Fundoplication with extensive dissection of the esophagogastric junction: Lessons learned and outcomes from 178 consecutives patients

INTRODUCTION

Antireflux surgery is commonly associated with significant recurrence and complication rates, and several surgical techniques have been proposed to minimize them. The aim of this study is to evaluate the results of a fundoplication with extensive dissection of the esophagogastric junction 1 and 3 years after the procedure.

METHODS

Retrospective observational study including 178 patients with gastroesophageal reflux disease or hiatal hernia who underwent fundoplication with extensive dissection of the esophagogastric junction between 2015 and 2020. Hernia recurrence, symptoms and quality of life at 1 and 3 years after surgery were assessed by barium transit, endoscopy and questionnaires for symptoms and quality of life (GERD-HRQL).

RESULTS

Heartburn rate was 7.5% and 10.7% at 1 and 3 years respectively, regurgitation 3.8% and 6.9% and dysphagia was 3.7% and 7.6%. The presence of hiatal hernia was evident preoperatively in 55.1% and in 7.8% and 9.6% at follow-up and the median GERD-HRQL scale was 27, 2 and 0 respectively. There were no cases of slippage of the fundoplication or symptoms suggestive of vagal injury. No differences were found when comparing the different types of fundoplication in terms of reflux and recurrence or complications.

CONCLUSIONS

Fundoplication with extensive dissection of the esophagogastric junction contributes to correct positioning and better anchorage of the fundoplication, which is associated with low rates of hiatal hernia and reflux recurrence, as well as absence of slippage and lower possibility of vagal injury.

Fenotipos de la enfermedad por reflujo gastroesofágico: una visión basada en su fisiopatología

The advancement of knowledge in pathophysiology and underlying etiologies of gastroesophageal reflux disease (GERD) has allowed the development of the concept of disease beyond the acidity of reflux. The variability in the symptom presentation and the response to treatment cannot be attributed only to reflux composition, since esophageal factors, such as structural, mechanical, biochemical, and physiological aspects, play an important role. The proposed personalized approach to GERD uses a stepwise approach that optimizes performance and phenotypic outcome while minimizing invasiveness, risk, and cost. Throughout the staggered approach to determine the GERD phenotype, clinicians may choose to stop further testing and continue treatment if available information identifies a different GERD phenotype. Since not all phenotypes GERD are the same and not all treatments are appropriate for all patients, therapeutic strategies must be personalized according to their phenotype.

Efficacy and safety comparative study of dexrabeprazole vs. esomeprazole for the treatment of gastroesophageal reflux disease

INTRODUCTION

A national survey in the general population showed that gastroesophageal reflux disease (GERD) is highly prevalent in Mexico.

OBJECTIVE

To compare the efficacy and safety of two isomers, dexrabeprazole (10 mg) vs. esomeprazole (20 mg), in the treatment of GERD for four weeks.

METHODS

Randomized, multicenter, prospective, double-blind phase III clinical trial in two groups that included 230 patients.

RESULTS

A statistically significant decrease in the severity of GERD symptoms (heartburn, regurgitation, epigastric pain and dysphagia), evaluated using a visual analogue scale, was observed with both treatments. Mean score for dexrabeprazole on Carlsson-Dent questionnaire at 28 days was 2.12, and for esomeprazole, 3.02. Both treatments were effective, with no statistically significant difference being recorded (p < 0.05). On SF-36 health questionnaire, both were observed to improve the quality-of-life score, with no significant difference being identified. Both drugs were well tolerated, and the adverse event incidence profile was low.

CONCLUSIONS

In the treatment of non-erosive GERD, the use of dexrabeprazole at 10 mg/day is as effective as esomeprazole 20 mg/day, with the advantage that the dose is lower with an appropriate safety profile.

Degree of concordance on the management of patients with gastroesophageal reflux disease. A study among specialists that are members of the Sociedad Latinoamericana de Neurogastroenterología (SLNG)

INTRODUCTION AND AIMS

Due to its different clinical manifestations, gastroesophageal reflux disease (GERD) requires diverse diagnostic and therapeutic interventions. The aim of the study was to evaluate the degree of agreement among Latin American specialists, with respect to the management of GERD.

