Laparoscopic fundoplication compared with laparoscopic gastric bypass in morbidly obese patients with gastroesophageal reflux disease

Current Status of Anti-Reflux Surgery as a Treatment for GERD

Anti-reflux surgery (ARS) is an efficient treatment option for gastroesophageal reflux disease (GERD). Despite growing evidence of the efficacy and safety of ARS, medications including proton pump inhibitors (PPIs) remain the most commonly administered treatments for GERD. Meanwhile, ARS can be an effective treatment option for patients who need medications continuously or for those who are refractory to PPI treatment, if proper candidates are selected. However, in practice, ARS is often regarded as a last resort for patients who are unresponsive to PPIs. Accumulating ARS-related studies indicate that surgery is equivalent to or better than medical treatment for controlling typical and atypical GERD symptoms. Furthermore, because of overall reduced medication expenses, ARS may be more cost-effective than PPI. Patients are selected for ARS based on endoscopic findings, esophageal acid exposure time, and PPI responsiveness. Although there is limited evidence, ARS may be expanded to include patients with normal acid exposure, such as those with reflux hypersensitivity. Additionally, other factors such as age, body mass index, and comorbidities are known to affect ARS outcomes; and such factors should be considered. Nissen fundoplication or partial fundoplication including Dor fundoplication and Toupet fundoplication can be chosen, depending on whether the patient prioritizes symptom improvement or minimizing postoperative symptoms such as dysphagia. Furthermore, efforts to reduce and manage postoperative complications and create awareness of the long-term efficacy and safety of the ARS are recommended, as well as adequate training programs for new surgeons.

Refractory Gastroesophageal Reflux Disease: Diagnosis and Management

Gastroesophageal reflux disease (GERD) is common, with increasing worldwide disease prevalence and high economic burden. A significant number of patients will remain symptomatic following an empiric proton pump inhibitor (PPI) trial. Persistent symptoms despite PPI therapy are often mislabeled as refractory GERD. For patients with no prior GERD evidence (unproven GERD), testing is performed off antisecretory therapy to identify objective evidence of pathologic reflux using criteria outlined by the Lyon consensus. In proven GERD, differentiation between refractory symptoms (persisting symptoms despite optimized antisecretory therapy) and refractory GERD (abnormal reflux metrics on ambulatory pH impedance monitoring and/or persistent erosive esophagitis on endoscopy while on optimized PPI therapy) can direct subsequent management. While refractory symptoms may arise from esophageal hypersensitivity or functional heartburn, proven refractory GERD requires personalization of the management approach, tapping from an array of non-pharmacologic, pharmacologic, endoscopic, and surgical interventions. Proper diagnosis and management of refractory GERD is critical to mitigate undesirable long-term complications such as strictures, Barrett's esophagus, and esophageal adenocarcinoma. This review outlines the diagnostic workup of patients presenting with refractory GERD symptoms, describes the distinction between unproven and proven GERD, and provides a comprehensive review of the current treatment strategies available for the management of refractory GERD.

Mid-term Outcomes of Nissen Fundoplication Versus Roux-en-y Gastric Bypass for Primary Management of Gastroesophageal Reflux Disease in Patients With Obesity

INTRODUCTION

The efficacy and outcomes of laparoscopic Nissen fundoplication (LNF) in patients with obesity is controversial. Specifically, concerns regarding long-term outcomes and recurrence in the setting of obesity has led to interest in laparoscopic Roux-en-Y gastric bypass (RYGB).

METHODS

In this retrospective cohort study, we studied patients with obesity who underwent either LNF or RYGB for gastroesophageal reflux disease. Baseline demographics, clinical variables, operative outcomes, and symptom severity scores were compared.

RESULTS

Baseline demographics, operative outcomes, and quality-of-life scores were similar. Proton pump inhibitor usage, quality-of-life, symptom severity scores, and satisfaction with the operation were similar between groups at mid-term follow-up.

DISCUSSION

RYGB and LNF produced similar improvements in disease-specific quality of life with similar rates of complications, side effects, and need for reoperation. This demonstrates that RYGB and LNF represent possible options for surgical management of gastroesophageal reflux disease in obese patients.

Anti-reflux surgery vs. bariatric surgery as anti-GERD and hiatal hernia treatment in obese patient. New surgical proposals

The persistence of obesity favors the failure of the Fundoplication (FP) in the treatment of Gastroesophageal Reflux (GER). However, the weight loss obtained with the performance of a Gastric Bypass (GBP) allows a good resolution of symptoms, without increasing the incidence of postoperative complications. All of this leads us to consider that while FP is the indication in patients with BMI < 30, in those patients with BMI > 35, GBP appears to be the procedure of choice. But there is still no position in the case of patients with a BMI between 30 and 35, although we must take into account that an increase in GER recurrence has been described after FP in patients with a BMI > 30. Although Sleeve Gastrectomy (SG) is one of the most frequently used bariatric procedures in recent years, its association with a high rate of postoperative GER has led several authors to propose its performance associated with an anti-reflux procedure in patients with GER symptoms. Likewise, if the existence of an Hiatal Hernia is verified, it must be treated by hiatoplasty, both during the performance of a GBP and a SG. This simultaneous treatment is not associated with an increase in complications.

Feasibility and Outcomes of Simultaneous Gastric Bypass with Paraesophageal Hernia Repair in Elderly Patients

BACKGROUND

Paraesophageal hernias (PEH) have a higher incidence in patients with obesity. Roux-en-Y gastric bypass (RYGB) with concomitant PEH repair is established as a valid surgical option for PEH management in patients with obesity. The safety and feasibility of this approach in the elderly population are not well elucidated.

METHODS

We performed a multicenter retrospective cohort study of patients aged 65 years and older who underwent simultaneous PEH repair and RYGB from 2008 to 2022. Patient demographics, hernia characteristics, postoperative complications, and weight loss data were collected. Obesity-related medical conditions' resolution rates were evaluated at the last follow-up. A matched paired t-test and Pearson's test were used to assess continuous and categorical parameters, respectively.

RESULTS

A total of 40 patients (82.5% female; age, 69.2 ± 3.6 years; BMI, 39.4 ± 4.7 kg/m2) with a mean follow-up of 32.3 months were included. The average hernia size was 5.8 cm. Most cases did not require mesh use during surgery (92.5%) with only 3 (7.5%) hernial recurrences. Postoperative complications (17.5%) and mortality rates (2.5%), as well as readmission (2.5%), reoperation (2.5%), and reintervention (0%) rates at 30-day follow-up were reported. There was a statistically significant resolution in gastroesophageal reflux disease (p < 0.001), hypertension (p = 0.019), and sleep apnea (p = 0.014).

