This report summarises conclusions from an evidence-based workshop which evaluated major clinical strategies for the management of the full spectrum of gastro-oesophageal reflux disease, with an emphasis on medical management.

The disease was defined by the presence of oesophageal mucosal breaks or by the occurrence of reflux induced symptoms severe enough to impair quality of life. Endoscopy negative patients were recognised as the most common subgroup; most of these patients can be diagnosed by a well structured symptom analysis. There is a consistent hierarchy of effectiveness of available initial and long term therapies that applies for all patient subgroups. Lifestyle measures were judged to be of such low efficacy that they were rejected as a primary therapy for all patient subgroups. Proton pump inhibitor therapy was considered the initial medical treatment of choice because of its clearly superior efficacy which results in the most prompt achievement of desirable outcomes at the lowest overall medical cost. It was acknowledged that most of patients require long term management and that any maintenance therapy should be chosen by step down to the regimen that is still effective, but least costly. Endoscopic monitoring of routine long term therapy was considered inappropriate, on the basis that control of symptoms is an acceptably reliable indicator of healing in patients with oesophagitis.

Laparoscopic antireflux surgery was recognised as a significant therapeutic advance, the results of which, however, depend substantially on the experience of the surgeon. There are currently no published direct comparisons of cost and efficacy outcomes of optimal medical and surgical therapies for reflux disease. To a significant degree, the choice between medical and surgical therapy should depend on informed patient preference.

Substantial advances have occurred recently in the understanding and treatment of reflux disease. By contrast, there has been relatively little research into the best …

https://gut.bmj.com/content/gutjnl/44/suppl_2/S1.full.pdf

An evidence-based appraisal of reflux disease management — the Genval Workshop Report

ContextSevere gastroesophageal reflux disease (GERD) is a lifelong problem
that can be complicated by peptic esophageal stricture and adenocarcinoma
of the esophagus.ObjectiveTo determine the long-term outcome of medical and surgical therapies
for GERD.Design and SettingFollow-up study conducted from October 1997 through October 1999 of
a prospective randomized trial of medical and surgical antireflux treatments
in patients with complicated GERD. Mean (median) duration of follow-up was
10.6 years (7.3 years) for medical patients and 9.1 years (6.3 years) for
surgical patients.ParticipantsTwo hundred thirty-nine (97%) of the original 247 study patients were
found (79 were confirmed dead). Among the 160 survivors (157 men and 3 women;
mean [SD] age, 67 [12] years), 129 (91 in the medical treatment group and
38 in the surgical treatment group) participated in the follow-up.Main Outcome MeasuresUse of antireflux medication, Gastroesophageal Reflux Disease Activity
Index (GRACI) scores, grade of esophagitis, frequency of treatment of esophageal
stricture, frequency of subsequent antireflux operations, 36-item Short Form
health survey (SF-36) scores, satisfaction with antireflux therapy, survival,
and incidence of esophageal adenocarcinoma, compared between the medical antireflux
therapy group and the fundoplication surgery group. Information on cause of
death was obtained from autopsy results, hospital records, and death certificates.ResultsEighty-three (92%) of 90 medical patients and 23 (62%) of 37 surgical
patients reported that they used antireflux medications regularly (P<.001). During a 1-week period after discontinuation of medication,
mean (SD) GRACI symptom scores were significantly lower in the surgical treatment
group (82.6 [17.5] vs 96.7 [21.4] in the medical treatment group; P = .003). However, no significant differences between the groups were
found in grade of esophagitis, frequency of treatment of esophageal stricture
and subsequent antireflux operations, SF-36 standardized physical and mental
component scale scores, and overall satisfaction with antireflux therapy.
Survival during a period of 140 months was decreased significantly in the
surgical vs the medical treatment group (relative risk of death in the medical
group, 1.57; 95% confidence interval, 1.01-2.46; P
= .047), largely because of excess deaths from heart disease. Patients with
Barrett esophagus at baseline developed esophageal adenocarcinomas at an annual
rate of 0.4%, whereas these cancers developed in patients without Barrett
esophagus at an annual rate of only 0.07%. There was no significant difference
between groups in incidence of esophageal cancer.ConclusionThis study suggests that antireflux surgery should not be advised with
the expectation that patients with GERD will no longer need to take antisecretory
medications or that the procedure will prevent esophageal cancer among those
with GERD and Barrett esophagus.

https://www.ualberta.ca/~loewen/Medicine/GIM%20Residents%20Core%20Reading/DYSPHAGIA,%20GERD,%20BARRETTS%20ESOPHAGUS/therapy%20for%20gerd%20outcomes.pdf

Long-term outcome of medical and surgical therapies for gastroesophageal reflux disease: follow-up of a randomized controlled trial.

A surgical instrument (200) includes an end effector (202) having a Clevis (224) and first and second jaws (226, 228) mutually rotatable between open and closed positions. The jaws are proximally directed and laterally displaced relative to an axis of a control shaft (206) of the instrument. The jaws hold first and second parts of a fastener, respectively. The first part includes a base having upstanding tissue piercing posts (256), and the second part includes another base defining apertures for receiving the posts, as well as a portion movable relative to the second base. When the upstanding posts are inserted into the apertures, the movable portion can be moved into a second configuration to lock the parts of the fastener together. The instrument is adapted to move the second part into the second configuration. A method for using the apparatus and fastener are also provided.

Surgical fastener aligning instrument particularly for transoral treatment of gastroesophageal reflux disease

Methods and devices are provided for reconfiguring a tissue within a hollow body organ using an entirely endoscopic approach in order to effectively reduce flow of fluid contents into a second hollow body organ in fluid communication with the first.

