When do you refer a patient with Gastroesophageal Reflux Disease (GERD) to a surgeon?

When to Refer a Patient with GERD to a Surgeon

Patients with GERD should be referred to a surgeon when they have persistent symptoms despite intensive medical therapy, documented pathologic reflux, or complications of GERD that require surgical intervention.

Indications for Surgical Referral

1. Failure of Medical Management

• Persistent GERD symptoms despite a therapeutic trial of 4-8 weeks of twice-daily PPI therapy 1
• Patients who have failed to respond to maximal medical therapy, including:
  • Intensive antireflux diet (≤45g fat/24h, no coffee, tea, soda, chocolate, mints, citrus, tomatoes, alcohol) 1
  • Optimal PPI dosing (twice daily before meals) 2
  • Addition of prokinetic therapy and lifestyle modifications 1

2. Documented Pathologic Reflux

• Patients with objectively documented GERD by 24-hour pH monitoring 2
• High burden of acid reflux (acid exposure time >12%) demonstrated by pH monitoring 1
• Patients with adequate esophageal peristalsis (important for successful surgical outcomes) 2

3. Complications of GERD

• Severe erosive esophagitis that persists after a 2-month course of PPI therapy 1
• History of esophageal stricture with recurrent symptoms of dysphagia 1
• Barrett's esophagus with dysplasia 1
• Presence of alarm symptoms (dysphagia, bleeding, anemia, weight loss, recurrent vomiting) 1

4. Patient Factors

• Young, healthy patients who prefer a surgical solution over lifelong medication 3
• Patients with concomitant heartburn/regurgitation who previously responded to PPI therapy 1
• Patients reporting unacceptable quality of life due to persistent symptoms 2

Pre-Surgical Evaluation

Before referring to a surgeon, ensure the following evaluations have been completed:

1. Endoscopic evaluation to assess mucosal damage, erosive esophagitis, Barrett's esophagus 1, 2
2. Esophageal manometry to evaluate esophageal motility and peristalsis 2
3. 24-hour pH monitoring (preferably off medication) to confirm pathologic reflux 1, 2

Cautions and Considerations

• Response to PPI therapy before operation is associated with effectiveness of surgery 1
• Lack of response to PPI therapy predicts lack of response to anti-reflux surgery 1
• Antireflux surgery is not superior to pharmacological acid suppression for the prevention of neoplastic progression of Barrett's esophagus 1
• Surgery carries risks including postoperative dysphagia and gas bloat syndrome 1
• Patients should understand that surgery may improve cough in approximately 85% of cases at 6-12 months following surgery 1

Surgical Options to Consider

1. Laparoscopic fundoplication - most established surgical approach 1, 3
2. Magnetic sphincter augmentation - emerging less invasive option 1
3. Endoscopic therapies - evolving options that may reduce the need for long-term PPI or fundoplication 3

Decision Algorithm

1. Start with optimal medical therapy (PPI twice daily, lifestyle modifications, diet)
2. If symptoms persist after 8-12 weeks:
   • Perform endoscopy, esophageal manometry, and pH monitoring
   • Confirm diagnosis of GERD and rule out other conditions
3. If pathologic reflux is confirmed and symptoms persist:
   • Refer to surgeon for consultation (not just for the technical service of endoscopy) 1
   • Ensure shared decision-making between patient, gastroenterologist, and surgeon 1

Remember that surgery should be considered in highly selected patients after careful consideration of benefits, risks, and alternatives through a shared decision-making process between clinicians and the patient 1.