Antireflux surgery for GORD in adults

Laparoscopic fundoplication can provide long-term control of symptoms in patients with GORD with similar efficacy to proton pump inhibitor (PPI) therapy.

Patient selection is crucial to the outcome of surgery. Fundoplication should be considered for problematic regurgitation or heartburn that persists despite drug therapy, or for symptoms associated with a large hiatus hernia. It is also likely to be effective in patients who have good symptom control with PPI therapy; in this group, surgical therapy should only proceed after informed consent and a discussion of the harms and benefits of long-term drug therapy versus surgery.

Patients with atypical symptoms, no mucosal changes at endoscopy, and a poor response to PPI therapy often do not improve after fundoplication, and commonly develop troublesome new symptoms.

Laparoscopic fundoplication has a low mortality rate but may be associated with significant adverse effects. The most common adverse effects are inadequate control of heartburn, dysphagia, increased flatus, delayed gastric emptying, dumping syndrome and, in severe cases, ‘gas bloat’ syndrome (an inability to belch or vomit).

Recurrent symptoms may be due to failure of the fundoplication with time; this may be due to disruption of the wrap, recurrence of a hiatus hernia or slippage of the fundoplication. The causes of these problems likely include both surgical and patient factors.