Methods and devices for tissue reconfiguration

Background:Although rare, esophageal achalasia is the best described primary esophageal motility disorder. Commonly used treatments are endoscopic botulin toxin injection (EBTI), endoscopic balloon dilation (EBD), and surgical myotomy with or without a fundoplication; however, reported outcomes most

Endoscopic and surgical treatments for achalasia: a systematic review and meta-analysis.

Operations which alter gastrointestinal function, but which do not require the removal of an organ or part of an organ, seem ideally suited to being undertaken laparoscopically. Fundoplication falls firmly into this category. The procedure was first reported in 1991 by Dallemagne who divided the short gastric vessels in performing the technique. The authors feel justified in calling their technique a Nissen fundoplication, as the anterior wall of the stomach is used without dividing the short gastric vessels as first described by Nissen.

Laparoscopic Nissen fundoplication.

OBJECTIVE: To determine whether division of the short gastric vessels (SGVs) and full mobilization of the gastric fundus is necessary to reduce the incidence of postoperative dysphagia and other adverse sequelae of laparoscopic Nissen fundoplication. SUMMARY BACKGROUND DATA: Based on historical and uncontrolled studies, division of the SGVs has been advocated during laparoscopic Nissen fundoplication to improve postoperative clinical outcomes. However, this modification has not been evaluated in a large prospective randomized trial. METHODS: One hundred two patients with proven gastroesophageal reflux disease presenting for laparoscopic Nissen fundoplication were prospectively randomized to undergo fundoplication with (52 patients) or without (50 patients) division of the SGVs. Patients with esophageal motility disorders, patients requiring a concurrent abdominal procedure, and patients who had undergone previous antireflux surgery were excluded. Patients were blinded to the postoperative status of their SGVs. Clinical assessment was performed by a blinded independent investigator who used multiple standardized clinical grading systems to assess dysphagia, heartburn, and patient satisfaction 1, 3, and 6 months after surgery. Objective measurement of lower esophageal sphincter pressure, esophageal emptying time, and distal esophageal acid exposure and radiologic assessment of postoperative anatomy were also performed. RESULTS: Operating time was increased by 40 minutes (median 65 vs. 105) by vessel division. Perioperative outcomes and complications, postoperative dysphagia, relief of heartburn, and overall satisfaction were not improved by dividing the SGVs. Lower esophageal sphincter pressure, acid exposure, and esophageal emptying times were similar for the two groups. CONCLUSION: Division of the SGVs during laparoscopic Nissen fundoplication did not improve any clinical or objective postoperative outcome.

Prospective Double-Blind Randomized Trial of Laparoscopic Nissen Fundoplication With Division and Without Division of Short Gastric Vessels

From September 1991 to October 1995, 320 Nissen fundoplications were undertaken laparoscopically by 12 surgeons at a single institution. To assess the performance of the procedure in the hands of five 'experienced' surgeons, the first 20 procedures performed by each surgeon or surgical trainee were excluded, providing a group of 174 patients for review. A short loose 360 degrees fundoplication was performed in all instances, with short gastric vessel division performed in 35.0 per cent of patients and hiatal repair in 66.7 per cent. Median operating time was 80 (range 30-210) min and median postoperative stay was 3 (range 1-19) days. Sixteen procedures (9.2 per cent) could not be completed laparoscopically and required conversion to open surgery. Some 144 patients were reviewed by a scientific officer 3 months after surgery, 85 at 12 months, and 32 at 2 years, using a standard clinical questionnaire. All but one were free from reflux symptoms, although 20.1 per cent reported some dysphagia at 3 months' follow-up; this figure declined to 11 per cent at 12 months and 6 per cent (two of 34 patients) at 2 years. At each follow-up interval, 91 per cent of patients were satisfied with the outcome of the surgery. Objective testing with oesophageal motility (75 patients) and barium swallow (113) studies 3-6 months after surgery confirmed the clinical outcome. Complications occurred in nine patients (5.2 per cent); four (2.3 per cent) of these required a subsequent operation within 30 days of surgery for bleeding (one patient), paraoesophageal herniation (one) and dysphagia (two). A further procedure was necessary in six other patients (3.4 per cent) for late problems, including paraoesophageal herniation (two), hiatal stenosis (three) and gastric obstruction (one). Revision was performed laparoscopically in two patients. The clinical results of laparoscopic Nissen fundoplication by 'experienced' laparoscopic surgeons were comparable with those of open surgery.

Laparoscopic surgery for gastro-oesophageal reflux: beyond the learning curve.

From September 1991 to January 1995 we performed 230 Nissen fundoplications by a laparoscopic technique. Whilst a loose 360° fundoplication secured by 3 or 4 sutures was performed in all instances, there was variation between surgeons regarding the performance of hiatal repair and division of short gastric vessels; 207 operations were completed laparoscopically and 23 were converted to an open operation when a satisfactory wrap could not be achieved. Operating time ranged from 30 to 260 min (median 95) and the median postoperative stay was 3 days (1–19).

Changing strategies in the performance of laparoscopic Nissen fundoplication as a result of experience with 230 operations

Three patients from an overall experience of more than 250 laparoscopic Nissen fundoplications have undergone further surgery for stenosis of the esophageal hiatus. This complication may be associated with diathermy dissection of the esophagus during laparoscopic mobilization. (Arch Surg. 1995;130:1014-1016)

R. Britten‐Jones

Papers

Laparoscopic Nissen fundoplication.

Prospective Double-Blind Randomized Trial of Laparoscopic Nissen Fundoplication With Division and Without Division of Short Gastric Vessels

Laparoscopic surgery for gastro-oesophageal reflux: beyond the learning curve.

Changing strategies in the performance of laparoscopic Nissen fundoplication as a result of experience with 230 operations

Stenosis of the esophageal hiatus following laparoscopic fundoplication