This document was reviewed and approved by the Board of Governors of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) in Feb 2010.
PreambleThe guidelines for the surgical treatment of gastroesophageal reflux disease (GERD) are a series of systematically developed statements to assist physicians and patient decisions about the appropriate use of laparoscopic surgery for GERD. The statements included in this guideline are the product of a systematic review of published literature on the topic, and the recommendations are explicitly linked to the supporting evidence. The strengths and weaknesses of the available evidence are highlighted and expert opinion sought where the evidence is lacking. This is an update of previous guidelines on this topic (last revision 06/2001) as new information has accumulated.
DisclaimerClinical practice guidelines are intended to indicate the best available approach to medical conditions as established by a systematic review of available data and expert opinion. The approach suggested may not necessarily be the only acceptable approach given the complexity of the healthcare environment. These guidelines are intended to be flexible, as the surgeon must always choose the approach best suited to the patient and to the variables at the moment of decision. These guidelines are applicable to all physicians who are appropriately credentialed regardless of specialty and address the clinical situation in question.These guidelines are developed under the auspices of SAGES, the guidelines committee and approved by the Board of Governors. The recommendations of each guideline undergo multidisciplinary review and are considered valid at the time of production based on the data available. New developments in medical research and practice pertinent to each guideline are reviewed, and guidelines will be periodically updated.
Literature Review MethodA large body of literature on the surgical treatment of GERD exists. A systematic literature search was performed on MEDLINE in March 2008. The search strategy was limited to adult English language articles and is shown in Figure 1.We identified 448 relevant articles. The abstracts were reviewed by four committee members (DS, WH, PR, GK) and divided into the following categories:
- Randomized studies, metaanalyses, and systematic reviews
- Prospective studies
- Retrospective studies
- Case reports
- Review articles
- Fundoplication versus medical treatment
- Laparoscopic versus open fundoplication
- Partial versus full fundoplication or partial versus partial
- Other technique
- Predictors of success
- Other articles
Levels of Evidence
|Level I||Evidence from properly conducted randomized, controlled trials|
|Level II||Evidence from controlled trials without randomization Cohort or case-control studies Multiple time series dramatic uncontrolled experiments|
|Level III||Descriptive case series, opinions of expert panels|
Limitations of the Available LiteratureDespite the availability of several randomized controlled trials and metaanalyses, most available studies are either prospective or retrospective reports. Several limitations exist in the examined literature. First, the general methodological quality of the available trials is low due to small patient numbers, inadequate trial design or methodology, lack of standardization, and lack of objective outcome assessment . Only a few studies report a power analysis and define a main outcome variable. Thus, the validity of several of the pooled analyses of the available metaanalyses is hampered by statistically significant heterogeneity related to small sample sizes. In addition, the reporting of outcomes varies significantly as does the follow-up period making it difficult to combine and compare such data. Furthermore, there are several differences in the surgical technique used that may directly impact the outcomes of interest and introduce bias into the reported outcomes. Finally, the majority of the studies do not report details on the expertise of their surgeons, and most have been conducted in single institutions making the generalization of their findings difficult.
IntroductionGERD has long been recognized as a significant public health concern. Heartburn afflicts nearly two thirds of US adults at some point in their lives, and accounts for 4 to 5 million physician office visits every year . This document outlines the indications for and surgical treatment of GERD. This document is not intended to debate the issues of medical or endoscopic management of GERD, which are well described in prior publications [4, 5].
DefinitionGERD was defined according to the Montreal consensus as “a condition which develops when the reflux of stomach contents causes troublesome symptoms and/or complications.” Symptoms were considered “troublesome” if they adversely affected an individual’s well being .From a surgical perspective, GERD is the failure of the antireflux barrier, allowing abnormal reflux of gastric contents into the esophagus . It is a mechanical disorder, which is caused by a defective lower esophageal sphincter (LES), a gastric emptying disorder, or failed esophageal peristalsis. These abnormalities result in a spectrum of disease ranging from symptoms only, such as “heartburn”, to esophageal tissue damage with or without subsequent complications including malignancy or airway disease. While the exact nature of the antireflux barrier is incompletely understood, the current view is that the LES, the diaphragmatic crura, and the phrenoesophageal ligament are key components [7, 8].
DiagnosisBefore considering surgery, objective documentation of gastroesophageal reflux is mandatory. This can often be achieved by flexible esophagoscopy. Endoscopic visualization of any “mucosal break”, defined as an area of slough or erythema clearly demarcated from adjacent normal-appearing mucosa , is considered objective proof of GERD in the appropriate clinical setting. This mucosal break is the minimum endoscopic lesion that is a reliable indicator of reflux esophagitis .In an appropriate setting, a peptic stricture is also acceptable evidence of GERD , as long as malignancy has been ruled out by multiple biopsies. Histological proof of Barrett’s esophagus is currently also considered objective evidence of GERD even though other very rare causes of Barrett’s esophagus may also exist [12, 13].In the absence of endoscopic evidence of reflux, the current gold-standard objective test to diagnose gastroesophageal reflux is the 24-hour ambulatory esophageal pH-metry. The variables with the highest sensitivity and specificity which are obtained from this test are: the total time with pH < 4 as recorded by a probe placed 5 cm above the LES, and a composite score (comprised of the following six variables: 1. total esophageal acid exposure time, 2. upright acid exposure time, 3. supine acid exposure time, 4. number of episodes of reflux, 5. number of reflux episodes lasting more than 5 minutes and 6. the duration of the longest reflux episode) . An alternative diagnostic modality to the 24-hour catheter-based pH-metry is the 48-hour wireless esophageal pH-monitoring probe (Bravo™, Medtronic, Shoreview, MN). The Bravo probe is considered equivalent to the catheter-based system, but no additional benefit has been realized by prolonging the study period to 48 hours [15, 16].
RecommendationBased on the available evidence, the diagnosis of GERD can be confirmed if at least one of the following conditions exists: a mucosal break seen on endoscopy in a patient with typical symptoms, Barrett’s esophagus on biopsy, a peptic stricture in the absence of malignancy, or positive pH-metry (Grade A).A newer test to objectively document gastroesophageal reflux is multichannel intraluminal esophageal impedance but the available evidence is insufficient to provide firm recommendations .
Indications for SurgeryWhen the diagnosis of reflux is objectively confirmed, surgical therapy should be considered in individuals who:
1) have failed medical management (inadequate symptom control, severe regurgitation not controlled with acid suppression, or medication side effects)OR
2) opt for surgery despite successful medical management (due to quality of life considerations, lifelong need for medication intake, expense of medications, etc.)OR
3) have complications of GERD (e.g., Barrett’s esophagus, peptic stricture) [18, 19]OR
4) have extra-esophageal manifestations (asthma, hoarseness, cough, chest pain, aspiration) [20-23].The coexistence of Barrett’s esophagus with gastroesophageal reflux symptoms is considered by many a clear indication for antireflux surgery . Surgical intervention for asymptomatic Barrett’s esophagus is more controversial, however. While the metaplastic changes of Barrett’s have been reported to regress to a greater degree in the post-surgical population compared with medically treated patients, to date there is no demonstrable improvement in esophageal adenocarcinoma rates [25, 26].
Preoperative WorkupThe aim of preoperative investigations is to select the appropriate reflux patients for surgical treatment in order to optimize outcomes. There is currently no consensus and significant variability among surgeons regarding which studies should be obtained before surgery and in what order.
- EGD: Is likely the one study that all patients should have preoperatively, as it can confirm the diagnosis of GERD or identify other etiologies of esophagogastric mucosal abnormalities and allows biopsies to be taken.
- pH-metry: Important for patients when the diagnosis of GERD cannot be confirmed on EGD or diagnostic uncertainty exists. A normal 24-hour intraesophageal pH study after an H2-blocker and proton pump inhibitor (PPI) free interval should strongly suggest an alternate diagnosis and lead to additional diagnostic investigations.
- Esophageal manometry: Frequently performed before surgery and advocated by many experts in order to identify conditions that might contraindicate fundoplication (such as achalasia) or modify the type of fundoplication according to a tailored approach based on esophageal motility. Nevertheless, there is no support in the literature for mandatory preoperative manometry [27-29], and there are numerous studies refuting the need for a tailored approach to fundoplication.
- Barium swallow: Frequently obtained test for better delineation of the anatomy. May be particularly valuable in patients with large hiatal hernias who have a shortened esophagus.
Medical Versus Surgical TreatmentTo date, seven randomized controlled trials with follow-up of these studies ranging from 1 to 10.6 years have compared surgical therapy with medical therapy for the treatment of GERD [31-37]. These studies strongly support surgery as an effective alternative to medical therapy [32-37] (level I) both for patients with good symptom control on medical therapy [32-37] and for those who achieve only partial symptomatic relief from PPIs  (level I).The majority of available studies also provide convincing objective evidence for the effectiveness of surgery. Based on pH metry and manometric data, fundoplication results in significantly less acid exposure and significantly increased LES pressure compared with medical therapy [32, 33, 38-40] (level I-III). The one level I study that failed to demonstrate differences in the duration of acid exposure was underpowered .Fundoplication has also been demonstrated to lead to improved or at least comparable quality of life to that of medically treated patients and is associated with high patient satisfaction rates [32, 33, 35, 36, 39] (level I-III). One study reported no difference or worse quality of life of postfundoplication patients if they were not taking acid reducing medications postoperatively  (level I).Regarding the use of acid reducing medications postoperatively, one level I evidence study reported it to be up to 62% of postfundoplication patients  (level I), whereas the majority of the available literature cites a much lower incidence (9% to 21%) up to 8 years after surgery [34, 41-45] (level I-III). Importantly, several studies have demonstrated that most patients who resume acid reducing medications postoperatively have no objective evidence for GERD recurrence on 24-hour pH studies [46, 47] (level II).There has been one randomized controlled trial evaluating cost between medical (omeprazole) and surgical therapy (open total and partial fundoplication) over a 5-year period . The study reported that total treatment costs in the medical group were significantly lower than for antireflux surgery in three European countries (Denmark, Norway, and Sweden) and higher in one (Finland)  (level I). One modeling study found that the cost equivalency point for medical and surgical therapy was at 10 years , whereas another still reported lower cost with medical therapy at 10 years  (level III).
RecommendationSurgical therapy for GERD is an equally effective alternative to medical therapy and should be offered to appropriately selected patients by appropriately skilled surgeons (Grade A). Surgical therapy effectively addresses the mechanical issues associated with the disease and results in long-term patient satisfaction (Grade A). For surgery to compete with medical treatment, it has to be associated with minimal morbidity and cost.
Surgical Technique, Learning Curves, and their Influence on OutcomeWhile the choice of technique for antireflux surgery has traditionally been based on anatomic considerations and the surgeon’s preference and expertise, this approach has been criticized in the literature as the lack of standardization makes outcome comparisons difficult. Recently, a randomized trial designed to compare medical and surgical therapy managed to standardize the Nissen fundoplication technique across several institutions and surgeons . Based on a consensus of 40 experienced foregut surgeons, the following standardized approach to Nissen fundoplication was followed: a) opening of the phrenoesophageal ligament in a left to right fashion, b) preservation of the hepatic branch of the anterior vagus nerve, c) dissection of both crura, d) transhiatal mobilization to allow approximately 3 cm of intraabdominal esophagus, e) short gastric vessel division to ensure a tension-free wrap, f) crural closure posteriorly with nonabsorbable sutures, g) creation of a 1.5 to 2-cm wrap with the most distal suture incorporating the anterior muscular wall of the esophagus, and h) bougie placement at the time of wrap construction . This standardization led to excellent postoperative outcomes comparable with medical treatment and included a 2% conversion rate, 3% postoperative complication rate, and a median postoperative length of stay of 2 days  (level I).The learning curve for laparoscopic antireflux surgery has been well documented in the literature with reports of increased failure rates , complications , reoperations , operative time , hospital days , and conversions to open surgery [53, 54] (level III) by less experienced surgeons. To minimize adverse outcomes as a result of the learning curve, studies have suggested that surgeons seek experienced supervision during their first 15-20 laparoscopic antireflux procedures  (level III). Nevertheless, good results have been reported by young surgeons after appropriate training in laparoscopic surgery [55, 56] (level II-III). The literature also suggests that reoperative antireflux surgery should be undertaken in high volume tertiary centers by experienced antireflux surgeons citing a decreased conversion rate compared with lower volume centers  (level II).
RecommendationThe standardization of antireflux surgery technique is highly desirable, as it has been shown to lead to good postoperative patient outcomes (Grade A). Like any other surgical procedure, laparoscopic antireflux surgery is subject to a learning curve, which may impact patient outcomes. Therefore, surgeons with little experience in advanced laparoscopic techniques and fundoplication in particular should have expert supervision during their early experience with the procedure to minimize morbidity and improve patient outcomes (Grade B). On the other hand, reoperative antireflux surgery should be performed in a high-volume center by an experienced foregut surgeon (Grade B).
Laparoscopic Versus Open Treatment of GERDTo date 12 randomized controlled trials and two metaanalyses have compared the results of open with laparoscopic fundoplication [58-78]. All but one of these trials compared open with laparoscopic Nissen fundoplication with some technical variations.Regarding immediate perioperative results, no study reported any mortality. In the most recent metaanalysis, perioperative morbidity was found to be significantly lower (65%) after laparoscopic compared with open fundoplication  (level I).The conversion rate to open surgery varied between 0 and 9.6% with the most recent randomized controlled trial reporting lower conversion rates (< 5%). Laparoscopic surgery was associated with longer operative duration (approximately 40 minutes) but also with significant reductions in the hospital stay (2.68 days) and in the return to normal activity (7.75 days) compared with the open approach  (level I).The two approaches have been demonstrated to have similar postoperative outcomes at the reported follow-up intervals (range 3 to 24 months) including reflux recurrence, dysphagia, bloating, and reoperation rates  (level I). Nevertheless, the most recent metaanalysis found a higher requirement for further surgery in the laparoscopic group even though treatment failures between the two techniques were comparable  (level I). Interestingly one randomized controlled trial that had shown significantly higher rates of reoperation after laparoscopic Nissen compared with open Nissen in the short term  did not find similar differences 5 years later  (level I). In another recent randomized controlled trial, the reoperation rate was similar; however, reoperation in the laparoscopic Toupet group was due to continued heartburn, and it was due to incisional hernias in the open Toupet group  (level I).Randomized studies investigating the immune system demonstrated significantly reduced white blood cells counts and serum C-reactive protein levels after laparoscopic fundoplication but no significant differences in serum cortisol levels indicative of the less invasive nature of the laparoscopic procedure [70, 74, 79, 80] (level I).
RecommendationBased on the available evidence that is of high quality (level I), laparoscopic fundoplication should be preferred over its open alternative as it is associated with superior early outcomes (shorter hospital stay and return to normal activities, and fewer complications) and no significant differences in late outcomes (failure rates) (Grade A). Nevertheless, antireflux surgeons should be aware that laparoscopic fundoplication takes longer to perform and has a higher incidence of reoperations at least in the short term (Grade A). Further study is needed to identify ways to minimize the incidence of reoperations after laparoscopic fundoplication.
