Learning > The art of GORD treatment

Anti-reflux surgery: who needs it and who decides? Lars Lundell MD, PhD Department of Surgery, Sahlgrenska University Hospital Gothenburg, Sweden

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The introduction of laparoscopic anti-reflux surgery has led to renewed interest in the operative treatment of gastro-esophageal reflux disease (GORD). Three groups of patients can be identified who are particularly suited to laparoscopic anti-reflux surgery. Failure to respond to medical treatment has been historically the main determinant for those referred for anti-reflux surgery. With the availability of modern anti secretory drugs most patients with chronic GORD can control their symptoms adequately by these means. Even effective medical therapy, however, is not without problems. In many patients rapid and consistent relapse of symptoms and oesophagitis occurs on cessation of therapy. Some of these patients do not want to be reliant on medication if alternatives exist. A second readily identifiable group of patients are those who are often described as "volume refluxes." They are bothered by persistent fluid regurgitation despite adequate control of their heartburn with proton pump inhibitor drugs. Thirdly there are those individuals who develop esophageal strictures and those with Barrett's oesophagus and concomitant reflux symptoms and also those with respiratory complications associated with presumed aspiration of gastric juice into the pharynx and into the respiratory tree. The low morbidity associated with laparoscopic anti-reflux surgery achieved in the best modern series means that the pendulum may swing back to surgery and therefore it is even more important that the right operation (fundoplication) is done for the right patient. Failure to create an adequate crural repair behind the wrap is associated with a risk of early postoperative para-esophageal herniation and proximal wrap migration. The question of tailored anti-reflux surgery based on the preoperative motor function of the body of the oesophagus is widely applied although the scientific basis for these selective approaches is rather weak. Partial fundoplication seems to be associated with very low rates of dysphagia and of gas bloat. Assessment of the postoperative result should ideally be done by an independent observer and should consider not only traditional outcome measures but also the impact of surgery on the quality of the patient's life. Investigations on the cost effectiveness of this surgical therapeutic strategy suggest important benefits of surgery to be incorporated into the clinical decision process, when assessing different long-term management alternatives for patient with chronic GORD.   View the Keyslides: Text and slides Broadband video

 

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