The following is an excerpted guideline from a National Guideline Clearinghouse summary. Vidyya chose this guideline for its relevance to newly approved endoscopic procedures. This is in no way an endorsement or recommendation of the guideline.
The original source material can be found at the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) Web site.
Exerpts From: Guideline for surgical treatment of gastroesophageal reflux disease.
Surg Endosc 1998 Feb;12(2):186-8
Before considering surgical treatment of GERD, it is recommended that
- esophagogastroduodenoscopy (with biopsy, where
- esophageal manometric evaluation
In selected cases, the following investigations may prove helpful:
- 24-hour intraesophageal pH monitoring, and
- barium cineradiography.
While not always available, these investigations should not only confirm the
diagnosis, but also lead to appropriate selection of patients for surgical
repair. In particular, biopsies from areas of suspected Barrett's epithelium may
document the presence of severe dysplasia or carcinoma. In such settings, an
antireflux procedure alone would be inappropriate and other interventions such
as resection or close endoscopic surveillance might be indicated. Upper
gastrointestinal endoscopy may also identify other esophagogastric mucosal
abnormalities, suggesting symptomatic etiologies other than GERD. Additionally,
a normal 24-hour intraesophageal pH study should strongly suggest an alternate
diagnosis and lead to additional diagnostic investigations. Finally, abnormal
peristalsis on esophageal manometric study may suggest a significant risk of
dysphagia following fundoplication.
Indications for Surgery
Surgical therapy should be considered in those individuals with documented
- have failed medical management or
- opt for surgery despite successful medical
management (due to life style considerations including age, time or
expense of medications, etc.) or
- have complications of GERD (e.g.
Barrett's/stricture; grade 3 or 4 esophagitis)or
- have "atypical" symptoms (asthma, hoarseness, cough, chest
pain, aspiration) and reflux documented on 24 hour pH monitoring.
In patients with Barrett's changes and severe dysplasia, the risk of
underlying malignancy may suggest consideration of esophagectomy, rather than
The primary goal of surgical intervention for GERD is to re-establish the
antireflux barrier without creation of undue side effects. In addition, most
surgeons feel it is necessary to:
- position the lower esophageal sphincter (LES)
within the abdomen where the sphincter is under positive
- close any associated hiatal defect.
Various safe and effective surgical techniques have been developed to realize
the above goals. The choice of technique has typically been based upon anatomic
considerations, as well as the surgeon's preference and expertise. Many of these
techniques have been extensively tested and proven to be effective in
controlling reflux with minimal side effects. The Nissen fundoplication has
emerged as the most widely accepted procedure for patients with normal
esophageal motility. For patients with compromised esophageal motility, one of
the various partial fundoplications (e.g. Toupet fundoplication ) is recommended
to decrease the possibility of postoperative dysphagia. The success of an
antireflux procedure depends upon the surgeon's familiarity and training with
the specific technique and his/her ongoing involvement in the pre- and
post-operative care. The choice of procedure and methods of access (open or
laparoscopic) should be determined by the surgeon's experience and training more
than by the technique itself. Special mention of the laparoscopic approaches for
the treatment of GERD follows.
Laparoscopic Treatment of GERD
Laparoscopic antireflux procedures rely on videoscopic technologies to allow
surgeons to reproduce the accepted "open" procedures in a minimally
invasive fashion. The benefits of a laparoscopic approach are analogous to those
realized with laparoscopic cholecystectomy and include a shorter and more
comfortable recovery with an earlier return to normal activities. Several
reports in the literature document the feasibility, safety, and favorable
results of laparoscopic antireflux procedures.
The indications for laparoscopic treatment of GERD are the same as those
outlined earlier in this document. Laparoscopic antireflux surgery should only
be offered by surgeons skilled and privileged in the equivalent open antireflux
procedure. Safe and effective laparoscopic treatment of GERD requires advanced
laparoscopic skills such as intracorporeal knot tying, the use of angled scopes
to achieve multiple viewing angles, and two-handed organ and tissue
manipulation. Therefore, appropriate training in advanced laparoscopic
techniques is mandatory. These skills are most appropriately acquired through a
residency, fellowship, or course that details the specific laparoscopic
antireflux technique and teaches the appropriate advanced skills. Such a course
should provide documentation of attendance and skills taught. Before attempting
such a procedure independently, the surgeon should be preceptored by a surgeon
experienced in the procedure. Finally, laparoscopic antireflux surgery requires
a well trained operating team familiar with the equipment, instruments and
techniques of antireflux surgery.
gastroesophageal refluxdisease (GERD) is a significant health concern.
Medical management is expensive and may be necessary lifelong. Effective
surgical therapy is available and, if performed by experienced surgeons, is
successful in greater than 90% of patients. Laparoscopic techniques that
reproduce their "open" counterpart are also available. When performed
by appropriately trained surgeons, these laparoscopic approaches appear to
hasten the patient's recovery and return to normal