Medical, Surgical, and Endoscopic Management of Gastroesophageal Reflux Disease

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Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal diseases facing society today. In the US alone, more than 19 million people have the disease. Approximately 20% of US adults have one episode of GERD in a week, with about 7% reporting significant daily heartburn symptoms requiring some type of treatment.1 Medical treatments for GERD, both prescription and over the counter, cost approximately $19 billion per year in the US. Fortunately the majority of GERD symptoms are minor and self-limiting; however, complications, including esophagitis, Barrett syndrome, and adenocarcinoma, are on the rise in Western countries, suggesting that GERD does not have a benign course in all patients. The term nonerosive reflux disease (NERD) has been used to describe the majority of patients that have a benign, uncomplicated disease course. This group has GERD symptoms without evidence of esophagitis on endoscopy. The clinical management of GERD has evolved rapidly since the early 1990s with the introduction of potent medications as well as less invasive surgical techniques to help treat patients with medically refractory disease. Novel medications to help prevent transient lower esophageal sphincter relaxations (tLESRs) are being developed and may be added to the armamentarium.2 Additionally, endoscopic therapies have gained some support, though long-term data suggest that these techniques are not durable. This article reviews the pathophysiology, presentation, workup, treatment, and emerging therapies for GERD with an emphasis on surgical management and outcomes to help primary care physicians have a better understanding of the role of surgery in this complex disease.