World J Surg

DOI 10.1007/s00268-017-3955-1

SURGICAL SYMPOSIUM CONTRIBUTION

Surgical Treatment of Gastroesophageal Reflux Disease

Francisco Schlottmann1 • Fernando A. Herbella2 •
Marco E. Allaix3 • Fabrizio Rebecchi3 • Marco G. Patti1

Ó Société Internationale de Chirurgie 2017

Abstract
Background Gastroesophageal reflux disease (GERD) affects an estimated 20% of the population in the USA, and its
prevalence is increasing worldwide. Lifestyle modifications and proton pump inhibitors (PPI) therapy are effective in
the majority of patients and remain the mainstay of treatment of GERD. However, some patients will need surgical
intervention because they have partial control of symptoms, do not want to be on long-term medical treatment, or
suffer complications related to PPI therapy.
Aims The aim of this study was to review the available evidence that supports laparoscopic antireflux surgery, and to
study the effect of surgical therapy on the natural history of GERD.
Results The key elements for the success of antireflux surgery are proper patient selection, careful analysis of the
indications for surgery, complete pre-operative work-up, and proper execution of the surgical technique.
Conclusions When the key elements are respected, antireflux surgery is very effective in controlling GERD, and it is
associated to minimal morbidity and mortality.

Introduction approximately $10 billion per year, with proton pump

Gastroesophageal reflux disease (GERD) is a frequent
disorder worldwide, especially in developed countries. This
disease affects approximately 20% of the population in the
USA and its prevalence is increasing worldwide, mostly
due to the epidemic of obesity [1]. The economic impact of
GERD is tremendous, with direct healthcare costs of
& Marco G. Patti
Marco_patti@med.unc.edu
1
Department of Surgery and Center for Esophageal Diseases
and Swallowing, University of North Carolina, 4030 Burnett-
Womack Building, Campus Box 7081, Chapel Hill,
NC 27599-7081, USA
2
Department of Surgery, Escola Paulista de Medicina, Federal
University of São Paulo, São Paulo, Brazil
3
Department of Surgical Sciences, University of Torino,
Turin, Italy
inhibitors (PPI) as the largest contributors to these expenses
(nearly $6 billion) [2, 3]. More difficult to measure are
indirect costs, such as impaired ability to work, workplace
absence and intangible costs of pain and suffering [4].
The main purpose of treatment of GERD is to control
symptoms, improve patients’ quality of life and prevent
complications (bleeding, esophageal stenosis, Barrett’s
esophagus and adenocarcinoma). Lifestyle modifications
and PPI therapy are effective in the majority of patients
with GERD. However, a small percentage of patients will
become candidates for surgical intervention because of
refractory symptoms or esophageal injury, non-compliance
with or a desire to avoid long-term medical treatment, or
evolution of complications related to PPI therapy.
Although laparoscopic fundoplication has proved to be safe
and effective in controlling patients’ symptoms, we dis-
tinguish three major predictors of failure of surgical treat-
ment: incomplete/wrong preoperative workup, wrong