MATERIALS AND METHODS

A cross-sectional study was conducted through a survey with 42 statements (22 related to diagnosis and 20 to treatment) applied to 56 specialists from Latin America. There were 4 possible statement responses: in complete agreement, in partial agreement, in partial disagreement, and in complete disagreement. Reproducibility, level of agreement, and concordance were measured through the Kappa statistic.

RESULTS

The response rate was 81% (47/56). General concordance was low, given that there was complete concordance in only 12 statements (28.6%). There was partial concordance in 22 statements (52.4%) and no concordance in 8 (19%). The following themes had the most disagreement: the performance of endoscopy before beginning treatment, the use of proton pump inhibitors (PPIs) in patients with extraesophageal symptoms and with no typical symptoms, and the combined use of PPIs and prokinetics.

CONCLUSIONS

In the present study, we found that there was agreement among the Latin American specialists for the diagnosis and management of GERD in less than one-third of the recommendations considered standard. The low concordance could be related to the fact that the availability of diagnostic tools and medications, as well as the prevalence of GERD phenotypes, are different in each country.

Degree of concordance on the management of patients with gastroesophageal reflux disease. A study among specialists that are members of the Sociedad Latinoamericana de Neurogastroenterología (SLNG)

INTRODUCTION AND AIMS

Due to its different clinical manifestations, gastroesophageal reflux disease (GERD) requires diverse diagnostic and therapeutic interventions. The aim of the study was to evaluate the degree of concordance among Latin American specialists, with respect to the management of GERD.

MATERIALS AND METHODS

A cross-sectional study was conducted through a survey with 42 statements (22 related to diagnosis and 20 to treatment) applied to 56 specialists from Latin America. There were 4 possible statement responses: in complete agreement, in partial agreement, in partial disagreement, and in complete disagreement. Reproducibility, level of agreement, and concordance were measured through the Kappa statistic.

RESULTS

The response rate was 81% (47/56). General concordance was low, given that there was complete concordance in only 12 statements (28.6%). There was partial concordance in 22 statements (52.4%) and no concordance in 8 (19%). The following themes had the most disagreement: the performance of endoscopy before beginning treatment, the use of proton pump inhibitors (PPIs) in patients with extraesophageal symptoms and with no typical symptoms, and the combined use of PPIs and prokinetics.

CONCLUSIONS

In the present study, we found that there was agreement among the Latin American specialists for the diagnosis and management of GERD in less than one-third of the recommendations considered standard. The low concordance could be related to the fact that the availability of diagnostic tools and medications, as well as the prevalence of GERD phenotypes, are different in each country.

Impact of head of bed elevation in symptoms of patients with gastroesophageal reflux disease: a randomized single-blind study (IBELGA)

BACKGROUND

The clinical impact of head-of-bed elevation in patients with gastro-oesophageal reflux disease is unclear, because of inconsistency and methodological limitations of previous studies.

PATIENTS AND METHODS

A randomised single-blind single-centre controlled clinical trial with a 2x2 cross-over design, in 39 pharmacologically treated patients with gastro-oesophageal reflux disease. Active intervention was to use a head-of-bed-elevation of 20cm for 6 weeks and then to sleep without inclination for 6 additional weeks, with a wash-out of 2 weeks between periods. The primary outcome was a change ≥10% in RDQ score and secondary outcomes were a change ≥10% in SF-36 score, patient preference and frequency of adverse events.

RESULTS

27 (69.2%) patients who used the intervention reached the primary outcome vs 13 (33.3%) patients in the control group (RR: 2.08; 95 CI%: 1.19 - 3.61). No effect was found in SF-36 score (RR: 1.11; 95% CI: 0.47 - 2.60). Preference favouring the intervention was 77.1% and adverse event proportion was 54.0%.

CONCLUSION

Head-of-bed elevation improved reflux symptoms but there was no effect on quality of life. The finding of a non-optimal risk-benefit ratio warrants additional studies before this intervention can be recommended (IBELGA, ClinicalTrials.gov identifier NCT02706938).

Expression of metalloproteinase-9 in patients with mild and severe forms of gastroesophageal reflux disease

Background

Gastroesophageal reflux disease develops when the stomach contents causes troublesome symptoms and complications. Mild forms are non-erosive and erosive esophagitis, and severe forms are Barrett's esophagus and Esophageal adenocarcinoma. Matrix metalloproteinases are endopeptidases that can degrade components of the extracellular matrix, they play an important role in tumor invasion as well as in metastasis.

