Surgical Treatment Of Gastroesophageal Reflux Disease Research Articles

Risk of Esophageal Adenocarcinoma After Antireflux Surgery in Patients With Gastroesophageal Reflux Disease in the Nordic Countries

Gastroesophageal reflux disease (GERD) is associated with a strong and severity-dependent increased risk of esophageal adenocarcinoma. Whether antireflux surgery prevents esophageal adenocarcinoma is a matter of uncertainty. To examine whether antireflux surgery is associated with reduced risk of esophageal adenocarcinoma and whether the risk is different between surgically and medically treated patients. In this multinational, population-based retrospective cohort study from Denmark, Finland, Iceland, Norway, and Sweden, patients undergoing surgery were followed up for a median of 12.7 years, and a comparison group of patients receiving medication only were followed up for a median of 4.8 years. All patients with a registered diagnosis of GERD (or an associated disorder), including 48 414 individuals undergoing surgery and 894 492 receiving medication only, were included in the study. The study periods varied in the different countries depending on the year of initiation of registration and the date of data retrieval, from January 1, 1964, to December 21, 2014. Antireflux surgery for GERD. The risk of esophageal adenocarcinoma over time after surgery was compared with that in a corresponding background population using standardized incidence ratios (SIRs) with 95% CIs and with patients with GERD who received medication using multivariable Cox proportional hazards regression, providing hazard ratios (HRs) with 95% CIs adjusted for confounders. In this study of 942 906 patients with GERD, 48 414 underwent antireflux surgery (median [interquartile range] age, 66.0 [58.0-73.0] years; 27 161 male [56.1%]) and 894 492 received medication only (median [interquartile range] age, 71.0 [62.0-78.0] years; 434 035 male [48.6%]). Among patients undergoing surgery, 177 developed esophageal adenocarcinoma. Esophageal adenocarcinoma risk decreased in a time-dependent manner after surgery compared with the background population (5 to <10 years after surgery: SIR, 7.63; 95% CI, 5.42-10.43; ≥15 years after surgery: SIR, 1.34; 95% CI, 0.98-1.80). Among patients with more severe and objectively determined GERD, the SIRs were 10.08 (95% CI, 6.98-14.09) at 5 to less than 10 years after surgery and 1.67 (95% CI, 1.15-2.35) at 15 years or more after surgery. The risk of esophageal adenocarcinoma did not change over time in surgical patients compared with patients who received medication only (5 to <10 years after surgery: HR, 2.02; 95% CI, 1.44-2.84; ≥15 years: HR, 1.80; 95% CI, 1.28-2.54). The risk remained stable over time in analyses restricted to severe reflux disease (5 to <10 years after surgery: HR, 1.81; 95% CI, 1.24-2.63; ≥15 years after surgery: HR, 1.69; 95% CI, 1.14-2.51). Medical and surgical treatment of GERD were associated with a similar reduced esophageal adenocarcinoma risk, with the risk decreasing to the same level as that in the background population over time, supporting the hypothesis that effective treatment of GERD might prevent esophageal adenocarcinoma.

Management of failure after surgery for gastro-esophageal reflux disease

Surgical treatment of gastro-esophageal reflux disease (ST-GERD) is well-codified and offers an alternative to long-term medical treatment with a better efficacy for short and long-term outcomes. However, failure of ST-GERD is observed in 2-20% of patients; management is challenging and not standardized. The aim of this study is to analyze the causes of failure and to provide a treatment algorithm. The clinical aspects of ST-GERD failure are variable including persistent reflux, dysphagia or permanent discomfort leading to an important degradation of the quality of life. A morphological and functional pre-therapeutic evaluation is necessary to: (i) determine whether the symptoms are due to recurrence of reflux or to an error in initial indication and (ii) to understand the cause of the failure. The most frequent causes of failure of ST-GERD include errors in the initial indication, which often only need medical treatment, and surgical technical errors, for which surgical redo surgery can be difficult. Multidisciplinary management is necessary in order to offer the best-adapted treatment.

