Surgical treatment of gastroesophageal reflux in adults

INTRODUCTION — Gastroesophageal reflux disease (GERD) is defined according to the Montreal consensus as "a condition which develops when the reflux of stomach contents causes troublesome symptoms and/or complications" [1]. It is manifested by a spectrum of nonspecific symptoms, including heartburn, regurgitation, dysphagia, laryngitis, dental problems, adult-onset asthma, and/or aspiration pneumonia. The prevalence of GERD is high and increasing globally [2].

Lifestyle modification and medications are the first-line treatment for GERD. Surgical or endoscopic treatment is generally reserved for patients who have persistent symptoms or develop complications despite optimal medical therapy [3]. Additionally, patients who are unable to tolerate, noncompliant with, or unwilling to take lifelong medications are also candidates.

Surgical and endoscopic management of GERD focuses on restoring a physiologic equivalent to the normal lower esophageal sphincter (LES). Manometric studies correlate GERD with a lower mean LES pressure, shorter mean intra-abdominal LES length, and shorter overall sphincter length. Each of these problems can be corrected by specific procedures. (See "Pathophysiology of reflux esophagitis", section on 'Gastroesophageal junction incompetence'.)

The surgical and endoscopic management of adult patients with GERD is reviewed in this topic. The pathophysiology, diagnosis, medical management, and complications of GERD are discussed elsewhere:

●(See "Clinical manifestations and diagnosis of gastroesophageal reflux in adults".)

●(See "Medical management of gastroesophageal reflux disease in adults".)

●(See "Approach to refractory gastroesophageal reflux disease in adults".)

●(See "Non-acid reflux: Clinical manifestations, diagnosis, and management".)

●(See "Complications of gastroesophageal reflux in adults".)

●(See "Gastroesophageal reflux and asthma".)

●(See "Radiofrequency treatment for gastroesophageal reflux disease".)

Management of GERD in neonates, infants, or pediatric patients is discussed separately:

●(See "Gastroesophageal reflux in premature infants".)

●(See "Gastroesophageal reflux in infants".)

●(See "Management of gastroesophageal reflux disease in children and adolescents".)

INDICATIONS — Antireflux procedures are most often performed to control gastrointestinal symptoms (eg, heartburn and regurgitation). It may also be performed for nongastrointestinal symptoms (eg, chronic cough, laryngeal disease, and asthma) when there is objective evidence to attribute such symptoms to reflux.

Gastrointestinal indications — The gastrointestinal symptoms are also referred to as typical symptoms. The following indications for antireflux procedures are often due to gastrointestinal symptoms.

Failed medical management — The most frequent indication for antireflux procedures is moderate-to-severe GERD incompletely controlled by optimal medical therapy, which consists of both drug therapy and lifestyle modifications [3]. Ten to 40 percent of patients continue to have substantial symptoms of "reflux" despite elimination of the heartburn component of their GERD and may wish to consider an antireflux procedure on this basis alone [4].

Patients with documented pathologic acid reflux who have complete or partial response to proton pump inhibitors (PPIs) are good candidates for one of the antireflux procedures if continued medical therapy is not desired. There is less agreement on whether patients with documented pathologic acid reflux who do not respond to maximal PPI therapy should be offered any antireflux procedures [5]. Furthermore, there are disagreements between specialists regarding the best antireflux procedure for such patients [4,6].

All would agree that continued symptoms despite adequate acid suppression with double-dose PPIs for over three months should serve as a warning that symptoms may not be due to excess esophageal acid exposure but to another diagnosis, such as reflux hypersensitivity, functional heartburn, a malignancy, or extragastrointestinal disease. Consequently, such patients should be properly assessed before antireflux surgery. Those patients who fail to meet objective criteria such as erosive esophagitis (Los Angeles Class C or D) or objectively elevated acid exposure should generally not be offered a surgical procedure in this setting. (See 'Preoperative evaluation' below and "Approach to refractory gastroesophageal reflux disease in adults", section on 'Diagnostic strategies and initial management'.)

Intolerance of or noncompliance with medical therapy — Such patients may opt for an antireflux procedure due to quality of life considerations despite successful medical management of GERD [7]. These include patients who respond to but experience complications with PPI therapy and young patients with a hypotensive sphincter who do not want to take medications for the rest of their lives [8]. However, patients should be counseled that medical therapy may need to be resumed if surgical therapy fails to alleviate their symptoms, which occurs 10 to 15 percent of the time. (See 'Operative failure' below.)

Complications of GERD — Complications of GERD, such as severe esophagitis (usually defined as Los Angeles class C or D) or benign peptic stricture, are diagnosed endoscopically and may be indications for antireflux surgery if patients fail medical therapy [7].

Surgical intervention for asymptomatic Barrett's esophagus is controversial. It remains to be established whether surgery is beneficial for preventing esophageal adenocarcinoma in Barrett's esophagus patients [9,10]. Patients with either Barrett-associated dysplasia or carcinoma should not undergo antireflux procedures before the lesion has been eradicated histologically by endoscopic therapy. (See "Barrett's esophagus: Surveillance and management", section on 'Management of dysplasia or intramucosal carcinoma'.)

Volume regurgitation — Patients with high-volume reflux may have typical gastrointestinal symptoms (eg, regurgitation) or atypical, nongastrointestinal symptoms (eg, cough or asthma due to aspiration, dental erosions). Such patients often fail PPI therapy because of persistent reflux of weakly acidic or alkaline gastric contents through an incompetent LES [8]. Nonacid reflux is an entity used to describe symptoms when patients are on PPI therapy (ie, PPI changes acid reflux to nonacid reflux). There are no patients who innately have nonacid reflux that do not respond to PPI therapy or are not detected by pH testing done off PPIs.

Surgical correction of the incompetent LES may alleviate volume regurgitation. Preoperative evaluation of high-volume or nonacidic reflux patients is more complicated and usually requires specialized pH testing before surgery. (See "Non-acid reflux: Clinical manifestations, diagnosis, and management", section on 'Diagnostic evaluation' and 'Esophageal pH testing' below.)

High-volume reflux should be distinguished from rumination, which is effortless regurgitation of food. Heartburn may be associated with rumination, causing even more confusion with GERD. Rumination often responds to behavioral therapy. (See "Rumination syndrome".)

Nongastrointestinal indications — About one-half of patients with GERD report upper respiratory symptoms, such as chronic cough, hoarseness, laryngitis, wheezing, asthma, chronic bronchitis, aspiration, or dental erosion [11-13]. However, the role of GERD in the pathogenesis of these atypical symptoms is often overestimated. In addition, idiopathic subglottic stenosis and even laryngeal cancer have also been implicated [14,15]. The nongastrointestinal symptoms are also referred to as atypical symptoms. (See "Clinical manifestations and diagnosis of gastroesophageal reflux in adults", section on 'Clinical manifestations'.)

