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The topic of “when and what” for gastroesophageal reflux disease (GERD) procedures centers on the correct indications for antireflux surgery gleaned from a thorough preoperative evaluation (the “when”) and on the right antireflux operation to perform once the ideal candidate is identified (the “what”). The goals of this evidence-based review are the following: (1) to identify the key indications for surgery and predictors of good outcomes in the initial evaluation of patients with symptoms of GERD; (2) to describe the operations for GERD in the armamentarium of the general surgeon and their indications, as well as the technical elements of the operation; and (3) to describe the optimal surgical treatment of GERD and obesity when the two diseases coexist.

A laparoscopic fundoplication is considered today the procedure of choice for the treatment of gastroesophageal reflux disease (GERD). Several eponyms are used in the literature to denote different antireflux operations: Nissen, Nissen-Rossetti, Toupet, Lind, Guarner, Hill, and Dor. We feel that it is more important to focus on the technical elements which make a fundoplication effective and long lasting. The type of fundoplication (total vs. partial) is tailored to the quality of esophageal peristalsis as documented by the preoperative manometry. In the USA, a partial fundoplication is chosen only for patients with very impaired or absent esophageal peristalsis. This article describes the technique of laparoscopic total fundoplication for GERD. Partial fundoplication is performed following the same technical elements as the total fundoplication. A 240° to 270° wrap rather than a 360° wrap is performed.

For hypertensive lower esophageal sphincter with dysphagia and chest pain, a laparoscopic cardiomyotomy is recommended. Recently, the role of gastroesophageal reflux in this abnormality has been recognized. A prospective study on six patients with manometrically proven hypertensive lower esophageal sphincter was performed. Laparoscopic floppy Nissen fundoplication was performed in all cases. The first follow up was performed 6 weeks after the operation. The mean follow up time was 56 months (range 50-61). Before the operation, all patients had abnormal esophageal acid exposure. Mean DeMeester score was 41.7 (range 16.7-86). Average LES pressure before the operation was 50.5 mmHg (range 35.6-81.3). Six weeks after operation, all patients were symptom free. DeMeester score returned to a normal level of 2.9. Furthermore, a marked decrease in the lower esophageal sphincter pressure (24.7 mmHg) was detected. At late follow up, all patients were symptom-free, and only two patients agreed to undergo functional testing. The mean DeMeester score of this two patients was 1.2. The pressure remained at normal value (15.7 mmHg). In our study, an antireflux operation normalized lower esophageal sphincter pressure suggesting that abnormal esophageal acid exposure may be an etiologic factor in the development of hypertensive lower esophageal sphincter.

Peptic esophageal stricture with dysphagia is a late manifestation of severe gastroesophageal reflux disease (GERD). Although laparoscopic fundoplication is an effective antireflux operation, its efficacy for persons with peptic esophageal stricture and dysphagia has not been well defined. The aim of this study was to evaluate outcomes after fundoplication in this subgroup of GERD patients. Forty GERD patients with moderate, severe, or incapacitating dysphagia and peptic esophageal stricture were compared to a control group of 121 GERD patients without significant dysphagia or stricture. Reflux symptom severity was scored by each patient preoperatively and at most recent follow-up postoperatively (mean 1.5 years) using a scale ranging from 0 to 4 (0 = symptoms absent; 4 = symptoms incapacitating). Symptom scores were compared by the Wilcoxon rank-sum test. Postoperative redilation and fundoplication failure rates were also determined. At a mean follow-up of 1.5 years after fundoplication, the median dysphagia score had improved from 3 to 0 (P