Quality of life in children who have undergone fundoplication surgery for the treatment of gastroesophageal reflux disease: a review of literature.

Health-related quality of life (QOL) in children is not just related to physical symptoms but also how a disease impacts them psychosocially-mental, emotional, behavioral, and school functioning, all of which contribute to the growth and development of a child. A chronic disease, such as gastroesophageal reflux disease (GERD) characterized by troublesome symptoms and complications, can significantly impair a child's QOL. This makes it vital that treatment options aim at addressing this. Fundoplication, the surgical treatment for GERD, is one of the most common upper gastrointestinal surgeries performed by pediatric surgeons. As with any medical treatment, there is an inherent need to determine the efficacy of the procedure not only in terms of objective physiologic measures but also QOL measures for both the children and parents. There are currently limited and inconsistent data on QOL outcomes postfundoplication in children with GERD. This literature review aims at critically analyzing the data by comparing current trends with research and identifying gaps in evidence to justify the need for further research within the field.

Current status of surgical management of gastroesophageal reflux in children.

Surgical therapy for gastroesophageal reflux disease (GERD) is controversial with considerable debate ranging from the indications for antireflux surgery to surgical technique. This article will attempt to clarify these issues with the most up-to-date information available on the prevalence, pathophysiology, diagnosis, and surgical treatment of GERD in children. Although laparoscopic Nissen fundoplication (LNF) has become the most popular operation performed for pathologic reflux, its superiority over both open surgery and other types of fundoplication is not well established. Large retrospective studies suggest LNF has a lower complication rate than open surgery. However, three prospective randomized controlled trials have been published recently which cast doubt on the superiority of LNF and suggest that LNF may have a higher failure rate compared to open fundoplication. Antireflux surgery has higher morbidity and failure rates in infants and in children with neurologic impairment. Based on the best available evidence, LNF may be less morbid, but have a higher rate of failure than open surgery. Pediatric surgeons should be mindful of the risks and benefits of both approaches to best counsel their patients. Larger prospective randomized controlled trials are needed to determine the best treatments for pediatric GERD.

Hiatal hernia and gastroesophageal reflux: Study of collagen in the phrenoesophageal ligament.

Gastroesophageal reflux disease (GERD) is defined by the intensity and/or quality of the reflux of gastric or duodenal contents into the esophagus. Surgical treatment of GERD has shown conflicting results and unacceptable recurrence rates, mainly due to herniation of the antireflux valve into the chest. A variety of techniques has been proposed to reduce GERD recurrence, including routine use of prosthesis in cruroplasty. The prevalence of GERD in patients with hiatal hernia (HH) can reach 94%. It is possible that the phrenoesophageal ligament (POL) engaged in the stabilization of the gastroesophageal junction in the abdomen may be an etiological factor of HH. We conducted a study to evaluate collagen in the constitution of the POL in patients with HH and cadavers without HH. POL samples were collected from 29 patients with HH and GERD (cases) and 32 samples from cadavers without HH (controls). Total collagen was quantified through the Picrosirius red histochemical technique, and type-I and type-III collagens were quantified immunohistochemically using a monoclonal antibody. The stained slides were photographed, and images were quantified by computer software (Image Pro Plus) to count the pixels per field. The mean age was 49.5 (±11.5) years for the cases and 38.5 (±13) years for the controls (p<0.01). Seventeen cases (58.6%) and six controls (18.75%) were female (p<0.01). The quantity of total (p<0.01), type-I (p<0.01), and type-III (p<0.05) collagens was significantly lower by about 60% in patients with HH compared with controls. Our data indicate that the composition of POL for patients with GERD and HH includes less total, type-I, and type-III collagens than that of the POL of cadavers without HH. The quality of the POL may be an etiological factor in the development of HH.