123

indication for the operation and/or inability to execute the
proper technical steps.
This review will focus on the analysis of the three causes
of surgical failure mentioned above and on the description
of the side effects and surgical outcomes of anti-reflux
surgery.
Preoperative workup
A diagnosis of GERD based on symptoms is wrong in many
patients because symptoms are not specific; the clinical
presentation is heterogeneous and there is considerable
overlap with other gastrointestinal disorders [5–7]. In fact,
Patti et al. [8] showed that after performing pH monitoring in
822 patients referred to the Swallowing Center of the
University of California with the diagnosis of GERD based
on symptom evaluation, 247 (30%) had a normal reflux
score. Thus, objective esophageal testing is mandatory to
document the presence of GERD, particularly when surgical
treatment is considered. The Esophageal Diagnostic Advi-
sory Panel achieved a consensus on the optimal preoperative
evaluation for patients with GERD, indicating that upper
endoscopy, barium esophagram, esophageal manometry and
pH monitoring are required before surgery [9].
Upper endoscopy
Endoscopy is often the first test performed to confirm
GERD. However, an estimate 50–60% of patients with
abnormal reflux evidenced by pH monitoring do not have
any evidence of mucosal damage [10, 11]. In addition,
particularly for low-grade esophagitis, a high inter-ob-
server variability has been shown [12]. Nevertheless,
endoscopy remains valuable for excluding other patholo-
gies such as eosinophilic esophagitis, gastritis, peptic ulcer,
benign stricture and cancer.
Barium esophagram
Although this test does not provide sufficient objective evi-
dence for diagnosing GERD, it has a great value in operative
planning because it provides information about anatomic
variations (i.e., presence and degree of esophageal shorten-
ing, diverticulum, stricture or hiatal hernia). In particular, the
ability to distinguish between a type I (sliding) hiatal hernia
and type III (mixed, paraesophageal) hiatal hernia will have
implications for the complexity of the operation.
Esophageal manometry
Manometry has limited valued for the diagnosis of GERD.
The main indications for its use are for correct placement
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World J Surg
of a probe for pH monitoring (5 cm above the upper border
of the lower esophageal sphincter), to exclude a primary
motility disorder such as achalasia and to assess esophageal
function in patients with connective tissue disorders
[13–15]. In addition, most surgeons will tailor the degree of
fundoplication (total vs. partial) based on the peristaltic
coordination and contractile force of the esophageal body,
although the data in support of this practice are weak [16].
Ambulatory pH monitoring
Esophageal pH testing is considered the gold standard for
the diagnosis of GERD because it objectively establishes
pathologic acid exposure and correlates specific symptoms
with episodes of reflux. It is important to discontinue acid
suppression medications on patients undergoing this test
(H2 blocking agents for 3 days and PPIs for 7 days before
the test) [17]. The pH monitoring can be performed by
either a transnasal catheter placement (5 cm above the
manometrically determined lower esophageal sphincter)
for 24 h, or an endoscopically placed a BRAVO wireless
capsule (5 cm above the squamocolumnar junction) which
collects pH data for 48 h [17]. The temporal correlation
between patients’ symptoms and reflux events (a given
symptom is considered associated with a reflux event if it
occurs within the 2 min interval after the reflux event) can
be established by either the symptom index [18] or the
symptom association probability [19]. Esophageal pH
testing can also be combined with impedance to detect any
type of reflux event (acid, weakly acidic or non-acidic),
which has particular value in patients who are refractory or
unresponsive to PPI therapy [20, 21]. However, impedance
testing is prone to interpretation error and the role of anti-
reflux surgery in patients with abnormal non-acid reflux on
acid suppression remains unclear [22].
Indications for anti-reflux surgery
Once a proper diagnosis of GERD is achieved, anti-reflux
surgery is an excellent option for patients with partial
control of symptoms with medication, for patients who do
Table 1 Indications for anti-reflux surgery
Symptoms (i.e., regurgitation, cough) not controlled by PPI
Non-acid reflux and symptoms on PPI therapy
Symptoms and large hiatal hernia
Poor patient’s compliance with medical therapy
Cost of medical therapy
Side effects of medications
Symptomatic young patients who refuse lifelong PPI
PPI proton pump inhibitors
World J Surg
not want to be on long-term medical treatment (compli-
ance/cost), or when complications of PPI treatment occur.
Indications for anti-reflux surgery are summarized in
Table 1.
Inadequate symptom control
While in the past surgery was often considered for patients
without a good response to PPI therapy, today the best
indication for anti-reflux surgery is instead good control of
symptoms with PPIs. In fact, the presence of typical
symptoms and a good response to acid suppression therapy
have shown to be the strongest positive predictors of suc-
cess after anti-reflux surgery [23, 24]. However, while PPI
therapy alters the pH of the gastric juice, it does not
eliminate the occurrence of gastroesophageal reflux epi-
sodes. Thus, some patients on PPIs will present with
symptomatic relief of their heartburn, but regurgitation and
respiratory symptoms persist. In contrast to medical ther-
apy, anti-reflux surgery restores the lower esophageal
sphincter function and abolishes reflux of all gastric con-
tent into the esophagus.
Symptoms and large hiatal hernia
Symptoms in patients with GERD and a large hiatal hernia
are more likely to persist despite medical therapy, mostly
because of a low compliance of the gastroesophageal
junction and an increased number of reflux episodes in the
supine position [25].
Poor compliance with medical treatment
Taking a pill 30 min before the first daily meal is easy for
most patients but not all. Poor compliance is one of the
most common causes of PPI therapy failure, with almost
half of PPI use occurring on-demand or intermittently
[26, 27]. The main factors determining whether or not
patients take PPIs are the presence or severity of symptoms
on the one hand and the fear of side effects on the other
[28].
Cost of medical therapy
Currently there are seven different PPIs available with a
wide range of cost. As mentioned before, PPI therapy
results in tremendous healthcare costs [2, 3]. Some
patients are economically limited and cannot afford
long-term medical treatment. As shown by the
REFLUX trial, laparoscopic fundoplication is a cost-
effective alternative to continued medical treatment