Partial Versus Total FundoplicationEleven randomized controlled trials and two metaanalyses have investigated the differences between partial and total fundoplications and one randomized controlled trial between two partial fundoplications [1, 27, 59, 76, 81-94] (level I).A single perioperative death, for an incidence of 0.07% across all these studies, has been reported. This death was a consequence of esophageal injury resulting in mediastinitis. No differences in perioperative morbidity were found across all published studies by the two published metaanalyses [1, 59] (level I). In addition, no differences in the length of the operative procedure between partial (independent of type) and total fundoplication have been reported, with an average duration across studies of approximately 90 minutes.Regarding specific postoperative patient outcomes, a significantly higher incidence of postoperative dysphagia, bloating, flatulence, and reoperation rate has been found for total compared with partial fundoplication  (level I). On the other hand, no significant differences between the two types of procedures were noted in the incidence of esophagitis, heartburn, persisting acid reflux, in the proportion of patients experiencing a good or excellent long-term outcome, or in the proportion of patients with a Visick I or II score  (level I). Interestingly, the notion that the type of fundoplication should be tailored to esophageal motility [95, 96] (level III) has been challenged by several studies. The available evidence suggests that the outcomes of patients with esophageal dysmotility are not affected by the type of fundoplication [94, 97] (level I).Since there is significant inhomogeneity in the type of partial fundoplication evaluated in the available randomized controlled trials, we also report outcomes in three different categories: anterior versus total, posterior versus total, and anterior versus posterior fundoplication.
Anterior versus Nissen fundoplicationFour randomized controlled trials reporting on 457 patients with a follow-up ranging from 6 months to 10 years have been published [81, 88, 90, 98-100] (level I) that compare the laparoscopic anterior fundoplication with the laparoscopic Nissen fundoplication. Two studies included a 180 degree anterior fundoplication and the other two a 90 degree one. Based on the findings of these trials, the anterior fundoplication was associated with significantly less postoperative dysphagia according to at least one of the evaluated dysphagia parameters compared with the Nissen fundoplication even during long term follow-up (up to 10 years)  (level I). On the other hand, the anterior fundoplication was found to be less effective for reflux control (based on patient symptoms and objective tests) as more patients required reoperations for reflux control  (level I). Patient satisfaction ratings were similar between the groups in all studies up to 10 years after surgery  (level I). Whether there are differences between a 90- and a 180 degree fundoplication is unclear, as no comparative studies exist; however, Engstrom et al have suggested that the 90 degree is inadequate  (level I).
Toupet versus Nissen fundoplicationNine randomized controlled trials (including both open and laparoscopic techniques) with follow-up of 1 to 5 years have compared the Toupet fundoplication with the Nissen. [27, 82, 83, 85, 86, 91-94, 97, 102, 103] (level I). The majority of published studies have demonstrated lower dysphagia rates after Toupet fundoplication and no difference in heartburn control between the two procedures at follow up (level I). In addition, no differences have been demonstrated for any of the other outcome parameters. Interestingly, a very recent study that compared variable lengths of fundoplication (1.5 cm vs 3 cm) for both procedures demonstrated that the 3-cm Toupet achieved superior reflux control over the 1.5 cm Toupet without differences in postoperative dysphagia. The Nissen fundoplication length did not influence reflux control, but a trend for a higher dysphagia rate was noted with the 3-cm wrap compared with the 1.5 cm wrap at the 12 month follow up of this study.  (level I). Longer follow-up data are needed to confirm the long-term comparative effectiveness between the Toupet and Nissen fundoplications as the current level I evidence does not go beyond 5 years. This is especially important because retrospective studies suggest inferior long-term reflux control after Toupet [104, 105] (level III).
Anterior versus Toupet fundoplicationOne randomized controlled trial has compared two partial fundoplications, 120 degree anterior and 180 to 200 degree posterior [101, 106] (level I). This study followed 95 patients for 5 years (93% follow-up) and found that posterior fundoplication was superior to the anterior by achieving better reflux control without increased incidence of postoperative dysphagia. In addition, this study demonstrated statistically significantly higher PPI intake, more esophageal acid exposure, higher reoperation rates, and lower patient satisfaction after anterior fundoplication during long-term follow-up and concluded that an anterior repair cannot be recommended for GERD due to insufficient reflux control  (level I).
RecommendationBased on the available evidence that is of high quality (level I), partial fundoplication is associated with less postoperative dysphagia, fewer reoperations, and similar patient satisfaction and effectiveness in controlling GERD compared with total fundoplication up to five years after surgery (Grade A). Furthermore, a tailored approach to esophageal motility appears unwarranted (Grade B). Nevertheless, the paucity of long-term follow-up data that compare the effectiveness of the procedures makes it hard to recommend one type of fundoplication over the other especially in an era where the long-term effectiveness of surgical treatment for GERD is questioned. It should also be noted that a body of literature suggests that anterior partial fundoplication may be less effective in the long term (Grade B) and retrospective data suggests that partial fundoplication may not be as effective as total in the long run (Grade C). Nonetheless, the evidence suggests that surgeons appropriately trained in minimally invasive techniques that perform surgery for GERD may minimize postoperative dysphagia by choosing a partial fundoplication (Grade A) or a short total fundoplication (1 to 2 cm) over a large bougie (56 French) (Grade C) and maximize the effectiveness of the procedure by choosing a a total fundoplication (Grade C) or a longer (at least 3 cm) posterior fundoplication (Grade C). It should also be noted that there are regional differences in expert opinion and practice in the choice of fundoplication type for GERD with most North American experts choosing a total fundoplication due to concerns for the long term effectiveness of the procedure. Controlled studies that take into account these guidelines are needed.
Other Technical Aspects That May Influence OutcomesThe following technical issues and patient factors may influence the outcome of fundoplication and are discussed separately:
Short gastric vessel divisionFive randomized controlled trials have evaluated the impact of short gastric vessel division on outcomes following laparoscopic antireflux surgery. Evidence from these high quality studies suggests no difference in physiologic, symptomatic, and quality of life outcomes up to 10 years after surgery [107-111] (level I). Furthermore, division of short gastric vessels at the time of fundoplication has been found to increase operating time [107, 110-112] (level I-II), increase flatus production and epigastric bloating, and decrease the ability to vent air from the stomach [108, 109, 111] (level I). However, it must be mentioned that a previous review based on the data from all but the most recent randomized controlled trial gave a low grade recommendation due to the inconsistency of results  and expert opinion in North America advocates for routine division.
RecommendationsWhen the fundus can be wrapped around the esophagus without significant tension, no division of the short gastrics seems necessary (Grade A). Division should be undertaken when a tension-free fundopliaction cannot be accomplished (Grade B). It should also be noted that expert opinion in North America advocates for the routine division of the short gastric vessels to minimize tension (grade C).
Crural closureThere have been no randomized controlled trials comparing closure with no closure of the crura. Individual reports stress the benefits of posterior crural repair for satisfactory outcomes [114-116], but others report no difference in outcomes [27, 110, 117-119]. Several authors have reported selective crural closure based on the size of the hiatal opening, but no clinical comparisons exist [38, 40, 43, 45, 120-125]. One study recommended division of the short gastric vessels, posterior closure of the crura, and fixation of the wrap to the crus demonstrating significantly decreased incidence of wrap slippage and need for secondary intervention when following this approach  (level III). One randomized controlled trial compared the efficacy of anterior with posterior crural repair and reported no difference in the anterior or posterior closure groups in terms of postoperative dysphagia, heartburn, and overall satisfaction at 6 month follow-up. To achieve a similar dysphagia rate, however, more patients in the posterior closure group had to undergo a second surgical procedure  (level I).Other potential technical factors that may reduce the incidence of wrap migration related to crural closure have also been evaluated. The use of prosthetic mesh as a buttress to a posterior crural closure has been reported to significantly decrease intrathoracic wrap migration  (level I) with one report recommending tailoring the type of crural closure, suture alone, mesh buttress, or tension free mesh closure, based on the size of the hiatal surface area  (level II).Minimal esophageal dissection techniques have also been proposed and reported as an acceptable method for fundoplication  (level II) with reports of decreased wrap transmigration in the pediatric population related to this technique  (level III). Nevertheless, expert opinion suggests that, in the case of a short esophagus, a more extensive mediastinal mobilization is needed to increase the segment of intraabdominal esophagus (at least 2 to 3 cm) and thus decrease the chance of herniation (level III).
RecommendationsCrural closure should be strongly considered during fundoplication when the hiatal opening is large and mesh reinforcement may be beneficial in decreasing the incidence of wrap herniation (Grade B). Anterior crural closure may be associated with less postoperative dysphagia, but additional evidence is needed to provide a firm recommendation (Grade C).
Use of robotic surgeryThe use of robotic surgery has been reported to be safe and feasible with similar outcomes during up to 1 year follow-up compared with laparoscopic antireflux surgery [125, 129-133] (level I-II). Most of the five available randomized controlled trials have reported a significant increase in operating times and cost when the robot is used [125, 132, 133] (level I). Unfortunately, there are no clinical data comparing ergonomics and surgeon workload between these two approaches; however, level I data from simulator studies have shown less surgeon workload with the use of the robot .
RecommendationWhile robotic assistance can be safely and effectively used for fundoplication, its higher cost compared with conventional laparoscopy and similar short-term patient outcomes make it a less than ideal initial choice (Grade B). Nevertheless, further study regarding learning curves and surgeon workload with the robotic technique are needed before stronger recommendations can be made.
Antireflux surgery in the morbidly obese patientThere is a clear association between GERD and morbid obesity with the disease being more prevalent as the body mass index (BMI) increases [135-142]. The long-term effectiveness of fundoplication in obese individuals (BMI >30) has been questioned due to higher failure rates [143, 144] (level II-III) compared with normal weight patients. Nevertheless, others have reported equivalent outcomes in obese and normal weight individuals [145-148] (level II-III). The laparoscopic Roux-en-Y gastric bypass (LRYGB) is the most effective and advantageous treatment option for GERD in the morbidly obese patient [149, 150], since it treats GERD effectively and provides the additional benefit of weight loss and improvement in comorbidities and is therefore the procedure of choice by many experts [151-156] (level II-III). Laparoscopic Roux-en-Y gastric bypass has also been reported to be a feasible and efficacious treatment in morbidly obese patients who have previously undergone laparoscopic antireflux surgery, although it is technically demanding and has a higher morbidity  (level III). While adjustable gastric banding may also improve GERD symptoms, conflicting reports exist, and it is therefore not the procedure of choice for this indication [137, 158-161].
RecommendationDue to concerns for higher failure rates after fundoplication in the morbidly obese patient (BMI >35 kg/m2) and the inability of fundoplication to address the underlying problem (obesity) and its associated comorbidities, gastric bypass should be the procedure of choice when treating GERD in this patient group (Grade B). The benefits in patients with BMI > 30 is less clear and needs further study.
Use of esophageal dilatorsLevel I evidence suggests that the use of an esophageal dilator decreases the long-term incidence of dysphagia . The only available randomized controlled trial reported a significant decrease in the postoperative dysphasia rate at 11 months follow-up in patients who had a 56 French bougie placed at the time of surgery versus patients who did not have a bougie placed, and there was no difference in perioperative morbidity and mortality  (level I). There was, however, a 1.2% incidence of esophageal injury due to placement of the bougie  (level I).
RecommendationThe placement of an esophageal dilator during the creation of laparoscopic fundoplication is advisable as it leads to decreased postoperative dysphagia but should be weighed against a small risk of esophageal injury (Grade B). A 56 French bougie has been found to be effective but the evidence is limited (Grade C).
Predictors of Success
Preoperative patient compliance with antireflux medications One study examined the predictive value of self-reported preoperative compliance with medical treatment. Patients compliant with their preoperative medical treatment of GERD with PPI showed a statistically significant larger improvement in the postoperative gastrointestinal quality of life index than patients who were non-compliant preoperatively. In addition, non-compliant patients had higher rates of post-fundoplication dysphagia at 1 year follow-up.
AgeAge has not been found to significantly affect the outcomes of antireflux surgery. Besides a tendency for longer postoperative hospitalization, patients > 65 years of age can expect an excellent outcome after surgery in at least 90% of cases, similar to younger patients .
Postoperative “diaphragmatic stressors”Sudden increases in intra-abdominal pressure in the early postoperative period are thought to predispose a patient to anatomical failure of fundoplication. One study has suggested that early postoperative gagging, belching, and vomiting (especially when associated with gagging) are predisposing factors for anatomical failure and the need for revision  (level III). In addition, hiatal hernias >3 cm at original operation have been reported to be predictors for anatomic failure (level II).
Psychological disease and interventionWhile major depression has not been shown to influence objective physiologic outcomes of fundoplication, it appears to impact postoperative quality of life. In particular, quality of life scores have been shown to improve postoperatively in depressed patients but to a lesser extent than in healthy subjects. In addition, severe postoperative dysphagia and severe bloating were found to be statistically significantly more common in patients with major depression compared with healthy controls  (level II). One study concluded that a 270 degree partial fundoplication had better outcomes in patients with major depression compared with a 360 degree fundoplication due to a lower incidence of postoperative dysphagia and gas bloat syndrome  (level II).Cognitive behavioral therapy in the postoperative period has been shown to improve dysphagia and gastrointestinal symptoms such as flatulence and abdominal pain in patients with a preoperative diagnosis of anxiety  (level I).
Atypical symptomsPatients with atypical symptoms of GERD, such as chest pain, asthma, chronic cough, hoarseness, otitis media, atypical loss of dental enamel, idiopathic pulmonary fibrosis, recurrent pneumonia, and chronic bronchitis  are known to respond less well to fundoplication compared with patients with typical symptoms (heartburn and regurgitation)  (level II). For this reason, several investigators have sought ways to preoperatively predict the success of fundoplication performed for atypical symptoms. Of the factors examined, the best predictors have been found to be good symptom correlation with reflux episodes during combined esophageal multichannel intraluminal impedance and pH monitoring  (level II), and a positive Bernstein esophageal acid infusion test  (level II).
Esophageal functionA normal LES pressure on manometry has not been shown to be associated with increased rates of postoperative dysphagia [172, 173] (level II). Patients with nonspecific spastic esophageal motor disorders (such as nutcracker esophagus, hypertensive LES syndrome) have been reported to be at increased risk for postoperative heartburn, regurgitation, and dysphagia after a 360 degree wrap  (level II).
Patterns of refluxPatients with upright reflux are thought to have more maladaptive behaviors associated with their reflux, including aerophagia, regurgitation, and dyspepsia compared with patients who experience typical reflux when supine . Nevertheless, with the exception of one study that suggested that patients with upright reflux have an increased rate of gas bloat syndrome postoperatively , the preponderance of evidence suggests that laparoscopic Nissen fundoplication is equally effective regardless of the pattern of reflux [30, 175] (level II).
Response to preoperative PPISymptomatic response to preoperative PPI treatment has been shown to be an excellent predictor of symptomatic response to fundoplication. One study found that patients with no response to preoperative PPI administration had lower satisfaction rates after fundoplication compared with patients who had at least a partial response  (level II). However, non-response to PPI is not considered a contraindication to antireflux surgery  as studies have demonstrated very good success rates in these patients (level II).
Preoperative gastric emptyingIt has been suggested that delayed gastric emptying may affect postoperative gastric distension and overall surgical outcomes. However, one large prospective non-randomized trial showed no relationship between gastric emptying and outcome following fundoplication  (level II).
- Surgeons should be aware that fundoplication in patients demonstrating poor compliance with PPI therapy preoperatively or with poor response to preoperative PPI treatment is associated with poorer outcomes (Grade C).
- Age should not be considered a contraindication for antireflux surgery in otherwise acceptable operative candidates, as outcomes in this patient group are similar to outcomes of younger patients (Grade C).
- Care should be taken to minimize early postoperative severe gagging, belching, and vomiting as weak evidence suggests that they may lead to anatomical failure of fundoplication (Grade C).
- A partial wrap should be considered in patients with a preoperative diagnosis of major depression, as it may lead to better postfundoplication outcomes in this patient group that tends to have generally inferior outcomes (Grade C).
