What is the diagnostic workup for a patient requiring fundoplication for Gastroesophageal Reflux Disease (GERD)?

Diagnostic Workup for Patients Requiring Fundoplication for GERD

The comprehensive diagnostic workup for patients requiring fundoplication should include endoscopy, pH monitoring, esophageal manometry, and assessment of esophageal peristaltic function to confirm pathologic GERD and exclude other conditions like achalasia. 1

Initial Diagnostic Evaluation

Endoscopic Assessment

• Complete endoscopic evaluation should include:
  • Inspection for erosive esophagitis (graded according to Los Angeles classification)
  • Assessment of diaphragmatic hiatus (Hill grade of flap valve)
  • Measurement of axial hiatal hernia length
  • Inspection for Barrett's esophagus (with Prague classification grading and biopsy when present) 1

Reflux Testing

• Prolonged wireless pH monitoring off medication (96-hour preferred if available) is essential when:
  • Endoscopy shows no erosive reflux disease (Los Angeles B or greater)
  • No long-segment (≥3cm) Barrett's esophagus is present
  • This confirms and phenotypes GERD or rules it out 1
• For patients with isolated extraesophageal symptoms, upfront objective reflux testing off medication should be performed rather than an empiric PPI trial 1
• In symptomatic patients with proven GERD who have persistent symptoms despite therapy, 24-hour pH-impedance monitoring on PPI can determine the mechanism of ongoing symptoms 1

Esophageal Function Testing

• High-resolution manometry is required to:
  • Assess esophageal peristaltic function
  • Exclude achalasia
  • Determine the appropriate type of fundoplication (partial vs. complete) 1
• Gastric emptying testing should be considered if delayed gastric emptying is suspected 1

Patient Selection for Fundoplication

Indications for Surgery

• Patients with proven GERD who:
  • Have typical symptoms (heartburn, regurgitation) not adequately controlled with optimized medical therapy
  • Have regurgitation-predominant GERD (responds particularly well to surgical intervention)
  • Show a prior response to PPI therapy but cannot tolerate long-term medication
  • Demonstrate a high burden of acid reflux (acid exposure time >12%) on pH monitoring 1

Contraindications and Cautions

• Absence of objective evidence of GERD
• Undiagnosed or untreated achalasia
• Severe esophageal hypomotility without proper preoperative assessment
• Obesity (may require consideration of bariatric approaches instead) 1

Surgical Options Based on Patient Characteristics

1. Non-obese patients with normal esophageal motility:

   • Laparoscopic Nissen fundoplication (360° wrap) 1, 2

2. Patients with esophageal hypomotility or impaired peristaltic reserve:

   • Partial fundoplication (Toupet 270° posterior or Dor anterior) to reduce risk of postoperative dysphagia 1, 2

3. Patients with small hiatal hernia (<3cm) without obesity:

   • Transoral incisionless fundoplication (TIF) may be considered in carefully selected patients 1, 3, 4

4. Obese patients with GERD:

   • Roux-en-Y gastric bypass is an effective primary anti-reflux intervention
   • Note: Sleeve gastrectomy has potential to worsen GERD 1

Preoperative Counseling

• Discuss expected outcomes: 80% success rate at 20-year follow-up for laparoscopic fundoplication 2
• Review potential complications:
  • Dysphagia (may occur in up to 9% as a new symptom) 5
  • Gas bloating
  • Inability to belch or vomit
  • Rare but serious complications: esophageal perforation, acute paraesophageal herniation 6

Common Pitfalls to Avoid

1. Inadequate preoperative testing:

   • Failure to objectively confirm GERD before surgery leads to poor outcomes
   • Not assessing esophageal motility can result in inappropriate fundoplication type selection

2. Operating on functional disorders:

   • Patients with functional heartburn or reflux hypersensitivity without objective evidence of pathologic reflux have poor surgical outcomes

3. Overlooking extraesophageal symptoms:

   • For patients with extraesophageal symptoms (cough, laryngitis), surgery should only be considered in highly selected cases with concomitant heartburn/regurgitation, prior response to PPI, and high acid burden on pH monitoring 1

4. Neglecting behavioral components:

   • Failing to address esophageal hypervigilance, visceral hypersensitivity, or behavioral disorders that may contribute to symptom perception 1

By following this systematic diagnostic approach, clinicians can properly identify appropriate surgical candidates for fundoplication, select the optimal surgical technique, and improve outcomes while minimizing complications.