CONCLUSIONS

The safety and effectiveness of simultaneous PEH repair and RYGB are adequate for the elderly population. Patient selection is crucial to reduce postoperative complications. Further studies with larger cohorts are needed to fully assess the impact of this surgery on elderly patients with obesity.

Laparoscopic fundoplication versus laparoscopic Roux-en-Y gastric bypass for gastro-oesophageal reflux disease in obese patients: protocol for a randomized clinical trial

BACKGROUND

Laparoscopic fundoplication (LF) is the standard surgical procedure for the treatment of gastro-oesophageal reflux disease (GORD). Laparoscopic Roux-en-Y gastric bypass (LRYGB) is commonly performed to achieve weight loss in obese patients, but it also has anti-reflux properties. Hence, in the obese population suffering from GORD, LRYGB could be an alternative to LF. The aim of this trial will be to compare LF and LRYGB in an obese population presenting with GORD and being considered for surgery.

METHODS

This will be an investigator-initiated randomized clinical trial. The research population will be obese patients (BMI 30-34.9 with waist circumference more than 88 cm (women) or more than 102 cm (men), or BMI 35-40 with any waist circumference) referred to a public hospital for consideration of anti-reflux surgery. The primary aim of the study will be to determine the efficacy of LF compared with LRYGB on subjective and objective control of GORD. Secondary aims include determining early and late surgical morbidity and the side-effect profile of LF compared with LRYGB and to quantify any non-reflux benefits of LRYGB (including overall quality of life) compared with LF.

CONCLUSION

This trial will determine whether LRYGB is effective and acceptable as an alternative to LF for the surgical treatment of GORD in obese patients Registration number: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12622000636752p (https://www.anzctr.org.au/).

Gastroesophageal Reflux Disease and the Patient with Obesity

Patients with obesity who present with gastroesophageal reflux disease (GERD) require a nuanced approach. Those with lower body mass index (BMI) (less than 33) can be counseled on weight loss, and if successful may be approached with laparoscopic fundoplication. Those who are unable to achieve weight loss or those who present with a BMI greater than or equal to 35 should proceed with laparoscopic Roux-en-Y gastric bypass (LRYGB). Conversion to LRYGB from sleeve gastrectomy is a safe and effective way to manage GERD after sleeve gastrectomy.

Gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease (GERD) is a common disorder in adults and children. The global prevalence of GERD is high and increasing. Non-erosive reflux disease is the most common phenotype of GERD. Heartburn and regurgitation are considered classic symptoms but GERD may present with various atypical and extra-oesophageal manifestations. The pathophysiology of GERD is multifactorial and different mechanisms may result in GERD symptoms, including gastric composition and motility, anti-reflux barrier, refluxate characteristics, clearance mechanisms, mucosal integrity and symptom perception. In clinical practice, the diagnosis of GERD is commonly established on the basis of response to anti-reflux treatment; however, a more accurate diagnosis requires testing that includes upper gastrointestinal tract endoscopy and reflux monitoring. New techniques and new reflux testing parameters help to better phenotype the condition. In children, the diagnosis of GERD is primarily based on history and physical examination and treatment vary with age. Treatment in adults includes a combination of lifestyle modifications with pharmacological, endoscopic or surgical intervention. In refractory GERD, optimization of proton-pump inhibitor treatment should be attempted before a series of diagnostic tests to assess the patient's phenotype.

Impact of bariatric surgery on gastroesophageal reflux disease and esophageal motility

PURPOSE OF REVIEW

Obesity is rapidly increasing in prevalence, and bariatric surgery has become a popular treatment option that can improve all-cause mortality in obese individuals. Gastroesophageal reflux disease (GERD) and esophageal motility disorders are common in the obese population, and the effects of bariatric surgery on these conditions differ depending on the type of bariatric surgery performed.

RECENT FINDINGS

Laparoscopic adjustable gastric banding has declined in popularity due to its contributions to worsening GERD symptoms and the development of esophageal dysmotility. Although laparoscopic sleeve gastrectomy (LSG) is the most popular type of bariatric surgery, a comprehensive assessment for acid reflux should be performed as LSG has been linked with worsening GERD. Novel methods to address GERD due to LSG include magnetic sphincter augmentation and concomitant fundoplication. Due to the decreased incidence of postoperative GERD and dysmotility compared to other types of bariatric surgeries, Roux-en-Y gastric bypass should be considered for obese patients with GERD and esophageal dysmotility.

SUMMARY

Bariatric surgery can affect esophageal motility and contribute to worsening or development of GERD. A thorough workup of gastrointestinal symptoms before bariatric surgery should be performed with consideration for formal testing with high-resolution manometry and pH testing. Based on these results, the choice of bariatric surgery technique should be tailored accordingly to improve clinical outcomes.

Hill Modified, a Novel Approach: Technique Description and Experience in Patients with Laparoscopic Sleeve Gastrectomy

BACKGROUND

Gastroesophageal reflux disease (GERD) is a common disease among patients with obesity, with an associated prevalence of 39 to 61% between the population who attends a bariatric surgery evaluation. Laparoscopic sleeve gastrectomy (LSG) has become a popular and valid option for obesity treatment, even though the literature is ambivalent regarding the increase or decrease in GERD after this surgery. Thus, it is necessary to propose new surgical techniques as a solution to GERD in patients with a concomitant LSG or with a history of it. Therefore, we present a modified technique based on Hill's gastropexy described originally in 1967.

OBJECTIVE

Describe and propose a surgical procedure for GERD management based on the Hill technique that can be applied in all patients who undergo an LSG or with a history of it.

METHODS

Retrospective observational study with a prospective database in which we described, Hill modified technique in a group of 16 patients with GERD who underwent this procedure concomitantly with an LSG or who presented with GERD after LSG with a 3-year follow-up. The surgical technique is based on an intra-abdominal esophageal length of a minimum of 3 cm and posterior fixation of the gastroesophageal junction to the crus.

RESULTS

Postoperative controls have shown satisfactory results in the control and management of GERD symptoms in this group of patients, with very few to no complications associated with the procedure and without reintervention or medication out of the standard protocol.

CONCLUSION

Hill modified technique can be used and presented as an option for GERD control in patients with LSG.