Revisional Surgery for Failed Antireflux ProceduresMost authors recommend the same surgical approach for the reoperative patient as for the primary procedure [2, 178-181] (level III). Multiple retrospective studies have evaluated the short- and long-term outcomes of revisional laparoscopic antireflux surgery with up to 12 years follow-up. Compared with primary repair, revisional surgery requires longer operative times and is associated with higher conversion rates to open surgery [179, 182] (level III), and higher complication rates (30 day mortality < 1%, esophagogastric perforations in 11 to 25% [179, 183], [gastric more often than esophageal perforation], pneumothorax in 7% to 18% [180, 184], splenic injuries in 2% , and vagal nerve injuries in 7%) [179, 180]. Nevertheless, postoperative dysphagia (3% to 17%) [179, 184-187] and gas bloat syndrome (5% to 34%) do not seem to be significantly higher after reoperation compared with primary repair. Patient satisfaction after reoperative laparoscopic antireflux surgery has been reported to be high (89%)  with resolution of heartburn symptoms in 68% to 89% of patients  and resolution of regurgitation in 83% to 88% [2, 181, 185] up to 18 months after revisional surgery. Nevertheless, up to 13% of patients may experience reflux recurrence at 3 months follow-up based on objective testing .
RecommendationsLaparoscopic reoperative antireflux surgery is feasible, safe, and effective but has higher complication rates compared with primary repair and should be undertaken only by experienced surgeons using a similar approach to primary fundoplication (Grade B).
OutcomesLaparoscopic antireflux surgery has proven to be a safe, effective, and durable treatment option for GERD (level I-III). Multiple studies have evaluated the short- and long-term outcomes of laparoscopic antireflux surgery with follow-up ranging up to 11 years [143, 188].
Response of typical GERD symptoms to antireflux surgeryTypical symptoms of gastrointestinal reflux disease improve in the majority of patients after surgery during short- [32, 36, 39, 42, 189-198] (level I-III) and long-term follow-up ( > 5 years) [31, 36, 37, 41, 42, 44, 47, 107, 109, 188, 199] (level I-III). Nevertheless, symptom control may be waning over time as studies  with shorter follow-up periods (3 years) report, in general, better symptom resolution (90%) than studies with longer term follow-up (67% of patients at 7-year follow-up [31, 37] (level I). Improvements have also been demonstrated for patients with Barrett’s esophagus , elderly patients , and patients with and without preoperative esophagitis .Following laparoscopic antireflux surgery, dysphagia has been reported to significantly improve from preoperative values [47, 188, 197, 198, 200-204] (level II-III). Despite reports of improved dysphagia following surgery, postoperative dysphagia remains a significant problem with reported reoperation rates ranging from 1.8 to 10.8% [33, 34, 38, 39, 143, 196, 205-207] (level I-III) and endoscopic dilatation rates ranging from 0 to 25% [34, 121, 143, 145, 189, 195, 196, 208-213] (level I-III). Although perioperative and early postoperative dysphagia have been reported as high as 76%  (level II), the majority of studies show early and mid dysphagia rates, up to 1 year postoperatively, less than 20% [33, 34, 38, 39, 44, 47, 120, 122, 189, 191, 192, 195, 196, 199, 200, 209, 210, 212, 214-221] (level I-III) and long-term rates around 5% to 8% [45, 109, 207, 222] (level I-II).Likewise, significant improvement in heartburn symptoms have been reported following laparoscopic antireflux surgery [47, 109, 110, 143, 188, 190, 193, 197, 198, 200-204, 209, 215, 221, 223, 224] (level I-III) with recurrence rates of ≤10% in the majority of studies [41, 47, 120, 143, 190, 196, 199, 203, 213, 215-217, 221, 225, 226] (level II-III). Regurgitation rates have also shown to be significantly improved following surgery with improvement rates of 87% to 97% reported [109, 143, 188, 190, 195, 198, 202, 203, 227] (level I-III). Although recurrent or new onset regurgitation has been reported in up to 23%  (level III) of patients following surgery, the majority of studies reported rates ranging from 0 to 11% [107, 109, 110, 143, 193, 196, 200, 201, 214-216, 221] (level I-III).
Response of atypical reflux symptoms to antireflux surgeryAtypical symptom improvement has been reported in 67% to 92% of patients after antireflux surgery [190, 193, 196, 209] (level II-III). Specifically, cough has been shown to significantly improve following laparoscopic antireflux surgery [20, 190, 193, 221, 223, 226] (level II-III) with cure rates of 53%  (level II), short-term improvement rates from 69% to100% [20, 221, 223, 226] (level II), and long-term improvement rates of 71%  (level II). Hoarseness [190, 193, 202, 221] (level II-III), sore throat [190, 193] (level II-III), and bronchitis [193, 202] (level III) have also been reported significantly improved following surgery. Improvement has also been reported for pulmonary symptoms [143, 196] (level II-III), aspiration [202, 206] (level III), and wheezing [190, 206] (level II-III) symptoms. While some reports have shown improvement in asthma [20, 193] (level II-III) and laryngitis  (level III) following antireflux surgery, others have reported no benefit [143, 202, 221] (level II-III).
Objective outcomesFunctional improvement, including a significant increase in LES pressure [32, 33, 38, 47, 122, 146, 198, 199, 215, 221, 223, 224, 226, 228-230] (level I-III) and a significant decrease in acid exposure [32-34, 38, 47, 120, 145, 146, 190, 198, 199, 203, 221, 223-225, 228-232] (level I-III) compared with preoperative values are documented in both short- and long-term studies, with pH studies returning to normal in approximately 88% to 94% of patients  (level II).
Postoperative complicationsComplication rates following antireflux surgery vary related to experience, technique, and degree and intensity of follow-up. Conversion rates to open surgery for laparoscopic antireflux surgery range from 0 to 24% [32-34, 39, 41, 43-45, 47, 59, 112, 120-125, 129-132, 145, 146, 157, 188, 195, 196, 198-200, 203, 204, 206, 208, 210, 212, 215, 219-222, 225-227, 229, 230, 232-241] (level I-III); however, most series from high-volume centers report conversion rates < 2.4% [32-34, 39] (level I).Specific intraoperative complications related to laparoscopic antireflux surgery include gastric and esophageal perforation and pneumothorax. The gastric and esophageal perforation rate varies according to technique and experience, with reported ranges from 0 to 4% [33, 34, 38, 44, 45, 47, 112, 120, 123-125, 146, 188, 196, 201, 214, 227, 236, 241, 242] (level I-III) and several authors reporting 0% in series with at least 50 patients [38, 47, 112, 124, 125, 146, 227] (level I-II). The highest incidence of perforation (4%) has been reported after redo fundoplication  (level III). Other authors studying techniques of laparoscopic antireflux surgery, specifically the thoracoscopic Belsey, have reported higher gastric and esophageal perforation rates (6.7% to 9.1%) [237, 243] (level III).Rates of pneumothorax during laparoscopic antireflux surgery in most series range from 0 to 1.5% [34, 38, 47, 112, 120, 124, 188, 195, 199, 214, 227, 228, 236, 241] (level I-III). Nevertheless, this complication rarely requires intervention as it is usually involves injury of the pleura but not the lung itself. Two series have evaluated the use of the robot and reported rates of 5% in the robot group  (level I) and 4% in the laparoscopic group  (level I).The duration of the operation is dependent on the technique used and has been reported to range from 49 to 210 minutes [43-45, 47, 120-122, 145, 146, 195-198, 200, 201, 203, 206, 208, 215, 219-221, 225, 226, 230, 241] (level I-III). A learning curve has been demonstrated with improved operating times as the number of cases increases [219, 220] (level II-III) and with high-volume centers reporting shorter operating room times (49 to 120 minutes) [33, 34, 38, 107, 110, 119, 124, 125, 130-133, 233] (level I). Length of stay following laparoscopic antireflux surgery ranges between 1 and 4 days [20, 33, 34, 38, 44, 47, 59, 120, 121, 123, 129, 145, 146, 188, 192, 195, 197, 198, 200, 202, 203, 206, 208-210, 214, 215, 220, 221, 225, 241] (level I-III). With regard to the effect of the learning curve on outcome, there is a marked paucity of data, with only one study being identified. The authors compared patient outcomes between the early and late experience of a single surgeon and reported that complication rates did not differ between his first 25 cases and a matched control group of 25 cases approximately 7 years later (level II). Nevertheless, during both periods, patients had high rates of dysphagia (23% vs 21% at 2 years), persistence of heartburn (27% vs 25%), and persistence of regurgitation (8% vs 12%) .Postoperative 30-day mortality has rarely been reported and is usually 0% [33, 34, 188, 190, 196, 204, 209] (level I-III). Complications related to incisions include wound infections, which are reported to range from 0.2% to 3.1% [38, 45, 188, 195, 199] (level II-III) and port-site hernias ranging from 0.17% to 9% [38, 109, 121, 122, 199, 204] (level I-II). Herniation of the wrap and wrap migration vary related to the technique used and the duration of follow-up and have been reported to range from 0.8% to 26% [32-34, 38, 44, 47, 132, 196, 199, 227, 233] (level I-III). One report demonstrated a significant decrease in the incidence of wrap herniation from 26% to 8% with the use of a mesh buttress at the hiatus  (level I). Reoperation rates also vary according to technique, indication, and follow-up and have been reported to range from 0 to 15% [32, 33, 39, 41, 43, 45, 47, 107, 109, 110, 112, 119, 121, 123, 145, 157, 188, 195, 196, 200, 201, 204, 214, 234, 241, 242] (level II-III).
Postoperative use of acid reducing medicationsThe resumption of acid reducing medications in patients after antireflux surgery has been reported to range widely (0 to 62%) at both short- and long-term follow-up [34, 107, 109, 123, 124, 130, 131, 234, 242], [31, 41-45, 47, 145, 189-191, 195, 196, 198-202, 204, 207, 209-212, 214, 215, 218, 224, 230, 244] (level I-III). Long-term medication use has been reported to range from 5.8% to 62% [31, 34, 41-44, 47, 107, 109, 196] (level I-III) with most studies reporting rates < 20% [41, 43, 44] (level II-III). One randomized controlled trial, however, reported a 62% incidence of antacid medication resumption after antireflux surgery,  which constitutes a very high rate compared with the rest of the literature.
Quality of life and satisfaction with surgerySatisfaction rates for surgery range from 62% to 97% [20, 41-43, 47, 122, 143, 145, 188, 190, 191, 196, 199, 204, 206-208, 211, 212, 221-223, 230, 241, 244] (level II-III) with long-term satisfaction rates (follow-up >5 years) ranging from 80% to 96% [41, 42, 45, 47, 143, 188, 196, 222] (level II-III). Additionally, 81% to 95% of patients, in both short- and long-term follow-up, stated that they would undergo surgery again [20, 42, 43, 47, 143, 188, 204, 206, 212, 223] (level II-III). Quality of life significantly improved after laparoscopic antireflux surgery in both early and long-term studies as documented from a variety of quality of life surveys including generic and disease-specific quality of life surveys [41-43, 189, 191-193, 197, 209, 213, 214, 224] (level II-III).
- Laparoscopic antireflux surgery is effective at restoring the mechanical barrier to reflux with significant improvements in the LES pressure and acid reflux exposure, can be performed safely with minimal perioperative morbidity and mortality, and leads to high patient satisfaction rates and improved quality of life (Grade A).
- Laparoscopic antireflux surgery is an effective treatment strategy for typical symptoms of GERD with significant improvements in rates of dysphagia, heartburn, and regurgitation and should be considered in appropriately selected patients and be performed by appropriately trained surgeons (Grade A).
- While atypical symptoms improve in a majority of patients after antireflux surgery, symptom persistence is higher compared with patients with typical symptoms and surgeons should therefore carefully select and counsel these patients preoperatively (Grade B).
- Patients undergoing laparoscopic antireflux surgery should be counseled preoperatively about the reported rates of symptom relapse and resumption of acid reducing medications (Grade A).
Barrett’s Esophagus and Antireflux Surgery
Definition and demographicBarrett’s esophagus is defined as a metaplastic change in which the squamous epithelium of the esophagus is replaced by a columnar epithelium containing goblet cells (intestinal metaplasia or IM). This metaplastic process is believed to be initiated by inflammation and injury induced by chronically refluxed acid and bile [245-248]. Barrett’s esophagus is present in 1.65% of the general population, 8.6% of symptomatic GERD patients presenting to a tertiary care center, and 10.8% of patients undergoing antireflux surgery [249-251]. Barrett’s esophagus (neoplasia not present) is associated with a significantly increased risk for developing esophageal adenocarcinoma (approximately 100 fold) over that of the general population [252, 253]. As intraepithelial neoplasia develops, the annual per patient risk for cancer increases further [245, 247, 248, 254-256].
Preoperative endoscopyUpper endoscopy should be performed as part of the preoperative work-up for antireflux surgery, as erosive esophagitis and Barrett’s esophagus are independent objective diagnostic criteria for GERD. A diagnosis of Barrett’s esophagus, depending on histological grade, may alter patient eligibility for and timing of antireflux surgery. When a columnar-lined esophagus is detected for the first time at preoperative endoscopy, four-quadrant biopsies are obtained from every 1-2 cm of the affected portion of the esophagus to confirm Barrett’s and determine its histological grade [245, 247, 257]. Endoscopic mucosal resection (EMR) may be used to remove eligible areas of nodularity or ulceration to rule out advanced neoplasia warranting immediate intervention (level II). If a patient has been diagnosed with Barrett’s before preoperative endoscopy, expert review of the prior pathology or repeat biopsy may be considered to confirm the histological grade before antireflux surgery (level III).
Histological assessment of Barrett’sThe histological features of biopsy specimens from a Barrett’s esophagus are graded according to the presence or absence of neoplasia; 1) no neoplasia (also known as non-neoplastic IM), 2) indefinite for neoplasia (IND), 3) low-grade intraepithelial neoplasia (LGIN), 4) high-grade intraepithelial neoplasia (HGIN), and intramucosal carcinoma (IMC). Standard, endoscopically-acquired biopsy specimens may not penetrate deeply enough into the esophageal wall to rule out involvement of the submucosa by cancer, therefore EMR or EUS may be indicated in cases suspicious for advanced neoplasia (level II). A finding of neoplasia prompts review by more than one expert pathologist to confirm the diagnosis and grade, given the interobserver variability reported for Barrett’s neoplasia [248, 257-260] (level I).
Impact of histology findings on antireflux surgery candidacy and timing of surgeryA finding of HGIN or adenocarcinoma on preoperative biopsy requires immediate attention and may delay (in the case of HGIN and IMC) or exclude (in the case of adenocarcinoma with submucosal invasion or deeper) antireflux surgery. Additional work-up for HGIN or adenocarcinoma may include chest CT, EUS and/or staging EMR (if visible lesion exists that is amenable to resection) [247, 257, 261-265] (level II).Adenocarcinoma involving the submucosa (or deeper) is managed with esophagectomy, radiation therapy, and/or chemotherapy, as indicated by tumor stage.HGIN and IMC have been historically managed with esophagectomy, although more recently certain endoscopic techniques (photodynamic therapy (PDT), EMR, and radiofrequency ablation (RFA)), alone and in combination, have been shown in randomized trials (as well as cohort trials and case series) to be safe and effective for complete histological eradication of the targeted lesion and for reducing the risk of neoplastic progression [264-285] (level I). Endoscopic techniques have become first-line therapy for HGIN and IMC at most centers (level III). If endoscopic therapy is elected, antireflux surgery may be delayed until complete eradication of the Barrett’s segment and accompanying neoplasia is achieved (level III).Non-neoplastic IM, IND or LGIN may be effectively treated with endoscopic eradication followed by long-term surveillance endoscopy (level I and II) or surveillance endoscopy alone (Level III). If surveillance alone is elected, antireflux surgery may be performed immediately. If endoscopic eradication is elected, antireflux surgery may be performed before, during or after ablative therapy (level III). Of the ablation modalities available, RFA has been shown to achieve high rates of complete histological eradication of IM, IND, and LGIN with an acceptable adverse event profile [277-285] (level I). Further, cost-utility studies show that ablative therapy is the preferred strategy over surveillance alone (all grades) and esophagectomy (HGIN) [286-289].
