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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.

The patient was a 35-year-old man who first underwent fundoplication due to hematemesis associated with reflux esophagitis 11 years earlier. Despite two subsequent antireflux operations, reflux-related symptoms persisted, and upper gastrointestinal endoscopy confirmed recurrent reflux esophagitis. After 24-h pH monitoring and Bilitec 2000 showing regurgitation of gastric and duodenal juice, distal gastrectomy with Roux-en-Y reconstruction was performed. The patient's postoperative course was uneventful, and recurrence has not appeared for 10 months after surgery. To our knowledge, this is the first report of successful surgery after three failed antireflux operations for recurrent reflux esophagitis. Distal gastrectomy should be considered after unsuccessful antireflux operations for intractable reflux esophagitis.

The purpose of this trial was to measure the health-related quality of life (HRQL) of gastroesophageal reflux disease (GERD) patients waiting for an antireflux operation.A total of 120 patients waiting for a laparoscopic fundoplication were sent questionnaires measuring their symptoms and quality of life.Ninety-five of the patients still needing an operation returned the questionaires and were included in the analysis. Thirty-one of 84 patients (37%) felt that the symptoms had worsened, and 51/90 (57%) were unsatisfied. Thirty percent suffered from throat or airway infections, 25% from swallowing difficulties, 48% from retrosternal pain, and 18% had asthma. The mean GERD HRQL score (0-45) was 21.7 (95% confidence interval, 19.7-23.7). Short Form-36 scores of this population were significantly worse when compared to patients with inguinal hernia or moderate asthma.Patients waiting for a fundoplication seem to have a significantly decreased health-related quality of life due to poor symptom control regardless of continuous medical treatment.

Modern upper GI function studies allow for the detection of several pathophysiological factors that contribute to gastroesophageal reflux disease. The information obtained can lead to therapeutic consequences in patients with an indication for a surgical intervention, i.e., an individualized choice of antireflux procedure according to the existing pathophysiologic defect.In an experimental study on mini-pigs the mechanical effect of four standardized antireflux operations (anterior and posterior 180 degrees hemifundoplication, Nissen-DeMeester and Nissen-Rossetti 360 degrees fundoplication) on the lower esophageal sphincter (LES) was investigated. It was the aim of the study to objectively determine the extent of changes in pressure and length parameters at the LES according to the performed antireflux procedure.It could be demonstrated that different degrees of fundic wrap formation lead to a proportional mechanical effect at the LES according to the size of this wrap.Choosing a distinct type of fundoplication will allow for a tailored augmentation of the LES according to the individual functional defect.

Antireflux operations are commonly performed in infants and children with complicated gastroesophageal reflux. The Nissen fundoplication has emerged as the “gold standard” antireflux procedure, although troublesome problems with wrap slippage over the stomach, complete or partial wrap disruption, and herniation of the wrap into the posterior mediastinum are frequent complications, leading to recurrent symptoms of reflux and a difficult reoperative procedure. We presently perform the uncut Collis-Nissen fundoplication as a primary antireflux procedure. This operation is particularly useful in the treatment of children with failed Nissen fundoplication. In this report, we describe our technique of performing this operation through a transabdominal approach and outline the advantages of the procedure.

One of the authors has developed a special device--the suturoscope--which allows endoscopic sutures with conventional suture material. After several modifications, in order to improve the prototype, the authors began its clinical application in 1992. Five bladder operations were performed--two antireflux operations, two meatotomies with meatoplasty, and an intramural ureteric ligation. The results indicate that this device is suitable for clinical use.

The antireflux operation according to Lich-Grégoir (L-G) poses no particular technical problems and involves no major surgical stress to the patient. Of its intraoperative complications lesions to the bladder mucosa have to be considered in the first place. Its postoperative complications calling for reoperation comprise recurrence of reflux, ureteral stricture and ureteral fistula. Results of the Lich-Grégoir operation performed in 176 instances are reported. The complication rate was 4.5 per cent. The complications are commented upon, and the types and time of reoperations are discussed.

Five children who were operated upon for esophageal atresia, were examined by lateral fluoroscopy with TV control, because they were suffering from recurring bronchitis and bronchopneumonia. In all these cases we found a normal anastomotic side, which showed frequently a barrier for passage of the bolus. This happened also without any manifested stenoses at the anatomotic level. Therefore the former upper esophageal pouch constituted a little reservoir. In all these cases we also observed a very manifest esophageal reflux. With each refluxwave the former upper pouch was refilled again, and reflux was seen from this part into the oro and laryngopharynx with cough and occasional aspiration. We are convinced that these phaenomena are responsible to the recurring bronchitis and bronchopneumonia. For treatment we suggest no eating, 2–3 hours before sleeping and elevating of the cranial upper part of the bed. It is possible, that an antireflux operation like fundoplicatio may be indicated.