Laparoscopic Nissen Fundoplication for Gastroesophageal Reflux Disease: A Retrospective Study of 50 Consecutive Cases

Background: Laparoscopic anti-reflux surgery has been proven to be an effective treatment for gastroesophageal reflux disease (GERD) in Western countries. On the other hand, the concept of surgical treatment of GERD has not widely spread in Japan, and the number of operations performed remains extremely low. Purpose: The aim of this study is to analyze our initial experience

Medically refractory gastroesophageal reflux disease in the obese: what is the best surgical approach?

Obesity is a recognized risk factor for gastroesophageal reflux disease (GERD). Traditional antireflux surgery (fundoplication) may not be appropriate in the morbidly obese, especially when other effective alternatives exist (bariatric surgery). A 13-item survey was designed to elicit professional opinions regarding the treatment of medically refractory GERD in obese patients. Members of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) were randomly selected and emailed a link to an online survey. A total of 550 surgeons were contacted via email, and 92 (17 %) completed the survey. Of the respondents, 88 % perform laparoscopic antireflux surgery, 63 % perform bariatric surgery, and 59 % perform both. Overall, 77 % completed a minimally invasive surgery fellowship. In response to the question "Would you perform a laparoscopic fundoplication in a patient with medically refractory GERD and a BMI of 'X'?" surgeons were less likely to offer fundoplication at a higher body mass index (BMI). The majority of respondents felt that laparoscopic Roux-en-Y gastric bypass was the best option (91 %), followed by laparoscopic sleeve gastrectomy (6 %). Many had a morbidly obese patient with a primary surgical indication of GERD denied a bariatric procedure by their insurance company (57 %), and 35 % of those surgeons chose to do nothing rather than subject the patient to a fundoplication. Respondents uniformly felt that bariatric surgery should be recognized as a standard surgical option for treating GERD in the obese (96 %). When surgical treatment of GERD is indicated in an obese patient, bariatric surgery is the optimal approach, in the opinion of surgeons responding to our survey. Unfortunately, third-party payers often decline to provide benefits for a bariatric procedure for this indication. Additional data is necessary to confirm our belief that the opinions elicited through this survey are consistent with the standard of care as defined by the medical community.

Fundoplication versus medical management of gastroesophageal reflux disease: systematic review and meta-analysis

Medical, endoscopic, and open/laparoscopic surgical methods are used to treat gastroesophageal reflux disease (GERD). This study aimed to perform a systematic review of randomized controlled trials comparing medical and surgical treatments of GERD in adult patients. For the study, MEDLINE and EMBASE (1980-2012) were searched. Two reviewers independently assessed methodologic aspects and extracted data from eligible studies, focusing on patient-relevant outcomes. The primary outcomes were health-related and GERD-specific quality-of-life aspects. Standardized mean differences (SMDs) between treatment groups were calculated and combined using random-effect meta-analysis. The study identified 11 publications reporting on 7 trials comparing surgical (open or laparoscopic) and medical treatment of GERD. Meta-analysis of both quality-of-life aspects showed a pooled-effect estimate in favor of fundoplication (SMD 0.18; 95 % confidence interval [CI] 0.01-0.35; SMD 0.33; 95 % CI 0.13-0.54). Heartburn and regurgitation were less frequent after surgical intervention. However, a considerable proportion of patients still needed antireflux medication after fundoplication. Nevertheless, the surgical patients were significantly more satisfied with their symptom control and showed higher satisfaction with the treatment received. This systematic review showed that surgical management of GERD is more effective than medical management with respect to patient-relevant outcomes in the short and medium term. However, long-term studies still are needed to determine whether antireflux surgery is an equivalent alternative to lifelong medical treatment.