Antireflux surgery for Barrett’s esophagusThe goals of treatment for patients with Barrett’s esophagus are similar to those of patients with gastroesophageal reflux disease patients and include relief of symptoms and cessation of ongoing epithelial damage related to reflux.Despite numerous publications on the role of antireflux surgery in Barrett’s esophagus, there are few randomized controlled trials. In a recent review evaluating the randomized trials in the treatment of Barrett’s done by Faybush and Sampliner in 2005, only one randomized trial compared medical and surgical therapy. This study, by Parilla et al. , compared the results of Histamine 2 receptor antagonist (H2RA) and proton pump inhibitors (PPIs) versus open Nissen fundoplication with the outcome measure being preventing Barrett’s esophagus to progressing to dysplasia and adenocarcinoma. With a median follow-up of 5 years, they reported that the Barrett’s esophagus segment did not change during the treatment period with high grade dysplasia developing in 2 patients in each arm and no significantly differences between the two groups in terms of progression to dysplasia or malignancy . They concluded that surgery cannot be advocated as the treatment of choice in patients with Barrett’s esophagus and that PPI alone doesn’t eliminate the risk of dysplasia or adenocarcinoma  (level I).Since 2005, there have been other published studies evaluating surgical and medical treatment for Barrett’s esophagus. A non-randomized prospective study by Rossi et al. compared high dose PPIs versus laparoscopic Nissen fundoplication in patient with low-grade dysplasia and reported a significantly improved regression of Barrett’s esophagus in the surgical group  (level II).Recently, a randomized prospective trial comparing treatment outcomes in patients with and without Barrett’s esophagus submitted to laparoscopic antireflux surgery or PPI therapy reported clinical response to therapy at 3 years was similar in the Barrett’s esophagus compared with the non- Barrett’s esophagus group . They also reported similar symptom outcomes (Gastrointestinal Symptom Rating Scale [GSRS] and Quality of Life in Reflux and Dyspepsia [QOLRAD]) in the medical versus surgical treatment arms but reported improved control of reflux using pH data  (level I).
Surveillance of Barrett’s esophagus after antireflux surgeryMedical professional society guidelines recommend surveillance endoscopy with four-quadrant biopsies to detect neoplastic progression every 3 years for non-neoplastic IM, every 6-12 months for LGIN, and every 3 months for HGIN . In patients who have had successful complete eradication of Barrett’s esophagus, surveillance should continue according to their baseline Barrett’s histology grade until further evidence is available. Antireflux surgery does not change these recommended surveillance guidelines. Further, there is no evidence indicating that surveillance is more difficult or less effective after antireflux surgery [210, 216, 247, 292, 293].
- Detection of Barrett’s esophagus with adenocarcinoma involving the submucosa or deeper excludes the patient from anti-reflux surgery and demands comprehensive stage-specific therapy (esophagectomy, chemotherapy, and/or radiation therapy) (Grade A).
- HGIN and IMC can be effectively treated with endoscopic therapy including PDT, EMR and RFA, alone or in combination (Grade B). Anti-reflux surgery can be performed after achieving complete histological eradication of the lesion with endoscopic therapy (Grade C). Esophagectomy remains an option for HGIN and IMC, either as salvage in the case of endoscopic therapy failure or as primary therapy.
- Antireflux surgery may be performed in a patient with non-neoplastic IM, IND and LGIN; with or without endoscopic therapy to eradicate the Barrett’s tissue. Specifically, RFA has been shown to be safe, clinically effective, and cost-effective in these disease states and may be performed in eligible patients before, during, or after anti-reflux surgery (Grade B).
- Antireflux surgery does not alter the need for continued surveillance endoscopy in patients with Barrett’s esophagus. Patients who have undergone endoscopic ablative therapy and anti-reflux surgery should continue surveillance endoscopy according to their baseline grade of Barrett’s (Grade A).
- The available evidence is inconclusive about the resolution or improvement of Barrett’s after antireflux surgery.
- Varin O, Velstra B, De Sutter S, Ceelen W (2009) Total vs partial fundoplication in the treatment of gastroesophageal reflux disease: a meta-analysis. Arch Surg 144:273-278
- Granderath F A, Kamolz T, Schweiger U M, Pointner R (2003) Laparoscopic refundoplication with prosthetic hiatal closure for recurrent hiatal hernia after primary failed antireflux surgery. Arch Surg 138:902-907
- (1994). Digestive diseases in the United States: Epidemiology and Impact, vol. NIH Publication No. 94-1447, NIDDK.
- Falk G W, Fennerty M B, Rothstein R I (2006) AGA Institute medical position statement on the use of endoscopic therapy for gastroesophageal reflux disease. Gastroenterology 131:1313-1314
- Kahrilas P J, Shaheen N J, Vaezi M F, Hiltz S W, Black E, Modlin I M, Johnson S P, Allen J, Brill J V (2008) American Gastroenterological Association Medical Position Statement on the management of gastroesophageal reflux disease. Gastroenterology 135:1383-1391, 1391 e1381-1385
- Wetscher G J, Redmont, E.J., Vititi, L.M.H. (1993). Pathophysiology of gastroesophageal reflux disease. In Gastroesophageal Reflux Disease, R.A. Hinder, ed. (Austin, TX: R. G. Landes Company), pp. 7-29.
- Little A G (1992) Mechanisms of action of antireflux surgery: theory and fact. World J Surg 16:320-325
- Ireland A C, Holloway R H, Toouli J, Dent J (1993) Mechanisms underlying the antireflux action of fundoplication. Gut 34:303-308
- Lundell L R, Dent J, Bennett J R, Blum A L, Armstrong D, Galmiche J P, Johnson F, Hongo M, Richter J E, Spechler S J, Tytgat G N, Wallin L (1999) Endoscopic assessment of oesophagitis: clinical and functional correlates and further validation of the Los Angeles classification. Gut 45:172-180
- Tam W C, Holloway R H, Dent J, Rigda R, Schoeman M N (2004) Impact of endoscopic suturing of the gastroesophageal junction on lower esophageal sphincter function and gastroesophageal reflux in patients with reflux disease. Am J Gastroenterol 99:195-202
- Armstrong D, Bennett J R, Blum A L, Dent J, De Dombal F T, Galmiche J P, Lundell L, Margulies M, Richter J E, Spechler S J, Tytgat G N, Wallin L (1996) The endoscopic assessment of esophagitis: a progress report on observer agreement. Gastroenterology 111:85-92
- Hassall E (1993) Barrett’s esophagus: congenital or acquired? Am J Gastroenterol 88:819-824
- Francalanci P, De Angelis P, Minnei F, Diomedi Camassei F, Torroni F, Dall’Oglio L, Callea F (2008) Eosinophilic esophagitis and Barrett’s esophagus: an occasional association or an overlap disease? Esophageal ‘double trouble’ in two children. Digestion 77:16-19
- Jamieson J R, Stein H J, DeMeester T R, Bonavina L, Schwizer W, Hinder R A, Albertucci M (1992) Ambulatory 24-h esophageal pH monitoring: normal values, optimal thresholds, specificity, sensitivity, and reproducibility. Am J Gastroenterol 87:1102-1111
- Gunnarsdottir A, Stenstrom P, Arnbjornsson E (2007) 48-hour wireless oesophageal pH-monitoring in children: are two days better than one? Eur J Pediatr Surg 17:378-381
- Ayazi S, Lipham J C, Portale G, Peyre C G, Streets C G, Leers J M, Demeester S R, Banki F, Chan L S, Hagen J A, Demeester T R (2009) Bravo catheter-free pH monitoring: normal values, concordance, optimal diagnostic thresholds, and accuracy. Clin Gastroenterol Hepatol 7:60-67
- Castell D O, Vela M (2001) Combined multichannel intraluminal impedance and pH-metry: an evolving technique to measure type and proximal extent of gastroesophageal reflux. Am J Med 111 Suppl 8A:157S-159S
- Spechler S J, Goyal R K (1996) The columnar-lined esophagus, intestinal metaplasia, and Norman Barrett. Gastroenterology 110:614-621
- Lagergren J, Bergstrom R, Lindgren A, Nyren O (1999) Symptomatic gastroesophageal reflux as a risk factor for esophageal adenocarcinoma. N Engl J Med 340:825-831
- Rakita S, Villadolid D, Thomas A, Bloomston M, Albrink M, Goldin S, Rosemurgy A (2006) Laparoscopic Nissen fundoplication offers high patient satisfaction with relief of extraesophageal symptoms of gastroesophageal reflux disease. Am Surg 72:207-212
- Meyer T K, Olsen E, Merati A (2004) Contemporary diagnostic and management techniques for extraesophageal reflux disease. Curr Opin Otolaryngol Head Neck Surg 12:519-524
- Lindstrom D R, Wallace J, Loehrl T A, Merati A L, Toohill R J (2002) Nissen fundoplication surgery for extraesophageal manifestations of gastroesophageal reflux (EER). Laryngoscope 112:1762-1765
- Oelschlager B K, Eubanks T R, Oleynikov D, Pope C, Pellegrini C A (2002) Symptomatic and physiologic outcomes after operative treatment for extraesophageal reflux. Surg Endosc 16:1032-1036
- Yau P, Watson D I, Devitt P G, Game P A, Jamieson G G (2000) Laparoscopic antireflux surgery in the treatment of gastroesophageal reflux in patients with Barrett esophagus. Arch Surg 135:801-805
- Rossi M, Barreca M, de Bortoli N, Renzi C, Santi S, Gennai A, Bellini M, Costa F, Conio M, Marchi S (2006) Efficacy of Nissen fundoplication versus medical therapy in the regression of low-grade dysplasia in patients with Barrett esophagus: a prospective study. Ann Surg 243:58-63
- Chang E Y, Morris C D, Seltman A K, O’Rourke R W, Chan B K, Hunter J G, Jobe B A (2007) The effect of antireflux surgery on esophageal carcinogenesis in patients with barrett esophagus: a systematic review. Ann Surg 246:11-21
- Fibbe C, Layer P, Keller J, Strate U, Emmermann A, Zornig C (2001) Esophageal motility in reflux disease before and after fundoplication: a prospective, randomized, clinical, and manometric study. Gastroenterology 121:5-14
- Yang H, Watson D I, Kelly J, Lally C J, Myers J C, Jamieson G G (2007) Esophageal manometry and clinical outcome after laparoscopic Nissen fundoplication. J Gastrointest Surg 11:1126-1133
- Frantzides C T, Carlson M A, Madan A K, Stewart E T, Smith C (2003) Selective use of esophageal manometry and 24-Hour pH monitoring before laparoscopic fundoplication. J Am Coll Surg 197:358-363; discussion 363-354
- Wayman J, Myers J C, Jamieson G G (2007) Preoperative gastric emptying and patterns of reflux as predictors of outcome after laparoscopic fundoplication. Br J Surg 94:592-598
- Spechler S J, Lee E, Ahnen D, Goyal R K, Hirano I, Ramirez F, Raufman J P, Sampliner R, Schnell T, Sontag S, Vlahcevic Z R, Young R, Williford W (2001) Long-term outcome of medical and surgical therapies for gastroesophageal reflux disease: follow-up of a randomized controlled trial. JAMA 285:2331-2338
- Anvari M, Allen C, Marshall J, Armstrong D, Goeree R, Ungar W, Goldsmith C (2006) A randomized controlled trial of laparoscopic nissen fundoplication versus proton pump inhibitors for treatment of patients with chronic gastroesophageal reflux disease: One-year follow-up. Surg Innov 13:238-249
- Mahon D, Rhodes M, Decadt B, Hindmarsh A, Lowndes R, Beckingham I, Koo B, Newcombe R G (2005) Randomized clinical trial of laparoscopic Nissen fundoplication compared with proton-pump inhibitors for treatment of chronic gastro-oesophageal reflux. Br J Surg 92:695-699
- Mehta S, Bennett J, Mahon D, Rhodes M (2006) Prospective trial of laparoscopic nissen fundoplication versus proton pump inhibitor therapy for gastroesophageal reflux disease: Seven-year follow-up. J Gastrointest Surg 10:1312-1316; discussion 1316-1317
- Lundell L, Miettinen P, Myrvold H E, Pedersen S A, Thor K, Lamm M, Blomqvist A, Hatlebakk J G, Janatuinen E, Levander K, Nystrom P, Wiklund I (2000) Long-term management of gastro-oesophageal reflux disease with omeprazole or open antireflux surgery: results of a prospective, randomized clinical trial. The Nordic GORD Study Group. Eur J Gastroenterol Hepatol 12:879-887
- Lundell L, Attwood S, Ell C, Fiocca R, Galmiche J P, Hatlebakk J, Lind T, Junghard O (2008) Comparing laparoscopic antireflux surgery with esomeprazole in the management of patients with chronic gastro-oesophageal reflux disease: a 3-year interim analysis of the LOTUS trial. Gut 57:1207-1213
- Lundell L, Miettinen P, Myrvold H E, Hatlebakk J G, Wallin L, Malm A, Sutherland I, Walan A (2007) Seven-year follow-up of a randomized clinical trial comparing proton-pump inhibition with surgical therapy for reflux oesophagitis. Br J Surg 94:198-203
- Anvari M, Allen C, Borm A (1995) Laparoscopic Nissen fundoplication is a satisfactory alternative to long-term omeprazole therapy. Br J Surg 82:938-942
- Ciovica R, Gadenstatter M, Klingler A, Lechner W, Riedl O, Schwab G P (2006) Quality of life in GERD patients: medical treatment versus antireflux surgery. J Gastrointest Surg 10:934-939
- Jenkinson A D, Kadirkamanathan S S, Scott S M, Yazaki E, Evans D F (2004) Relationship between symptom response and oesophageal acid exposure after medical and surgical treatment for gastro-oesophageal reflux disease. Br J Surg 91:1460-1465
- Dassinger M S, Torquati A, Houston H L, Holzman M D, Sharp K W, Richards W O (2004) Laparoscopic fundoplication: 5-year follow-up. Am Surg 70:691-694; discussion 694-695
- Kamolz T, Granderath F A, Schweiger U M, Pointner R (2005) Laparoscopic Nissen fundoplication in patients with nonerosive reflux disease. Long-term quality-of-life assessment and surgical outcome. Surg Endosc 19:494-500
- Rosenthal R, Peterli R, Guenin M O, von Flue M, Ackermann C (2006) Laparoscopic antireflux surgery: long-term outcomes and quality of life. J Laparoendosc Adv Surg Tech A 16:557-561
- Zaninotto G, Portale G, Costantini M, Rizzetto C, Guirroli E, Ceolin M, Salvador R, Rampado S, Prandin O, Ruol A, Ancona E (2007) Long-term results (6-10 years) of laparoscopic fundoplication. J Gastrointest Surg 11:1138-1145