The Nissen-Sleeve (N-Sleeve): Results of a Cohort Study

BACKGROUND

The Montpellier bariatric team has recently proposed some technical alternatives to decrease the rate of gastroesophageal reflux disease (GERD) after bariatric surgery and also to offer patients an alternative in case of contraindication to Roux-en-Y gastric bypass (RYGBP): the Nissen-Sleeve (N-Sleeve).

OBJECTIVES

We present here the results from a cohort of patients that underwent an operation with this newly designed anti-reflux bariatric procedure N-Sleeve: Nissen valve added to a standard SG.

METHODS

Data from a prospective, observational, and monocentric cohort. All consecutive patients presenting to the bariatric surgery department for a laparoscopic sleeve gastrectomy between 2016 and 2018 with GERD were included in the study. The fundus was stapled with a margin from the valve, and the valve was created with tissue at a distance from the greater curvature so as to avoid a double layer stapling of the stomach.

RESULTS

A total of 70 patients were included in the study. Ninety percent of the cohort presented with a hiatal hernia at the time of surgery. No mortality was observed during the follow-up period. Concerning GERD, 76% of all patients had preoperative esophageal syndromes, whereas 21% were asymptomatic with associated esophagitis. Grade A-C esophagitis was present in 99% of the cohort, but no Barrett's esophagus was present. Fifty-six (80%) patients used PPIs regularly. At 1 year of follow-up, one patient was still symptomatic.

CONCLUSIONS

Comparative trials remain necessary between N-Sleeve and standard bariatric procedures to refine the specific indications of each of them and determine the eventual role of the N-Sleeve.

ESNM/ANMS consensus paper: Diagnosis and management of refractory gastro-esophageal reflux disease

Up to 40% of patients with symptoms suspicious of gastroesophageal reflux disease (GERD) do not respond completely to proton pump inhibitor (PPI) therapy. The term "refractory GERD" has been used loosely in the literature. A distinction should be made between refractory symptoms (ie, symptoms may or may not be GERD-related), refractory GERD symptoms (ie, persisting symptoms in patients with proven GERD, regardless of relationship to ongoing reflux), and refractory GERD (ie, objective evidence of GERD despite adequate medical management). The present ESNM/ANMS consensus paper proposes use the term "refractory GERD symptoms" only in patients with persisting symptoms and previously proven GERD by either endoscopy or esophageal pH monitoring. Even in this context, symptoms may or may not be reflux related. Objective evaluation, including endoscopy and esophageal physiologic testing, is requisite to provide insights into mechanisms of symptom generation and evidence of true refractory GERD. Some patients may have true ongoing refractory acid or weakly acidic reflux despite PPIs, while others have no evidence of ongoing reflux, and yet others have functional esophageal disorders (overlapping with proven GERD confirmed off therapy). In this context, attention should also be paid to supragastric belching and rumination syndrome, which may be important contributors to refractory symptoms.

Bariatric surgery in patients with gastroesophageal reflux disease and/or hiatus hernia

INTRODUCTION

Gastroesophageal reflux disease (GERD) and hiatus hernia (HH) are frequently encountered comorbidities in patients seeking bariatric and metabolic surgery (BMS) for obesity. sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and one anastomosis gastric bypass (OAGB) are the three commonest bariatric procedures performed worldwide. The purpose of this review was to analyze and compare the data on outcomes of these three procedures in patients with GERD and/or HH.

EVIDENCE ACQUISITION

We examined published English language scientific literature available on PubMed for data comparing SG, RYGB, and OAGB with specific focus on GERD outcomes and outcomes in those with GERD and/or HH.

EVIDENCE SYNTHESIS

Several authors have addressed the outcome of GERD after bariatric surgery. There have been randomized control trials and comparative studies in the literature comparing the results of these procedure. But very few studies have exclusively looked into the outcome of different procedures in patients with pre-existing GERD and/or HH. In this narrative review, we evaluate pros and cons of three commonest bariatric procedures worldwide in this subgroup of patients seeking BMS. We also suggest an algorithm on the basis of our experience and the available data in scientific literature.

CONCLUSIONS

Though RYGB is the best anti reflux procedure it is associated with significant higher morbidity/mortality as compared to SG and OAGB. These two procedures can be used in the majority of patients with GERD and/or HH seeking BMS with an acceptance that some patients will need conversion to RYGB in the long term.

Best reoperative strategy for failed fundoplication: redo fundoplication or conversion to Roux-en-Y gastric diversion?

BACKGROUND

Failed fundoplication is a difficult reoperative challenge, with limited evidence differentiating outcomes of a redo fundoplication versus conversion to Roux-en-Y anatomy with a gastric diversion (RYGD). The aim of this study was to determine the impact of these reoperative strategies on symptom resolution.

METHODS

A retrospective single institution study of patients with failed fundoplications undergoing conversion to RYGD or redo fundoplication between 2006 and 2019 was conducted. Patient characteristics, preoperative evaluation, operative findings, and postoperative outcomes were recorded and analyzed.

RESULTS

180 patients with symptomatic, failed fundoplications were identified: 101 patients (56.1%) underwent conversion to RYGD, and 79 patients (43.9%) underwent redo fundoplication. Body mass index (BMI) was significantly higher for the patients undergoing RYGD with mean BMI of 34.3 ± 6.9 vs 27.7 ± 3.9 kg/m² (p < 0.001). Patients undergoing conversion to RYGD were also more comorbid than their counterparts, with higher rates of obstructive sleep apnea (17.8% vs 5.1%, p = 0.01), but similar rates of hypertension (54.5% vs 44.3%, p = 0.18, asthma/COPD (25.7% vs 16.5%, p = 0.13), diabetes (10.9% vs 10.1%, p = 0.87), and hyperlipidemia (29.7% vs 36.7%, p = 0.32). Mean operative times were significantly higher for the RYGD (359.6 ± 90.4 vs 238.8 ± 75.6 min, p < 0.0001), as was mean estimated blood loss (168.8 ± 207.5 vs 81.0 ± 145.4, p < 0.0001). Conversion rates from minimally invasive to open were similar (10.9% vs 11.4%, p = 0.92). The incidence of recurrent reflux symptoms was not significantly different (p = 0.46) between RYGD (16.8%) and redo fundoplication (12.8%), at an average follow-up of 50.6 ± 140.7 vs 34.7 ± 39.2 months, (p = 0.03). For the RYGD cohort, patients also had resolution of other comorbidities including obesity 35.6%, OSA 16.7%, hyperlipidemia 10.0%, hypertension 9.1%, and diabetes 9.1%. On average, patients decreased their BMI by 6.8 ± 5.5 kg/m² and lost 69.6% of their excess body weight. Mean length of stay was higher in patients undergoing RYGD (5.3 ± 7.3 vs 3.0 ± 1.9 days, p = 0.01). Thirty-day readmission rates were similar (9.9% vs 3.8%, p = 0.12). The reoperation rate was higher in the RYGD cohort (17.8% vs 2.5%, p = 0.001).