Gastro-oesophageal reflux. Part 1: smoking and alcohol reduction

Gastro-oesophageal reflux disease (GORD) is defined as an abnormal reflux of the stomach contents into the oesophagus, which provokes symptoms and impairs the quality of life. GORD has a high prevalence and incurs costs to the healthcare system. This is the first paper in a series of three exploring the conservative, medical and surgical treatment of GORD. This first paper presents a review of the effect of smoking and alcohol on reflux symptoms and the impact of smoking and alcohol reduction on symptoms of GORD. A search for English language studies on adults was conducted using three databases, MEDLINE, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL). Eleven relevant studies were included in the review. The effect of alcohol on the stimulation of reflux has been debated over the years in different studies. Some studies state that alcohol consumption induces reflux and moderate amounts exacerbate nocturnal gastro-oesophageal heartburn reflux. However, other studies have found no association between alcohol consumption and reflux. Most reflux occurs during smoking because nicotine causes the lower oesophageal sphincter to relax, which increases the risk of reflux. Similarly, the number of cigarettes smoked is associated with the risk of reflux. Nurses need to be aware of the effect of smoking and alcohol on reflux to provide evidence-based advice to empower patients to change their lifestyle, which results in increased therapeutic compliance and a better clinical status. There is no evidence that reducing alcohol consumption decreases symptoms and only limited evidence on the effectiveness of smoking cessation. Further research into the effectiveness of these lifestyle modifications is therefore required.

What Should be the Approach in the Long-term Management of Patients with Gastroesophageal Reflux Disease?

Objective: The aim of this study is to review available treatment options and to review current opinions in the management of patients with chronic gastroesophageal reflux disease (GERD). Materials and methods: This is a review article. Articles for the literature review were collected by using Google Search Scholar Engine. Literature search included relevant original and review articles addressing issues like medical treatment for GERD, surgical treatment for GERD, studies comparing surgical and medical treatment for GERD. GERD is a common and chronic syndrome. Patients affected with syndrome experience symptoms which affect their quality of life. The goals of treatment in this condition is to control symptoms, heal injured esophageal mucosa and to prevent complications. Both proton pump inhibitor (PPI) therapy and antireflux surgery are equally effective in controlling symptoms and in healing esophageal mucosal injury. In the recent years, laparoscopic surgery is increasingly been offered to patients with GERD. However, there is still controversy over best approach to management of GERD. This study attempted to review current opinions of this issue. Conclusion: PPIs is an option for initial management of GERD. However, this condition been a chronic condition, relapse is common while on therapy with medications or following discontinuation of therapy. Hence, a treatment option which provides effective control of symptoms and prevents or minimizes complications has to be offered to patients. Medical therapy with PPI and laparoscopic antireflux surgery, both can achieve these therapeutic goals. Hence, in the light of this literature review it is recommended to individualize the treatment offered to the patient with GERD, in consultation with the patient himself or herself.

Transoral incision free fundoplication (TIF) - A new paradigm in the surgical treatment of GERD.

An estimated 10 billion dollars is spent treating gastro-oesophageal reflux disease (GERD) in the USA every year. The present article reports a case of the safe and successful use of transoral incisionless fundoplication (TIF) using the EsophyX90™ device in the surgical treatment of GERD.

Laparoscopic Nissen fundoplication combined with posterior gastropexy in surgical treatment of GERD

