective randomized trial of Nissen fundoplication and
Angelchik prosthesis in the surgical treatment of medically refractory gastro-oesophageal reflux disease. Br
J Surg 1991; 78:1181.
69. Ganz RA, Edmundowicz SA, Taiganides PA, et al. Long-term Outcomes of Patients Receiving a Magnetic
Sphincter Augmentation Device for Gastroesophageal Reflux. Clin Gastroenterol Hepatol 2016; 14:671.
70. Lipham JC, DeMeester TR, Ganz RA, et al. The LINX® reflux management system: confirmed safety and
efficacy now at 4 years. Surg Endosc 2012; 26:2944.
71. Bonavina L, DeMeester T, Fockens P, et al. Laparoscopic sphincter augmentation device eliminates reflux
symptoms and normalizes esophageal acid exposure: one- and 2-year results of a feasibility trial. Ann Surg
2010; 252:857.
72. Jafri SM, Arora G, Triadafilopoulos G. What is left of the endoscopic antireflux devices? Curr Opin
Gastroenterol 2009; 25:352.
73. Dughera L, Rotondano G, De Cento M, et al. Durability of Stretta Radiofrequency Treatment for GERD:
Results of an 8-Year Follow-Up. Gastroenterol Res Pract 2014; 2014:531907.
74. Funk LM, Zhang JY, Drosdeck JM, et al. Long-term cost-effectiveness of medical, endoscopic and surgical
management of gastroesophageal reflux disease. Surgery 2015; 157:126.
75. Liang WT, Yan C, Wang ZG, et al. Early and Midterm Outcome After Laparoscopic Fundoplication and a
Minimally Invasive Endoscopic Procedure in Patients with Gastroesophageal Reflux Disease: A
Prospective Observational Study. J Laparoendosc Adv Surg Tech A 2015; 25:657.
76. Yan C, Liang WT, Wang ZG, et al. Comparison of Stretta procedure and toupet fundoplication for
gastroesophageal reflux disease-related extra-esophageal symptoms. World J Gastroenterol 2015;
21:12882.
77. http://www.sages.org/publications/guidelines/endoluminal-treatments-for-gastroesophageal-reflux-disease-
gerd/ (Accessed on July 15, 2013).
78. Dominitz JA, Dire CA, Billingsley KG, Todd-Stenberg JA. Complications and antireflux medication use after
antireflux surgery. Clin Gastroenterol Hepatol 2006; 4:299.
79. Malhi-Chowla N, Gorecki P, Bammer T, et al. Dilation after fundoplication: timing, frequency, indications,
and outcome. Gastrointest Endosc 2002; 55:219.
80. Boddy AP, Mehta S, Bennett J, et al. Postoperative esophageal physiology studies may help to predict
long-term symptoms following laparoscopic Nissen fundoplication. Surg Endosc 2008; 22:1298.
81. Lord RV, Kaminski A, Oberg S, et al. Absence of gastroesophageal reflux disease in a majority of patients
taking acid suppression medications after Nissen fundoplication. J Gastrointest Surg 2002; 6:3.
82. Kalinowska E, Tarnowski W, Bielecki K, Banasiewicz J. Quality of life before and after laparoscopic
fundoplication. Does quality of life depend on psychological factors? Preliminary report. Wiad Lek 2006;
59:772.
83. Granderath FA, Kamolz T, Granderath UM, Pointner R. Gas-related symptoms after laparoscopic 360
degrees Nissen or 270 degrees Toupet fundoplication in gastrooesophageal reflux disease patients with
aerophagia as comorbidity. Dig Liver Dis 2007; 39:312.
84. De Vault K. Gas bloat syndrome: a pre- or postoperative dysmotility syndrome? Am J Gastroenterol 1995;
90:1536.
85. Masqusi S, Velanovich V. Pyloroplasty with fundoplication in the treatment of combined gastroesophageal
reflux disease and bloating. World J Surg 2007; 31:332.
86. Nguyen NT, Dholakia C, Nguyen XM, Reavis K. Outcomes of minimally invasive esophagectomy without
pyloroplasty: analysis of 109 cases. Am Surg 2010; 76:1135.
87. Lamb PJ, Myers JC, Jamieson GG, et al. Long-term outcomes of revisional surgery following laparoscopic
fundoplication. Br J Surg 2009; 96:391.
88. Dassinger MS, Torquati A, Houston HL, et al. Laparoscopic fundoplication: 5-year follow-up. Am Surg 2004;
70:691.
89. Cowgill SM, Arnaoutakis D, Villadolid D, et al. Results after laparoscopic fundoplication: does age matter?
Am Surg 2006; 72:778.
90. Mardani J, Lundell L, Engström C. Total or posterior partial fundoplication in the treatment of GERD: results
of a randomized trial after 2 decades of follow-up. Ann Surg 2011; 253:875.