For patients whose respiratory symptoms are accompanied by typical reflux symptoms and positive esophageal pH testing, relief of respiratory symptoms might also be achieved by antireflux procedures. The surgical outcome is also less favorable for patients who either only have respiratory symptoms or have abnormal esophageal motility [16]. In such patients, careful patient selection by objective esophageal testing and with multidisciplinary input (otolaryngology, pulmonary, and allergy specialists) can increase the likelihood of positive results. (See 'Preoperative evaluation' below.)

Chronic cough — After a thorough, objective medical workup to document proximal esophageal exposure, patients with chronic cough associated with GERD can have an excellent rate of resolution (77 to 81 percent) and quality-of-life outcomes with antireflux surgery [17,18].

Laryngeal disease — A direct causal relationship between pharyngeal acid exposure and laryngeal diseases remains controversial [19,20]. As such, antireflux surgery is not to be used as the first-line treatment for posterior laryngitis. However, it is reasonable to consider surgery for patients who have abnormal pharyngeal acid exposure on a double probe pH study when medical therapy has been maximized, is not tolerated, or is impractical [21]. (See "Laryngopharyngeal reflux in adults: Evaluation, diagnosis, and management".)

While some data have shown that laryngeal symptoms can be treated successfully by laparoscopic fundoplication, others have suggested that surgery was not consistently effective in patients who were unresponsive to aggressive PPI therapy [22]; thus, failure to respond to a PPI should serve as a warning that symptoms may not be relieved with surgery.

Documented response rates for airway diseases are less favorable than those for fundoplication performed for typical gastroesophageal symptoms. Approximately 70 percent of patients will experience symptom improvement, while approximately 33 percent of patients may remain on medication but often at a reduced dosage [23].

Asthma — Gastroesophageal reflux is common among patients with asthma [24]. Reciprocally, respiratory symptoms, including those associated with asthma, are increased among patients with GERD. However, consensus has not been reached on the role of antireflux surgery in patients with asthma that is thought to be related to GERD [25]. (See "Gastroesophageal reflux and asthma".)

PREOPERATIVE EVALUATION — Symptoms of GERD are highly prevalent. As such, symptoms alone, with or without response to proton pump inhibitor (PPI) therapy, are not specific enough to diagnose GERD. Before antireflux procedures, objective data from esophageal testing are required to anatomically and physiologically evaluate the presence and severity of GERD and determine the indication and best operative approach for each patient [26].

A multisociety consensus panel recommended that upper endoscopy, pH testing (except for those with pathognomonic findings on endoscopy), and esophageal manometry be performed for all patients with gastrointestinal symptoms before antireflux procedures [27]. Additional pH testing and other studies may be required for those with extragastrointestinal symptoms (table 1):

Upper endoscopy — Esophageal and gastric endoscopy should be performed to assess the esophageal and gastric mucosa for signs of malignancy prior to proceeding with any antireflux procedure. Patients with endoscopic findings of severe (Los Angeles grade C or D) esophagitis, biopsy-proven Barrett's esophagus ≥1 cm, or a benign peptic stricture may forego pH testing as these criteria establish the diagnosis of pathologic GERD [28]. (See "Clinical manifestations and diagnosis of gastroesophageal reflux in adults", section on 'Upper gastrointestinal endoscopy'.)

Esophageal pH testing — Patients with typical (gastrointestinal) symptoms of GERD should undergo traditional pH testing. Patients with atypical (extragastrointestinal) symptoms may require additional pH testing, such as one with dual pH probe or impedance in order to document proximal and/or nonacidic reflux.

Traditional pH testing — Ambulatory pH testing is the gold standard for diagnosing pathologic GERD. Prior to antireflux procedures, all patients with nonerosive GERD, including those with Los Angeles grade A or B (mild) esophagitis and those with short-segment (<1 cm) Barrett's esophagus, should undergo pH testing to document abnormal distal esophageal acid exposure. An abnormal pH test in a PPI-dependent patient with typical symptoms predicts successful outcomes with antireflux surgery [29]. In one study, the result of pH testing led to a change of treatment in 41 percent of patients [30].

Traditional pH testing can be done via a transnasal catheter for 24 hours or a wireless pH system for 48 or 96 hours after the patient has been off acid suppression for seven days. Esophageal acid exposure is considered pathological if acid exposure time (AET) is >6 percent [28]. (See "Clinical manifestations and diagnosis of gastroesophageal reflux in adults", section on 'Ambulatory esophageal pH monitoring'.)

MII (impedance) testing — Multichannel intraluminal impedance (MII) is a catheter-based method to detect intraluminal bolus movement within the esophagus. MII is performed in combination with manometry or pH testing. Combined MII and pH (MII-pH) testing can detect both acid and nonacid gastroesophageal reflux. It should be recognized that this testing is somewhat controversial, and interpretation is operator dependent. In observational studies, the result of impedance testing has led to a change of treatment in 20 percent of patients [31,32].

MII is indicated to document weakly acidic or nonacidic reflux in patients who are refractory to PPI, have high-volume regurgitation, or have nongastrointestinal symptoms. This test can also help exclude rumination (effortless regurgitation), which may be confused with volume reflux, or supragastric belching, which may induce reflux. (See "Esophageal multichannel intraluminal impedance testing".)

Dual pH probe — A dual pH probe test is usually performed in patients with suspected laryngopharyngeal reflux to document proximal reflux events [33]. Pharyngeal pH can also be monitored using the Restech probe, which is inserted nasally and positioned below the uvula under direct visual guidance [34]. The probe records the pH values of liquid and aerosolized refluxate in the oropharynx in real time for 24 hours. In a small retrospective study, pharyngeal pH monitoring using the Restech probe better predicted a successful outcome for extraesophageal symptoms after antireflux surgery than proximal esophageal probes [35]. (See "Laryngopharyngeal reflux in adults: Evaluation, diagnosis, and management", section on 'LPR testing'.)

Symptom association — A correlation between a patient's symptoms and reflux events can be calculated by computer software, which associates a symptom with a reflux event if the symptom occurs within two minutes of the reflux event. Symptom association is usually presented as either the symptom index (SI) or symptomatic association probability (SAP). An SI >50 percent or an SAP >95 percent is considered positive.

Symptom association scores are most useful in determining if a particular symptom (eg, cough) is associated with acid reflux. In clinical practice, SI, and especially SAP, are primarily used in patients who have atypical but no typical symptoms. For those with typical symptoms and a positive acid exposure time, SI or SAP is hardly relevant.

Decisions to proceed with antireflux procedures, however, should not be made on the basis of a positive SI or SAP alone. The calculation of SI and SAP is performed by the computer software (of standard and MII pH testing) without manual reading of the tracings and is highly dependent on the number of symptoms provided by the patient during the testing period. Additionally, SI and SAP have only been validated for acid reflux, not nonacid reflux (as detectable by MII) [36].