Laparoscopic Nissen fundoplication (LNF) has become established as the procedure of choice in the surgical management of the majority of patients suffering from gastroesophageal reflux disease (GERD). Postoperative paraesophageal herniation has an incidence range up to 7% in the immediate postoperative period. A prospective randomized trial was scheduled to study the role of posterior gastropexy, in combination with LNF, in prevention of paraesophageal herniation and improvement of postoperative results in surgical treatment of GERD. Eighty-two patients with GERD were randomized to LNF combined with (group A, n = 40) or without (group B, n = 42) posterior gastropexy. Subjective evaluation using disease-specific and generic questionnaires and structured interviews, and objective evaluation by endoscopy, esophageal manometry, and 24-h pH monitoring, were performed before operation, at 2 and 12 months after surgery, and then every year. Crura approximation was performed by stitches if the diameter was less than 6 cm, or with a patch to reinforce the conventional crural closure or by tension-free technique to close the hiatus. Posterior gastropexy (group A) was performed with one stitch between the posterior wall of the wrap and the crura near the arcuate ligament. Sixteen patients of group A and 15 patients of group B with concomitant abdominal diseases had simultaneous procedures [cholecystectomy 25, vagotomy 2, ventral hernia repair 1, gastric polypectomy 1, gastric fundus diverticulectomy 1, gastrointestinal stromal tumor (GIST) wedge resection 1]. In mean follow-up of 48 +/- 26 months (range 7-94 months), one patient of group B presented with paraesophageal herniation in the first postoperative month (reoperation), while recurrent gastroesophageal reflux (Visick III or IV), successfully treated by medication, was noted in three patients of group B and in one patient of group A. Only mild dysphagia, during the first two postoperative months, was noted in nine patients of group A and eight patients of group B. Six patients of each group with Barrett's esophagus had endoscopic improvement after the second postoperative month. Visick score in groups A/B was I in 26/11 (P < 0.0001), II in 13/27 (P = 0.037), III in 1/2 (not significant, NS), and IV in 0/2. Generally, Visick score was I or II in 39/38 in groups A/B (97.5%/90.5%, NS) and III or IV in 1/4 (2.5%/9.5%, P < 0.0001). LNF combined with posterior gastropexy may prevent postoperative paraesophageal or sliding herniation in surgical treatment of GERD, providing better early and long-term postoperative results. (Registered Clinical Trial number: NCT00872755. www.clinicaltrials.gov .).

Beliefs about surgery: Development and validation of an instrument to assess cognitive representations about surgery, in the context of a chronic illness

Objectives: Within a trial of medical and surgical treatments for gastro-esophageal reflux disease (GORD), involving randomised arms and preference arms, we tested the applicability of the Beliefs about Medicines Questionnaire (BMQ) and developed and tested the validity of a new Beliefs about Surgery Questionnaire (BSQ). Methods: Patients with GORD (N = 43) were interviewed to elicit their beliefs about medical and surgical treatments. These contributed to the development of BSQ items. The BMQ and BSQ were completed by trial participants at baseline (randomised trial: N = 325; preference trial: N = 414). Factor analysis and discriminant function analysis were used to assess validity. Results: Principal components analysis (PCA) largely replicated the four-factor BMQ structure. PCA of the combined BMQ/BSQ yielded six factors explaining 54.5% variance. BSQ items loaded onto distinct factors, demonstrating divergence from BMQ. As predicted, BMQ/BSQ scores enabled correct classification of 78.5% of participants to medication and surgery groups in the preference trial (χ2(6) = 205.9, p < 0.001) but only 54.5% (no better than chance) in the randomised trial (χ2(6) = 9.4, p = 0.154). Conclusions: The BSQ is a valid measure of perceptions about surgical treatments for GORD. With the BMQ, it provides information that may guide patients’ choices about treatment. This measure may be applicable to other conditions.

Is there a changing trend in surgical management of gastroesophageal reflux disease in children?

Gastroesophageal reflux disease (GORD) is a pathological process in infants manifesting as poor weight gain, signs of esophagitis, persistent respiratory symptoms and changes in neurobehaviour. It is currently estimated that approximately one in every 350 children will experience severe symptomatic gastroesophageal reflux necessitating surgical treatment. Surgery for GORD is currently one of the common major operations performed in infants and children. Most of the studies found favour laparoscopic approach which has surpassed open antireflux surgery as the gold standard of surgical management for GORD. However, it must be interpreted with caution due to the limitation of the studies, especially the small number of subject included in these studies. This review reports the changing trends in the surgical treatment of GORD in children.