over 5 years [29].
Side effects of medical treatment
While maintenance treatment with PPIs is generally safe,
adverse effects may occur specially with extended use. PPI
therapy has been shown to increase the risk of hypomag-
nesemia, vitamin B12 deficiency, osteoporosis, Clostridium
difficile infection and community-acquired pneumonia
[30]. Recently, PPI use has been associated with major
adverse cardiac events in patients taking clopidogrel due to
an impaired metabolic activation of anti-platelet agents and
in the general population probably related to vitamin
deficiencies, electrolyte abnormalities and reduced activity
of nitric oxide synthase [31].
Young patients
Young patients may not want to accept a strategy for life-
long medication use due to quality of life considerations,
anticipated expense or concerns about the accumulated risk
of side effects. Surgery should be at least discussed with
young symptomatic patients.
Surgical technique
A laparoscopic fundoplication is today considered the
procedure of choice for the surgical treatment of GERD.
The standardization of the following technical steps is
recommended to achieve optimal surgical outcomes:
Step 1 Division of gastrohepatic ligament and identifi-
cation of right crus of the diaphragm and posterior vagus
nerve.
Step 2 Division of peritoneum and phrenoesophageal
membrane above the esophagus and identification of the
left crus of the diaphragm and anterior vagus nerve.
Step 3 Extensive mediastinal dissection in order to have
2–3 cm of esophagus without any tension below the
diaphragm.
Step 4 Division of the upper short gastric vessels to
ensure a tension-free wrap.
Step 5 Creation of a window between gastric fundus,
esophagus and diaphragmatic crura and placement of
Penrose drain around the esophagus.
Step 6 Closure of the diaphragmatic crura with inter-
rupted non-absorbable sutures. Placement of a mesh is
recommended for patients with large paraesophageal
hernias.
Step 7 Insertion of a 56-French dilator into the esoph-
agus and across the esophageal junction to avoid a tight
fundoplication and postoperative dysphagia.
Step 8 Wrap construction. There are two types of
fundoplication, total or partial (anterior or posterior).
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Based on previous data showing similar control of
abnormal reflux with a total fundoplication and either a
partial posterior or anterior fundoplication [32–34], the
choice of the type of the wrap should be based on the
surgeon’s own training and experience.
Side effects of anti-reflux surgery
Two symptoms may cause patients’ dissatisfaction despite
control of reflux: dysphagia and bloating.
Almost every postoperative fundoplication patient
experiences some degree of transient dysphagia. Long-term
dysphagia is rare and it should raise concern for a technical
problem. The use of a dilator down the esophagus and
across the esophagogastric junction during formation of the
fundoplication has been shown to decrease the incidence of
postoperative dysphagia [35]. A wrap made with the body
of the stomach rather than the fundus, or a too-tight or too-
long ([2.5 cm) wrap, may also cause long-term dysphagia.
In case of severely impaired or absent esophageal peri-
stalsis, a partial wrap is preferable because a 360° wrap
may cause dysphagia [36]. Endoscopic dilatation repre-
sents the initial therapy in most patients with persisting
post-fundoplication dysphagia and redo surgery may be
needed for failure of endoscopic treatment [37].
Gas-related symptoms such as bloating, flatulence and
inability to belch are also common after fundoplication
[38]. The LOTUS trial reported that postoperative bloating
was present in 40% of patients 5 years after laparoscopic
anti-reflux surgery [39]. It is unclear why some patients
develop severe bloating after this procedure and others do
not. Patients with preoperative tendencies for air swallows
and belching may be more affected by this side effect.
Some authors believe that the type of fundoplication may
be related to the incidence of bloating. Broeders et al. [40]
reported that the incidence of bloating was significantly
higher after complete fundoplication than after partial
fundoplication. Although prokinetics have been shown to
reduce gas-related symptoms in patients with functional
bloating and irritable bowel syndrome [41], there is cur-
rently no reliable therapy for gas-related symptoms after
anti-reflux surgery.
Outcomes of laparoscopic anti-reflux surgery
Ten-year follow-up studies have shown that reflux control
and symptomatic relief is achieved in about 80–90% of
patients after a total fundoplication for GERD [42–44].
Recently, Robinson et al. [45] reported excellent long-term
results with 94% of patients having occasional or fewer
reflux symptoms at 20-year follow-up. Interestingly, 43%
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of those patients were using PPIs at the time of the inter-
view. Interestingly, although many patients use PPIs after
anti-reflux surgery, only one-third have objective evidence
of recurrent reflux when tested by pH monitoring [46].
Davis et al. [47] reviewed 13 randomized clinical trials
that assessed outcomes after laparoscopic anti-reflux sur-
gery and concluded that preoperative large hiatal hernia,
atypical symptoms, poor response to acid suppression
therapy and body mass index [30–35 kg/m2 are correlated
with poor outcomes. In contrast, the presence of typical
symptoms with clinical response to PPI therapy is the best
predictors of good outcomes after anti-reflux surgery
[23, 24]. Horgan et al. [48] reported that improper surgical
technique is also associated with poorer outcomes, with
failure of crural closure and malformation of the wrap as
the main technical reasons for failure of anti-reflux
procedures.
Although anti-reflux surgery has proved to be beneficial
for patients, the utilization of laparoscopic fundoplication
has declined in the USA in recent years [49, 50]. It is true
that the obesity epidemic and the rapid increase in the
utilization of bariatric procedures may have contributed to
this decline. However, patients and gastroenterologists
concerns about surgical side effects need for reoperation
and recurrence of GERD symptoms may also be related to
the decrease in the number of anti-reflux operations. In
other words, non-optimal surgical results may have led to
an ‘‘under-utilization’’ by gastroenterologists or ‘‘under-
selection’’ by patients for anti-reflux surgery. In order to
restore the appropriate level of confidence in anti-reflux
surgery and to achieve excellent surgical outcomes, a
complete preoperative workup, correct indications and a
proper surgical technique are needed.
Compliance with ethical standards
Conflict of interest The authors have no conflict of interest to
declare.
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