Esophageal manometry — Esophageal manometry is the most reliable way to assess lower esophageal sphincter (LES) competence and esophageal peristalsis. Manometric findings may change the management or the surgical approach (eg, partial instead of complete fundoplication for those with weak peristalsis) in 17 percent of patient [27]. Manometry occasionally provides alternative diagnoses requiring a very different treatment approach, such as scleroderma or achalasia. Achalasia may be confused with PPI-resistant GERD and is a contraindication for antireflux surgery. (See "Overview of the treatment of achalasia".)

Additionally, manometry is also used to determine the precise location of the gastroesophageal junction for accurate pH catheter placement. (See "Overview of gastrointestinal motility testing", section on 'Esophageal manometry'.)

CHOICE OF PROCEDURE — There is no one best procedure for all patients with GERD. When the requisite surgical and endoscopic expertise is available, patients should ideally be offered a spectrum of rather than a single antireflux procedure. As such, patients can choose the procedure that affords the right combination of efficacy/durability and potential adverse effects/perturbation to gastrointestinal physiology to them. The shared decision-making process also sets the correct expectation for treatment outcomes.

Contemporary antireflux procedures — Currently available antireflux procedures include:

●Transoral incisionless fundoplication (TIF) with or without hiatal hernia repair

●Magnetic sphincter augmentation (MSA)

●Laparoscopic Hill gastropexy

●Laparoscopic partial fundoplication

●Laparoscopic Nissen (complete) fundoplication

These procedures vary by efficacy and durability on one hand and adverse effect profiles on the other. At one end of the spectrum, laparoscopic Nissen fundoplication is highly effective in relieving GERD symptoms and is the most durable amongst all the procedures; however, it is also associated with the greatest potential for adverse effects, such as dysphagia, difficulty in vomiting, and gas bloating. At the other end of the spectrum, endoscopic procedures such as Stretta and TIF are least likely to be associated with adverse effects. However, their efficacy and durability are not as good as those of a complete fundoplication. Partial fundoplications, Hill procedure, and MSA generally fall in the middle of the spectrum balancing both efficacy/durability and adverse effect profile .

GERD is a spectrum of disease that includes normal, nonerosive reflux disease (NERD), erosive reflux disease (ERD), and Barrett's esophagus by endoscopic standards. Normal and NERD patients can be treated with TIF, while NERD and early or healing ERD can be treated with MSA. Patients with severe or nonhealing ERD or Barrett's esophagus often have a significantly higher prevalence of hiatal hernia, lower LES pressures, and more esophageal acid exposure. They are best treated with partial or complete (Nissen) fundoplication, respectively.

In addition to patient preference, anatomic and patient/surgeon factors such as obesity, esophageal motility, complicated GERD, prior operations, and available local expertise also influence the choice of operation (algorithm 1):

Patients who prefer endoscopic therapy — Endoscopic antireflux procedures, such as Stretta or TIF, are appropriate for patients who wish to avoid both life-long medications for GERD [37]. Both Stretta and TIF have been found to be superior to continued medical therapy in randomized trials. (See 'Endoscopic versus medical therapy' below.)

However, the efficacy and availability of Stretta has been called into question. The 2022 American College of Gastroenterology guidelines stated that "Since data on the efficacy of radiofrequency energy (Stretta) as an antireflux procedure is inconsistent and highly variable, we cannot recommend its use as an alternative to medical or surgical antireflux therapies" [3]. Stretta is discussed in detail elsewhere. (See "Radiofrequency treatment for gastroesophageal reflux disease".)

While Stretta is a purely endoscopic procedure, TIF is best described as endoscopic surgery because it is typically performed under general anesthesia, and many surgeons are performing TIF with a concomitant laparoscopic hiatal hernia repair (termed c-TIF) [38]. The endoscopic version of TIF is contraindicated in the presence of any hiatal hernia or a GERD-related complication (LA C or D erosive esophagitis, Barrett’s esophagus, or peptic stricture) [3]. (See 'Transoral incisionless fundoplication' below.)

Patients with obesity — For patients with severe obesity (body mass index ≥35 kg/m²) who desire bariatric surgery, Roux-en-Y gastric bypass (RYGB) is the bariatric procedure of choice; sleeve gastrectomy should not be performed as it maybe refluxogenic. (See "Laparoscopic Roux-en-Y gastric bypass", section on 'Gastroesophageal reflux disease' and "Laparoscopic sleeve gastrectomy", section on 'GERD'.)

Although RYGB is superior to laparoscopic fundoplication in symptom control in an comparative observation study of 100 patients [39], RYGB is also associated with higher risk of both complications and recurrent GERD [39,40]. A laparoscopic fundoplication is a reasonable alternative to RYGB for patients who desire surgical treatment of GERD but not bariatric surgery. Such patients should be followed in a medical weight loss program.

MSA can be performed for GERD after bariatric surgery [41,42]. This is most common after sleeve gastrectomy, where fundoplication is technically difficult due to anatomical reasons. MSA has also been performed after RYGB [43].

Patients with esophageal dysmotility — If achalasia is identified, an alternative treatment pathway should be followed, and antireflux surgery alone is contraindicated.

For patients with manometric finding of mild ineffective esophageal motility, a loose Nissen, MSA, or TIF can be tolerated in addition to a partial fundoplication or Hill procedure [44,45]. (See "High resolution manometry", section on 'Ineffective esophageal motility (IEM)'.)

For patients with severely decreased esophageal motility, a laparoscopic partial fundoplication (eg, Toupet) or Hill procedure, rather than a complete (Nissen) fundoplication or MSA, should be performed. (See 'Partial versus complete fundoplication' below.)

Patients with complex paraesophageal hernia — Some surgeons prefer a partial fundoplication because in such patients, esophageal manometry data may not be accurate due to the anatomic difficulty with catheter placement. However, both types of fundoplications are acceptable following repair of a complex paraesophageal hernia, depending on clinical scenario and surgeon preference. This is discussed in detail elsewhere. (See "Surgical management of paraesophageal hernia", section on 'Fundoplication'.)

Patients with complicated GERD — Fundoplication remains the standard treatment for patients with GERD complicated by hiatal hernia >2 cm, severe (Los Angeles class C or D) erosive esophagitis, peptic stricture, and/or Barrett's esophagus [46]. Newer procedures such as c-TIF or LINX have been attempted in patients with hiatal hernias >2 cm, but long-term results are not yet available.

Patients eligible for multiple procedures — For patients who desire surgical treatment, have normal esophageal length and motility, and have no GERD-related complications listed above (ie, most patients with early, uncomplicated disease), surgical options include fundoplications, MSA, and TIF [27].