CONCLUSIONS

RYBG and redo fundoplication are equivalent in terms of resolution of reflux. RYGD resulted in significant loss of excess body weight.

Minimally Invasive Roux-en-Y Gastric Bypass for Fundoplication failure offers Excellent Gastroesophageal Reflux Control

Roux-en-Y gastric bypass (RYGB) may represent a superior alternative to reoperative fundoplication in patients with symptomatic failure. Our goal was to assess early outcomes of patients after RYGB for failed fundoplication. Records of patients who underwent fundoplication takedown and RYGB from March 2007 to June 2013 were reviewed for demographics, comorbidities, operative findings, and perioperative outcomes. Data are reported as medians (range). Forty-five patients who had undergone 64 prior antireflux procedures (range, one to three fundoplications) were identified. Median patient age was 56 years (range, 25 to 72 years) with a body mass index of 33 kg/m2 (range, 22 to 51 kg/m2). Most patients had comorbidities: hypertension (60%), anxiety/ depression (44.4%), dyslipidemia (33.3%), asthma (31%), obstructive sleep apnea (26.7%), arthritis (22.2%), and diabetes (11.1%). Median symptom-free interval was 3 years (range, 0 to 25 years). All patients had an anatomic reason for failure: 83 per cent had a hiatal hernia and 35 per cent had a slipped Nissen fundoplication. The procedures were accomplished laparoscopically in 28, robotically in 13, and open in four cases. Median operative time was 367 minutes (range, 190 to 600 minutes) and estimated blood loss averaged 100 mL (range, 25 to 500 mL). Five patients (11%) required reoperation: one for an anastomotic leak, one for anastomotic obstruction, and three for early obstruction resulting from adhesions. Two patients developed respiratory failure requiring prolonged mechanical ventilation. Length of stay averaged four days (range, 1 to 33 days) with two readmissions: one for melena and one for vomiting and dehydration; neither required intervention. There was no mortality. At 11 months of follow-up (range, 2.3 to 54 months), 93.3 per cent of patients were symptom-free. When primary fundoplication for gastroesophageal reflux disease fails, fundoplication takedown and RYGB can be accomplished safely with minimally invasive techniques. The conversion to a RYGB has an acceptable perioperative morbidity and excellent early symptom control, and, therefore, should be considered for reoperative patients gastroesophageal reflux disease.

Modified laparoscopic sleeve gastrectomy with Rossetti antireflux fundoplication: results after 220 procedures with 24-month follow-up

BACKGROUND

Gastroesophageal reflux disease (GERD), including erosive esophagitis, is highly prevalent in the obese population. Laparoscopic sleeve gastrectomy (LSG) is one of the most frequently performed bariatric procedures. The relationship between LSG and GERD has gained increasing attention. This retrospective study aimed to assess the effectiveness of combined LSG and modified Rossetti antireflux fundoplication for the treatment of GERD on morbidly obese patients after bariatric surgery.

OBJECTIVES

To assess the effectiveness, on morbid obese patients, of combined SG and Rossetti fundoplication for the treatment of GERD in obese patients.

SETTING

Public Hospital, Italy.

METHODS

From January 2015 to May 2018, 220 obese patients (167 female; 53 male) underwent LSG and modified Rossetti antireflux fundoplication procedure, performed by 4 different expert bariatric surgeons. Data have been collected in an Excel file and processed by XLStat to perform statistical analyses. We analyzed short-term complications and medium-term results with 24-month follow-up in terms of weight loss, remission of co-morbidities, and resolution of GERD.

RESULTS

Mean BMI was 42.58 ± 5.93 kg/m² (range, 31.70-63.16). Patients suffering from GERD before surgery were 137 of 220 (62.3%). No intraoperative complications or conversion were reported. Regular postoperative course was recorded in 90% of patients (198 of 220 patients). Gastric perforation has always occurred on the fundoplicated portion of the stomach. This perforation, which is different from the well-known post-LSG gastric fistula, may be because of incorrect gastric fundus manipulation. Rate of reoperation was 14 of 220 (6.4%). A good sense of repletion without episodes of vomiting, nausea, or dysphagia was reported in 95% of the analyzed patients. Of patients, 98.5% did not suffer from reflux symptoms and did not take proton pump inhibitors. A decrease in BMI and percent of total weight loss at follow-up were comparable with LSG. Endoscopic follow-up is still ongoing. Improvement in esophagitis was observed in 63 of 65 (96.92%) patients and all 4 patients shows improvement in Barrett's esophagus.

CONCLUSIONS

LSG and modified Rossetti antireflux fundoplication procedure is a tolerated and feasible procedure in obese patients, with good postoperative weight loss results and improvement in GERD.

Efficacy and Safety of Recurrent Paraesophageal Hernia Repair with Roux-en-Y Gastric Bypass

Roux-en-Y gastric bypass (RYGB) has been explored as a revisional option to failed paraesophageal hernia (PEH) repair with fundoplication, particularly in patients suffering from obesity. However, few studies have assessed long-term outcomes of RYGB with revisional PEH repairin regard to acid-suppressing medication use. We retrospectively identified 19 patients who underwent revisional PEH repair with RYGB between 2011 and 2018. The median operative time was 232 minutes with a median hospital length of stay of two days. The median length of follow-up was 24 months. Two patients (10.5%) had complications in the first 30 days, and five patients (26.3%) had complications within one year. Of the 12 patients on preoperative acid suppression, 6 (50%) were either off medication or on reduced dose at 12 months. The median BMI decrease was 14.4 kg/m2at 12 months and did not change significantly afterward. Although rates of acid-suppression medication use did not change overall after revisional PEH repair with RYGB, patients experienced successful long-term management of morbid obesity and sustained weight loss. Revisional PEH repair with RYGB is a safe and effective option, with a complication rate comparable with the reported rates after revisional foregut procedures such as revisional Nissen fundoplication.