Objective

To correlate the expression of metalloproteinase 9 (MMP-9) in esophageal biopsies from patients with mild and severe forms of Gastroesophageal reflux disease.

Method

Cross-sectional study. The expression of MMP-9 was determined in biopsies of esophageal tissue of patients with mild and severe GRD. The included variables were age, sex, diagnosis, smoking and alcoholic habits, body mass index (BMI) and expression of MMP-9. Descriptive statistics was performed, Kappa for concordance in diagnosis as well as X2.

Results

There were 50 patients, 32 (64%) men and 18 (36%) women, mean age 52.13 ± 14.75 years of age. 12 (24%) with smoking and 7 (14%) with alcoholism. Average BMI was 26.71 ± 4.07 kg/m² (15 to 33); 40 (80%) with obesity. The inter observer concordance for histopathological diagnosis was 1.0 and 0.84 for esophagitis degrees. 27 (54%) patients had esophagitis, 16 (32%) Barrett's esophagus and 7 (14%) esophageal cancer. There was expression of MMP-9 in four patients with esophagitis, five with Barrett's esophagus and five with esophageal cancer. Statistical significance was found between the expression of MMP-9 and smoking (p = 0.011) and histopathological diagnosis (p = 0.052).

Conclusions

The expression of MMP-9 is most common in severe forms compared to the mild forms of GRD.

Modified inspiratory muscle training (m-IMT) as promising treatment for gastro-oesophageal reflux disease (GERD)

BACKGROUND

Gastro-oesophageal reflux disease (GERD) is one of the most common diseases, but is still a challenge to cure. Different medical treatments are used, first of all Proton pump inhibitors (PPIs), however these are sometimes ineffective and long-term intake can lead to underestimated complications. Recently, some studies investigated the role of inspiratory muscle training (IMT) in the medical treatment of GERD. It seems that IMT is able to increase the pressure generated by the lower oesophageal sphincter (LES), reduce spontaneous releases of LES, acid exposure, use of PPIs, and improve symptoms and quality of life for GERD patients.

OBJECTIVE

The aim of this study was to evaluate the effectiveness of IMT in association with myofunctional therapy exercises of swallowing set by Daniel Garliner (m-IMT) on the symptoms of patients with non-erosive gastro-oesophageal reflux disease (NERD).

METHODS

Twenty-one adult patients with NERD were enrolled from May to December 2017 and performed m-IMT over a period of 4 weeks. Before and after treatment, all the patients completed the following questionnaires: GERD oesophageal symptomatology (GERDQ), extra-oesophageal GERD symptomatology (RSI), quality of life (GERD-Health Related Quality of Life Questionnaire (GERD-HRQL), and underwent laryngeal endoscopy.

RESULTS

Nineteen patients completed m-IMT. GERDQ (from 8.36±3.94 to 1.7±3.41; p<.05), RSI (from to 21.68±10.26 to 6.93±8.37; p<.05) and GERDHRQL (from 25.68±16.03 to 8.4±11.06; p<.05) the questionnaire scores significantly reduced after treatment. In addition, the laryngeal endoscopy score greatly improved (from 14.24±4.15 to 7.4±1.77; p<.05).

CONCLUSIONS

m-IMT is a low cost therapy without side effects. It could be useful in association with PPI or alone for selected GERD cases and for mild NERD forms, in association with diet. Further studies are required to prove the effects of m-IMT on GERD symptoms and decide the best treatment schedule.

Risk factors associated with gastroesophageal reflux disease relapse in primary care patients successfully treated with a proton pump inhibitor

BACKGROUND

There are no studies on the factors associated with gastroesophageal reflux disease (GERD) relapse in primary care patients.

AIM

To identify the risk factors associated with GERD relapse in primary care patients that responded adequately to short-term treatment with a proton pump inhibitor.

PATIENTS AND METHODS

A cohort study was conducted that included GERD incident cases. The patients received treatment with omeprazole for 4 weeks. The ReQuest questionnaire and a risk factor questionnaire were applied. The therapeutic success rate and relapse rate were determined at 4 and 12 weeks after treatment suspension. A logistic regression analysis of the possible risk factors for GERD relapse was carried out.

