Surgery for Acid Reflux ReliefIndications of Antireflux Surgery
Antireflux surgery is indicated for the treatment of objectively documented, relatively severe GERD. Candidates for surgery include not only patients with erosive esophagitis, stricture, and Barrett's esophagus but also those without severe mucosal injury who are dependent on PPIs for symptom relief. Patients with atypical or respiratory symptoms who have a good response to intensive medical treatment are also candidates. The option of antireflux surgery should be given to all patients who have demonstrated the need for long-term medical therapy, particularly if escalating doses of PPIs are needed to control symptoms. Antireflux surgery may be the preferred option in patients younger than 50 years, those who are noncompliant with their drug regimen, those for whom medications are a financial burden, and those who favor a single intervention over long-term drug treatment. It may be the treatment of choice in patients who are at high risk of progression despite medical therapy. Although this population is not well defined, risk factors that predict progressive disease and a poor response to medical therapy include (a) nocturnal reflux on 24-hour esophageal pH study, (b) a structurally deficient LES, (c) mixed reflux of gastric and duodenal juice, and (d) mucosal injury at presentation.
Preoperative Evaluation
Successful antireflux surgery is largely defined by two objectives: the achievement of long-term relief of reflux symptoms and the absence of complications or complaints after the operation. In practice, achieving these two deceptively simple goals is difficult. Both are critically dependent on establishing that the symptoms for which the operation is performed are the result of excess esophageal exposure to gastric juice, as well as the proper performance of the appropriate antireflux procedure. Success can be expected in the vast majority of patients if these two criteria are met. The status of the LES is not as important a factor as in the days of open surgery. Patients with normal resting sphincters are often selected for antireflux surgery in the era of laparoscopic fundoplication. The outcome is not dependent on sphincter function.
There are four important goals of the diagnostic approach to patients suspected of having GERD and being considered for antireflux surgery.
Objective Documentation
The introduction of laparoscopic access, coupled with the growing recognition that surgery is a safe and durable treatment for GERD, has dramatically increased the number of patients being referred for laparoscopic fundoplication. The threshold for surgical referral is such that increasing numbers of patients without endoscopic esophagitis or other objective evidence of the presence of reflux are now considered candidates for laparoscopic antireflux surgery. These facts combine to underscore the importance of selecting patients for surgery who are likely to have a successful outcome. Although a Nissen fundoplication will reliably and reproducibly halt the return of gastroduodenal juice into the esophagus, little benefit is likely if the patient's symptoms are not caused by this specific pathophysiologic derangement. Thus, in large part, the anticipated success rate of laparoscopic fundoplication is directly proportional to the degree of certainty that GERD is the underlying cause of the patient's complaints.
Three factors predictive of a successful outcome following antireflux surgery have emerged . These are (a) an abnormal score on 24-hour esophageal pH monitoring; (b) the presence of typical symptoms of GERD, namely heartburn or regurgitation; and (c) symptomatic improvement in response to acid suppression therapy prior to surgery. It is immediately evident that each of these factors helps to establish that GERD is indeed the cause of the patient's symptoms and that they have little to do with the severity of the disease.
Endoscopic evaluation
Twenty-four hour ambulatory pH monitoring
Assessment of esophageal length
Radiographic evaluation
Assessment of esophageal body and gastric function
Antireflux surgery is indicated for the treatment of objectively documented, relatively severe GERD. Candidates for surgery include not only patients with erosive esophagitis, stricture, and Barrett's esophagus but also those without severe mucosal injury who are dependent on PPIs for symptom relief. Patients with atypical or respiratory symptoms who have a good response to intensive medical treatment are also candidates. The option of antireflux surgery should be given to all patients who have demonstrated the need for long-term medical therapy, particularly if escalating doses of PPIs are needed to control symptoms. Antireflux surgery may be the preferred option in patients younger than 50 years, those who are noncompliant with their drug regimen, those for whom medications are a financial burden, and those who favor a single intervention over long-term drug treatment. It may be the treatment of choice in patients who are at high risk of progression despite medical therapy. Although this population is not well defined, risk factors that predict progressive disease and a poor response to medical therapy include (a) nocturnal reflux on 24-hour esophageal pH study, (b) a structurally deficient LES, (c) mixed reflux of gastric and duodenal juice, and (d) mucosal injury at presentation.
Preoperative Evaluation
Successful antireflux surgery is largely defined by two objectives: the achievement of long-term relief of reflux symptoms and the absence of complications or complaints after the operation. In practice, achieving these two deceptively simple goals is difficult. Both are critically dependent on establishing that the symptoms for which the operation is performed are the result of excess esophageal exposure to gastric juice, as well as the proper performance of the appropriate antireflux procedure. Success can be expected in the vast majority of patients if these two criteria are met. The status of the LES is not as important a factor as in the days of open surgery. Patients with normal resting sphincters are often selected for antireflux surgery in the era of laparoscopic fundoplication. The outcome is not dependent on sphincter function.
There are four important goals of the diagnostic approach to patients suspected of having GERD and being considered for antireflux surgery.
Objective Documentation
The introduction of laparoscopic access, coupled with the growing recognition that surgery is a safe and durable treatment for GERD, has dramatically increased the number of patients being referred for laparoscopic fundoplication. The threshold for surgical referral is such that increasing numbers of patients without endoscopic esophagitis or other objective evidence of the presence of reflux are now considered candidates for laparoscopic antireflux surgery. These facts combine to underscore the importance of selecting patients for surgery who are likely to have a successful outcome. Although a Nissen fundoplication will reliably and reproducibly halt the return of gastroduodenal juice into the esophagus, little benefit is likely if the patient's symptoms are not caused by this specific pathophysiologic derangement. Thus, in large part, the anticipated success rate of laparoscopic fundoplication is directly proportional to the degree of certainty that GERD is the underlying cause of the patient's complaints.
Three factors predictive of a successful outcome following antireflux surgery have emerged . These are (a) an abnormal score on 24-hour esophageal pH monitoring; (b) the presence of typical symptoms of GERD, namely heartburn or regurgitation; and (c) symptomatic improvement in response to acid suppression therapy prior to surgery. It is immediately evident that each of these factors helps to establish that GERD is indeed the cause of the patient's symptoms and that they have little to do with the severity of the disease.
Endoscopic evaluation
Twenty-four hour ambulatory pH monitoring
Assessment of esophageal length
Radiographic evaluation
Assessment of esophageal body and gastric function