●TIF is performed endoscopically for patients who do not have a large hiatal hernia but requires general anesthesia. Any hiatal hernia >2 cm requires concomitant laparoscopic repair (ie, c-TIF). The current version of TIF has not been compared with another antireflux surgical procedure in a randomized trial, although TIF is generally considered to have fewer side effects. (See 'Transoral incisionless fundoplication' below.)

●Fundoplications and MSA show similar efficacy in symptom control and risk of adverse events at least in short follow-up, whereas there is much more long-term data on fundoplications than MSA. (See 'Fundoplication versus MSA' below.)

●Studies comparing partial fundoplications with the complete (Nissen) fundoplication have consistently reported fewer adverse events (eg, gas bloating, dysphagia). As such, in 2023 a multisociety guidelines endorsed partial over complete fundoplication when both are feasible [27]. The 2022 United European Gastroenterology (UEG) and European Association for Endoscopic Surgery (EAES) guidelines endorsed the same [47]. The 2021 Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guidelines suggested choosing between a complete or partial fundoplication based on the patient's values and preferences. Those who value resolution of reflux symptoms over the risk of dysphagia should undergo a complete rather than partial fundoplication and vice versa [7]. (See 'Partial versus complete fundoplication' below.)

●The comparison of surgical options is a complex topic since there is heterogeneity of techniques and technical choices that may impact outcome. As such, the best choice for an individual patient may be the procedure in which the surgeon is most skilled [8]. In Europe, the two preferred procedures are laparoscopic Nissen fundoplication and the posterior partial (Toupet) fundoplication [48]. In North America, laparoscopic Nissen fundoplication is most commonly performed [49]. (See 'Comparison between surgical options' below.)

OPERATIVE TECHNIQUES — A variety of antireflux procedures have been described for the treatment of GERD.

Fundoplication procedures — Important variables of a fundoplication procedure include the completeness of the wrap (complete versus partial), combination with other procedures (eg, vagotomy or gastroplasty), and surgical approaches [50].

Complete fundoplications — The original fundoplication as described by Rudolph Nissen in 1956 involved passage of the gastric fundus behind the esophagus to encircle the distal 6 cm of the esophagus [51]. Since that time, many variations and modifications have been described, and the same-named procedure may be performed differently by different surgeons.

Most contemporary surgeons choose to perform a loose ("floppy") Nissen fundic wrap that is about 2 to 3 cm in length, followed by a posterior crural repair (figure 1A-B) [52,53]. Important technical points of a successful laparoscopic Nissen fundoplication include [8]:

●Extensive mediastinal dissection should be performed, especially when a hiatal hernia is present, to reduce >2 cm of esophagus to below the diaphragm without tension. Reduction of hiatal hernia may also contribute to the efficacy of antireflux surgery [54]. If the intra-abdominal esophagus is <2 cm despite the surgeon's best efforts at esophageal mobilization, a Collis gastroplasty should be performed. (See 'Collis gastroplasty' below.)

●The short gastric vessels are typically transected to ensure a tension-free ("floppy") fundoplication. The Rosetti technique does not divide the short gastric vessels. (See 'Rosetti-Nissen fundoplication' below.)

●The lower esophageal sphincter (LES) and fundus normally undergo vagally mediated relaxation with swallowing. An incorrectly performed fundoplication may prevent appropriate relaxation of the LES with swallowing. It is therefore important that the fundus is the only part of the stomach used for reinforcing the LES; the wrap is placed around the esophagus, not the upper stomach, and the vagal nerves must not be injured during dissection.

●A posterior crural repair is performed by approximating the right and left pillar of the right crus with sutures. Mesh placement is optional and controversial. A trial of 159 patients reported that, compared with suture repair alone, mesh reinforcement did not decrease the incidence of recurrent hiatal hernia rate but increased solid dysphagia rate at three years [55]. (See "Surgical management of paraesophageal hernia", section on 'Closure of hiatal defect'.)

●A 50 to 60 French bougie may be placed in the stomach (along the lesser curvature) to calibrate the tightness of the fundoplication [56]. However, the necessity of a bougie has been questioned [57].

●The length of the overall sphincter can be affected by altering the length of a fundoplication; however, too long a fundoplication may lead to obstructive symptoms. Most surgeons would perform a wrap of 2 to 3 cm [58].

Rosetti-Nissen fundoplication — A common modification to a complete fundoplication is a 360-degree fundic wrap without division of the short gastric vessels (Rosetti-Nissen). A 2011 meta-analysis of five randomized trials concluded that clinical outcome following laparoscopic Nissen fundoplication appears to be similar regardless of whether the short gastric vessels are divided [59].

However, most surgeons in the United States prefer to divide the short gastric vessels to allow for greater freedom of mobilization and reduced concern about torque on the fundoplication (which is hard to measure) and also facilitate lower esophageal relaxation [52].

The 2021 SAGES guidelines recommended choosing between the standard Nissen fundoplication and the Rosetti modification based on the patient's values and preferences. Those who value resolution of reflux symptoms over the risk of potential gas bloat symptoms should choose division of the short gastric vessel as opposed to nondivision, and vice versa [7].

Partial fundoplications — A partial 270 degree posterior wrap (Toupet) is used for patients with severe associated motor abnormalities (figure 1A-B) [60]. A partial 180 degree anterior wrap (Dor) has also been described [61].

Based on currently available data, the choice of anterior versus posterior or partial versus complete (Nissen) fundoplication should be left to the individual surgeon. Many trials and meta-analyses have shown that a well-constructed partial fundoplication can result in similar reflux control to that of a well-performed complete fundoplication. (See 'Partial versus complete fundoplication' below and 'Anterior versus posterior fundoplication' below.)

Collis gastroplasty — Patients with a shortened esophagus from chronic inflammation or altered anatomy present a unique challenge for fundoplication [62]. Although opinions vary regarding what constitutes adequate esophageal mobilization, it is generally accepted that increasing the intra-abdominal esophageal length can also be facilitated by reduction of hiatal hernia, approximation of the diaphragmatic crura, or tethering of the distal esophagus below the diaphragm. The bulk of a fundoplication may also keep the gastroesophageal junction within the abdomen.

In 311 consecutive patients undergoing minimally invasive surgery for GERD and/or hiatal hernia, the distance between the endoscopically localized gastroesophageal junction and the apex of the diaphragmatic hiatus after maximal thoracic esophagus mobilization was <1.5 cm in 31.8 percent of the patients who had "true" shortened esophagus [63].

If the intra-abdominal esophagus is <2 cm despite the surgeon's best efforts at esophageal mobilization, a Collis gastroplasty (esophageal lengthening procedure) combined with a fundoplication should be performed. A (modified) Collis gastroplasty can be performed with a variety of either transthoracic or transabdominal techniques [64]. A survey of about 1000 patients reported that, at four years, those who underwent a laparoscopic Collis gastroplasty with fundoplication had similar symptom control, satisfaction, and quality of life compared with those who underwent fundoplication alone [65].