RESULTS

Of the 83 patient total, 74 (89.16%) responded to treatment. Symptoms recurred in 36 patients (48.64%) at 4 weeks and in 13 patients (17.57%) at 12 weeks, with an overall relapse rate of 66.21%. The OR multivariate analysis (95% CI) showed the increases in the possibility of GERD relapse for the following factors at 12 weeks after treatment suspension: basic educational level or lower, 24.95 (1.92-323.79); overweight, 1.76 (0.22-13.64); obesity, 0.25 (0.01-3.46); smoking, 0.51 (0.06-3.88); and the consumption of 4-12 cups of coffee per month, 1.00 (0.12-7.84); citrus fruits, 14.76 (1.90-114.57); NSAIDs, 27.77 (1.12-686.11); chocolate, 0.86 (0.18-4.06); ASA 1.63 (0.12-21.63); carbonated beverages, 4.24 (0.32-55.05); spicy food 7-16 times/month, 1.39 (0.17-11.17); and spicy food ≥ 20 times/month, 4.06 (0.47-34.59).

CONCLUSIONS

The relapse rate after short-term treatment with omeprazole was high. The consumption of citrus fruits and NSAIDs increased the possibility of GERD relapse.

Post-fundoplication symptoms and complications: Diagnostic approach and treatment

Laparoscopic Nissen fundoplication is currently considered the surgical treatment of choice for gastroesophageal reflux disease (GERD) and its long-term effectiveness is above 90%. Adequate patient selection and the experience of the surgeon are among the predictive factors of good clinical response. However, there can be new, persistent, and recurrent symptoms after the antireflux procedure in up to 30% of the cases. There are numerous causes, but in general, they are due to one or more anatomic abnormalities and esophageal and gastric function alterations. When there are persistent symptoms after the surgical procedure, the surgery should be described as "failed". In the case of a patient that initially manifests symptom control, but the symptoms then reappear, the term "dysfunction" could be used. When symptoms worsen, or when symptoms or clinical situations appear that did not exist before the surgery, this should be considered a "complication". Postoperative dysphagia and dyspeptic symptoms are very frequent and require an integrated approach to determine the best possible treatment. This review details the pathophysiologic aspects, diagnostic approach, and treatment of the symptoms and complications after fundoplication for the management of GERD.

Oesophageal disease: gastroesophageal reflux disease, Barrett's oesophagus, achalasia and eosinophilic oesophagitis

The most interesting conclusions and/or advances presented at Digestive Disease Week 2016 were the following: a) gastroesophageal reflux disease: proton pump inhibitor-refractory reflux disease is frequently associated with poor treatment adherence, psychiatric comorbidities and functional gastrointestinal disorders. These possible entities should be investigated in all cases of proton pump inhibitor-refractory reflux disease; b) Barrett's oesophagus: the efficacy of screening remains unclear; however, new minimally-invasive techniques such as the cytosponge allow more effective detection, both of Barrett's oesophagus and Barrett's oesophagus-associated dysplasia or neoplasia; c) achalasia: evidence indicates that peroral endoscopic myotomy is as effective as surgery and is a safer alternative; d) eosinophilic oesophagitis: high-dose proton pump inhibitors are required to rule out proton pump inhibitor-responsive eosinophilic oesophagitis; montelukast is not clearly effective in the treatment of eosinophilic oesophagitis, although moderate efficacy cannot be ruled out.

Comparison of the Carlsson-Dent and GERD-Q questionnaires for gastroesophageal reflux disease symptom detection in a general population

INTRODUCTION

Gastroesophageal reflux disease (GERD) is an extremely common pathology in the general population and one of the main reasons for consultation in gastroenterology. There are different instruments for detecting its symptoms, but few studies comparing one tool with another have been conducted in Mexico.

AIMS

To compare the effectiveness of the Carlsson-Dent questionnaire (CDQ) and the GERD-Q questionnaire (GQQ) in detecting GERD symptoms in a general population.

MATERIALS AND METHODS

A prospective, descriptive, cross-sectional study was conducted on 220 individuals in an open population within the time frame of May-June 2015. The subjects were evaluated through the self-assessment CDQ and GQQ. The positive scores from the CDQ (≥ 4) were compared with those of the GQQ (≥ 8), to determine which of the two instruments more easily detected patients with GERD symptoms.

RESULTS

Fifty-seven percent of the patients were men and the mean patient age was 38.1 years. Fifty percent of the subjects presented with GERD symptoms with a positive score in at least one questionnaire; 45% had positive CDQ results and 23% had positive GQQ results. Fifty-seven percent of the patients with a positive CDQ score presented with overweight/obesity, as did 72% of the patients with a positive GQQ result. Finally, 20% of the individuals had positive results for reflux symptoms in both questionnaires.

