Antireflux surgery is performed for chronic reflux disease as an alternative to medical therapy and for patients who are partial or complete failures to such therapy.
In the short term, over 1-2 years, antireflux surgery is extremely effective with more than 90% of patients satisfied when surgery performed by experienced surgeons.
Antireflux surgery is not recommended in PPI nonresponders.
Two types of surgical procedures performed are total fundoplication (Nissen type) and partial fundoplication, anterior or posterior.
No difference in the level of long-term reflux control between a partial and a total fundoplication exists, provided that the fundoplication is 180 degrees.
An incomplete partial fundoplication is not as effective at reflux control as a total or partial fundoplication of 180 degrees.
Side effects of total fundoplication are mainly associated with obstructive mechanical side effects, and the inability to vent air from the stomach.
Following total fundoplication, a proportion of patients will experience difficulty swallowing and have compromised passage of food through the esophagus into the stomach, increased bloating and flatulence.
The above side effects are less common with partial fundoplication.
The number of antireflux surgeries performed annually has been declining, and the procedure should be performed at expert centers.
Following antireflux surgery, 15% to 25% of patients will require PPI therapy.
Contraindications include patients with high risk for cardiovascular complications, and patients who have reflux-related symptoms but no clear-cut reflux.
Most controlled clinical trials comparing modern medical therapy with PPI-based therapy with laparoscopic or open antireflux surgery demonstrate the superiority of antireflux surgery.
The LOTUS trial, compared 500 patients randomized to either standardized antireflux surgery or esomeprazole therapy, showed a nearly equivalent outcome between the 2 study groups.
A trial comparing laparoscopic fundoplication with esomeprazole therapy found similar remission rates after 3 years and a higher rate with esomeprazole after 5 years.36 While esomeprazole was associated with more symptoms of reflux compared with fundoplication, patients who underwent this surgery reported higher rates of dysphagia, flatulence, and bloating.
Antireflux surgery can have severe side effects such as dysphagia, gas bloat syndrome, and flatulence and the intended effect may only be temporary, as up to 60% of patients will require antireflux medications regularly in the decade afterward.
Mortality at least 0.2% in antireflux invasive surgery.
Incidence of splenectomy 5%.
Mortality at least 0.2%.