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Back To Vidyya Guideline - Gastroesophageal Reflux

Summary Excerpts


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.

Original Content:
Surg Endosc 1998 Feb;12(2):186-8

    Preoperative Work-Up

    Before considering surgical treatment of GERD, it is recommended that patients undergo:

    1. esophagogastroduodenoscopy (with biopsy, where appropriate)
    2. esophageal manometric evaluation

    In selected cases, the following investigations may prove helpful:

    1. 24-hour intraesophageal pH monitoring, and
    2. 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.

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  1. Indications for Surgery

    Surgical therapy should be considered in those individuals with documented GERD who:

    1. have failed medical management or

    2. opt for surgery despite successful medical management (due to life style considerations including age, time or expense of medications, etc.) or

    3. have complications of GERD (e.g. Barrett's/stricture; grade 3 or 4 esophagitis)or

    4. 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 antireflux surgery.

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  2. Surgical Techniques

    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:

    1. position the lower esophageal sphincter (LES) within the abdomen where the sphincter is under positive (intraabdominal) pressure

      AND

    2. 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.

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  3. 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.

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  4. Summary

    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 function.

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