- Pessaux P, Arnaud J P, Delattre J F, Meyer C, Baulieux J, Mosnier H (2005) Laparoscopic antireflux surgery: five-year results and beyond in 1340 patients. Arch Surg 140:946-951
- Lord R V, Kaminski A, Oberg S, Bowrey D J, Hagen J A, DeMeester S R, Sillin L F, Peters J H, Crookes P F, DeMeester T R (2002) Absence of gastroesophageal reflux disease in a majority of patients taking acid suppression medications after Nissen fundoplication. J Gastrointest Surg 6:3-9; discussion 10
- Anvari M, Allen C (2003) Five-year comprehensive outcomes evaluation in 181 patients after laparoscopic Nissen fundoplication. J Am Coll Surg 196:51-57; discussion 57-58; author reply 58-59
- Myrvold H E, Lundell L, Miettinen P, Pedersen S A, Liedman B, Hatlebakk J, Julkunen R, Levander K, Lamm M, Mattson C, Carlsson J, Stahlhammar N O (2001) The cost of long term therapy for gastro-oesophageal reflux disease: a randomised trial comparing omeprazole and open antireflux surgery. Gut 49:488-494
- Heudebert G R, Marks R, Wilcox C M, Centor R M (1997) Choice of long-term strategy for the management of patients with severe esophagitis: a cost-utility analysis. Gastroenterology 112:1078-1086
- Arguedas M R, Heudebert G R, Klapow J C, Centor R M, Eloubeidi M A, Wilcox C M, Spechler S J (2004) Re-examination of the cost-effectiveness of surgical versus medical therapy in patients with gastroesophageal reflux disease: the value of long-term data collection. Am J Gastroenterol 99:1023-1028
- Attwood S E, Lundell L, Ell C, Galmiche J P, Hatlebakk J, Fiocca R, Lind T, Eklund S, Junghard O (2008) Standardization of surgical technique in antireflux surgery: the LOTUS Trial experience. World J Surg 32:995-998
- Soper N J, Dunnegan D (1999) Anatomic fundoplication failure after laparoscopic antireflux surgery. Ann Surg 229:669-676; discussion 676-667
- Watson D I, Baigrie R J, Jamieson G G (1996) A learning curve for laparoscopic fundoplication. Definable, avoidable, or a waste of time? Ann Surg 224:198-203
- Deschamps C, Allen M S, Trastek V F, Johnson J O, Pairolero P C (1998) Early experience and learning curve associated with laparoscopic Nissen fundoplication. J Thorac Cardiovasc Surg 115:281-284; discussion 284-285
- Contini S, Bertele A, Nervi G, Zinicola R, Scarpignato C (2002) Quality of life for patients with gastroesophageal reflux disease 2 years after laparoscopic fundoplication. Evaluation of the results obtained during the initial experience. Surg Endosc 16:1555-1560
- Contini S, Scarpignato C (2004) Does the learning phase influence the late outcome of patients with gastroesophageal reflux disease after laparoscopic fundoplication? Surg Endosc 18:266-271
- Funch-Jensen P, Bendixen A, Iversen M G, Kehlet H (2008) Complications and frequency of redo antireflux surgery in Denmark: a nationwide study, 1997-2005. Surg Endosc 22:627-630
- Bais J E, Bartelsman J F, Bonjer H J, Cuesta M A, Go P M, Klinkenberg-Knol E C, van Lanschot J J, Nadorp J H, Smout A J, van der Graaf Y, Gooszen H G (2000) Laparoscopic or conventional Nissen fundoplication for gastro-oesophageal reflux disease: randomised clinical trial. The Netherlands Antireflux Surgery Study Group. Lancet 355:170-174
- Catarci M, Gentileschi P, Papi C, Carrara A, Marrese R, Gaspari A L, Grassi G B (2004) Evidence-based appraisal of antireflux fundoplication. Ann Surg 239:325-337
- Chrysos E, Tsiaoussis J, Athanasakis E, Zoras O, Vassilakis J S, Xynos E (2002) Laparoscopic vs open approach for Nissen fundoplication. A comparative study. Surg Endosc 16:1679-1684
- Draaisma W A, Buskens E, Bais J E, Simmermacher R K, Rijnhart-de Jong H G, Broeders I A, Gooszen H G (2006) Randomized clinical trial and follow-up study of cost-effectiveness of laparoscopic versus conventional Nissen fundoplication. Br J Surg 93:690-697
- Draaisma W A, Rijnhart-de Jong H G, Broeders I A, Smout A J, Furnee E J, Gooszen H G (2006) Five-year subjective and objective results of laparoscopic and conventional Nissen fundoplication: a randomized trial. Ann Surg 244:34-41
- Franzen T, Anderberg B, Wiren M, Johansson K E (2005) Long-term outcome is worse after laparoscopic than after conventional Nissen fundoplication. Scand J Gastroenterol 40:1261-1268
- Hakanson B S, Thor K B, Thorell A, Ljungqvist O (2007) Open vs laparoscopic partial posterior fundoplication. A prospective randomized trial. Surg Endosc 21:289-298
- Heikkinen T J, Haukipuro K, Bringman S, Ramel S, Sorasto A, Hulkko A (2000) Comparison of laparoscopic and open Nissen fundoplication 2 years after operation. A prospective randomized trial. Surg Endosc 14:1019-1023
- Heikkinen T J, Haukipuro K, Koivukangas P, Sorasto A, Autio R, Sodervik H, Makela H, Hulkko A (1999) Comparison of costs between laparoscopic and open Nissen fundoplication: a prospective randomized study with a 3-month followup. J Am Coll Surg 188:368-376
- Heikkinen T J, Haukipuro K, Sorasto A, Autio R, Sodervik H, Makela H, Hulkko A (2000) Short-term symptomatic outcome and quality of life after laparoscopic versus open Nissen fundoplication: a prospective randomized trial. Int J Surg Investig 2:33-39
- Laine S, Rantala A, Gullichsen R, Ovaska J (1997) Laparoscopic vs conventional Nissen fundoplication. A prospective randomized study. Surg Endosc 11:441-444
- Luostarinen M, Virtanen J, Koskinen M, Matikainen M, Isolauri J (2001) Dysphagia and oesophageal clearance after laparoscopic versus open Nissen fundoplication. A randomized, prospective trial. Scand J Gastroenterol 36:565-571
- McHoney M, Eaton S, Wade A, Klein N J, Stefanutti G, Booth C, Kiely E M, Curry J I, Drake D P, Pierro A (2005) Inflammatory response in children after laparoscopic vs open Nissen fundoplication: randomized controlled trial. J Pediatr Surg 40:908-913; discussion 913-904
- Nilsson G, Larsson S, Johnsson F (2000) Randomized clinical trial of laparoscopic versus open fundoplication: blind evaluation of recovery and discharge period. Br J Surg 87:873-878
- Nilsson G, Larsson S, Johnsson F (2002) Randomized clinical trial of laparoscopic versus open fundoplication: evaluation of psychological well-being and changes in everyday life from a patient perspective. Scand J Gastroenterol 37:385-391
- Nilsson G, Wenner J, Larsson S, Johnsson F (2004) Randomized clinical trial of laparoscopic versus open fundoplication for gastro-oesophageal reflux. Br J Surg 91:552-559
- Perttila J, Salo M, Ovaska J, Gronroos J, Lavonius M, Katila A, Lahteenmaki M, Pulkki K (1999) Immune response after laparoscopic and conventional Nissen fundoplication. Eur J Surg 165:21-28
- Peters M J, Mukhtar A, Yunus R M, Khan S, Pappalardo J, Memon B, Memon M A (2009) Meta-analysis of randomized clinical trials comparing open and laparoscopic anti-reflux surgery. Am J Gastroenterol 104:1548-1561; quiz 1547, 1562
- Salminen P T, Hiekkanen H I, Rantala A P, Ovaska J T (2007) Comparison of long-term outcome of laparoscopic and conventional nissen fundoplication: a prospective randomized study with an 11-year follow-up. Ann Surg 246:201-206
- Wenner J, Nilsson G, Oberg S, Melin T, Larsson S, Johnsson F (2001) Short-term outcome after laparoscopic and open 360 degrees fundoplication. A prospective randomized trial. Surg Endosc 15:1124-1128
- Ackroyd R, Watson D I, Majeed A W, Troy G, Treacy P J, Stoddard C J (2004) Randomized clinical trial of laparoscopic versus open fundoplication for gastro-oesophageal reflux disease. Br J Surg 91:975-982
- Sietses C, Wiezer M J, Eijsbouts Q A, Beelen R H, van Leeuwen P A, von Blomberg B M, Meijer S, Cuesta M A (1999) A prospective randomized study of the systemic immune response after laparoscopic and conventional Nissen fundoplication. Surgery 126:5-9
- Sietses C, Wiezer M J, Eijsbouts Q A, van Leeuwen P A, Beelen R H, Meijer S, Cuesta M A (2000) The influence of laparoscopic surgery on postoperative polymorphonuclear leukocyte function. Surg Endosc 14:812-816
- Baigrie R J, Cullis S N, Ndhluni A J, Cariem A (2005) Randomized double-blind trial of laparoscopic Nissen fundoplication versus anterior partial fundoplication. Br J Surg 92:819-823
- Chrysos E, Tsiaoussis J, Zoras O J, Athanasakis E, Mantides A, Katsamouris A, Xynos E (2003) Laparoscopic surgery for gastroesophageal reflux disease patients with impaired esophageal peristalsis: total or partial fundoplication? J Am Coll Surg 197:8-15
- Hagedorn C, Lonroth H, Rydberg L, Ruth M, Lundell L (2002) Long-term efficacy of total (Nissen-Rossetti) and posterior partial (Toupet) fundoplication: results of a randomized clinical trial. J Gastrointest Surg 6:540-545
- Laws H L, Clements R H, Swillie C M (1997) A randomized, prospective comparison of the Nissen fundoplication versus the Toupet fundoplication for gastroesophageal reflux disease. Ann Surg 225:647-653; discussion 654
- Lundell L, Abrahamsson H, Ruth M, Sandberg N, Olbe L C (1991) Lower esophageal sphincter characteristics and esophageal acid exposure following partial or 360 degrees fundoplication: results of a prospective, randomized, clinical study. World J Surg 15:115-120; discussion 121
- Segol P, Hay J M, Pottier D (1989) [Surgical treatment of gastroesophageal reflux: which operation to choose: Nissen, Toupet or Lortat-Jacob? A multicenter randomized trial]. Gastroenterol Clin Biol 13:873-879
- Walker S J, Holt S, Sanderson C J, Stoddard C J (1992) Comparison of Nissen total and Lind partial transabdominal fundoplication in the treatment of gastro-oesophageal reflux. Br J Surg 79:410-414
- Watson D I, Jamieson G G, Lally C, Archer S, Bessell J R, Booth M, Cade R, Cullingford G, Devitt P G, Fletcher D R, Hurley J, Kiroff G, Martin C J, Martin I J, Nathanson L K, Windsor J A (2004) Multicenter, prospective, double-blind, randomized trial of laparoscopic nissen vs anterior 90 degrees partial fundoplication. Arch Surg 139:1160-1167
- Watson D I, Jamieson G G, Pike G K, Davies N, Richardson M, Devitt P G (1999) Prospective randomized double-blind trial between laparoscopic Nissen fundoplication and anterior partial fundoplication. Br J Surg 86:123-130
- Spence G M, Watson D I, Jamiesion G G, Lally C J, Devitt P G (2006) Single center prospective randomized trial of laparoscopic Nissen versus anterior 90 degrees fundoplication. J Gastrointest Surg 10:698-705
- Thor K B, Silander T (1989) A long-term randomized prospective trial of the Nissen procedure versus a modified Toupet technique. Ann Surg 210:719-724
- Zornig C, Strate U, Fibbe C, Emmermann A, Layer P (2002) Nissen vs Toupet laparoscopic fundoplication. Surg Endosc 16:758-766
- Lundell L, Abrahamsson H, Ruth M, Rydberg L, Lonroth H, Olbe L (1996) Long-term results of a prospective randomized comparison of total fundic wrap (Nissen-Rossetti) or semifundoplication (Toupet) for gastro-oesophageal reflux. Br J Surg 83:830-835
- Strate U, Emmermann A, Fibbe C, Layer P, Zornig C (2008) Laparoscopic fundoplication: Nissen versus Toupet two-year outcome of a prospective randomized study of 200 patients regarding preoperative esophageal motility. Surg Endosc 22:21-30
- Hunter J G, Trus T L, Branum G D, Waring J P, Wood W C (1996) A physiologic approach to laparoscopic fundoplication for gastroesophageal reflux disease. Ann Surg 223:673-685; discussion 685-677
- Patti M G, Arcerito M, Feo C V, De Pinto M, Tong J, Gantert W, Tyrrell D, Way L W (1998) An analysis of operations for gastroesophageal reflux disease: identifying the important technical elements. Arch Surg 133:600-606; discussion 606-607
- Booth M I, Stratford J, Jones L, Dehn T C (2008) Randomized clinical trial of laparoscopic total (Nissen) versus posterior partial (Toupet) fundoplication for gastro-oesophageal reflux disease based on preoperative oesophageal manometry. Br J Surg 95:57-63
- Cai W, Watson D I, Lally C J, Devitt P G, Game P A, Jamieson G G (2008) Ten-year clinical outcome of a prospective randomized clinical trial of laparoscopic Nissen versus anterior 180( degrees ) partial fundoplication. Br J Surg 95:1501-1505
- Woodcock S A, Watson D I, Lally C, Archer S, Bessell J R, Booth M, Cade R, Cullingford G L, Devitt P G, Fletcher D R, Hurley J, Jamieson G G, Kiroff G, Martin C J, Martin I J, Nathanson L K, Windsor J A (2006) Quality of life following laparoscopic anterior 90 degrees versus Nissen fundoplication: results from a multicenter randomized trial. World J Surg 30:1856-1863
- Ludemann R, Watson D I, Jamieson G G, Game P A, Devitt P G (2005) Five-year follow-up of a randomized clinical trial of laparoscopic total versus anterior 180 degrees fundoplication. Br J Surg 92:240-243
- Engstrom C, Lonroth H, Mardani J, Lundell L (2007) An anterior or posterior approach to partial fundoplication? Long-term results of a randomized trial. World J Surg 31:1221-1225; discussion 1226-1227
- Mickevicius A, Endzinas Z, Kiudelis M, Jonaitis L, Kupcinskas L, Maleckas A, Pundzius J (2008) Influence of wrap length on the effectiveness of Nissen and Toupet fundoplication: a prospective randomized study. Surg Endosc 22:2269-2276
- Guerin E, Betroune K, Closset J, Mehdi A, Lefebvre J C, Houben J J, Gelin M, Vaneukem P, El Nakadi I (2007) Nissen versus Toupet fundoplication: results of a randomized and multicenter trial. Surg Endosc 21:1985-1990
- Jobe B A, Wallace J, Hansen P D, Swanstrom L L (1997) Evaluation of laparoscopic Toupet fundoplication as a primary repair for all patients with medically resistant gastroesophageal reflux. Surg Endosc 11:1080-1083
- Patti M G, Robinson T, Galvani C, Gorodner M V, Fisichella P M, Way L W (2004) Total fundoplication is superior to partial fundoplication even when esophageal peristalsis is weak. J Am Coll Surg 198:863-869; discussion 869-870
- Hagedorn C, Jonson C, Lonroth H, Ruth M, Thune A, Lundell L (2003) Efficacy of an anterior as compared with a posterior laparoscopic partial fundoplication: results of a randomized, controlled clinical trial. Ann Surg 238:189-196
