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 

Indications

• 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

Fundoplication

• 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