Anatomical Repair (Fundoplication) is the Recommended Treatment
For dyspepsia refractory to medical treatment with the gastroesophageal junction (GEJ) positioned just above the diaphragm and the stomach in place, anatomical repair via laparoscopic fundoplication is the appropriate surgical intervention. This clinical scenario describes a sliding hiatal hernia with GERD that has failed medical management, requiring definitive surgical correction rather than endoscopic plication 1.
Why Anatomical Repair Over Endoscopic Plication
The laparoscopic approach is the recommended surgical approach for anti-reflux surgery in patients with anatomical gastro-oesophageal alterations causing refractory GERD 1.
Endoscopic gastric plication is not an established treatment for hiatal hernia with GEJ displacement; it lacks evidence for durability and effectiveness in correcting anatomical defects 1.
A barium swallow should be conducted to rule out anatomical gastro-oesophageal alterations, especially before surgery, confirming the structural nature of the problem 1.
Diagnostic Confirmation Before Surgery
Correct diagnosis of GERD is mandatory before planning surgery, based on clinical context and overall study results 1.
MII-pH monitoring over 24 hours is the best available tool for diagnosis of GERD to confirm that symptoms are truly reflux-related 1.
Endoscopy should always be performed to rule out GERD complications before proceeding to surgical intervention 1.
Surgical Approach and Technique
The choice between total (Nissen) or partial fundoplication should be left to surgeon preferences and expertise, though both are acceptable options 1.
The laparoscopic approach has been demonstrated to be feasible, safe, and effective for anti-reflux surgery 1.
The possibility of a "short" esophagus must be considered in patients who failed previous operations, and lengthening procedures (Collis gastroplasty) may need to be considered if primary repair fails 1.
Common Pitfall to Avoid
Do not continue escalating medical therapy indefinitely when anatomical pathology (hiatal hernia with GEJ displacement) is present 1. While PPIs are appropriate first-line therapy for functional dyspepsia, structural abnormalities causing mechanical reflux require anatomical correction 1.
Patients who do not respond to medical treatment should be referred for endoscopy and surgical evaluation rather than pursuing endoscopic plication, which lacks evidence for this indication 1.
Other complex procedures such as total esophagogastric dissociation are not recommended as first-line surgery and should only be evaluated on an individual patient basis 1.