- Yang H, Watson D I, Lally C J, Devitt P G, Game P A, Jamieson G G (2008) Randomized trial of division versus nondivision of the short gastric vessels during laparoscopic Nissen fundoplication: 10-year outcomes. Ann Surg 247:38-42
- Engstrom C, Blomqvist A, Dalenback J, Lonroth H, Ruth M, Lundell L (2004) Mechanical consequences of short gastric vessel division at the time of laparoscopic total fundoplication. J Gastrointest Surg 8:442-447
- O’Boyle C J, Watson D I, Jamieson G G, Myers J C, Game P A, Devitt P G (2002) Division of short gastric vessels at laparoscopic nissen fundoplication: a prospective double-blind randomized trial with 5-year follow-up. Ann Surg 235:165-170
- Blomqvist A, Dalenback J, Hagedorn C, Lonroth H, Hyltander A, Lundell L (2000) Impact of complete gastric fundus mobilization on outcome after laparoscopic total fundoplication. J Gastrointest Surg 4:493-500
- Chrysos E, Tzortzinis A, Tsiaoussis J, Athanasakis H, Vasssilakis J, Xynos E (2001) Prospective randomized trial comparing Nissen to Nissen-Rossetti technique for laparoscopic fundoplication. Am J Surg 182:215-221
- Gad El-Hak N, Abo Zied M, Aboelenen A, Fouad A, Abd Alla T, El-Shoubary M, Kandel T, Hamdy E, Abdel Wahab M, Fathy O, El-ebidy G, Sultan A, Elfiky A, Elghwalby N, Ezzat F (2005) Short gastric vessels division in Laparoscopic Nissen Fundoplication. Hepatogastroenterology 52:1742-1747
- Neufeld M, Graham A (2007) Levels of evidence available for techniques in antireflux surgery. Dis Esophagus 20:161-167
- Donahue P E, Larson G M, Stewardson R H, Bombeck C T (1977) Floppy Nissen fundoplication. Rev Surg 34:223-224
- DeMeester T R, Bonavina L, Albertucci M (1986) Nissen fundoplication for gastroesophageal reflux disease. Evaluation of primary repair in 100 consecutive patients. Ann Surg 204:9-20
- Wu J S, Dunnegan D L, Luttmann D R, Soper N J (1996) The influence of surgical technique on clinical outcome of laparoscopic Nissen fundoplication. Surg Endosc 10:1164-1169; discussion 1169-1170
- Watson D I, Pike G K, Baigrie R J, Mathew G, Devitt P G, Britten-Jones R, Jamieson G G (1997) Prospective double-blind randomized trial of laparoscopic Nissen fundoplication with division and without division of short gastric vessels. Ann Surg 226:642-652
- Anvari M, Allen C (1998) Laparoscopic Nissen fundoplication: two-year comprehensive follow-up of a technique of minimal paraesophageal dissection. Ann Surg 227:25-32
- Watson D I, Jamieson G G, Devitt P G, Kennedy J A, Ellis T, Ackroyd R, Lafullarde T, Game P A (2001) A prospective randomized trial of laparoscopic Nissen fundoplication with anterior vs posterior hiatal repair. Arch Surg 136:745-751
- Gotley D C, Smithers B M, Rhodes M, Menzies B, Branicki F J, Nathanson L (1996) Laparoscopic Nissen fundoplication–200 consecutive cases. Gut 38:487-491
- Lefebvre J C, Belva P, Takieddine M, Vaneukem P (1998) Laparoscopic Toupet fundoplication: prospective study of 100 cases. Results at one year and literature review. Acta Chir Belg 98:1-4
- Zaninotto G, Molena D, Ancona E (2000) A prospective multicenter study on laparoscopic treatment of gastroesophageal reflux disease in Italy: type of surgery, conversions, complications, and early results. Study Group for the Laparoscopic Treatment of Gastroesophageal Reflux Disease of the Italian Society of Endoscopic Surgery (SICE). Surg Endosc 14:282-288
- Victorzon M, Tolonen P (2003) Symptomatic outcome of laparoscopic fundoplication, using a minimal dissection technique. Scand J Surg 92:138-143
- Kala Z, Dolina J, Kysela P, Hermanova M, Prochazka V, Kroupa R, Izakovicova-Holla L, Hep A (2006) Intraoperative manometry of the lower esophageal sphincter pressure during laparoscopic antireflux surgery with a mechanical calibration–early results. Hepatogastroenterology 53:710-714
- Morino M, Pellegrino L, Giaccone C, Garrone C, Rebecchi F (2006) Randomized clinical trial of robot-assisted versus laparoscopic Nissen fundoplication. Br J Surg 93:553-558
- Granderath F A, Schweiger U M, Kamolz T, Asche K U, Pointner R (2005) Laparoscopic Nissen fundoplication with prosthetic hiatal closure reduces postoperative intrathoracic wrap herniation: preliminary results of a prospective randomized functional and clinical study. Arch Surg 140:40-48
- Granderath F A (2007) Measurement of the esophageal hiatus by calculation of the hiatal surface area (HSA). Why, when and how? Surg Endosc 21:2224-2225
- St Peter S D, Valusek P A, Calkins C M, Shew S B, Ostlie D J, Holcomb G W, 3rd (2007) Use of esophagocrural sutures and minimal esophageal dissection reduces the incidence of postoperative transmigration of laparoscopic Nissen fundoplication wrap. J Pediatr Surg 42:25-29; discussion 29-30
- Wykypiel H, Wetscher G J, Klaus A, Schmid T, Gadenstaetter M, Bodner J, Bodner E (2003) Robot-assisted laparoscopic partial posterior fundoplication with the DaVinci system: initial experiences and technical aspects. Langenbecks Arch Surg 387:411-416
- Muller-Stich B P, Reiter M A, Wente M N, Bintintan V V, Koninger J, Buchler M W, Gutt C N (2007) Robot-assisted versus conventional laparoscopic fundoplication: short-term outcome of a pilot randomized controlled trial. Surg Endosc 21:1800-1805
- Draaisma W A, Ruurda J P, Scheffer R C, Simmermacher R K, Gooszen H G, Rijnhart-de Jong H G, Buskens E, Broeders I A (2006) Randomized clinical trial of standard laparoscopic versus robot-assisted laparoscopic Nissen fundoplication for gastro-oesophageal reflux disease. Br J Surg 93:1351-1359
- Cadiere G B, Himpens J, Vertruyen M, Bruyns J, Germay O, Leman G, Izizaw R (2001) Evaluation of telesurgical (robotic) NISSEN fundoplication. Surg Endosc 15:918-923
- Nakadi I E, Melot C, Closset J, DeMoor V, Betroune K, Feron P, Lingier P, Gelin M (2006) Evaluation of da Vinci Nissen fundoplication clinical results and cost minimization. World J Surg 30:1050-1054
- Stefanidis D, Wang F, Korndorffer J R, Jr., Dunne J B, Scott D J (2009) Robotic assistance improves intracorporeal suturing performance and safety in the operating room while decreasing operator workload. Surg Endosc
- El-Serag H B, Ergun G A, Pandolfino J, Fitzgerald S, Tran T, Kramer J R (2007) Obesity increases oesophageal acid exposure. Gut 56:749-755
- Hampel H, Abraham N S, El-Serag H B (2005) Meta-analysis: obesity and the risk for gastroesophageal reflux disease and its complications. Ann Intern Med 143:199-211
- Friedenberg F K, Xanthopoulos M, Foster G D, Richter J E (2008) The association between gastroesophageal reflux disease and obesity. Am J Gastroenterol 103:2111-2122
- El-Serag H (2008) The association between obesity and GERD: a review of the epidemiological evidence. Dig Dis Sci 53:2307-2312
- El-Serag H (2008) Role of obesity in GORD-related disorders. Gut 57:281-284
- Murray L, Johnston B, Lane A, Harvey I, Donovan J, Nair P, Harvey R (2003) Relationship between body mass and gastro-oesophageal reflux symptoms: The Bristol Helicobacter Project. Int J Epidemiol 32:645-650
- El-Serag H B, Graham D Y, Satia J A, Rabeneck L (2005) Obesity is an independent risk factor for GERD symptoms and erosive esophagitis. Am J Gastroenterol 100:1243-1250
- Fisichella P M, Patti M G (2009) Gastroesophageal Reflux Disease and Morbid Obesity: Is There a Relation? World J Surg
- Morgenthal C B, Lin E, Shane M D, Hunter J G, Smith C D (2007) Who will fail laparoscopic Nissen fundoplication? Preoperative prediction of long-term outcomes. Surg Endosc 21:1978-1984
- Perez A R, Moncure A C, Rattner D W (2001) Obesity adversely affects the outcome of antireflux operations. Surg Endosc 15:986-989
- Ng V V, Booth M I, Stratford J J, Jones L, Sohanpal J, Dehn T C (2007) Laparoscopic anti-reflux surgery is effective in obese patients with gastro-oesophageal reflux disease. Ann R Coll Surg Engl 89:696-702
- Anvari M, Bamehriz F (2006) Outcome of laparoscopic Nissen fundoplication in patients with body mass index > or=35. Surg Endosc 20:230-234
- Fraser J, Watson D I, O’Boyle C J, Jamieson G G (2001) Obesity and its effect on outcome of laparoscopic Nissen fundoplication. Dis Esophagus 14:50-53
- D’Alessio M J, Arnaoutakis D, Giarelli N, Villadolid D V, Rosemurgy A S (2005) Obesity is not a contraindication to laparoscopic Nissen fundoplication. J Gastrointest Surg 9:949-954
- Kendrick M L, Houghton S G (2006) Gastroesophageal reflux disease in obese patients: the role of obesity in management. Dis Esophagus 19:57-63
- Sise A, Friedenberg F K (2008) A comprehensive review of gastroesophageal reflux disease and obesity. Obes Rev 9:194-203
- Frezza E E, Ikramuddin S, Gourash W, Rakitt T, Kingston A, Luketich J, Schauer P (2002) Symptomatic improvement in gastroesophageal reflux disease (GERD) following laparoscopic Roux-en-Y gastric bypass. Surg Endosc 16:1027-1031
- Smith S C, Edwards C B, Goodman G N (1997) Symptomatic and clinical improvement in morbidly obese patients with gastroesophageal reflux disease following Roux-en-Y gastric bypass. Obes Surg 7:479-484
- Patterson E J, Davis D G, Khajanchee Y, Swanstrom L L (2003) Comparison of objective outcomes following laparoscopic Nissen fundoplication versus laparoscopic gastric bypass in the morbidly obese with heartburn. Surg Endosc 17:1561-1565
- Raftopoulos I, Awais O, Courcoulas A P, Luketich J D (2004) Laparoscopic gastric bypass after antireflux surgery for the treatment of gastroesophageal reflux in morbidly obese patients: initial experience. Obes Surg 14:1373-1380
- Varela J E, Hinojosa M W, Nguyen N T (2009) Laparoscopic fundoplication compared with laparoscopic gastric bypass in morbidly obese patients with gastroesophageal reflux disease. Surg Obes Relat Dis 5:139-143
- Ikramuddin S (2008) Surgical management of gastroesophageal reflux disease in obesity. Dig Dis Sci 53:2318-2329
- Perry Y, Courcoulas A P, Fernando H C, Buenaventura P O, McCaughan J S, Luketich J D (2004) Laparoscopic Roux-en-Y gastric bypass for recalcitrant gastroesophageal reflux disease in morbidly obese patients. JSLS 8:19-23
- Forsell P, Hallerback B, Glise H, Hellers G (1999) Complications following Swedish adjustable gastric banding: a long-term follow-up. Obes Surg 9:11-16
- Dixon J B, O’Brien P E (1999) Gastroesophageal reflux in obesity: the effect of lap-band placement. Obes Surg 9:527-531
- Gutschow C A, Collet P, Prenzel K, Holscher A H, Schneider P M (2005) Long-term results and gastroesophageal reflux in a series of laparoscopic adjustable gastric banding. J Gastrointest Surg 9:941-948
- Tolonen P, Victorzon M, Niemi R, Makela J (2006) Does gastric banding for morbid obesity reduce or increase gastroesophageal reflux? Obes Surg 16:1469-1474
- Patterson E J, Herron D M, Hansen P D, Ramzi N, Standage B A, Swanstrom L L (2000) Effect of an esophageal bougie on the incidence of dysphagia following nissen fundoplication: a prospective, blinded, randomized clinical trial. Arch Surg 135:1055-1061; discussion 1061-1052
- Kamolz T, Granderath F A, Pointner R (2003) The outcome of laparoscopic antireflux surgery in relation to patients’ subjective degree of compliance with former antireflux medication. Surg Laparosc Endosc Percutan Tech 13:155-160
- Pizza F, Rossetti G, Limongelli P, Del Genio G, Maffettone V, Napolitano V, Brusciano L, Russo G, Tolone S, Di Martino M, Del Genio A (2007) Influence of age on outcome of total laparoscopic fundoplication for gastroesophageal reflux disease. World J Gastroenterol 13:740-747
- Iqbal A, Kakarlapudi G V, Awad Z T, Haynatzki G, Turaga K K, Karu A, Fritz K, Haider M, Mittal S K, Filipi C J (2006) Assessment of diaphragmatic stressors as risk factors for symptomatic failure of laparoscopic nissen fundoplication. J Gastrointest Surg 10:12-21
- Kamolz T, Granderath F A, Pointner R (2003) Does major depression in patients with gastroesophageal reflux disease affect the outcome of laparoscopic antireflux surgery? Surg Endosc 17:55-60
- Kamolz T, Granderath F A, Bammer T, Pasiut M, Pointner R (2001) Psychological intervention influences the outcome of laparoscopic antireflux surgery in patients with stress-related symptoms of gastroesophageal reflux disease. Scand J Gastroenterol 36:800-805
- DeVault K R (2001) Gastroesophageal reflux disease: extraesophageal manifestations and therapy. Semin Gastrointest Dis 12:46-51
- Bresadola V, Dado G, Favero A, Terrosu G, Barriga Sainz M, Bresadola F (2006) Surgical therapy for patients with extraesophageal symptoms of gastroesophageal reflux disease. Minerva Chir 61:9-15
- del Genio G, Tolone S, del Genio F, Aggarwal R, d’Alessandro A, Allaria A, Rossetti G, Brusciano L, del Genio A (2008) Prospective assessment of patient selection for antireflux surgery by combined multichannel intraluminal impedance pH monitoring. J Gastrointest Surg 12:1491-1496
- Allen C J, Anvari M (2002) Preoperative symptom evaluation and esophageal acid infusion predict response to laparoscopic Nissen fundoplication in gastroesophageal reflux patients who present with cough. Surg Endosc 16:1037-1041
- Patti M G, Perretta S, Fisichella P M, D’Avanzo A, Galvani C, Gorodner V, Way L W (2003) Laparoscopic antireflux surgery: preoperative lower esophageal sphincter pressure does not affect outcome. Surg Endosc 17:386-389
- Cowgill S M, Bloomston M, Al-Saadi S, Villadolid D, Rosemurgy A S, 2nd (2007) Normal lower esophageal sphincter pressure and length does not impact outcome after laparoscopic Nissen fundoplication. J Gastrointest Surg 11:701-707
- Winslow E R, Clouse R E, Desai K M, Frisella P, Gunsberger T, Soper N J, Klingensmith M E (2003) Influence of spastic motor disorders of the esophageal body on outcomes from laparoscopic antireflux surgery. Surg Endosc 17:738-745
- Cowgill S M, Al-Saadi S, Villadolid D, Arnaoutakis D, Molloy D, Rosemurgy A S (2007) Upright, supine, or bipositional reflux: patterns of reflux do not affect outcome after laparoscopic Nissen fundoplication. Surg Endosc 21:2193-2198
- Papasavas P K, Keenan R J, Yeaney W W, Caushaj P F, Gagne D J, Landreneau R J (2003) Prediction of postoperative gas bloating after laparoscopic antireflux procedures based on 24-h pH acid reflux pattern. Surg Endosc 17:381-385