Surgical management of gastroesophageal reflux disease in the obese patient

BACKGROUND

Gastroesophageal reflux disease (GERD) affects two thirds of the American population. Obesity is also a disease that affects two thirds of the population. The pathophysiology of reflux disease is reasonably understood, however, the degree to which obesity affects this disease remains poorly defined. Therefore the approach to GERD in the obese patient requires special attention and its own algorithm.

METHODS

A literature search was conducted to consolidate the current available literature on GERD and its management in the obese. In addition, the authors reviewed the literature and present expert opinion on controversial topics.

RESULTS

It is well established that GERD is increased in obesity and the pathophysiology is reviewed. Management options for GERD are discussed, with a focus on the obese population. Management strategies including fundoplication and gastric bypass are discussed. In addition, bariatric surgery in the setting of GERD is also reviewed.

CONCLUSIONS

Currently this is an extremely controversial topic and this white paper presents a strong review of the literature to help guide the management of this challenging disease in this population. Expert recommendations are given throughout the paper based upon the current available data.

THE ROLE OF THE TRANSDIAPHRAGMATIC PRESSURE GRADIENT IN THE PATHOPHYSIOLOGY OF GASTROESOPHAGEAL REFLUX DISEASE

ABSTRACT Gastroesophageal reflux disease (GERD) is the most common disease of the upper gastrointestinal tract in the Western world. GERD pathophysiology is multifactorial. Different mechanisms may contribute to GERD including an increase in the transdiaphragmatic pressure gradient (TPG). The pathophysiology of GERD linked to TPG is not entirely understood. This review shows that TPG is an important contributor to GERD even when an intact esophagogastric barrier is present in the setting of obesity and pulmonary diseases.

Moderating the Enthusiasm of Sleeve Gastrectomy: Up to Fifty Percent of Reflux Symptoms After Ten Years in a Consecutive Series of One Hundred Laparoscopic Sleeve Gastrectomies

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has become a popular one-stage bariatric procedure with a proven efficacy on weight loss. However, the relationship between LSG and gastroesophageal reflux disease (GERD) remains a subject of debate. The objective is to determine the long-term effect of LSG on weight loss and reflux disease.

METHODS

A retrospective analysis of 100 consecutive patients who underwent an LSG between January 2005 and March 2009 was performed. The effect of LSG on weight evolution and the relationship between preoperative and postoperative GERD symptoms and PPI dependency was analyzed.

RESULTS

A mean follow-up of 8.48 years (range 6.1-10.3) was achieved. We observed a long-term % excess weight loss (%EWL) of 60%. A significant increase in reflux symptoms and use of PPIs was seen. Seventeen percent suffered from reflux disease preoperatively versus 50% at the end of the postoperative follow-up (RR = 2.5882, 95% CI [1.6161-4.1452], p value = 0.0001). The chance of developing de novo reflux after LSG was 47.8% (32/67). Reflux disease was present in 7 of the 26 patients who underwent a secondary Roux-en-Y gastric bypass (RYGB). In four of these seven patients, reflux disease disappeared completely after the secondary RYGB (57.1%).

CONCLUSIONS

A satisfactory long-term effect on weight loss was achieved. However, a significant increase in GERD and PPI dependency after LSG was noted. New onset GERD was seen in more than 40% of the study population. Conversion to RYGB is a good option in patients with refractory reflux disease after LSG.

Management of Gastroesophageal Reflux Disease

Management of gastroesophageal reflux disease (GERD) commonly starts with an empiric trial of proton pump inhibitor (PPI) therapy and complementary lifestyle measures, for patients without alarm symptoms. Optimization of therapy (improving compliance and timing of PPI doses), or increasing PPI dosage to twice daily in select circumstances, can reduce persistent symptoms. Patients with continued symptoms can be evaluated with endoscopy and tests of esophageal physiology, to better determine their disease phenotype and optimize treatment. Laparoscopic fundoplication, magnetic sphincter augmentation, and endoscopic therapies can benefit patients with well-characterized GERD. Patients with functional diseases that overlap with or mimic GERD can also be treated with neuromodulators (primarily antidepressants), or psychological interventions (psychotherapy, hypnotherapy, cognitive and behavioral therapy). Future approaches to treatment of GERD include potassium-competitive acid blockers, reflux-reducing agents, bile acid binders, injection of inert substances into the esophagogastric junction, and electrical stimulation of the lower esophageal sphincter.

A New Algorithm to Reduce the Incidence of Gastroesophageal Reflux Symptoms after Laparoscopic Sleeve Gastrectomy

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is one of the most prefered treatment option for morbid obesity. However, the effects of LSG on gastroesophageal reflux disease (GERD) are controversial. Asymptomatic GERD and hiatal hernia (HH) is common in obese patients. Therefore, it is important to identify the high risk patients prior to surgery. This study aims to evaluate efficacy of cruroplasty for HH during LSG in morbidly obese patients using ambulatory pH monitoring (APM) results, and to investigate the patients' selection criteria for this procedure.

METHODS

This retrospective study includes outcomes of 59 patients who underwent LSG and HH repair according to our patient selection algorithm. Outcomes included preoperative GERD Health-Related Quality of Life (GERD-HRQL) questionnaire, APM results, percentage of postoperative excess weight loss, and total weight loss.

RESULTS

For a total of 402 patients, APM was applied in 70 patients who had a positive score of GERD-HRQL, and 59 patients underwent LSG and concomitant HH repair who had a DeMeester score of 14.7% or above. There was no statistically significant difference in weight loss at 6 and 12-month follow-up. Two patients (3.3%) had symptoms of GERD at 12 months postoperatively, and only one (1.6%) patient required treatment of proton pump inhibitor for reflux. In the total cohort, 11 (2.7%) patients also evolved de novo GERD symptoms.

CONCLUSIONS

This study confirm that careful attention to patient selection and surgical technique can reduce the symptoms of GERD at short-term. Routine bilateral crus exploration could be a major risk factor of postoperative GERD.

Patients Having Bariatric Surgery: Surgical Options in Morbidly Obese Patients with Barrett's Esophagus

This article summarizes the currently knowledge and results observed in patients with obesity and Barrett's esophagus which were presented and discussed during the IFSO 2014 held in Montreal. In this meeting, the surgical options for the management after bariatric surgery were discussed. For this purpose, a complete revision of the available literature was done including Pubmed, Medline, Scielo database, own experience, and experts opinion. A total of 49 publications were reviewed and included in the present paper. The majority of authors agree that gastric bypass is the procedure of choice. Sleeve gastrectomy is not an absolute contraindication. Up to now, gastric bypass appears to be the best procedure for treatment of obese patients with Barrett's esophagus. Future investigations should give the definitive consensus.

