Indications for Interventional and Surgical Therapy in GERD

Abstract

Reflecting the multifactorial background of gastroesophageal reflux disease (GERD) and the large variation in its clinical presentation, it is not surprising that “one therapeutic option would fit all patients with GERD” is not a realistic therapeutic option. Extracting data from literature regarding therapeutic decision-making requires a critical view for the composition of the involved patient populations and especially regarding indications for surgery. GERD may present with several different symptoms, which can overlap with other diseases and other disorders presenting with reflux-like symptoms. Therefore, the most important initial issue, when facing a patient, who needs a decision regarding an indication for endoscopic or surgical therapy, is a precise diagnostic workup including an upper GI-endoscopy, impedance-pH-monitoring, high-resolution manometry, and in cases of dysphagia or signs of delayed gastric emptying additional radiographic and scintigraphic investigations. PPI therapy is very effective and it remains the standard treatment for acute symptoms of GERD. There is no place for surgical therapy as an acute therapeutic option. In addition, it must be emphasized that PPI therapy is the most frequent form of long-term therapy in GERD patients and shows a good safety profile. The worst component in waiting for many years to establish a justified indication for antireflux surgery is the fact that after unnecessary waiting the chances for being able to correct effectively the anatomical and functional changes in such a patient are decreasing, if this decision is postponed too long. Therefore, it is important to start diagnostic activities at the right time to assess the functional and anatomic status of the patient and determine what the nature of her/his GERD is in order to gain objective findings for therapeutic decision-making. It is very important for every single patient to undergo adequate investigations prior to surgery. Optimal information about the background of the disease can only be obtained by extensive diagnostic testing of the individual situation of the disease and its pathophysiologic causes.