Surgical approaches — In contemporary surgical practice, fundoplication is performed laparoscopically or robotically in most patients. Laparoscopic or robotic fundoplication is endorsed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and is considered the current gold standard of antireflux procedures against which all other procedures are benchmarked [7].

Transabdominal fundoplication — Laparoscopic fundoplications can offer significant advantages over the open operation with similar efficacy and safety [66]. Studies with follow-up as long as 17 years have also associated laparoscopic fundoplication with excellent durability and fewer complications (eg, incisional hernia) compared with open surgery [67-69].

Although robotic antireflux surgery offers no specific advantages over other laparoscopic techniques and is more costly to perform [70], its use has increased from 5.4 to 26 percent from 2012 to 2018, according to data from the Michigan Surgical Quality Collaborative [71].

Transthoracic fundoplication — In contemporary surgical practice, transthoracic antireflux procedures are rarely used except in patients with concurrent pulmonary disease requiring evaluation, extensive prior abdominal surgery, severe obesity, or a shortened esophagus requiring extensive mobilization and/or a Collis gastroplasty [72,73]. The Belsey Mark IV operation involves a partial fundoplication performed by transthoracic approach, which allows full esophageal mobilization [74]. The Nissen fundoplication with or without a Collis gastroplasty can also be performed through the chest.

Hill gastropexy — The Hill procedure involves imbrication of the anterior and posterior collar sling muscular fibers at the level of the gastroesophageal junction around the esophagus with tethering of the complex to the median arcuate ligament and closure of the diaphragm. Intraoperative manometry is used to achieve a desired LES pressure [75,76]. This operation has also been performed laparoscopically and is advocated by those who support reconstruction of the angle of His and the importance of the "gastroesophageal valve" for preventing reflux [75]. It can also be used in a patient with a small stomach because of prior gastric resection [77].

In a randomized trial, laparoscopic Hill gastropexy and laparoscopic Nissen fundoplication yielded similar and both excellent outcomes at one-year follow-up [78]. In a single-center retrospective study with a median follow-up of 18.5 years, 85 percent of patients who underwent Hill gastropexy reported good to excellent symptomatic outcomes and quality of life [79].

In contemporary practice, the Hill gastropexy has been combined with Nissen fundoplication to improve clinical outcomes and reduce long-term recurrences [80,81].

Magnetic sphincter augmentation (MSA) — In 2012, the US Food and Drug Administration (FDA) approved the LINX Reflux Management System as a treatment for GERD. The device works by augmenting the LES with a ring made up of a series of rare earth magnets. The magnets have sufficient attraction to increase the LES closure pressure but permit food passage with swallowing. (See "Magnetic sphincter augmentation (MSA)".)

Eligible patients must have GERD confirmed by a pH study. In addition, the manufacturer of the LINX device also suggests that the patient have no large (>3 cm), severe (Los Angeles class C or D) esophagitis, Barrett's esophagus, obesity (body mass index >35 kg/m²), esophageal dysmotility, or prior upper gastrointestinal tract surgery. Patients who have allergies to titanium, stainless steel, nickel, or iron should not receive a LINX prosthesis. Patients who have the MSA device can undergo magnetic resonance imaging in a system up to 1.5 Tesla (1.5 T).

MSA is implanted laparoscopic or robotically. The techniques are discussed in another topic. (See "Magnetic sphincter augmentation (MSA)", section on 'Implantation technique'.)

MSA implantations have consistently demonstrated reduced GERD symptoms and improved GERD-related quality of life scores, cessation of proton pump inhibitor use, and substantial normalization of objective GERD measurements in the majority of patients [82]. (See "Magnetic sphincter augmentation (MSA)", section on 'Clinical improvements'.)

Dysphagia can occur early or late (>30 days) after MSA implantation by different mechanisms and is treated differently. Device erosion occurs in 0.3 percent of patients at four years; between 3 and 7 percent of the MSA devices are explanted by combined endoscopic and laparoscopic means. (See "Magnetic sphincter augmentation (MSA)", section on 'Postoperative complications'.)

Transoral incisionless fundoplication — Transoral incisionless fundoplication (TIF) is an endoscopic procedure performed under general anesthesia to create a full-thickness serosa-to-serosa plication that is 3 to 5 cm in length and 200 to 300 degrees in circumference (partial fundoplication).

TIF can be performed in patients with typical GERD symptoms, no or only low-grade erosive esophagitis (grades A and B), and no or only small hiatal hernia (≤2 cm). TIF is contraindicated in patients with high-grade erosive esophagitis, Barrett's esophagus, atypical and extragastrointestinal symptoms of GERD, scleroderma, or other esophageal pathology or surgery [83].

The current TIF 2.0 uses the EsophyX device, which has been CE marked for the European market (2006) and FDA approved for the United States market (2009) for TIF procedures. The success of the TIF technique is highly contingent on proper patient selection. Patients with a hiatal hernia of <2 cm or Hill grade I or II valves are the most likely candidates. However, because the majority of refractory GERD patients have a hiatal hernia of ≥2 cm, they do not match these strict requirements and are therefore unfit for TIF alone. The c-TIF (also known as HH-TIF [combined laparoscopic hiatal hernia repair with TIF 2.0]) is a new modified approach that combines laparoscopic hiatal hernia repair and TIF in the same session [38]. In 2017, the FDA issued an updated clearance to include patients with hiatal hernias >2 cm when a laparoscopic hiatal hernia repair reduces the hernia to ≤2 cm [84].

The efficacy of TIF 2.0 for typical GERD symptoms has been reported in two United States trials against medical therapy (TEMPO [85-87] and RESPECT [88]), and its durability up to 10 years has been addressed by two European trials [89,90]. The efficacy of TIF 2.0 for atypical GERD symptoms has also been reported [91].

TIF 2.0 has not been directly compared with any surgical antireflux procedures in randomized trials. (See 'Endoscopic versus surgical therapy' below.)

MORBIDITIES AND MORTALITY — Major acute complications or mortalities from a laparoscopic fundoplication are uncommon [92]. Long-term complications could be caused by a structural problem of the fundoplication (eg, malposition of the wrap) or functional abnormalities [93]. Some of these long-term problems require reoperative intervention. (See 'Revisional surgery' below.)

Acute complications and mortality — The reported 30-day surgical mortality rate of laparoscopic fundoplication is less than 0.1 to 0.2 percent [94].

Acute complications of laparoscopic fundoplications include gastric or esophageal injury, splenic injury or splenectomy, pneumothorax, bleeding, pneumonia, fever, wound infections, bloating, and dysphagia. In a study of 2655 patients, 4.1 percent had a complication within 30 days of surgery, including 1.1 percent infection, 0.9 percent bleeding, and 0.9 percent esophageal perforation [95].