Surgical Anti-Reflux Options Beyond Fundoplication

PURPOSE OF REVIEW

This paper provides an overview of current and future surgical interventions available for the management of gastroesophageal reflux disease (GERD) beyond the well established and recognized fundoplication. Review the current indications and outcomes of these surgical procedures.

RECENT FINDINGS

Fundoplication has been a cornerstone of the surgical management of GERD. However, other effective surgical options exist and can be considered based on prior interventions as well as patient, anatomical or other factors. These options are intended to address some of the shortcomings or potential complications of fundoplication such as symptom recurrence, dysphagia, or gas bloating, for example. Alternative procedures to fundoplication include magnetic sphincter augmentation, electrical stimulation and Roux-en-Y gastric bypass. The indication for surgical management remains failure of or inability to tolerate medical therapy.

Laparoscopic sleeve gastrectomy combined with Rossetti fundoplication (R-Sleeve) for treatment of morbid obesity and gastroesophageal reflux

BACKGROUND

Gastroesophageal reflux (GERD) can be considered an obesity-related disease. Roux-en-Y gastric bypass is considered the gold standard for its therapeutic effects on acid reflux.

OBJECTIVES

The aim of this retrospective study is to assess the effectiveness of combined laparoscopic sleeve gastrectomy and Rossetti antireflux fundoplication for the treatment of morbidly obese patients with GERD.

SETTING

A private academic hospital in Italy.

METHODS

Forty obese patients with GERD underwent laparoscopic sleeve gastrectomy-Rossetti laparoscopic fundoplication from January 1 to October 31, 2015. A specific informed consent was obtained. Minimum follow-up was 12 months. No cases were lost to follow-up.

RESULTS

Mean body mass index was 44.4 ± 4.7 kg/m²; all patients had GERD. Mean operative time was 38 ± 6 minutes. The mortality rate was 0%. No intraoperative or medium- or long-term complications were reported. Excess weight loss percent at 1, 3, 6, 12 months was 25.6 ± 6.1, 41.9 ± 12.5, 56.7 ± 13.0, 61.7 ± 13.6, respectively. Excess body mass index loss percent at 1, 3, 6, 12 months was 29.3 ± 3.4, 47.2 ± 5.2, 64.0 ± 8.6, 73.3 ± 9.9, respectively. At the 12-month follow-up visit, 95% of the patients reported a good sense of repletion without episodes of vomiting, nausea, or dysphagia.

CONCLUSIONS

Rossetti laparoscopic fundoplication is well tolerated, feasible, and safe in obese patients with GERD, with good postoperative weight results. Following this evidence, 2 monocentric prospective and randomized studies will start to analyze and confirm the reported data.

Surgery for Gastroesophageal Reflux Disease in the Morbidly Obese Patient

The prevalence of gastroesophageal reflux disease (GERD) has mirrored the increase in obesity, and GERD is now recognized as an obesity-related comorbidity. There is growing evidence that obesity, specifically central obesity, is associated with the complications of chronic reflux, including erosive esophagitis, Barrett's esophagus, and esophageal adenocarcinoma. While fundoplication is effective in creating a competent gastroesophageal junction and controlling reflux in most patients, it is less effective in morbidly obese patients. In these patients a bariatric operation has the ability to correct both the obesity and the abnormal reflux. The Roux-en-Y gastric bypass is the preferred procedure.

The Improvement of Gastroesophageal Reflux Disease and Barrett's after Bariatric Surgery

Obesity and gastroesophageal reflux disease (GERD) are prevalent in Western populations. In obese patients, high-resolution manometry often shows altered gastroesophageal pressure gradients, promoting retrograde gastric content flow into the esophagus and esophagogastric junction disruption, leading to a hiatal hernia. Hernia recurrence is higher in the obese, and recurrence is seen regardless of the operative approach used. Bariatric surgery is the gold-standard treatment for GERD in obese patients, and symptom improvement varies depending on the specific bariatric procedure performed, Roux-en-Y (RYGB), laparoscopic adjustable gastric banding (LAGB), or sleeve gastrectomy (SG). Studies have shown these surgeries significantly improve GERD, but RYGB had the greatest effect. Limited data is available examining the progression or regression of Barrett's following bariatric surgery. We currently recommend RYGB for morbidly obese patients with Barrett's esophagus.

Prevalence of Barrett's Esophagus in Bariatric Patients Undergoing Sleeve Gastrectomy

BACKGROUND

The appearance and incidence of gastroesophageal reflux after sleeve gastrectomy is not yet resolved, and there is an important controversy in the literature. No publications regarding the appearance of Barrett's esophagus after sleeve gastrectomy are present in the current literature.

PURPOSE

The purpose of this paper was to report the incidence of Barrett's esophagus in patients submitted to sleeve.

MATERIAL AND METHODS

Two hundred thirty-one patients are included in this study who were submitted to sleeve gastrectomy for morbid obesity. None had Barrett's esophagus. Postoperative upper endoscopy control was routinely performed 1 month after surgery and 1 year after the operation, all completed the follow-up in the first year, 188 in the second year, 123 in the third year, 108 in the fifth year, and 66 patients over 5 years after surgery.

RESULTS

Among 231 patients operated on and followed clinically, reflux symptoms were detected in 57 (23.2%). Erosive esophagitis was found in 38 patients (15.5%), and histological examination confirmed Barrett's esophagus in 3/231 cases (1.2%) with presence of intestinal metaplasia.

CONCLUSION

Bariatric surgeons should be aware of the association of gastroesophageal reflux (GER) disease and obesity. Appropriate bariatric surgery should be indicated in order to prevent the occurrence of esophagitis and Barrett's esophagus.

A comparison of outcomes of bariatric surgery in patient greater than 70 with 18 month of follow up

BACKGROUND

There is a scarcity of data available to determine the safety and effectiveness of bariatric surgery in the elderly population. Additionally, there are no studies showing the effect of the single anastomosis duodenal switch (SADS) has on the elderly obese, in comparison with other more popular procedures. Here we compare laparoscopic gastric band surgery (LAGB), Laparoscopic Roux-en-Y gastric bypass surgery (LRYGB), and the SADS to analyze the weight loss, perioperative and postoperative morbidity in the patients >70 years of age at a single US center.