The development of a new measure of quality of life in the management of gastro-oesophageal reflux disease: the Reflux questionnaire

This paper reports on the development of a new measure of health-related quality of life for use among patients with gastro-oesophageal reflux disease (GORD), funded as part of the REFLUX trial. This is a large UK multi centre trial that aims to compare the clinical and cost effectiveness of minimal access surgery with best medical treatment for patients with GORD within the NHS. Potential items were identified via a series of interviews and focus groups carried out with patients who were receiving/had received medical or surgical treatment for GORD. The final measure consisted of 31 items covering 7 categories (Heartburn; Acid reflux; Wind; Eating and swallowing; Bowel movements; Sleep; Work, physical and social activities). The measure produced two outputs: a quality of life score (RQLS) and five Reflux symptom scores. Reliability (internal consistency), criterion validity with the SF-36 and, sensitivity to change in terms of relationship with reported change in prescribed medication were assessed amongst a sample of 794 patients recruited into the trial. The measure was shown to be internally consistent, to show criterion validity with the SF-36 and sensitive to changes in patients use of prescribed medication at baseline and 3 month follow-up. The Reflux questionnaire is a new self-administered questionnaire for use amongst patients with GORD. Initial findings suggest that the new measure is valid, reliable, acceptable to respondents and simple to administer in both a clinical and research context.

Effects of manometrically discovered nonspecific motility disorders of the esophagus on the outcomes of antireflux surgery.

Nonspecific motility disorders (NMDs) of the esophagus are common manometric findings in patients evaluated for gastroesophageal reflux disease (GERD). However, it is unclear how these disorders affect the outcomes of antireflux surgery. The purpose of this study was to assess symptomatic outcomes of patients with and without NMDs undergoing surgical treatment for GERD. A prospectively gathered database of all patients undergoing antireflux surgery was retrospectively reviewed for preoperative symptoms, symptom severity using the GERD-HRQL (best score 0, worst score 50), esophageal manometry measurements, presence of NMD, type of operation, any transient or permanent postoperative dysphagia, severity of postoperative dysphagia (best score 0, worst score 5), and postoperative symptom severity. A total of 239 patients were studied; 24% had a NMD identified by preoperative esophageal manometry, and 17% of this +NMD group had preoperative dysphagia or atypical chest/epigastric pain compared to 28% of those without a NMD (-NMD group) (P=NS). Preoperative symptom scores were +NMD 33 vs. -NMD 27 (P=0.01). Postoperative symptom scores were +NMD 5 vs. -NMD 3 (P=NS). There were no differences in preoperative or postoperative dysphagia scores. Transient postoperative dysphagia was 15.8% in the +NMD group vs. 16.4% in the -NMD group (P=NS). Postoperative dilation was 0% in the +NMD group vs. 2% in the -NMD group (P=NS). Manometrically discovered NMDs do not appear to affect preoperative symptoms or symptomatic outcomes of patients surgically treated for GERD. These findings my reflect the severity of GERD and may improve with antireflux surgery.

Anti-reflux surgery improves pulmonary function in lung transplant patients

Background: As immediate posttransplant surgical outcomes have improved the greatest limitation of lung transplantation remains chronic allograft dysfunction. While immunologic factors are believed to be the primary cause of chronic allograft dysfunction other injuries to the lung may also play a role. Gastroesophageal reflux disease (GERD) with resultant aspiration has been implicated as a potential contributing factor in chronic allograft dysfunction. Surgical treatment of GERD has been shown to be safe with minimal morbidity in the lung transplant population. In this study we sought to determine the effect of fundoplication surgery in lung transplant patients with documented GERD.

What did the Laparoscopic Nissen Approach of the Gastro-oesophageal Reflux Really Change for the Patients 8 Years Later?