- Wilkerson P M, Stratford J, Jones L, Sohanpal J, Booth M I, Dehn T C (2005) A poor response to proton pump inhibition is not a contraindication for laparoscopic antireflux surgery for gastro esophageal reflux disease. Surg Endosc 19:1272-1277
- Byrne J P, Smithers B M, Nathanson L K, Martin I, Ong H S, Gotley D C (2005) Symptomatic and functional outcome after laparoscopic reoperation for failed antireflux surgery. Br J Surg 92:996-1001
- Iqbal A, Awad Z, Simkins J, Shah R, Haider M, Salinas V, Turaga K, Karu A, Mittal S K, Filipi C J (2006) Repair of 104 failed anti-reflux operations. Ann Surg 244:42-51
- Oelschlager B K, Lal D R, Jensen E, Cahill M, Quiroga E, Pellegrini C A (2006) Medium- and long-term outcome of laparoscopic redo fundoplication. Surg Endosc 20:1817-1823
- Khajanchee Y S, O’Rourke R, Cassera M A, Gatta P, Hansen P D, Swanstrom L L (2007) Laparoscopic reintervention for failed antireflux surgery: subjective and objective outcomes in 176 consecutive patients. Arch Surg 142:785-901; discussion 791-782
- Coelho J C, Goncalves C G, Claus C M, Andrigueto P C, Ribeiro M N (2004) Late laparoscopic reoperation of failed antireflux procedures. Surg Laparosc Endosc Percutan Tech 14:113-117
- Cowgill S M, Arnaoutakis D, Villadolid D, Rosemurgy A S (2007) “Redo” fundoplications: satisfactory symptomatic outcomes with higher cost of care. J Surg Res 143:183-188
- Curet M J, Josloff R K, Schoeb O, Zucker K A (1999) Laparoscopic reoperation for failed antireflux procedures. Arch Surg 134:559-563
- Floch N R, Hinder R A, Klingler P J, Branton S A, Seelig M H, Bammer T, Filipi C J (1999) Is laparoscopic reoperation for failed antireflux surgery feasible? Arch Surg 134:733-737
- Ohnmacht G A, Deschamps C, Cassivi S D, Nichols F C, 3rd, Allen M S, Schleck C D, Pairolero P C (2006) Failed antireflux surgery: results after reoperation. Ann Thorac Surg 81:2050-2053; discussion 2053-2054
- Szwerc M F, Wiechmann R J, Maley R H, Santucci T S, Macherey R S, Landreneau R J (1999) Reoperative laparoscopic antireflux surgery. Surgery 126:723-728; discussion 728-729
- Cowgill S M, Gillman R, Kraemer E, Al-Saadi S, Villadolid D, Rosemurgy A (2007) Ten-year follow up after laparoscopic Nissen fundoplication for gastroesophageal reflux disease. Am Surg 73:748-752; discussion 752-743
- Zeman Z, Tihanyi T (2007) Quality of life and patient satisfaction after laparoscopic antireflux surgery using the QOLARS questionnaire. Surg Endosc 21:1418-1422
- Kaufman J A, Houghland J E, Quiroga E, Cahill M, Pellegrini C A, Oelschlager B K (2006) Long-term outcomes of laparoscopic antireflux surgery for gastroesophageal reflux disease (GERD)-related airway disorder. Surg Endosc 20:1824-1830
- Balci D, Turkcapar A G (2007) Assessment of quality of life after laparoscopic Nissen fundoplication in patients with gastroesophageal reflux disease. World J Surg 31:116-121
- Neumayer C, Ciovica R, Gadenstatter M, Erd G, Leidl S, Lehr S, Schwab G (2005) Significant weight loss after laparoscopic Nissen fundoplication. Surg Endosc 19:15-20
- Ciovica R, Gadenstatter M, Klingler A, Neumayer C, Schwab G P (2005) Laparoscopic antireflux surgery provides excellent results and quality of life in gastroesophageal reflux disease patients with respiratory symptoms. J Gastrointest Surg 9:633-637
- Biertho L, Sebajang H, Allen C, Anvari M (2006) Does laparoscopic Nissen fundoplication lead to chronic gastrointestinal dysfunction? Surg Endosc 20:1360-1363
- Tedesco P, Lobo E, Fisichella P M, Way L W, Patti M G (2006) Laparoscopic fundoplication in elderly patients with gastroesophageal reflux disease. Arch Surg 141:289-292; discussion 292
- Zacharoulis D, O’Boyle C J, Sedman P C, Brough W A, Royston C M (2006) Laparoscopic fundoplication: a 10-year learning curve. Surg Endosc 20:1662-1670
- Mark L A, Okrainec A, Ferri L E, Feldman L S, Mayrand S, Fried G M (2008) Comparison of patient-centered outcomes after laparoscopic Nissen fundoplication for gastroesophageal reflux disease or paraesophageal hernia. Surg Endosc 22:343-347
- Papasavas P K, Keenan R J, Yeaney W W, Caushaj P F, Gagne D J, Landreneau R J (2003) Effectiveness of laparoscopic fundoplication in relieving the symptoms of gastroesophageal reflux disease (GERD) and eliminating antireflux medical therapy. Surg Endosc 17:1200-1205
- Vidal O, Lacy A M, Pera M, Valentini M, Bollo J, Lacima G, Grande L (2006) Long-term control of gastroesophageal reflux disease symptoms after laparoscopic Nissen-Rosetti fundoplication. J Gastrointest Surg 10:863-869
- Desai K M, Soper N J, Frisella M M, Quasebarth M A, Dunnegan D L, Brunt L M (2003) Efficacy of laparoscopic antireflux surgery in patients with Barrett’s esophagus. Am J Surg 186:652-659
- Desai K M, Frisella M M, Soper N J (2003) Clinical outcomes after laparoscopic antireflux surgery in patients with and without preoperative endoscopic esophagitis. J Gastrointest Surg 7:44-51; discussion 51-42
- Fernando H C, El-Sherif A, Landreneau R J, Gilbert S, Christie N A, Buenaventura P O, Close J M, Luketich J D (2005) Efficacy of laparoscopic fundoplication in controlling pulmonary symptoms associated with gastroesophageal reflux disease. Surgery 138:612-616; discussion 616-617
- Mehta S, Hindmarsh A, Rhodes M (2005) Changes in functional gastrointestinal symptoms as a result of antireflux surgery. Surg Endosc 19:1447-1450
- Bloomston M, Nields W, Rosemurgy A S (2003) Symptoms and antireflux medication use following laparoscopic Nissen fundoplication: outcome at 1 and 4 years. JSLS 7:211-218
- Huttl T P, Hohle M, Wichmann M W, Jauch K W, Meyer G (2005) Techniques and results of laparoscopic antireflux surgery in Germany. Surg Endosc 19:1579-1587
- Brouwer R, Kiroff G K (2003) Improvement of respiratory symptoms following laparoscopic Nissen fundoplication. ANZ J Surg 73:189-193
- Triponez F, Dumonceau J M, Azagury D, Volonte F, Slim K, Mermillod B, Huber O, Morel P (2005) Reflux, dysphagia, and gas bloat after laparoscopic fundoplication in patients with incidentally discovered hiatal hernia and in a control group. Surgery 137:235-242
- Menon V S, Manson J M, Baxter J N (2003) Laparoscopic fundoplication: learning curve and patient satisfaction. Ann R Coll Surg Engl 85:10-13
- Duffy J P, Maggard M, Hiyama D T, Atkinson J B, McFadden D W, Ko C Y, Hines O J (2003) Laparoscopic Nissen fundoplication improves quality of life in patients with atypical symptoms of gastroesophageal reflux. Am Surg 69:833-838
- Ozmen V, Oran E S, Gorgun E, Asoglu O, Igci A, Kecer M, Dizdaroglu F (2006) Histologic and clinical outcome after laparoscopic Nissen fundoplication for gastroesophageal reflux disease and Barrett’s esophagus. Surg Endosc 20:226-229
- Liu J Y, Woloshin S, Laycock W S, Schwartz L M (2002) Late outcomes after laparoscopic surgery for gastroesophageal reflux. Arch Surg 137:397-401
- Salminen P T, Laine S O, Ovaska J T (2006) Late subjective results and symptomatic outcome after laparoscopic fundoplication. Surg Laparosc Endosc Percutan Tech 16:203-207
- Kamolz T, Granderath F, Pointner R (2003) Laparoscopic antireflux surgery: disease-related quality of life assessment before and after surgery in GERD patients with and without Barrett’s esophagus. Surg Endosc 17:880-885
- Fernando H C, Schauer P R, Buenaventura P O, Christie N A, Close J M, Luketich J D (2003) Outcomes of minimally invasive antireflux operations in the elderly: a comparative review. JSLS 7:311-315
- Pitcher D E, Curet M J, Martin D T, Castillo R R, Gerstenberger P D, Vogt D, Zucker K A (1994) Successful management of severe gastroesophageal reflux disease with laparoscopic Nissen fundoplication. Am J Surg 168:547-553; discussion 553-544
- Abbas A E, Deschamps C, Cassivi S D, Allen M S, Nichols F C, 3rd, Miller D L, Pairolero P C (2004) Barrett’s esophagus: the role of laparoscopic fundoplication. Ann Thorac Surg 77:393-396
- Wetscher G J, Glaser K, Gadenstatter M, Wieschemeyer T, Profanter C, Klinger P (1998) Laparoscopic partial posterior fundoplication improves poor oesophageal contractility in patients with gastrooesophageal reflux disease. Eur J Surg 164:679-684
- Popiela T, Kawiorski W, Richter P, Legutko J, Kibil W (2005) Late complications after antireflux procedures using intraoperative continuous computer-video manometry monitoring. Acta Chir Belg 105:275-282
- Hunter J G, Smith C D, Branum G D, Waring J P, Trus T L, Cornwell M, Galloway K (1999) Laparoscopic fundoplication failures: patterns of failure and response to fundoplication revision. Ann Surg 230:595-604; discussion 604-596
- Champault G G, Barrat C, Rozon R C, Rizk N, Catheline J M (1999) The effect of the learning curve on the outcome of laparoscopic treatment for gastroesophageal reflux. Surg Laparosc Endosc Percutan Tech 9:375-381
- Kiviluoto T, Siren J, Farkkila M, Luukkonen P, Salo J, Kivilaakso E (1998) Laparoscopic Nissen fundoplication: a prospective analysis of 200 consecutive patients. Surg Laparosc Endosc 8:429-434
- Brehant O, Pessaux P, Arnaud J P, Delattre J F, Meyer C, Baulieux J, Mosnier H (2006) Long-term outcome of laparoscopic antireflux surgery in the elderly. J Gastrointest Surg 10:439-444
- Allen C J, Anvari M (2004) Does laparoscopic fundoplication provide long-term control of gastroesophageal reflux related cough? Surg Endosc 18:633-637
- Anvari M, Allen C (2003) Surgical outcome in gastro-esophageal reflux disease patients with inadequate response to proton pump inhibitors. Surg Endosc 17:1029-1035
- Cuschieri A, Hunter J, Wolfe B, Swanstrom L L, Hutson W (1993) Multicenter prospective evaluation of laparoscopic antireflux surgery. Preliminary report. Surg Endosc 7:505-510
- Allen C J, Anvari M (1998) Gastro-oesophageal reflux related cough and its response to laparoscopic fundoplication. Thorax 53:963-968
- Granderath F A, Granderath U M, Pointner R (2008) Laparoscopic revisional fundoplication with circular hiatal mesh prosthesis: the long-term results. World J Surg 32:999-1007
- Hong D, Swanstrom L L, Khajanchee Y S, Pereira N, Hansen P D (2004) Postoperative objective outcomes for upright, supine, and bipositional reflux disease following laparoscopic nissen fundoplication. Arch Surg 139:848-852; discussion 852-844
- Swoger J, Ponsky J, Hicks D M, Richter J E, Abelson T I, Milstein C, Qadeer M A, Vaezi M F (2006) Surgical fundoplication in laryngopharyngeal reflux unresponsive to aggressive acid suppression: a controlled study. Clin Gastroenterol Hepatol 4:433-441
- Hinder R A, Filipi C J, Wetscher G, Neary P, DeMeester T R, Perdikis G (1994) Laparoscopic Nissen fundoplication is an effective treatment for gastroesophageal reflux disease. Ann Surg 220:472-481; discussion 481-473
- Lindeboom M Y, Ringers J, van Rijn P J, Neijenhuis P, Stokkel M P, Masclee A A (2004) Gastric emptying and vagus nerve function after laparoscopic partial fundoplication. Ann Surg 240:785-790
- Ogut F, Ersin S, Engin E Z, Kirazli T, Midilli R, Unsal G, Bor S (2007) The effect of laparoscopic Nissen fundoplication on laryngeal findings and voice quality. Surg Endosc 21:549-554
- Granderath F A, Schweiger U M, Pointner R (2007) Laparoscopic antireflux surgery: tailoring the hiatal closure to the size of hiatal surface area. Surg Endosc 21:542-548
- el-Sherif A E, Adusumilli P S, Pettiford B L, d’Amato T A, Schuchert M J, Clark A, DiRenzo C, Landreneau J P, Luketich J D, Landreneau R J (2007) Laparoscopic clam shell partial fundoplication achieves effective reflux control with reduced postoperative dysphagia and gas bloating. Ann Thorac Surg 84:1704-1709
- del Genio G, Rossetti G, Brusciano L, Limongelli P, Pizza F, Tolone S, Fei L, Maffettone V, Napolitano V, del Genio A (2007) Laparoscopic Nissen-Rossetti fundoplication with routine use of intraoperative endoscopy and manometry: technical aspects of a standardized technique. World J Surg 31:1099-1106
- El Nakadi I, Closset J, De Moor V, Coppens E, Zalcman M, Deviere J, Gelin M (2004) Laparoscopic Nissen fundoplication after failure of Enteryx injection into the lower esophageal sphincter. Surg Endosc 18:818-820
- Champion J K (2003) Thoracoscopic Belsey fundoplication with 5-year outcomes. Surg Endosc 17:1212-1215
- Glaser K, Wetscher G J, Klingler A, Klingler P J, Eltschka B, Hollinsky C, Achem S R, Hinder R A (2000) Selection of patients for laparoscopic antireflux surgery. Dig Dis 18:129-137
- Tucker J G, Ramshaw B J, Newman C L, Sims M S, Mason E M, Duncan T D, Lucas G W (1996) Laparoscopic fundoplication in the treatment of severe gastroesophageal reflux disease: preliminary results of a prospective trial. South Med J 89:60-64
- Khajanchee Y S, Hong D, Hansen P D, Swanstrom L L (2004) Outcomes of antireflux surgery in patients with normal preoperative 24-hour pH test results. Am J Surg 187:599-603
- Neuhauser B, Hinder R A (2001) Laparoscopic reoperation after failed antireflux surgery. Semin Laparosc Surg 8:281-286
- Walsh J D, Landercasper J, Boyd W C, Lambert P J, Havlik P J (2003) Patient outcomes and dysphagia after laparoscopic antireflux surgery performed without use of intraoperative esophageal dilators. Am Surg 69:219-223; discussion 223-214
- Nguyen N T, Schauer P R, Hutson W, Landreneau R, Weigel T, Ferson P F, Keenan R J, Luketich J D (1998) Preliminary results of thoracoscopic Belsey Mark IV antireflux procedure. Surg Laparosc Endosc 8:185-188
- Bonatti H, Bammer T, Achem S R, Lukens F, DeVault K R, Klaus A, Hinder R A (2007) Use of acid suppressive medications after laparoscopic antireflux surgery: prevalence and clinical indications. Dig Dis Sci 52:267-272
- Shaheen N, Ransohoff D F (2002) Gastroesophageal reflux, barrett esophagus, and esophageal cancer: scientific review. JAMA 287:1972-1981
- Reid B J (1991) Barrett’s esophagus and esophageal adenocarcinoma. Gastroenterol Clin North Am 20:817-834
- Peters J H, Hagen J A, DeMeester S R (2004) Barrett’s esophagus. J Gastrointest Surg 8:1-17