METHODS

A retrospective analysis was performed on 53 consecutive patients ≥70 years old who underwent weight loss surgery from 2009 to 2015.Weight loss in terms of the percentage excess body mass index lost (%EBMIL), percentage excess weight lost (%EWL) and body mass index (BMI) points lost, resolution of comorbidities, length of stay, early (30-day) and late complication rates were compared using descriptive statistics and non-linear regression analysis.

RESULTS

Of 53 patients, 24 underwent LAGB, 14 underwent LRYGB and 15 underwent SADS. The average patient age was 72.7 ± 2.5 years (range, 70-81.4) and 66 % were females. There was no statistical difference in the demographic data between three groups except for age and sleep apnea. There were no operative or early deaths. There were differences in complication rates between the surgical arms; however, with our small data set statistical significance was not achieved. There was 1 patient who lost to follow up in SADS group. Follow up time period was 18 months.  % EBMIL and BMI reduction showed a statistically significant difference between the procedures, where the SADS had the highest loss of  %EBMIL and BMI points. Comorbidities prevalence decreased post-operatively with SADS having higher percentage of patients who had resolution of their comorbidities.

CONCLUSION

Each of the three procedures can be performed on patients older than 70 with low morbidity rate. However, when the focus is weight loss alone, the SADS procedure is the most effective of the three procedures in regards to weight loss in the short term for patients older than 70. The SADS is as safe as RYGB but LAGB with all its limitations is still the safest bariatric procedure.

Unmet needs in treating laryngo-pharyngeal reflux disease: where do we go from here?

INTRODUCTION

Many patients experience ear, nose and throat symptoms associated with their gastroesophageal reflux disease. These symptoms are purportedly caused by reflux of gastroduodenal contents into the larynx, which leads to laryngopharyngeal reflux (LPR). Various modalities are used to diagnose LPR, including ambulatory pH monitoring, laryngoscopy, and esophagogastroduodenoscopy, as well as a few new emerging diagnostic tests. However, there are still no established diagnostic criteria or gold standard methodologies that can reliably distinguish LPR from other conditions.

AREAS COVERED

In this review, we will evaluate currently available diagnostic tests and therapeutic options for patients with laryngeal signs and symptoms of reflux and briefly discuss the development and emergence of new treatments. Numerous studies have investigated the role of proton pump inhibitor therapy in this patient population, but have led to disparate and often inconsistent results. Expert commentary: While a subgroup of patients with LPR appears to respond to PPI therapy, many patients show no symptomatic improvement, particularly with respect to extraesophageal symptoms. As such, there is a vital need to explore alternative treatment options, including anti-reflux surgery, lifestyle changes, and other classes of medications to better address LPR.

Nissen Sleeve (N-Sleeve) operation: preliminary results of a pilot study

BACKGROUND

Sleeve gastrectomy (SG) is one of the most frequently performed bariatric procedures worldwide. Despite its impressive results, there is a growing concern about the relationship between SG and gastroesophageal reflux disease (GERD).

OBJECTIVES

We present our pilot study of patients operated with a Nissen anti-reflux valve added to a standard SG.

SETTING

University hospital in Montpellier, France.

METHODS

A prospective monocentric study including 25 consecutive patients operated with a laparoscopic Nissen-Sleeve (N-Sleeve) gastrectomy was carried out between September 2013 and March 2014. Inclusion criteria were indication for bariatric surgery for patients with GERD (Montreal's definition and classification). All patients were followed postoperatively for 1 year.

RESULTS

There were 13 (54%) females and 12 (46%) males with mean age of 41±12 (20-65) years. Mean body mass index was 42±4.8 (35-53) kg/m². Preoperatively, all patients had esophageal syndromes. Twenty-three (92%) patients had typical symptoms of GERD, but 2 were asymptomatic; however, they had esophageal injury. Esophagitis grade I-III presented in 10 (40%) patients and Barrett's esophagus in 8 (32%) cases. Two (8%) patients also had extraesophageal syndrome represented by asthma. Nineteen (76%) patients previously took proton pump inhibitors, regularly and 22 (88%) had experienced a hiatal hernia. There was no conversion to the open technique. Operative time was 84±13 (54-106) minutes. There were no deaths. Complications included one case of staple line bleeding and one Nissen valve perforation without recognized ischemia. No staple line failure was observed. Three months after N-Sleeve, 19 (76%) patients remained asymptomatic without proton pump inhibitor use. At 6 months and 1 year, 3 (12%) patients were still experiencing reflux. Excess weight loss at 1 year was 58±23%, total weight loss was 27±10%, and body mass index change was -11±4 kg/m².

CONCLUSION

The N-Sleeve seems to be a safe procedure that provides an adequate reflux control with no clear interference on the expected bariatric results of a standard SG.

Stomach intestinal pylorus sparing surgery (SIPS) with laparoscopic fundoplication (LF): a new approach to gastroesophageal reflux disease (GERD) in the setting of morbid obesity

The increase in the prevalence of obesity and gastroesophageal reflux disease (GERD) has paralleled one another. Laparoscopic fundoplication (LF) (Nissen or Toupet) is a minimally invasive form of anti-reflux surgery. The duodenal switch is a highly effective weight loss surgery with a proven record of long term weight loss success. However, fundoplication alone does not give satisfactory results when used for GERD in morbidly obese patients. Here we present a novel approach combining stomach intestinal pylorus sparing surgery (SIPS) with LF for morbidly obese patients with GERD. The data from patients who underwent the SIPS procedure along with LF in past year was retrospectively analyzed. The variables collected were age, sex, height, weight, intra-operative and post-operative complications, length of stay, operative time, and estimated blood loss. All revisions were excluded. Descriptive statistics such as mean and standard deviation were used to analyze the data. The total sample size of the study was 5 patients, with a mean age of 59.6 ± 16.4 years, a mean weight of 292.1 ± 73.6 lbs., and a mean body mass index (BMI) of 43.4 ± 6.3. Weight loss patterns were the same as those without LF. All the 5 patients had resolution or improvement in their GERD symptoms within 6 months. SIPS with LF provides substantial and sustained weight loss and GERD resolution. Long term follow ups and further study on this novel surgical technique is recommended.