CONCLUSIONS

There was a prevalence of GERD symptoms in 50% of the individuals studied from a general population. The GQQ detected a greater number of GERD symptoms in patients that presented with overweight/obesity and the CDQ was considered easier for patients to understand and answer. It is striking that there was only 20% agreement between the two questionnaires, suggesting that they may be useful for identifying GERD symptoms in different populations.

[Oesophageal diseases: gastroesophageal reflux disease, Barrett's disease, achalasia and eosinophilic oesophagitis]

The most important novel findings presented on oesophageal disease in DDW 2015 were the following: 1) GERD: a) hypervigilance seems to be a key pathogenic factor in reflux symptoms refractory to PPI; b) post-reflux swallowing-induced peristaltic waves could be an excellent diagnostic criterion for GERD; c) laryngeal pH-metry is not useful in the diagnosis of extra-oesophageal symptoms; d) the recommendation of weight loss adequately recorded in the clinical reports of patients with GERD and obesity or overweight is an excellent quality indicator and is associated with better outcomes. 2) Barrett's oesophagus: a) persistent low-grade dysplasia in more than one endoscopy and a diagnosis of "indefinite for dysplasia" are associated with a high risk of neoplastic progression; b) narrow-band imaging allows areas of dysplasia on Barrett's oesophagus to be identified with high sensitivity and specificity; c) initial endoscopy fails to identify a high percentage of advanced neoplasms in Barrett's oesophagus. Early re-endoscopy should be considered; d) endoscopists specialized in Barret's oesophagus obtain a much higher yield in the diagnosis of advanced lesions. Patients at high risk-men, older patients, smokers and those with long-segment Barrett's oesophagus-could benefit from follow-up in a referral center. 3) Achalasia: POEM seems safe and effective, independently from patient characteristics (age, comorbidity) and the technical variations used. 4) Eosinophilic esophagitis: topical budesonide and exclusion diets are reasonably effective in PPI non-responders.

Clinical assessment and health-related quality of life in patients with non-cardiac chest pain

INTRODUCTION

Non-cardiac chest pain (NCCP) is mainly related to oesophageal disease, and in spite of being a common condition in Mexico, information regarding it is scarce.

AIM

To assess the clinical characteristics and health-related quality of life of patients with NCCP of presumed oesophageal origin.

MATERIAL AND METHODS

Patients with NCCP of presumed oesophageal origin with no previous treatment were included in the study. Associated symptoms were assessed and upper gastrointestinal endoscopy and 24-hour oesophageal pH monitoring were performed to diagnose gastroesophageal reflux disease, while oesophageal manometry was used to determine oesophageal motility disorders. The SF-36 Health-Related Quality of Life (HR-QoL) questionnaire was completed and its results compared to a control group without oesophageal symptoms.

RESULTS

The study included 33 patients, of which 61% were women, and the mean age was 46.1 (±11.6) years. Causes of NCCP were gastroesophageal reflux disease in 48%, achalasia in 34%, and functional chest pain in 18%. The average progression time for chest pain was 24 (2-240) months, with ≤ 3 events/week in 52% of the patients. The most frequent accompanying symptoms were: regurgitation (81%), dysphagia (72%) and heartburn (66%). Patients with NCCP show deterioration in HR-QoL compared to the control group (P=.01), regardless of chest pain aetiology. The most affected areas were general perception of health, emotional issues, and mental health sub-scale (P>0.05).

CONCLUSIONS

In our population, patients with NCCP show deterioration in HR-QoL regardless of the aetiology, frequency, and accompanying symptoms.

[What is the utility of proton pump inhibitor testing in non-cardiac chest pain?]

BACKGROUND AND AIMS

Noncardiac chest pain (NCCP) often represents a diagnostic and therapeutic challenge. Given that gastroesophageal reflux disease (GERD) is the most common cause of NCCP, initial treatment with proton-pump inhibitors (PPI) has been proposed for all patients (PPI testing), reserving esophageal function testing solely for non-responders. The aim of the present study was to provide evidence on the clinical utility of PPI testing with high-dose pantoprazole in patients with NCCP.

