This document discusses when surgery is appropriate for patients with gastroesophageal reflux disease (GERD). It defines GERD and notes that up to 50% of patients with GERD symptoms may not have pathological reflux. Indications for anti-reflux surgery include failed medical management, complications of GERD, and extra-esophageal manifestations. Long-term surgical outcomes data on 400 patients found 80% had improvement at 8 years, though 41% required continued PPI use and 15 patients (3.75%) required reoperation. Special surgical considerations are discussed for patients with Barrett's esophagus, hiatal hernia, and idiopathic pulmonary fibrosis. The key recommendations are to take a careful history

1. Who, What, and When:
Who are the Patients that Need Surgery
and When Should We Intervene?
Andrew S. Wright MD
University of Washington
Center for Videoendoscopic surgery
@andrewswright

2. Nothing to disclose
SAGES 2015 Disclosure Slide

5. GERD
• Spectrum of disease
Typical
Symptoms
Atypical
Symptoms

6. GERD
• Spectrum of disease
Typical
Symptoms
Atypical
Symptoms
Esophageal
Injury
PEH Pulmonary
Disease

7. GERD
Montreal Definition
“A condition which develops when the reflux
of stomach contents causes troublesome
symptoms and/or complications”

8. GERD
Montreal Definition
“A condition which develops when the reflux
of stomach contents causes troublesome
symptoms and/or complications”
Definition of Troublesome?

9. Causes of GERD
Gut. 2014 Jul; 63(7): 1185–1193

10. Causes of GERD
Gut. 2014 Jul; 63(7): 1185–1193
Note: No mention of abnormal or increased gastric acid secretion

11. Medical Therapy

12. Failure of Medical Therapy
• Inadequate Acid Suppression
• Non-acid reflux/regurgitation
• Poor compliance

13. Failure of Medical Therapy
• Inadequate Acid Suppression
• Non-acid reflux/regurgitation
• Poor compliance
• Incorrect Diagnosis
– Up to 50% of patients with GERD symptoms have
no pathologic reflux

14. Diagnosis
• Upper GI
• 24hr pH monitoring
– 48hr Bravo may be more sensitive
– Role of impedance still unclear
• Manometry
• EGD

15. Indications for Surgery - 2015
• Failed Medical Management

16. Indications for Surgery - 2015
• Failed Medical Management
• Desire surgery despite successful
management

17. Indications for Surgery - 2015
• Failed Medical Management
• Desire surgery despite successful
management
• Complications of GERD

18. Indications for Surgery - 2015
• Failed Medical Management
• Desire surgery despite successful
management
• Complications of GERD
• Extra-esophageal manifestations

19. Long-term Surgical Outcomes
92 month FU (6-175)
400 patients

20. Long-term Surgical Outcomes

21. Long-term Surgical Outcomes

22. Long-term Surgical Outcomes
• 41% on PPI
• 15/400 reoperations
– 9 recurrent reflux
– 6 side effect of primary operations

23. Special Case: Barrett’s
82 patients
Median 8 year FU (1-16)

24. Special Case: Hiatal Hernia
• Repair of asymptomatic type I (sliding) HH not
indicated (+++, strong)

25. Special Case: Hiatal Hernia
• Repair of asymptomatic type I (sliding) HH not
indicated (+++, strong)
• All symptomatic PEH (types II-IV) should be
repaired (+++, strong)

26. Special Case: Hiatal Hernia
• Repair of asymptomatic type I (sliding) HH not
indicated (+++, strong)
• All symptomatic PEH (types II-IV) should be
repaired (+++, strong)
• Asymptomatic PEH may not be indicated.
Consider age and co-morbidities (+++, weak)
– Risk of needing emergent surgery 2%/year

27. Special Case:
Idiopathic Pulmonary Fibrosis

28. Special Case: Recurrent Disease

29. Recommendations
• Take a careful history
• Make the correct diagnosis

30. Recommendations
• Take a careful history
• Make the correct diagnosis
• Be realistic with your patients
– 80% improved at 8 years
– 40% back on PPIs
– 25% side effects (dysphagia, bloat, diarrhea)
– 3% re-operation rate

31. Recommendations
• Take a careful history
• Make the correct diagnosis
• Be realistic with your patients
– 80% improved at 8 years
– 40% back on PPIs
– 25% side effects (dysphagia, bloat, diarrhea)
– 3% re-operation rate
• Do a Good Operation

32. “Either partial or complete fundoplication is
acceptable as long as the surgeon constructs the
fundoplication well, and this is the important point:
We, as surgeons or other medical professionals,
have a tendency to blame the operation when we
should blame how the operation was done. A good
operation done badly will lead to poor results.”
- Vic Velanovich
Surgical Technique

33. SAGES Foregut Group
https://www.facebook.com/groups/SAGESforegut/