Structural problems — Up to 30 percent of laparoscopic fundoplications could be affected by a structural problem with positioning or construction of the wrap [95], which could negatively impact the patient's quality of life [96].

●Wrap too loose – Excess laxity of the fundoplication can lead to herniation of the esophagogastric junction through the hiatus into the chest. This can occur with the wrap disrupted or the wrap intact (slipped wrap) [97]. Hiatal herniation is the most common reason for a "slipped fundoplication" or a wrapped stomach to be around the gastric cardia and can lead to recurrent reflux symptoms such as heartburn, regurgitation, or esophagitis.

●Wrap too tight – An excessively long or tight wrap can cause stenosis without herniation [98]. A stenotic fundoplication can lead to persistent dysphagia.

A suspected structural problem should be evaluated by barium upper esophagram and upper endoscopy [99]. Depending on the severity of the patient's symptoms, a structural problem can be managed medically (eg, proton pump inhibitor for recurrent GERD), endoscopically (eg, dilation of a tight but intact wrap), or surgically [100]. (See 'Revisional surgery' below.)

Small migration of the fundoplication in a cephalad direction may result from inadequate esophageal mobilization, an unrecognized shortened esophagus, or from progressive laxity of the hiatal opening. However, it is not clear whether these findings are associated with symptoms and thus can account for the dysphagia. An asymptomatic patient can be followed expectantly. Patients with symptoms of dysphagia or perceived reflux should undergo manometry, pH testing, and endoscopy in order to understand the impact, if any, of cephalad migration of the fundoplication.

At the time of the barium swallow, patients should be asked to swallow a 13 mm barium tablet. Patients with dysphagia in whom the 13 mm barium tablet passes slowly through the esophagus and who had normal motility preoperatively are candidates for dilation. Approximately 2 to 12 percent of patients required dilation after fundoplication [101-104].

There is no consensus on the optimal dilation technique (ie, bougie versus guidewire dilation). The author performs direct bougie dilation, with or without endoscopic guidance. In the author's experience, the procedure is well tolerated and produces good results. Tortuous pathways through the fundic wrap are best managed by guidewire dilation. Pneumatic dilation is very rarely needed. (See "Endoscopic interventions for nonmalignant esophageal strictures in adults".)

Patients who have a complete fundoplication may be candidates for revision to a partial fundoplication if dysphagia persists and effective barium tablet passage cannot be established despite dilation. (See 'Revisional surgery' below.)

Functional problems — Even in the absence of structural, mechanical, or anatomical problems, upper abdominal symptoms are common after fundoplications. Typical symptoms after fundoplication include dysphagia and gas bloating, which occurred in 11 and 40 percent of patients, respectively, in one trial [105]. Management of patient symptoms after fundoplication depends upon duration of the symptoms as well as the size and tightness of the wrap.

In a systematic review and meta-analysis of eight randomized trials, prevalence of postoperative dysphagia, gas bloating, inability to belch, dilatation for dysphagia, and reoperation were higher after Nissen fundoplication than Toupet fundoplication, but subgroup analyses showed that differences with respect to dysphagia disappeared over time [106]. In a retrospective study of 441 patients who underwent Nissen or a partial fundoplication, persistent postoperative dysphagia occurred in approximately one-quarter of patients at a median follow-up of three years but did not differ between the type of fundoplication [107]. (See 'Partial versus complete fundoplication' below.)

Dysphagia — In the immediate postoperative period, most patients will have some degree of dysphagia after fundoplication and require a period of modified dietary intake primarily consisting of liquids for 2 to 12 weeks. Dysphagia that persists for more than 12 weeks requires evaluation, which typically begins with a barium swallow to assess the anatomic placement of the fundoplication. (See 'Structural problems' above.)

The type of procedure performed is a determinant of postoperative dysphagia. One report found that dysphagia was more frequent with the laparoscopic Rosetti-Nissen procedure (11 percent) than with either the laparoscopic Nissen (2 percent) or Toupet (2 percent) procedure [108]. Although preoperative testing cannot reliably predict postoperative dysphagia, the most common predictor of postoperative dysphagia is the presence of preoperative dysphagia [109]. Thus, patients with preoperative dysphagia should be counseled appropriately before surgery. One must also consider the crural closure as a potential source of dysphagia in the postoperative setting [110].

Gas bloat syndrome — Symptoms of gas bloat syndrome (a sensation of intestinal gas with the inability to belch) can be elicited in a significant number of patients after fundoplication. The pathogenesis is not well understood, although it was seen more frequently in the past when longer and tighter fundoplications were created [111]. Symptoms may be due to aerophagia or vagal dysfunction, although this has not been well studied. It may also be in part due to dysfunction in gastric emptying, which may have been unrecognized preoperatively or occur secondarily to vagal damage [112]. The author performs a solid phase gastric emptying study to confirm the diagnosis of long-term gastric emptying dysfunction. (See "Gastroparesis: Etiology, clinical manifestations, and diagnosis", section on 'Scintigraphic gastric emptying'.)

In patients with only mild symptoms, we suggest empiric trials of chewable simethicone tablets or charcoal caplets. We also instruct patients not to drink with a straw or ingest carbonated beverages until symptoms resolve, although there is no evidence that these strategies are effective. Although there are no randomized trials, an empiric trial with metoclopramide (10 mg four times daily) may be helpful. Short courses of two to three months are typical, but some patients may require long-term treatment, placing them at risk for complications including irreversible tardive dyskinesia (especially in older patients). Domperidone is an alternative to consider and is available under an investigation new device (IND) program from compounding pharmacies in the United States. Erythromycin can be considered as an alternative; however, some patients experience significant gastric distress forcing discontinuation.

Symptoms tend to lessen over time in most patients. In patients with severe persistent symptoms despite the above treatment approaches, pyloroplasty, pyloric Botox injection, and pneumatic pyloric dilatation are options in select patients who have documented gastroparesis [113,114]. Some studies have described a reduced incidence of gas bloat with partial fundoplication [111]; conversion from a full to a partial fundoplication has been reported but is rarely required.

Recurrent reflux symptoms — Some patients describe a "sticking" sensation in their lower or mid chest that they mistakenly attribute to recurrent GERD. Such patients often resume antisecretory medications. However, it is unlikely that patients whose fundoplication is functionally intact have persistent GERD. Thus, we suggest that they be objectively studied prior to restarting antisecretory medications to identify those who require dilation or a revision.

