Surgical Management of GERD: Recommendations for Patient Selection and Preoperative Work-Up

Abstract

While first-line therapy for uncomplicated gastroesophageal reflux disease (GERD) continues to be medical management with proton pump inhibitors (PPIs), anti-reflux surgery remains an important tool in the stepwise management of the disease. In general, surgery is justified in patients with GERD symptoms that have been present for an extended period of time (typically greater than 1 year), who have objectively documented reflux, and who have failed medical therapy, either through an inability to tolerate medications, or by suffering from persistent symptoms despite adequate medical therapy. Because surgical approaches vary depending on esophageal function and anatomy, patients must be carefully evaluated prior to operative intervention. Given the complex physiology of GERD and its multitude of potential effects on the esophagus, there is no single test that can provide all the essential information needed to plan a safe and appropriate operation. Thus, a thorough, multimodal preoperative evaluation is necessary. This should include a detailed history and physical, as well as objective, evaluation of the degree and severity of reflux through upper endoscopy and/or pH monitoring. Additionally, it is vital to document esophageal anatomy and function with upper GI series and esophageal manometry prior to embarking on surgery. On completion of this evaluation, the surgeon should be able to discern whether or not the patient’s symptoms are compatible with and correlate to the presence of objectively documented pathological reflux, and whether there is any indication of abnormal anatomy or function that would require alterations of surgical approach. Armed with this information, patients can be selected and managed appropriately, allowing us to optimize surgical outcomes in anti-reflux procedures.