Laparoscopic fundoplication for gastroesophageal reflux disease

Abstract

Gastroesophageal reflux disease (GERD) is a condition that develops when the reflux of gastric contents into the esophagus leads to troublesome symptoms and/or complications. Heartburn is the cardinal symptom, often associated with regurgitation. In patients with endoscopy-negative heartburn refractory to proton pump inhibitor (PPI) therapy and when the diagnosis of GERD is in question, direct reflux testing by impedance-pH monitoring is warranted. Laparoscopic fundoplication is the standard surgical treatment for GERD. It is highly effective in curing GERD with a 80% success rate at 20-year follow-up. The Nissen fundoplication, consisting of a total (360°) wrap, is the most commonly performed antireflux operation. To reduce postoperative dysphagia and gas bloating, partial fundoplications are also used, including the posterior (Toupet) fundoplication, and the anterior (Dor) fundoplication. Currently, there is consensus to advise laparoscopic fundoplication in PPI-responsive GERD only for those patients who develop untoward side-effects or complications from PPI therapy. PPI resistance is the real challenge in GERD. There is consensus that carefully selected GERD patients refractory to PPI therapy are eligible for laparoscopic fundoplication, provided that objective evidence of reflux as the cause of ongoing symptoms has been obtained. For this purpose, impedance-pH monitoring is regarded as the diagnostic gold standard.

Keywords: Gastroesophageal reflux disease; Impedance-pH monitoring; Laparoscopic fundoplication; Proton pump inhibitors; Refractory gastroesophageal reflux disease.

Figure 1

Diagnostic algorithm for proton pump inhibitor responsive patients with typical reflux symptoms. Endoscopy should be performed in uninvestigated patients and in patients with previous detection of reflux esophagitis or Barrett’s esophagus. Impedance-pH monitoring should be performed during proton pump inhibitor (PPI) withdrawal after symptoms have recurred. SAP: Symptom association probability; SI: Symptom index.

Figure 2

Diagnostic algorithm for proton pump inhibitor refractory patients with typical reflux symptoms. Endoscopy should be performed in uninvestigated patients and in patients with previous detection of reflux esophagitis or Barrett’s esophagus. Impedance-pH monitoring should be performed during ongoing proton pump inhibitor (PPI) treatment. SAP: Symptom association probability; SI: Symptom index.