Background: Nissen fundoplication (NF) is recognized as the surgical treatment of the gastro-oesophageal reflux disease (GERD). NF can be achieved either by open surgery or by laparoscopic approach.Methods : From 1987 to 1997, 210 patients were treated for GERD by NF : 61 by open and 149 by laparoscopic approach. All the patients were followed more than 1 year and were scored by clinical assessment (Visick scale adaptation). In case of Visick score > 1, Gl-endoscopy, X-ray series or 24-hour pH-study complete the evaluation.Results : The operative time was comparable between both groups. The postoperative recovery was statistically faster in the laparoscopic group (p = 0.0001). The mean time of follow-up was 6 years after open NF and 4 years after laparoscopic NF. After open NF or laparoscopic NF, 72% and 67% of the patients are respectively scored Visick 1,13% and 21 % - Visick 2,6.8% and 6% -Visick 3 and 8.2% and 6% -Visick 4 (NS). Patients with recurrence of GERD were scored Visick 4, so failure of the surgical treatment is observed in 5 patients after open NF and 9 patients after laparoscopic NF. The occurrence of incisional hernia was significantly higher in the open group (p = 0.0001).Conclusion : NF remains a safe procedure for surgical treatment of GERD and can be achieved by laparoscopic approach with comparable results to those by open laparotomy. In our experience, the advantages of the laparoscopic approach is a faster postoperative recovery and a lower risk of incisional hernia.

Gastroesophageal reflux disease in the older patient: presentation, treatment, and complications.

Gastroesophageal reflux disease (GERD) is common in the elderly. Patients often complain of less severe or frequent heartburn than their younger cohorts, but because of prolonged acid exposure over many years, the elderly have more complicated reflux disease including esophagitis, peptic strictures, and Barrett's esophagus. Potential factors aggravating GERD in the elderly include medications, which reduce lower esophageal sphincter pressure, higher frequency of hiatal hernia, impaired motility, and decreased saliva volume and bicarbonate concentration. Early endoscopy is indicated in all elderly patients with GERD, regardless of symptom severity. The medical and surgical treatment of GERD in the elderly generally follows the same principles as for any adult patient.

Gastroesophageal reflux disease (GERD): Back to surgery?

Part 1 GERD - mechanisms and diagnosis: pathogenesis a possible role for helicobacter pylori in the pathogenesis of reflux oesophagus epidemiology clinical symptoms and prognosis endoscopic classification of reflux oesophagitis by the MUSE system diagnosis. Part 2 State of the art - lecture: solving the GORDian knot, I.M. Modlin et al. Part 3 GERD - nonoperative treatment: inhibition of acid secretion treatment of motility disorders interventional endoscopic therapy. Part 4 GERD and Barrett's oesophagus: the prognosis of Barrett's oesophagus and its relationship with GERD endoscopic surveillance of Barrett's oesophagus is there regression in Barrett's oesophagus?. Part 5 Surgical treatment of GERD: Nissen fundoplication - the gold standard long-term outcome after open fundoplication complications and late consequences of open fundoplication for GERD laparoscopic fundoplication - history of a trend-setting operation laparoscopic antireflux surgery - principles governing assessment of patients for endoscopic surgery and options for surgical treatment failure and pitfalls of Nissen repair. Part 6 International results of laparoscopic fundoplication: German experience with laparoscopic antireflux surgery laparoscopic Nissen fundoplication in the USA early results in the Swiss experience with laparoscopic fundoplication for GERD laparoscopic antireflux surgery in the United Kingdom and Ireland laparoscopic floppy Nissen fundoplication - the Groote Schuur hospital experience. Part 7 Safe performance of a laparoscopic fundoplication: laparoscopic treatment of gastro-oesophageal reflux - Nissen-Rosseti fundoplication safe performance of a laparoscopic Nissen fundoplication - standard technique II the technique of Nissen fundoplication laparoscopic Toupet partial fundoplication laparoscopic anterior partial fundoplication laparoscopic treatment of paraoesophageal hernia laparoscopic cardiomyotomy for achalasia. Part 8 Conclusion: gastro-oesophageal reflux disease (GERD) - back to surgery?, M.W. Buchler et al.