A subset of patients have persistent symptoms without objective evidence of esophageal dysfunction radiographically or by esophageal pH studies [115,116]. The cause of persistent symptoms in such patients is unclear but may involve anatomic, functional, and psychological factors [117]. Care of such patients should be individualized. Historically, this would have been a setting where a Bernstein test could have been used, but this is rarely performed today. Esophageal pH impedance studies may add diagnostic information in the setting of apparent surgical failure and help direct next steps (eg, adding a proton pump inhibitor). Medical therapy aimed at treating esophageal spasm can provide relief in some patients. (See "Clinical manifestations and diagnosis of gastroesophageal reflux in adults".)

Operative failure — Antireflux surgery has a failure rate of 10 to 15 percent [48]. Operative failure is usually defined as persistent, recurrent, or new-onset symptoms. The main symptoms of operative failure are recurrent reflux symptoms and/or dysphagia. (See 'Dysphagia' above.)

Consensus has not been achieved on what constitutes treatment success or failure. As an example, while continued use of antisecretory medications may be considered treatment failure, many patients on acid suppression medications do not have documented pathologic reflux [116]. Furthermore, some patients who require antisecretory medications after surgery still report high quality of life compared with preoperative status.

In a Swedish population-based study of 2655 patients who underwent antireflux surgery, 470 patients (17.7 percent) were assumed to have developed recurrent reflux by long-term (six-month) antacid medication use (393 patients [83.6 percent]) or repeat antireflux surgery (77 patients [16.4 percent]) at a median follow-up of 5.6 years [95]. Risk factors for developing recurrent reflux included female sex (hazard ratio [HR] 1.57, 95% CI 1.29-1.90), older age (HR 1.41, 95% CI 1.10-1.81 for age ≥61 years compared with ≤45 years), and comorbidity (HR 1.36, 95% CI 1.13-1.65 for Charlson comorbidity index score ≥1 compared with 0). The recurrence rate is likely underestimated due to the fact that patients with recurrent reflux who did not take antacid medications consistently or underwent repeat surgery would have been missed.

Revisional surgery — Approximately 5 to 10 percent of patients will need revisional surgery after laparoscopic fundoplication [103,118]. The reoperation rate increases with time: in a national registry study of over 4000 contemporary antireflux operations (including hiatal hernia), the 1, 5, 10 and 15 year rates of repeat antireflux surgery were 3.1, 9.3, 11.7, and 12.8 percent, respectively [104]. In a series of 109 patients who underwent revisional surgery after a median time of 26 months, the indications for revisional surgery were dysphagia (48 percent), reflux (33 percent), paraesophageal herniation (15 percent), and atypical symptoms (4 percent) [118].

Recurrence of reflux symptoms after a fundoplication requires a thorough workup before reoperation as fundoplication usually fails because of either the wrong indication for surgery, flawed or insufficient preoperative workup, or technical mistakes in executing the operation [8]. In the author's experience, the most common technical reasons for failed antireflux surgery are disruption of the fundoplication and excessive cephalad migration in the face of unrecognized shortened esophagus. (See 'Structural problems' above.)

A reoperative fundoplication is the most commonly performed salvage procedure for failed fundoplication if additional medical and/or endoscopic therapy fails [119]. However, the success rate for revisional surgery is lower than primary surgery, and about 10 percent of patients will continue to complain of reflux or dysphagia after revisional surgery [120]. Medical therapy remains the only option at that point. Patients with obesity may consider Roux-en-Y gastric bypass, which is an extremely effective antireflux operation (see 'Patients with obesity' above). Rare patients undergo distal esophageal resection, but there are no outcomes data for this group.

LONG-TERM EFFICACY — Endoscopic and surgical antireflux procedures have been compared against medical therapy and each other in randomized and nonrandomized comparative studies [27]. The results summarized in this section and should inform the choice of procedures. (See 'Choice of procedure' above.)

Endoscopic versus medical therapy

●In a meta-analysis of five trials comparing Stretta against continued medical therapy, Stretta resulted in a higher quality of life and a trend toward better symptom control, less proton pump inhibitor (PPI) use, and greater patient satisfaction [27]. The complications of Stretta are mild (eg, dysphagia), although repeated treatment is often required. (See "Radiofrequency treatment for gastroesophageal reflux disease", section on 'Complications'.)

●In a meta-analysis of four trials comparing TIF 2.0 against continued medical therapy, TIF resulted in a higher quality of life, greater patient satisfaction, less PPI use, and fewer recurrences [27]. (See 'Transoral incisionless fundoplication' above.)

Surgical versus medical therapy — The comparison of operative management with medical management in controlled trials has identified mixed long-term results, with some studies finding comparable control of symptoms and others reporting better control by a fundoplication. As examples:

●A 2015 Cochrane review of four trials (including LOTUS [105,121] and REFLUX [122,123]) found that, in the short and medium term, laparoscopic fundoplication was associated with better GERD-specific quality of life and fewer heartburn or reflux symptoms but a higher risk of adverse events (eg, dysphagia) compared with medical therapy [124]. However, all of the trials were at high risk of bias; the overall quality of evidence was low or very low, and none of the trials reported long-term quality-of-life data.

●In a 2019 trial conducted in Veterans Affairs (VA) gastroenterology clinics, 366 patients with PPI-refractory heartburn who failed to respond to a two-week course of double-dose omeprazole underwent a systematic workup including endoscopy, esophageal biopsy, esophageal manometry, and multichannel intraluminal impedance-pH monitoring (on PPI therapy) [125]. After excluding those who did not have objective evidence for reflux-related heartburn, 78 patients (21 percent) were randomly assigned to laparoscopic Nissen fundoplication, active medical management (omeprazole plus baclofen with or without desipramine), or control medical management (omeprazole plus placebo). At one year, more patients who underwent surgery (67 percent) achieved a ≥50 percent decrease in GERD-health related quality of life score compared with those who received medical treatments (28 percent active medical management, 12 percent control). In a prespecified subgroup analysis, patients with esophageal visceral hypersensitivity (symptom association probability [SAP] of >95 percent alone) responded to surgery as well as those with acid reflux (acid reflux alone or with SAP of >95 percent).

●In a trial comparing magnetic sphincter augmentation (MSA) against twice-daily PPI therapy in 152 patients with moderate-to-severe regurgitation, 89 versus 10 percent were relieved of symptoms at six months, respectively [126].

The 2022 American College of Gastroenterology (ACG) practice guidelines stated that "We recommend antireflux surgery performed by an experienced surgeon as an option for long-term treatment of patients with objective evidence of GERD, especially those who have severe reflux esophagitis (Los Angeles grades C or D), large hiatal hernias, and/or persistent, troublesome GERD symptoms" [3]. The 2021 Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guidelines suggested "managing adult patients with confirmed chronic or chronic refractory gastroesophageal reflux with surgical fundoplication rather than continued medical treatment (conditional recommendation based on very low certainty in the evidence of effects)" [7]. (See "Approach to refractory gastroesophageal reflux disease in adults", section on 'Subsequent management'.)

