Skip to main content
SpringerLink
Log in

Pathophysiology of gastroesophageal reflux disease: how an antireflux procedure works (or does not work)

  • Original Article
  • Published:
Updates in Surgery Aims and scope Submit manuscript

Abstract

The pathophysiology of gastroesophageal reflux disease is complex and linked to an intricate valve mechanism at the level of the esophagogastric junction that must counteract a trans-diaphragmatic pressure gradient, which is constantly forcing gastric contents upwards. Surgical antireflux therapy is usually aimed towards reinforcement of this valve mechanism. The valve mechanism is made up by the intra-abdominal length of the esophagus; the diaphragmatic sphincter, the angle of His, and the lower esophageal sphincter: all these elements must be restored with an antireflux procedure. Hiatal approximation and fundoplication determine excellent outcomes in patients in whom the abnormal reflux is mostly due to the valve mechanism. In patients with altered intra-abdominal pressure due to obesity, a bariatric procedure such as a Roux-en-Y gastric bypass is probably more appropriate. For patients with an altered intra-thoracic pressure such as in idiopathic pulmonary fibrosis, a fundoplication has been shown to be beneficial in resolving symptoms and avoiding progression of the diseases.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Menezes MA, Herbella FAM (2017) Pathophysiology of gastroesophageal reflux disease. World J Surg 41(7):1666–1671

    Article  PubMed  Google Scholar 

  2. Harding SM, Allen JE, Blumin JH, Warner EA, Pellegrini CA, Chan WW (2013) Respiratory manifestations of gastroesophageal reflux disease. Ann N Y Acad Sci 1300:43–52. https://doi.org/10.1111/nyas.12231

    Article  PubMed  Google Scholar 

  3. Herbella FA, Andolfi C, Vigneswaran Y, Patti MG, Pinna BR (2016) Importance of esophageal manometry and pH monitoring for the evaluation of otorhinolaryngologic (ENT) manifestations of GERD. A multicenter study. J Gastrointest Surg 20(10):1673–1678. https://doi.org/10.1007/s11605-016-3212-1

    Article  PubMed  Google Scholar 

  4. Schlottmann F, Herbella FA, Allaix ME, Rebecchi F, Patti MG (2017) Surgical treatment of gastroesophageal reflux disease. World J Surg 41(7):1685–1690. https://doi.org/10.1007/s00268-017-3955-1

    Article  PubMed  Google Scholar 

  5. Makris KI, Lee T, Mittal SK (2009) Roux-en-Y reconstruction for failed fundoplication. J Gastrointest Surg 13(12):2226–2232

    Article  PubMed  Google Scholar 

  6. Nadaleto BF, Herbella FA, Patti MG (2016) Gastroesophageal reflux disease in the obese: pathophysiology and treatment. Surgery 159(2):475–486

    Article  PubMed  Google Scholar 

  7. Neto SC, Herbella FA, Silva LC, Patti MG (2014) Ratio between proximal/distal gastroesophageal reflux does not discriminate abnormal proximal reflux. World J Surg 38(4):890–896. https://doi.org/10.1007/s00268-013-2341-x

    Article  PubMed  Google Scholar 

  8. Johnson LF, Demeester TR (1974) Twenty-four-hour pH monitoring of the distal esophagus. A quantitative measure of gastroesophageal reflux. Am J Gastroenterol 62(4):325–332

    CAS  PubMed  Google Scholar 

  9. Jamieson JR, Stein HJ, DeMeester TR, Bonavina L, Schwizer W, Hinder RA, Albertucci M (1992) Ambulatory 24-h esophageal pH monitoring: normal values, optimal thresholds, specificity, sensitivity, and reproducibility. Am J Gastroenterol 87(9):1102–1111

    PubMed  CAS  Google Scholar 

  10. Herbella FA, Patti MG (2010) Gastroesophageal reflux disease: from pathophysiology to treatment. World J Gastroenterol 16(30):3745–3749