91. Broeders JA, Roks DJ, Ahmed Ali U, et al. Laparoscopic anterior 180-degree versus nissen fundoplication
for gastroesophageal reflux disease: systematic review and meta-analysis of randomized clinical trials. Ann
Surg 2013; 257:850.
92. Nijjar RS, Watson DI, Jamieson GG, et al. Five-year follow-up of a multicenter, double-blind randomized
clinical trial of laparoscopic Nissen vs anterior 90 degrees partial fundoplication. Arch Surg 2010; 145:552.
93. Khan M, Smythe A, Globe J, et al. Randomized controlled trial of laparoscopic anterior versus posterior
fundoplication for gastro-oesophageal reflux disease. ANZ J Surg 2010; 80:500.
94. Watson DI, Jamieson GG, Pike GK, et al. Prospective randomized double-blind trial between laparoscopic
Nissen fundoplication and anterior partial fundoplication. Br J Surg 1999; 86:123.
95. Engström C, Lönroth H, Mardani J, Lundell L. An anterior or posterior approach to partial fundoplication?
Long-term results of a randomized trial. World J Surg 2007; 31:1221.
96. Broeders JA, Roks DJ, Ahmed Ali U, et al. Laparoscopic anterior versus posterior fundoplication for
gastroesophageal reflux disease: systematic review and meta-analysis of randomized clinical trials. Ann
Surg 2011; 254:39.
97. Galmiche JP, Hatlebakk J, Attwood S, et al. Laparoscopic antireflux surgery vs esomeprazole treatment for
chronic GERD: the LOTUS randomized clinical trial. JAMA 2011; 305:1969.
98. Grant AM, Wileman SM, Ramsay CR, et al. Minimal access surgery compared with medical management
for chronic gastro-oesophageal reflux disease: UK collaborative randomised trial. BMJ 2008; 337:a2664.
99. Grant AM, Cotton SC, Boachie C, et al. Minimal access surgery compared with medical management for
gastro-oesophageal reflux disease: five year follow-up of a randomised controlled trial (REFLUX). BMJ
2013; 346:f1908.
100. Garg SK, Gurusamy KS. Laparoscopic fundoplication surgery versus medical management for gastro-
oesophageal reflux disease (GORD) in adults. Cochrane Database Syst Rev 2015; :CD003243.
101. Hatlebakk JG, Zerbib F, Bruley des Varannes S, et al. Gastroesophageal Acid Reflux Control 5 Years After
Antireflux Surgery, Compared With Long-term Esomeprazole Therapy. Clin Gastroenterol Hepatol 2016;
14:678.
Topic 2278 Version 24.0
GRAPHICS
Preoperative evaluation for gastroesophageal reflux disease
Detailed clinical history and physical examination to determine:

A. Clinically significant GERD
B. Atypical GERD
C. Medical treatment failure/medication intolerance
D. Noncompliance
E. Prospect of lifelong medical therapy
If work-up is indicated:
Endoscopy to assess degree/presence of esophagitis/Barrett's esophagus
24-48 continuous pH probe
Esophageal manometry
Optional additional evaluations:

Barium swallow to assess possible esophageal shortening
Gastric emptying study to assess presence of delayed gastric emptying
Impendence study to determine the presence of non-acid reflux
Graphic 82167 Version 1.0
Nissen fundoplication
The Nissen fundoplication provides a 360° "wrap" or collar around the

esophagus. Mobilization of the fundus is generally accomplished by dividing the
short gastric vessels to the spleen. A variant of this procedure, the Nissen
Rosati fundoplication, does not divide the short gastric vessels.
Toupet fundoplication
The Toupet fundoplication is a partial fundoplication creating a collar of

approximately 270° around the esophagus posteriorly.
Contributor Disclosures
Steven D Schwaitzberg, MD Nothing to disclose Joseph S Friedberg, MD Nothing to disclose Nicholas J
Talley, MD, PhD Grant/Research Support: Rome Foundation; Abbott Pharmaceuticals; Commonwealth
Diagnostics Laboratories; Pfizer; Salix [Irritable bowel syndrome]; Prometheus Laboratories Inc [Irritable bowel
syndrome (IBS Diagnostic)]; Janssen [Constipation]. Consultant/Advisory Boards: Adelphi Values [Functional
dyspepsia (patient-reported outcome measures)]; (Budesonide)]; GI therapies [Chronic constipation (Rhythm
IC)]; Sax Institute, Allergan PLC, Yuhan. Patent Holder: Biomarkers of irritable bowel syndrome [Irritable bowel
syndrome]; Licensing Questionairre (Mayo); Nestec European Patents. Wenliang Chen, MD, PhD Nothing to
disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform
to UpToDate standards of evidence.
Conflict of interest policy

Surgical Management of Gastroesophageal Reflux in Adults - UpToDate

Enviado por

Dados do documento

Direitos autorais

Formatos disponíveis

Compartilhar este documento

Compartilhar ou incorporar documento

Opções de compartilhamento

Você considera este documento útil?

Este conteúdo é inapropriado?

Direitos autorais:

Formatos disponíveis

Surgical Management of Gastroesophageal Reflux in Adults - UpToDate

Enviado por

Direitos autorais:

Formatos disponíveis

Surgical management of gastroesophageal reflux in adults - UpToDate 21/08/17, 6*14 p.m.

Official reprint from UpToDate®

Author: Steven D Schwaitzberg, MD

● Failed optimal medical management

delayed emptying may contribute to the reflux.

whether earlier consideration of surgical therapy to prevent complications of GERD is warranted.

Laparoscopic Nissen fundoplication — Nissen fundoplication can also be effectively performed

● Typical GERD symptoms

● Partial response to daily PPI therapy

● Absence of a large hiatal hernia (>3 cm) or severe esophagitis

POSTOPERATIVE SYMPTOM MANAGEMENT — Management of patients after fundoplication depends upon

LONG-TERM EFFICACY — Long-term observational studies of laparoscopic fundoplication by experienced

● Optimized, contemporary medical (esomeprazole, 20 to 40 mg/day) and surgical (standardized laparoscopic

● Basics topics (see "Patient education: Hiatal hernia (The Basics)")

SUMMARY AND RECOMMENDATIONS — Gastroesophageal reflux disease (GERD) is manifested by a

anterior with a posterior fundoplication' above.)

Use of UpToDate is subject to the Subscription and License Agreement.

d on December 18, 2007).

of a randomized trial after 2 decades of follow-up. Ann Surg 2011; 253:875.

Topic 2278 Version 24.0

Preoperative evaluation for gastroesophageal reflux disease

Detailed clinical history and physical examination to determine:

C. Medical treatment failure/medication intolerance

E. Prospect of lifelong medical therapy

24-48 continuous pH probe

Optional additional evaluations:

Gastric emptying study to assess presence of delayed gastric emptying

Impendence study to determine the presence of non-acid reflux

Graphic 82167 Version 1.0

The Nissen fundoplication provides a 360° "wrap" or collar around the

Graphic 51213 Version 3.0

The Toupet fundoplication is a partial fundoplication creating a collar of

Graphic 78957 Version 2.0

Conflict of interest policy

Você também pode gostar