- Sharma P, McQuaid K, Dent J, Fennerty M B, Sampliner R, Spechler S, Cameron A, Corley D, Falk G, Goldblum J, Hunter J, Jankowski J, Lundell L, Reid B, Shaheen N J, Sonnenberg A, Wang K, Weinstein W (2004) A critical review of the diagnosis and management of Barrett’s esophagus: the AGA Chicago Workshop. Gastroenterology 127:310-330
- Ronkainen J, Aro P, Storskrubb T, Johansson S E, Lind T, Bolling-Sternevald E, Vieth M, Stolte M, Talley N J, Agreus L (2005) Prevalence of Barrett’s esophagus in the general population: an endoscopic study. Gastroenterology 129:1825-1831
- Rex D K, Cummings O W, Shaw M, Cumings M D, Wong R K, Vasudeva R S, Dunne D, Rahmani E Y, Helper D J (2003) Screening for Barrett’s esophagus in colonoscopy patients with and without heartburn. Gastroenterology 125:1670-1677
- Attwood S E, Lundell L, Hatlebakk J G, Eklund S, Junghard O, Galmiche J P, Ell C, Fiocca R, Lind T (2008) Medical or surgical management of GERD patients with Barrett’s esophagus: the LOTUS trial 3-year experience. J Gastrointest Surg 12:1646-1654; discussion 1654-1645
- Sharma P, Falk G W, Weston A P, Reker D, Johnston M, Sampliner R E (2006) Dysplasia and cancer in a large multicenter cohort of patients with Barrett’s esophagus. Clin Gastroenterol Hepatol 4:566-572
- Shaheen N J, Crosby M A, Bozymski E M, Sandler R S (2000) Is there publication bias in the reporting of cancer risk in Barrett’s esophagus? Gastroenterology 119:333-338
- Skacel M, Petras R E, Gramlich T L, Sigel J E, Richter J E, Goldblum J R (2000) The diagnosis of low-grade dysplasia in Barrett’s esophagus and its implications for disease progression. Am J Gastroenterol 95:3383-3387
- Buttar N S, Wang K K, Sebo T J, Riehle D M, Krishnadath K K, Lutzke L S, Anderson M A, Petterson T M, Burgart L J (2001) Extent of high-grade dysplasia in Barrett’s esophagus correlates with risk of adenocarcinoma. Gastroenterology 120:1630-1639
- Vaughan T L, Dong L M, Blount P L, Ayub K, Odze R D, Sanchez C A, Rabinovitch P S, Reid B J (2005) Non-steroidal anti-inflammatory drugs and risk of neoplastic progression in Barrett’s oesophagus: a prospective study. Lancet Oncol 6:945-952
- Wang K K, Sampliner R E (2008) Updated guidelines 2008 for the diagnosis, surveillance and therapy of Barrett’s esophagus. Am J Gastroenterol 103:788-797
- Odze R D (2006) Diagnosis and grading of dysplasia in Barrett’s oesophagus. J Clin Pathol 59:1029-1038
- Haggitt R C, Tryzelaar J, Ellis F H, Colcher H (1978) Adenocarcinoma complicating columnar epithelium-lined (Barrett’s) esophagus. Am J Clin Pathol 70:1-5
- Montgomery E, Bronner M P, Goldblum J R, Greenson J K, Haber M M, Hart J, Lamps L W, Lauwers G Y, Lazenby A J, Lewin D N, Robert M E, Toledano A Y, Shyr Y, Washington K (2001) Reproducibility of the diagnosis of dysplasia in Barrett esophagus: a reaffirmation. Hum Pathol 32:368-378
- Oh D S, Hagen J A, Chandrasoma P T, Dunst C M, Demeester S R, Alavi M, Bremner C G, Lipham J, Rizzetto C, Cote R, Demeester T R (2006) Clinical biology and surgical therapy of intramucosal adenocarcinoma of the esophagus. J Am Coll Surg 203:152-161
- Nguyen N T, Schauer P, Luketich J D (2000) Minimally invasive esophagectomy for Barrett’s esophagus with high-grade dysplasia. Surgery 127:284-290
- Luketich J D, Landreneau R J (2004) Minimally invasive resection and mechanical cervical esophagogastric anastomotic techniques in the management of esophageal cancer. J Gastrointest Surg 8:927-929
- Prasad G A, Wang K K, Buttar N S, Wongkeesong L M, Krishnadath K K, Nichols F C, 3rd, Lutzke L S, Borkenhagen L S (2007) Long-term survival following endoscopic and surgical treatment of high-grade dysplasia in Barrett’s esophagus. Gastroenterology 132:1226-1233
- Prasad G A, Wu T T, Wigle D A, Buttar N S, Wongkeesong L M, Dunagan K T, Lutzke L S, Borkenhagen L S, Wang K K (2009) Endoscopic and surgical treatment of mucosal (T1a) esophageal adenocarcinoma in Barrett’s esophagus. Gastroenterology 137:815-823
- Overholt B F, Lightdale C J, Wang K K, Canto M I, Burdick S, Haggitt R C, Bronner M P, Taylor S L, Grace M G, Depot M (2005) Photodynamic therapy with porfimer sodium for ablation of high-grade dysplasia in Barrett’s esophagus: international, partially blinded, randomized phase III trial. Gastrointest Endosc 62:488-498
- Pech O, Gossner L, May A, Rabenstein T, Vieth M, Stolte M, Berres M, Ell C (2005) Long-term results of photodynamic therapy with 5-aminolevulinic acid for superficial Barrett’s cancer and high-grade intraepithelial neoplasia. Gastrointest Endosc 62:24-30
- May A, Gossner L, Behrens A, Kohnen R, Vieth M, Stolte M, Ell C (2003) A prospective randomized trial of two different endoscopic resection techniques for early stage cancer of the esophagus. Gastrointest Endosc 58:167-175
- Ell C, May A, Gossner L, Pech O, Gunter E, Mayer G, Henrich R, Vieth M, Muller H, Seitz G, Stolte M (2000) Endoscopic mucosal resection of early cancer and high-grade dysplasia in Barrett’s esophagus. Gastroenterology 118:670-677
- Seewald S, Akaraviputh T, Seitz U, Brand B, Groth S, Mendoza G, He X, Thonke F, Stolte M, Schroeder S, Soehendra N (2003) Circumferential EMR and complete removal of Barrett’s epithelium: a new approach to management of Barrett’s esophagus containing high-grade intraepithelial neoplasia and intramucosal carcinoma. Gastrointest Endosc 57:854-859
- Hage M, Siersema P D, van Dekken H, Steyerberg E W, Haringsma J, van de Vrie W, Grool T E, van Veen R L, Sterenborg H J, Kuipers E J (2004) 5-aminolevulinic acid photodynamic therapy versus argon plasma coagulation for ablation of Barrett’s oesophagus: a randomised trial. Gut 53:785-790
- Sharma P, Wani S, Weston A P, Bansal A, Hall M, Mathur S, Prasad A, Sampliner R E (2006) A randomised controlled trial of ablation of Barrett’s oesophagus with multipolar electrocoagulation versus argon plasma coagulation in combination with acid suppression: long term results. Gut 55:1233-1239
- Tigges H, Fuchs K H, Maroske J, Fein M, Freys S M, Muller J, Thiede A (2001) Combination of endoscopic argon plasma coagulation and antireflux surgery for treatment of Barrett’s esophagus. J Gastrointest Surg 5:251-259
- Morino M, Rebecchi F, Giaccone C, Taraglio S, Sidoli L, Ferraris R (2003) Endoscopic ablation of Barrett’s esophagus using argon plasma coagulation (APC) following surgical laparoscopic fundoplication. Surg Endosc 17:539-542
- Dulai G S, Jensen D M, Cortina G, Fontana L, Ippoliti A (2005) Randomized trial of argon plasma coagulation vs. multipolar electrocoagulation for ablation of Barrett’s esophagus. Gastrointest Endosc 61:232-240
- Montes C G, Brandalise N A, Deliza R, Novais de Magalhaes A F, Ferraz J G (1999) Antireflux surgery followed by bipolar electrocoagulation in the treatment of Barrett’s esophagus. Gastrointest Endosc 50:173-177
- Shaheen N J, Sharma P, Overholt B F, Wolfsen H C, Sampliner R E, Wang K K, Galanko J A, Bronner M P, Goldblum J R, Bennett A E, Jobe B A, Eisen G M, Fennerty M B, Hunter J G, Fleischer D E, Sharma V K, Hawes R H, Hoffman B J, Rothstein R I, Gordon S R, Mashimo H, Chang K J, Muthusamy V R, Edmundowicz S A, Spechler S J, Siddiqui A A, Souza R F, Infantolino A, Falk G W, Kimmey M B, Madanick R D, Chak A, Lightdale C J (2009) Radiofrequency ablation in Barrett’s esophagus with dysplasia. N Engl J Med 360:2277-2288
- Sharma V K, Wang K K, Overholt B F, Lightdale C J, Fennerty M B, Dean P J, Pleskow D K, Chuttani R, Reymunde A, Santiago N, Chang K J, Kimmey M B, Fleischer D E (2007) Balloon-based, circumferential, endoscopic radiofrequency ablation of Barrett’s esophagus: 1-year follow-up of 100 patients. Gastrointest Endosc 65:185-195
- Sharma V K, Kim H J, Das A, Dean P, DePetris G, Fleischer D E (2008) A prospective pilot trial of ablation of Barrett’s esophagus with low-grade dysplasia using stepwise circumferential and focal ablation (HALO system). Endoscopy 40:380-387
- Pouw R E, Wirths K, Eisendrath P, Sondermeijer C M, Kate F J, Fockens P, Deviere J, Neuhaus H, Bergman J J (2009) Efficacy of Radiofrequency Ablation Combined With Endoscopic Resection for Barrett’s Esophagus With Early Neoplasia. Clin Gastroenterol Hepatol
- Velanovich V (2009) Endoscopic endoluminal radiofrequency ablation of Barrett’s esophagus: initial results and lessons learned. Surg Endosc 23:2175-2180
- Sharma V K, Jae Kim H, Das A, Wells C D, Nguyen C C, Fleischer D E (2009) Circumferential and focal ablation of Barrett’s esophagus containing dysplasia. Am J Gastroenterol 104:310-317
- Fleischer D E, Overholt B F, Sharma V K, Reymunde A, Kimmey M B, Chuttani R, Chang K J, Lightdale C J, Santiago N, Pleskow D K, Dean P J, Wang K K (2008) Endoscopic ablation of Barrett’s esophagus: a multicenter study with 2.5-year follow-up. Gastrointest Endosc 68:867-876
- Pouw R E, Gondrie J J, Sondermeijer C M, ten Kate F J, van Gulik T M, Krishnadath K K, Fockens P, Weusten B L, Bergman J J (2008) Eradication of Barrett esophagus with early neoplasia by radiofrequency ablation, with or without endoscopic resection. J Gastrointest Surg 12:1627-1636; discussion 1636-1627
- Ganz R A, Overholt B F, Sharma V K, Fleischer D E, Shaheen N J, Lightdale C J, Freeman S R, Pruitt R E, Urayama S M, Gress F, Pavey D A, Branch M S, Savides T J, Chang K J, Muthusamy V R, Bohorfoush A G, Pace S C, DeMeester S R, Eysselein V E, Panjehpour M, Triadafilopoulos G (2008) Circumferential ablation of Barrett’s esophagus that contains high-grade dysplasia: a U.S. Multicenter Registry. Gastrointest Endosc 68:35-40
- Vij R, Triadafilopoulos G, Owens D K, Kunz P, Sanders G D (2004) Cost-effectiveness of photodynamic therapy for high-grade dysplasia in Barrett’s esophagus. Gastrointest Endosc 60:739-756
- Pohl H, Sonnenberg A, Strobel S, Eckardt A, Rosch T (2009) Endoscopic versus surgical therapy for early cancer in Barrett’s esophagus: a decision analysis. Gastrointest Endosc 70:623-634
- Das A, Wells C, Kim H J, Fleischer D E, Crowell M D, Sharma V K (2009) An economic analysis of endoscopic ablative therapy for management of nondysplastic Barrett’s esophagus. Endoscopy 41:400-408
- Inadomi J M, Somsouk M, Madanick R D, Thomas J P, Shaheen N J (2009) A cost-utility analysis of ablative therapy for Barrett’s esophagus. Gastroenterology 136:2101-2114 e2101-2106
- Faybush E M, Sampliner R E (2005) Randomized trials in the treatment of Barrett’s esophagus. Dis Esophagus 18:291-297
- Parrilla P, Martinez de Haro L F, Ortiz A, Munitiz V, Molina J, Bermejo J, Canteras M (2003) Long-term results of a randomized prospective study comparing medical and surgical treatment of Barrett’s esophagus. Ann Surg 237:291-298
- Oberg S, Johansson J, Wenner J, Johnsson F, Zilling T, von Holstein C S, Nilsson J, Walther B (2001) Endoscopic surveillance of columnar-lined esophagus: frequency of intestinal metaplasia detection and impact of antireflux surgery. Ann Surg 234:619-626
- Hofstetter W L, Peters J H, DeMeester T R, Hagen J A, DeMeester S R, Crookes P F, Tsai P, Banki F, Bremner C G (2001) Long-term outcome of antireflux surgery in patients with Barrett’s esophagus. Ann Surg 234:532-538; discussion 538-539
Figure 1. MEDLINE SEARCH STRATEGYMarch 2008Database: Ovid MEDLINE® < 1950 to March Week 2 2008 >Search Strategy:
- Gastroesophageal Reflux/ (16387)
- exp Surgical Procedures, Minimally invasive/ (190792)
- Robotics/ (5031)
- Fundoplication/ (2421)
- (*Gastroesophageal Reflux/ or *Fundoplication/) and (2 or 3) (3359)
- limit 5 to (comment or letter or news or newspaper article) (185)
- 5 not 6 (3174)
- limit 7 to english language (2522)
- 8 and *Gastroesophageal Reflux/th, su (1104)
- limit 9 to systematic reviews (46)
- limit 9 to meta analysis (3)
- limit 9 to randomized controlled trial (66)
- limit 9 to evidence based medicine reviews (3)
- 10 or 11 or 12 or 13 (112)
- 9 not 14 (992)
- limit 15 to (clinical trial, phase i or clinical trial, phase ii or clinical trial, phase iii or clinical trial, phase iv or clinical trial or consensus development conference or consensus development conference, nih or controlled clinical trial or guideline or practice guideline) (59)
- 15 not 16 (933)
- limit 17 to “review articles” (236)
- 17 not 18 (699)
- (surg$ or endoscop$ or laparo$ or digest$ or gastro$ or gut).jw. (748495)
- 19 and 20 (604)
- limit 21 to humans (586)
- limit 22 to yr=”2003 – 2008″ (236)
This document was reviewed and approved by the Board of Governors of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) in Feb 2010.
This is a revision of a SAGES publication printed Jun 2001, revised Feb 2010.
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Guidelines for clinical practice are intended to indicate preferable approaches to medical problems as established by experts in the field. These recommendations will be based on existing data or a consensus of expert opinion when little or no data are available. Guidelines are applicable to all physicians who address the clinical problem(s) without regard to specialty training or interests, and are intended to indicate the preferable, but not necessarily the only acceptable approaches due to the complexity of the healthcare environment. Guidelines are intended to be flexible. Given the wide range of specifics in any health care problem, the surgeon must always choose the course best suited to the individual patient and the variables in existence at the moment of decision.
Guidelines are developed under the auspices of the Society of American Gastrointestinal and Endoscopic Surgeons and its various committees, and approved by the Board of Governors. Each clinical practice guideline has been systematically researched, reviewed and revised by the guidelines committee, and reviewed by an appropriate multidisciplinary team. The recommendations are therefore considered valid at the time of its production based on the data available. Each guideline is scheduled for periodic review to allow incorporation of pertinent new developments in medical research knowledge, and practice.