    Article  PubMed  PubMed Central  Google Scholar 

  11. Benati CD, Herbella FA, Patti MG (2014) Manometric parameters in patients with suspected gastroesophageal reflux disease and normal pH monitoring. GED Gastroenterol Endosc Dig 33(2):52–57

    Google Scholar 

  12. Del Grande LM, Herbella FA, Bigatao AM, Abrao H, Jardim JR, Patti MG (2016) Pathophysiology of gastroesophageal reflux in patients with chronic pulmonary obstructive disease is linked to an increased transdiaphragmatic pressure gradient and not to a defective esophagogastric barrier. J Gastrointest Surg 20(1):104–110

    Article  PubMed  Google Scholar 

  13. Roman S, Holloway R, Keller J, Herbella F, Zerbib F, Xiao Y, Bernard L, Bredenoord AJ, des Varannes SB, Chen M, Fox M, Kahrilas PJ, Mittal RK, Penagini R, Savarino E, Sifrim D, Wu J, Decullier E, Pandolfino JE, Mion F (2017) Validation of criteria for the definition of transient lower esophageal sphincter relaxations using high-resolution manometry. Neurogastroenterol Motil 29(2):e12920. https://doi.org/10.1111/nmo.12920 (Epub 2016 Jul 31)

    Article  Google Scholar 

  14. Miller L, Vegesna A, Kalra A, Besetty R, Dai Q, Korimilli A, Brasseur JG (2007) New observations on the gastroesophageal antireflux barrier. Gastroenterol Clin N Am 36(3):601–617

    Article  Google Scholar 

  15. Pandolfino JE, Kim H, Ghosh SK, Clarke JO, Zhang Q, Kahrilas PJ (2007) High-resolution manometry of the EGJ: an analysis of crural diaphragm function in GERD. Am J Gastroenterol 102(5):1056–1063 (Epub 2007 Feb 23)

    Article  PubMed  Google Scholar 

  16. DeMeester TR, Wernly JA, Bryant GH, Little AG, Skinner DB (1979) Clinical and in vitro analysis of determinants of gastroesophageal competence. A study of the principles of antireflux surgery. Am J Surg 137(1):39–46

    Article  CAS  PubMed  Google Scholar 

  17. Franzén T, Tibbling L (2014) Is the severity of gastroesophageal reflux dependent on hiatus hernia size? World J Gastroenterol 20(6):1582–1584. https://doi.org/10.3748/wjg.v20.i6.1582

    Article  PubMed  PubMed Central  Google Scholar 

  18. Kahrilas PJ, Shi G, Manka M, Joehl RJ (2000) Increased frequency of transient lower esophageal sphincter relaxation induced by gastric distention in reflux patients with hiatal hernia. Gastroenterology 118(4):688–695

    Article  CAS  PubMed  Google Scholar 

  19. Menezes MA, Herbella FA, Patti MG (2016) Laparoscopic antireflux surgery in patients with connective tissue diseases. J Laparoendosc Adv Surg Tech A 26(4):296–298

    Article  PubMed  Google Scholar 

  20. Su A, Gandhy R, Barlow C, Triadafilopoulos G (2017) Clinical and manometric characteristics of patients with Parkinson’s disease and esophageal symptoms. Dis Esophagus 30(4):1–6

    Article  CAS  PubMed  Google Scholar 

  21. Diener U, Patti MG, Molena D, Fisichella PM, Way LW (2001) Esophageal dysmotility and gastroesophageal reflux disease. J Gastrointest Surg 5(3):260–265

    Article  CAS  PubMed  Google Scholar 

  22. Herbella FA, Tedesco P, Nipomnick I, Fisichella PM, Patti MG (2007) Effect of partial and total laparoscopic fundoplication on esophageal body motility. Surg Endosc 21(2):285–288