PATIENTS AND METHODS

We carried out a study of diagnostic performance with a cohort design in patients with NCCP, who had been assessed by the Cardiology Service. All patients underwent upper endoscopy, esophageal manometry, and 24h esophageal pH monitoring before PPI testing with pantoprazole 40 mg every 12h for 1 month. Before and after treatment, we assessed the severity (intensity and frequency) of chest pain, quality of life, and anxiety and depression by means of specific questionnaires. The diagnosis of GERD was based on a pathological finding of esophageal pH monitoring. A positive response to PPI testing was defined as an improvement in chest pain >50% compared with the baseline score after 1 month of PPI therapy.

RESULTS

We included 30 consecutive patients (17 men/13 women) with a mean age of 49 years. Of these 30 patients, 20 with NCCP had GERD (67%, 95%CI: 47%-83%). A positive response to PPI therapy was observed in 13 of the 30 (43%) patients with NCCP: 11 of the 20 (55%) patients in the GERD-positive group and 2 of the 10 (20%) in the GERD-negative group. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of PPI testing was 55%, 80%, 85%, 47% and 63%, respectively. A significant reduction in chest pain after pantoprazole therapy (P=.003) and a slight non significant improvement in anxiety and depression was achieved in the GERD-positive group as compared to the GERD-negative group.

CONCLUSIONS

In NCCP, PPI testing with pantoprazole has a low sensitivity for the diagnosis of GERD, placing in doubt the strategy of reserving functional study to non-responders to antisecretory therapy. Esophageal function testing and accurate diagnosis would allow appropriate targeted therapy for all patients with NCCP.

[Implementation and evaluation of a blended learning course on gastroesophageal reflux disease for physicians in Latin America]

Integrating evidence-based clinical practice guidelines on gastroesophageal reflux disease into medical practice is of prime importance in Latin America, given its high prevalence in this region. The aim of this project was to implement and assess an educational intervention on gastroesophageal reflux disease, aimed at primary care physicians in Latin America, with contents based on current clinical guidelines. The course included initial activities, whether face-to-face or through distance learning, and a 2-month period of Internet study and interaction. A pilot test was carried out in Uruguay, which was then repeated in 5 countries (Mexico, Colombia, Venezuela, Argentina and again in Uruguay). A global template was designed, which was then adapted to each of the countries: this was done with the participation of local institutions and leaders. Local credits were given for recertification. Participation was free. Of 3,110 physicians invited to participate, 1,143 (36.8%) started the course. Of these, 587 (51.4%) accessed at least half the contents of the course and 785 (68.7%) took part in the clinical discussions. A total of 338 (29.6%) completed all the requirements of the course and received a certificate. Among physicians who took both the pre- and post-intervention knowledge tests, scores improved from 60 to 80% (P<.001). Ninety-two percent of planned changes in clinical practice were related to the pedagogic aims of the course. In conclusion, a multifaceted, 2-phase continuing education course was successfully imparted in Latin America, with an overall design that was adapted to each country. Determination of specific needs and the participation of national experts were fundamental to the success of the course.

[The Mexican consensus on gastroesophageal reflux disease. Part II]

OBJECTIVE

To update the themes of endoscopic and surgical treatment of Gastroesophageal Reflux Disease (GERD) from the Mexican Consensus published in 2002.

METHODS

Part I of the 2011 Consensus dealt with the general concepts, diagnosis, and medical treatment of this disease. Part II covers the topics of the endoscopic and surgical treatment of GERD. In this second part, an expert in endoscopy and an expert in GERD surgery, along with the three general coordinators of the consensus, carried out an extensive bibliographic review using the Embase, Cochrane, and Medline databases. Statements referring to the main aspects of endoscopic and surgical treatment of this disease were elaborated and submitted to specialists for their consideration and vote, utilizing the modified Delphi method. The statements were accepted into the consensus if the level of agreement was 67% or higher.

RESULTS

Twenty-five statements corresponding to the endoscopic and surgical treatment of GERD resulted from the voting process, and they are presented herein as Part II of the consensus. The majority of the statements had an average level of agreement approaching 90%.

CONCLUSION

Currently, endoscopic treatment of GERD should not be regarded as an option, given that the clinical results at 3 and 5 years have not demonstrated durability or sustained symptom remission. The surgical indications for GERD are well established; only those patients meeting the full criteria should be candidates and their surgery should be performed by experts.