Single-anastomosis gastric bypass (SAGB): appraisal of clinical evidence

Single-anastomosis (mini-) gastric bypass (SAGB) was proposed by Dr. Robert Rutledge. Criticism and prejudice against this procedure was raised by surgeons who preferred a more difficult procedure, laparoscopic Roux-en-Y gastric bypass (RYGB). Increasing data indicates the procedure is an effective and durable bariatric procedure. SAGB has lower operation risks compared to RYGB. The weight loss is better after SAGB because of a greater malabsorptive component than RYGB, but SAGB had a higher incidence of micronutrient deficiencies. Randomized controlled trial and long-term data demonstrate that SAGB can be regarded as a simpler and safer alternative to RYGB. We propose this procedure to be renamed "single-anastomosis gastric bypass (SAGB)" because the key feature of SAGB is the "single anastomosis" compared with the two anastomoses of RYGB.

Laparoscopic Nissen fundoplication with gastric plication as a potential treatment of morbidly obese patients with GERD, first experience and results

BACKGROUND

Laparoscopic Nissen fundoplication is an effective treatment for gastroesophageal reflux disease (GERD). However, there is no consensus for the surgical treatment of GERD in morbidly obese patients.

METHODS

Twenty-five morbidly obese patients with GERD underwent our novel procedure, laparoscopic Nissen fundoplication with gastric plication (LNFGP), and were monitored for 6 to 18 months. Operative complication, weight loss, and GERD symptoms were monitored.

RESULTS

The study subjects consisted seven males and 18 females. The average age was 38.2 years (from 18 to 58), and the mean BMI was 37.9 kg/m(2) (from 31.5 to 56.4). The mean operative time was 145.6 min (from 105 to 190). All procedures were performed via laparoscopic surgery. Two patients (8%) displayed a major 30-day perioperative complication. The first patient had an acute leak on the second postoperative day. The patient received a laparoscopic revision sleeve gastrectomy and was discharged 5 days later after an uneventful recovery. Another patient developed an intra-abdominal abscess 3 weeks after surgery and received laparoscopic drainage and a revision sleeve gastrectomy. Upon follow-up, only four (16%) patients experienced occasional acid regurgitation symptoms; however, no anti-acid medication was required. A significant decrease in the prevalence of erosive esophagitis (80 vs. 17%) after LNFGP was observed. The mean weight loss was 9.7, 14.1, 17.9, and 18.1% at 1, 3, 6 and 12 months, respectively. The mean BMI decreased to 30.8 kg/m(2) 1 year post surgery with a mean body weight loss of 25 kg.

CONCLUSIONS

LNFGP appears to be an acceptable treatment option for treating GERD in morbidly obese patients who refuse Roux-en-Y gastric bypass. However, further study is indicated to verify this novel procedure.

Gastroesophageal Reflux Symptoms After Laparoscopic Sleeve Gastrectomy for Morbid Obesity. The Importance of Preoperative Evaluation and Selection

Background:

Gastroesophageal reflux disease (GERD) is prevalent in morbidly obese patients, and its severity appears to correlate with body mass index (BMI).

Aim:

The aim of this study is to investigate the status of GERD after laparoscopic sleeve gastrectomy (LSG).

Materials and Methods:

A prospectively maintained database of all the patients who underwent LSG from February 2008 to May 2011 was reviewed.

Results:

A total of 131 patients were included. The mean age and the BMI of the patients were 49.4 years and 48.9 kg/m², respectively. Prior to LSG, subjective reflux symptoms were reported in 67 (51%) patients. Anatomical presence of hiatal hernia was endoscopically confirmed in 35 (52%) patients who reported reflux symptoms prior to LSG. All these patients underwent simultaneous hiatal hernia repair during their LSG. The overall mean operative time was 106 min (range: 48-212 min). There were no intra- and 30-day postoperative complications. Out of the 67 preoperative reflux patients, 32 (47.7%) reported resolution of their symptoms after the operation, 20 (29.9%) reported clinical improvement, and 12 (22.2%) reported unchanged or persistent symptoms. Three patients developed new-onset reflux symptoms, which were easily controlled with proton pump inhibitors. No patient required conversion to gastric bypass or duodenal switch because of the severe reflux symptoms. At 18 months, the follow-up data were available in 60% of the total patients.

Conclusion:

LSG results in resolution or improvement of the reflux symptoms in a large number of patients. Proper patient selection, complete preoperative evaluation to identify the presence of hiatal hernia, and good surgical techniques are the keys to achieve optimal outcomes.

Gastroesophageal reflux disease in the obese: Pathophysiology and treatment

Obesity is a condition that has increased all over the world in the last 3 decades. Overweight and gastroesophageal reflux disease (GERD) are related. GERD may have different causative factors in the obese compared with lean individuals. This review focuses on the proper treatment for GERD in the obese based on its pathophysiology. Increased abdominal pressure may play a more significant role in obese subjects with GERD than the defective esophagogastric barrier usually found in nonobese individuals. A fundoplication may be used to treat GERD in these individuals; however, outcomes may be not as good as in nonobese patients and it does not act on the pathophysiology of the disease. All bariatric techniques may ameliorate GERD symptoms owing to a decrease in abdominal pressure secondary to weight loss. However, some operations may lead to a disruption of natural anatomic antireflux mechanisms or even lead to slow gastric emptying and/or esophageal clearance and thus be a refluxogenic procedure. Roux-en-Y gastric bypass decreases both acid and bile reflux from the stomach into the esophagus. On the other hand, gastric banding is a refluxogenic operation, and sleeve gastrectomy may show different outcomes based on the anatomy of the gastric tube.

Gastroesophageal reflux disease after bariatric procedures

GERD is a significant comorbidity in bariatric patients preoperatively and postoperatively. Surgeons should be aware of appropriate evaluation, procedures choices, and management options. Revision surgery for reflux symptoms is common and appropriate anatomy and outcomes should be considered when offering these interventions to our patients. Patient selection is important to ensure avoiding postoperative development or worsening of GERD.

Refractory gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a condition that develops when the reflux of stomach contents into the esophagus causes troublesome symptoms, esophageal injury, and/or complications. Use of proton pump inhibitors (PPI) remains the standard therapy for GERD and is effective in most patients. Those whose symptoms are refractory to PPIs should be evaluated further and other treatment options should be considered, according to individual patient characteristics. Response to PPIs could be total (no symptoms), partial (residual breakthrough symptoms), or absent (no change in symptoms). Patients experiencing complete response do not usually need further management. Patients with partial response can be treated surgically or by using emerging endoscopic therapies. Patients who exhibit no response to PPI need further evaluation to rule out other causes.