    Article  CAS  PubMed  Google Scholar 

  23. Herbella FA, Sweet MP, Tedesco P, Nipomnick I, Patti MG (2007) Gastroesophageal reflux disease and obesity. Pathophysiology and implications for treatment. J Gastrointest Surg 11(3):286–290

    Article  PubMed  Google Scholar 

  24. Gourcerol G, Benanni Y, Boueyre E, Leroi AM, Ducrotte P (2013) Influence of gastric emptying on gastro-esophageal reflux: a combined pH-impedance study. Neurogastroenterol Motil 25(10):800. https://doi.org/10.1111/nmo.12181

    Article  PubMed  CAS  Google Scholar 

  25. Pregun I, Bakucz T, Banai J, Molnár L, Pavlik G, Altorjay I, Orosz P, Csernay L, Tulassay Z, Herszényi L (2009) Gastroesophageal reflux disease: work-related disease? Dig Dis 27(1):38–44. https://doi.org/10.1159/000210102 (Epub 2009 May 8)

    Article  PubMed  Google Scholar 

  26. Stylopoulos N, Rattner DW (2005) The history of hiatal hernia surgery: from Bowditch to laparoscopy. Ann Surg 241(1):185–193

    PubMed  PubMed Central  Google Scholar 

  27. Allison PR (1973) Hiatus hernia: (a 20-year retrospective survey). Ann Surg 178(3):273–276

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. Herbella FA (2017) Secrets for successful laparoscopic antireflux surgery. Ann Laparosc Endosc Surg 2:46

    Article  Google Scholar 

  29. Watson DI, Jamieson GG, Devitt PG, Matthew G, Britten-Jones RE, Game PA, Williams RS (1995) Changing strategies in the performance of laparoscopic Nissen fundoplication as a result of experience with 230 operations. Surg Endosc 9(9):961–966

    Article  CAS  PubMed  Google Scholar 

  30. Herbella FA, Patti MG, Del Grande JC (2011) Hiatal mesh repair—current status. Surg Laparosc Endosc Percutan Tech 21(2):61–66

    Article  PubMed  Google Scholar 

  31. Richter J, Kumar A, Lipka S, Miladinovic B, Velanovich V (2018) Efficacy of laparoscopic Nissen fundoplication vs transoral incisionless fundoplication or proton pump inhibitors in patients with gastroesophageal reflux disease: a systematic review and network meta-analysis. Gastroenterology. https://doi.org/10.1053/j.gastro.2017.12.021 (Epub ahead of print)

    Article  PubMed  Google Scholar 

  32. Herbella FA, Oliveira DR, Del Grande JC (2004) Eponyms in esophageal surgery. Dis Esophagus 17(1):1–9

    Article  CAS  PubMed  Google Scholar 

  33. Nissen R (1956) Gastropexy as the lone procedure in the surgical repair of hiatus hernia. Am J Surg 92(3):389–392

    Article  CAS  PubMed  Google Scholar 

  34. Herbella FA, Del Grande J (2001) Human cadavers as an experimental model for esophageal surgery. Dis Esophagus 14(3–4):218–222

    Article  CAS  PubMed  Google Scholar 

  35. Aye RW, Rehse D, Blitz M, Kraemer SJ, Hill LD (2011) The Hill antireflux repair at 5 institutions over 25 years. Am J Surg 201(5):599–604

    Article  PubMed  Google Scholar 

  36. Varshney S, Kelly JJ, Branagan G, Somers SS, Kelly JM (2002) Angelchik prosthesis revisited. World J Surg 26(1):129–133 (Epub 2001 Nov 26)

    Article  PubMed  Google Scholar 

  37. Asti E, Bonitta G, Lovece A, Lazzari V, Bonavina L (2016) Longitudinal comparison of quality of life in patients undergoing laparoscopic Toupet fundoplication versus magnetic sphincter augmentation: observational cohort study with propensity score analysis. Medicine (Baltimore) 95(30):e4366. https://doi.org/10.1097/MD.0000000000004366

