Treatment Guideline Chart
Gastroesophageal reflux disease is a condition which results from the recurrent backflow of gastric contents into the esophagus and adjacent structures causing troublesome symptoms and/or tissue injury.
It is produced by various mechanisms such as frequent occurrence of transient relaxation of the lower esophageal sphincter or pressure abnormalities in the lower esophageal sphincter (which can be caused by hormonal and neural mediators, food, drugs and patient lifestyle).
Typical symptoms are acid regurgitation and heartburn.
Acid regurgitation is the perception of flow of refluxed gastric contents into the mouth or hypopharynx.
Heartburn is the burning sensation in the retrosternal region.

Surgical Intervention

Antireflux Surgery

  • Has evolved from open type to a laparoscopic procedure and in recent years, to transoral incisionless fundoplication
  • Surgical success is highest in patients presenting with typical GERD symptoms and demonstrating good response to treatment with PPI
    • In considering antireflux surgery, inform patients regarding the risk of long-term PPI therapy after surgery
  • Esophageal manometry, ambulatory reflux studies, endoscopy and other functional testing should be done before antireflux surgery to rule out other disorders, eg achalasia, non-reflux-induced esophageal spasm, scleroderma 


  • Failed medical management
    • Noncompliance with therapy, medication side effects, inadequate symptom control, refractory GERD
    • However, surgery is generally not recommended in those who are unresponsive to PPI therapy
  • Severe erosive GERD or severe GERD complications (eg peptic stricture, Barrett’s esophagus)
  • Large hiatal hernia
  • Extraesophageal conditions (eg cough, asthma, chest pain, aspiration)
  • Young patients requiring long-term management
  • Patient preference
    • Despite success with medications, patient may opt for surgery due to cost of medications, life-long need to take acid-suppressive agents


  • Involves either a partial or a complete (360 degrees) wrap of the LES with a section of the stomach, thus, increasing LES pressure
  • Advantages include less pain, fewer incisional hernias, shorter hospital stay, quicker return to work, less defective wraps at follow-up endoscopy
  • Complications include inability to belch and vomit, persistent dysphagia, postprandial pain, epigastric fullness, bloating, temporary swallowing discomfort, intense flatus
  • Trans-oral or endoluminal fundoplication is a new modified version of an open or laparoscopic fundoplication and involves accessing the stomach through the mouth, eliminating the need for incisions
    • Is currently not recommended as an alternative to medical or traditional surgery as data are lacking to support its role
  • Recent publications have, however, noted long-term follow-up of patients who had antireflux surgery (up to 13 years post-op) showed a high rate of symptom relapse which required continuing intake of antireflux medications
  • Expertise or experience of the surgeon performing the procedure is highly predictive of clinical success

Endoluminal Treatments 

  • Recent procedures, eg titanium beads implantation and full-thickness plication, intend to reduce acid reflux episodes or transient LES relaxations and increase LES basal pressure
  • Currently performed in clinical trials as durable long-term benefits have not been shown
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