Endoscopic versus surgical therapy

●Stretta has not been compared with any surgical antireflux procedure in a randomized trial. In a meta-analysis of eight nonrandomized comparative studies, Stretta was associated with fewer complications and lower cost than fundoplications [27]. However, over a longer period of follow-up, patients reported greater satisfaction and quality of life, fewer recurrences, and less PPI use with fundoplication.

●TIF has not been directly compared with fundoplication in any randomized trial either. In a network meta-analysis of TIF versus laparoscopic fundoplication versus PPI therapy, laparoscopic fundoplication was associated with greater sphincter augmentation than TIF. Quality-of-life improvement scores were actually higher with TIF, but the follow-up period was shorter [127].

Comparison between surgical options

Partial versus complete fundoplication — Multiple randomized trials have compared laparoscopic complete (Nissen) fundoplication with laparoscopic partial (posterior or anterior) fundoplication. In a meta-analysis of 20 trials, partial fundoplications achieved similar symptom control and durability as complete fundoplication while incurring fewer adverse effects (eg, dysphagia, gas bloating, hiatal hernia) [27].

In three trials that compared complete with partial fundoplication in patients with known esophageal dysmotility, partial fundoplication achieved similar reflux symptom control while incurring postoperative dysphagia in fewer patients [27].

Anterior versus posterior fundoplication — The laparoscopic anterior fundoplication (90- to 180-degree wrap) was proposed as an alternative to the laparoscopic posterior fundoplication (180- to 360-degree wrap) to reduce postfundoplication symptoms but was reported to have higher rates of recurrence of reflux [128-133].

●A meta-analysis of nine randomized trials totaling 840 patients associated posterior fundoplication with better heartburn control but anterior fundoplication with lower risk of postoperative dysphagia [134]. Similar patient satisfaction scores and reoperation rates were associated with both procedures.

Fundoplication versus MSA — MSA has not been compared with Nissen fundoplication in randomized trials. In several meta-analyses of up to nine observational studies, both procedures were safe and effective in symptom control with up to one year of follow-up [27,135,136]; one meta-analysis associated MSA with fewer gas bloat symptoms and increased ability to vomit and belch [136]. In a propensity score matched retrospective study, MSA and Toupet (partial) fundoplication had similar GERD control and side effect profiles [137]. (See "Magnetic sphincter augmentation (MSA)", section on 'MSA versus fundoplication'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Gastroesophageal reflux in adults".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Hiatal hernia (The Basics)")

●Beyond the Basics topics (see "Patient education: Gastroesophageal reflux disease in adults (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Indications for antireflux procedures – Antireflux procedures are most often performed to control gastrointestinal symptoms (eg, heartburn and regurgitation) that are refractory to medical therapy. It may also be performed for extragastrointestinal symptoms (eg, chronic cough, laryngeal disease, asthma) when there is objective evidence to attribute such symptoms to reflux. (See 'Indications' above.)

●Preoperative evaluation – All patients seeking an antireflux procedure for gastrointestinal symptoms should undergo upper endoscopy, pH testing (except those with pathognomonic findings of pathologic reflux on endoscopy), and esophageal manometry (table 1). Impedance or dual-probe pH testing may be required for extragastrointestinal symptoms. (See 'Preoperative evaluation' above.)

●Contemporary antireflux procedures – Currently available antireflux procedures include (see 'Contemporary antireflux procedures' above):

•Transoral incisionless fundoplication (TIF)

•Magnetic sphincter augmentation (MSA)

•Laparoscopic Hill gastropexy

•Laparoscopic partial fundoplication

•Laparoscopic Nissen (complete) fundoplication

●Choice of antireflux procedures – The choice of an antireflux procedure for gastroesophageal reflux disease (GERD) should take into consideration factors such as patient preference for surgical versus endoscopic treatment, obesity, esophageal dysmotility, complicated GERD, prior operations, and available local expertise (algorithm 1):

•For most patients seeking treatment for GERD, we suggest a surgical rather than an endoscopic procedure (Grade 2C). Surgical procedures are generally more effective and durable than endoscopic procedures. Endoscopic procedures are appropriate for those who wish to avoid both lifelong medications and surgery. (See 'Patients who prefer endoscopic therapy' above.)

•Patients who are willing to undergoing obesity (bariatric) surgery should undergo Roux-en-Y gastric bypass (RYGB) but not sleeve gastrectomy. Those who are not willing to undergo obesity surgery may undergo a fundoplication while followed by a medical weight loss program. (See 'Patients with obesity' above.).

•For patients with severely decreased esophageal motility, we suggest a partial fundoplication (Grade 2C). It has been associated with a lower risk of dysphagia compared with a complete fundoplication in this patient population. (See 'Patients with esophageal dysmotility' above.)

•Either a partial or complete fundoplication is appropriate following a complex paraesophageal hernia repair. The surgeon may choose based on the clinical scenario. (See "Surgical management of paraesophageal hernia", section on 'Fundoplication'.)

•For patients with one or more complications related to GERD (eg, severe erosive esophagitis, Barrett's esophagus, peptic stricture) or a hiatal hernia >2 cm, we suggest one of the fundoplication procedures (Grade 2C). (See 'Patients with complicated GERD' above.)

•Patients who are eligible for multiple procedures may choose one based on their values and preferences. Those who value control of reflux symptoms more than side effects (gas bloating, dysphagia) should choose complete over partial fundoplication and vice versa. MSA has comparable short-term results to fundoplication but lack long-term data on durability. TIF has not been compared with any other antireflux procedures in a randomized trial. Local expertise and surgeon preference also matter. (See 'Patients eligible for multiple procedures' above.)

●Morbidities and mortality – Although the mortality and early postoperative complication rates are low, patients may develop long-term complications after antireflux surgery. (See 'Morbidities and mortality' above.)

•Up to 30 percent of laparoscopic fundoplications could be affected by a structural problem such as a disrupted wrap, a slipped (herniated) wrap, or stenotic wrap. Patients should be evaluated with a barium esophagram and upper endoscopy. Treatment ranges from medical, endoscopic, to surgical, depending on the severity of symptoms. (See 'Structural problems' above.)

•Postoperative symptoms of dysphagia and gas bloating occur in 11 and 40 percent of patients, respectively, after fundoplication. Dysphagia that persists for more than 12 weeks requires evaluation with barium esophagram. Patients in whom a 13 mm barium tablet passes slowly through the esophagus and who had normal motility preoperatively are candidates for dilation. Gas bloating is managed medically; most patients improve over time. (See 'Functional problems' above.)

•Antireflux surgery has a failure rate of 10 to 15 percent. The main symptoms of operative failure are recurrent reflux symptoms and/or dysphagia. (See 'Operative failure' above.)

•Approximately 5 to 10 percent of patients will need revisional surgery after laparoscopic fundoplication. (See 'Revisional surgery' above.)