    Article  Google Scholar 

  38. Salvador R, Costantini M, Capovilla G, Polese L, Merigliano S (2017) Esophageal penetration of the magnetic sphincter augmentation device: history repeats itself. J Laparoendosc Adv Surg Tech A 27(8):834–838. https://doi.org/10.1089/lap.2017.0182 (Epub 2017 Jun 6)

    Article  PubMed  Google Scholar 

  39. Bonavina L, Attwood S (2016) Laparoscopic alternatives to fundoplication for gastroesophageal reflux: the role of magnetic augmentation and electrical stimulation of the lower esophageal sphincter. Dis Esophagus 29(8):996–1001. https://doi.org/10.1111/dote.12425 (Epub 2015 Dec 17)

    Article  PubMed  CAS  Google Scholar 

  40. Weijenborg PW, Savarino E, Kessing BF, Roman S, Costantini M, Oors JM, Smout AJ, Bredenoord AJ (2015) Normal values of esophageal motility after antireflux surgery; a study using high-resolution manometry. Neurogastroenterol Motil 27(7):929–935. https://doi.org/10.1111/nmo.12554

    Article  PubMed  CAS  Google Scholar 

  41. Xu JY, Xie XP, Song GQ, Hou XH (2007) Healing of severe reflux esophagitis with PPI does not improve esophageal dysmotility. Dis Esophagus 20(4):346–352

    Article  PubMed  Google Scholar 

  42. Gerritsen A, Furnée EJ, Gooszen HG, Wondergem M, Hazebroek EJ (2013) Evaluation of gastrectomy in patients with delayed gastric emptying after antireflux surgery or large hiatal hernia repair. World J Surg 37(5):1065–1071. https://doi.org/10.1007/s00268-013-1953-5

    Article  PubMed  Google Scholar 

  43. Williams VA, Watson TJ, Gellersen O, Feuerlein S, Molena D, Sillin LF, Jones C, Peters JH (2007) Gastrectomy as a remedial operation for failed fundoplication. J Gastrointest Surg 11(1):29–35

    Article  PubMed  Google Scholar 

  44. Treitl D, Nieber D, Ben-David K (2017) Operative treatments for reflux after bariatric surgery: current and emerging management options. J Gastrointest Surg 21(3):577–582. https://doi.org/10.1007/s11605-017-3361-x (Epub 2017 Jan 13)

    Article  PubMed  Google Scholar 

  45. Peters JH, DeMeester TR, Crookes P, Oberg S, de Vos Shoop M, Hagen JA, Bremner CG (1998) The treatment of gastroesophageal reflux disease with laparoscopic Nissen fundoplication: prospective evaluation of 100 patients with “typical” symptoms. Ann Surg 228(1):40–50

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  46. Gasper WJ, Sweet MP, Hoopes C, Leard LE, Kleinhenz ME, Hays SR, Golden JA, Patti MG (2008) Antireflux surgery for patients with end-stage lung disease before and after lung transplantation. Surg Endosc 22(2):495–500

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgements

We are indebted to Ms. Debora Gallegos for illustrating the manuscript.

Author information

Authors and Affiliations

  1. Department of Surgery, Federal University of São Paulo, São Paulo, Brazil

    Fernando A. M. Herbella

  2. Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina

    Francisco Schlottmann

  3. Department of Medicine and Surgery, University of North Carolina, Chapel Hill, NC, USA

    Francisco Schlottmann & Marco G. Patti

Authors
  1. Fernando A. M. Herbella
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Francisco Schlottmann
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Marco G. Patti
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Fernando A. M. Herbella.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Research involving human participants and/or animals

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

No informed consent is required.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Herbella, F.A.M., Schlottmann, F. & Patti, M.G. Pathophysiology of gastroesophageal reflux disease: how an antireflux procedure works (or does not work). Updates Surg 70, 343–347 (2018). https://doi.org/10.1007/s13304-018-0562-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s13304-018-0562-0

Keywords

Search

Navigation