SAGES

Reimagining surgical care for a healthier world

Multi-Society Consensus Conference on GERD

Re-Voting

1a) The panel recommends EGD, Manometry, and pH testing for all patients with esophageal symptoms of reflux undergoing pre-operative evaluation, however, patients with LA grade B or greater erosive esophagitis on endoscopy may not require pH testing to confirm the diagnosis of GERD.(Required)
1b) The panel recommends patients with extra-esophageal GERD symptoms or equivocal findings on essential testing require more diligent workup.(Required)
• Removed specific mentioning of Impedance testing
4a) The panel recommends adult patients with obesity and medically refractory GERD may benefit from either gastric bypass or fundoplication
    This is based on systematic review of the literature with meta-analysis:
  • Small desirable effects with bypass (Benefits)
    • Gastric Bypass had nearly equivalent to slightly better subjective reflux symptom resolution compared to fundoplication
  • Moderate undesirable effects with bypass (Harms)
    • Equivalent objective reflux recurrence
    • More perioperative complications (Clavien dindo grade 2+) occurred after bypass compared to fundoplication
  • However, the panel recognized that because this guideline was focused on the treatment of GERD, there are many potential additional benefits with gastric bypass. As such, despite the additional harms with bypass seen in the literature, either fundoplication or bypass could be offered for the treatment of GERD in patients who are also obese.
  • Of note, the patients included in these studies had a mean BMI of 46.2 in bypass patients and 34.7 in those that underwent fundoplication. Our manuscript highlights the additional consideration that patients with a higher BMI may require additional counseling before a decision is made.
(Required)
4c) The panel recommends adult patients with obesity and medically refractory GERD, who have failed previous fundoplication, may benefit from either gastric bypass or redo fundoplication
    This is based on systematic review of the literature with meta-analysis:
  • Small desirable effects with bypass (Benefits)
    • Gastric Bypass had nearly equivalent subjective reflux symptom resolution compared to redo fundoplication
    • Bypass also had slightly lower rates of recurrent hiatal hernias and nearly equivalent to slightly lower rates of PPI use postoperatively.
  • Moderate undesirable effects with bypass (Harms)
    • Bypass patients had slightly higher rates of subjective reflux recurrence compared to redo fundoplication
    • Bypass had higher rates of perioperative complications (Clavien dindo grade 2+) and significantly higher reoperative rates compared to redo fundoplication
  • Despite the additional harms with bypass seen in the literature, either redo fundoplication or bypass could be offered for the treatment of GERD in patients who are also obese.
(Required)