What are the treatment options for an adult patient with severe gastroesophageal reflux disease (GERD) who has failed medical management with proton pump inhibitors (PPIs)?

Fundoplication for Severe GERD After Failed Medical Management

For adult patients with severe GERD who have failed medical management with PPIs, fundoplication is a highly effective treatment option that should be pursued only after confirming objective evidence of pathologic reflux and ensuring at least 3 months of intensive medical therapy has been attempted. 1, 2

Prerequisites Before Considering Surgery

Before proceeding to fundoplication, you must complete the following steps:

Confirm the Diagnosis is Actually GERD

• Reassess the accuracy of the GERD diagnosis if PPI therapy has been ineffective, as conditions such as functional dyspepsia, eosinophilic esophagitis, achalasia, rumination syndrome, and gastroparesis can mimic GERD but will not respond to fundoplication. 1
• Perform 24-hour multichannel intraluminal impedance-pH monitoring off PPI therapy to objectively document pathologic acid reflux—this is the gold standard for confirming GERD. 2, 3
• Obtain upper endoscopy with biopsies to document the LA classification grade of erosive esophagitis and exclude alternative diagnoses like eosinophilic esophagitis or malignancy. 2

Optimize Medical Therapy First

Intensive medical therapy must be attempted for a minimum of 3 months before surgery is considered, including: 1, 4, 5

• Twice-daily PPI dosing (e.g., omeprazole 40 mg before breakfast and dinner, taken 30-60 minutes before meals) 1, 4
• Strict antireflux diet: ≤45 grams of fat per 24 hours, complete elimination of coffee, tea, soda, chocolate, mints, citrus products including tomatoes, and alcohol 1, 4
• Lifestyle modifications: elevate head of bed 6-8 inches, avoid lying down for 2-3 hours after meals, weight loss if BMI ≥25 kg/m², smoking cessation 1, 4
• Addition of prokinetic therapy (e.g., metoclopramide 10 mg three times daily) if symptoms persist despite the above measures, though be aware of the black box warning for tardive dyskinesia 1
• Elimination of medications that worsen reflux when possible (nitrates, calcium channel blockers, bisphosphonates, theophylline, progesterone) 1

Complete Preoperative Evaluation

Once intensive medical therapy has failed, perform: 2

• High-resolution esophageal manometry to assess peristaltic function and exclude achalasia or severe motility disorders that would contraindicate total fundoplication 2
• Barium swallow to identify hiatal hernia, strictures, or short esophagus 2
• Serial pH monitoring while on therapy to confirm that medical treatment has truly failed to control reflux 1

Indications for Fundoplication

Surgery is strongly recommended when: 1, 2

• Objective documentation of pathologic GERD exists (positive pH monitoring) 1
• Patient has failed at least 3 months of intensive medical therapy as outlined above 1, 5
• Persistent troublesome symptoms significantly impair quality of life 1
• Patient fits the clinical profile suggesting GERD is the cause of symptoms (heartburn, regurgitation, especially large-volume regurgitation, nocturnal coughing/choking) 1, 6

Surgery is particularly appropriate for: 1, 6

• Patients who are PPI-responsive but develop intolerable side effects or complications from long-term PPI therapy 1, 3
• Patients with prominent regurgitation that limits work, exercise, or daily activities despite maximal medical therapy 6
• Young, otherwise healthy patients who require lifelong acid suppression and prefer a definitive treatment 7

Surgical Approach and Expected Outcomes

Technique

• Laparoscopic fundoplication is the standard approach, with significantly lower morbidity than open surgery (in-hospital mortality 0.14%). 2, 3, 7
• Nissen fundoplication (360° wrap) is most commonly performed and has an 80% success rate at 20-year follow-up. 3
• Partial fundoplication (Toupet 270° or Dor anterior wrap) should be strongly considered in patients with impaired esophageal peristalsis on manometry to reduce postoperative dysphagia. 2, 3
• The wrap must be tension-free, hiatal closure is essential to prevent wrap herniation, and vagus nerve preservation is critical. 2

Efficacy

• Fundoplication improves or eliminates symptoms in 85-90% of properly selected patients who have failed intensive medical therapy. 1, 5, 8
• The LOTUS trial showed 85% remission rate at 5 years with surgery versus 92% with esomeprazole, though this difference became non-significant after accounting for dropouts. 1
• Health-related quality of life is significantly better after fundoplication compared to continued medical management at 3 months and 1 year. 1, 9
• Heartburn and regurgitation are less frequent after surgery, and patient satisfaction with symptom control is significantly higher. 9

Important Complications and Counseling Points

Patients must receive thorough preoperative counseling about potential complications: 1

• Postoperative dysphagia occurs in 5-43% of patients, more commonly after total fundoplication than partial wraps, though it typically improves within 4-8 weeks. 2, 8, 3
• Gas bloat syndrome is common, characterized by inability to belch or vomit effectively, with associated flatulence and early satiety. 2, 8
• Symptom recurrence can occur, and some patients will require resumption of acid-suppressive medication postoperatively. 1, 9
• Reoperation rate is approximately 6% for complications, though most resolve. 8
• Surgery does not reduce the risk of direct aspiration of oral contents. 1

Critical Pitfalls to Avoid

• Do not proceed to surgery if the diagnosis of GERD has not been objectively confirmed with pH monitoring, as surgery will fail if the symptoms are not actually due to reflux. 1, 3
• Do not operate on patients who have not completed at least 3 months of intensive medical therapy, as this is inadequate to determine true medical failure. 1, 5
• Do not recommend surgery for patients who are well-controlled on medical therapy simply to avoid long-term PPI use, as the risks of surgery outweigh benefits in this population. 1
• Do not assume surgery will help extraesophageal symptoms (chronic cough, laryngitis, asthma) unless there is clear objective evidence linking these symptoms to reflux, as response rates are lower than for typical GERD symptoms. 1, 4