Surgical management of reflux

Surgical therapy for the management of gastro-esophageal reflux disease may appear to be superseded by powerful drugs. The evidence needs careful examination particularly as regards management of complicated reflux

The evidence from clinical trails is reported addressing the questions. Does surgery improve symptom control, and is there a difference between open and laparoscopic/keyhole surgery?  Can surgery improve the outcome in patients with stricture? What is the role of surgery in patients with Barrett’s and can it prevent degeneration to cancer? The evidence from trials of therapy indicate that surgery is more effective than medical treatment, but does carry significant complications. Nissen fundoplication improves oesophagitis compared with medical treatment between 3 and 38 months. Longer- term follow up shows no significant difference at 10 years. There is no significant difference between open and laparoscopic fundoplication for remission at 3 months to 2 years. The complication rates are higher with open surgery. There is no strong evidence that fundoplication will prevent oesophageal adenocarcinoma related to Barrett’s oesophagus. Photodynamic therapy for high-grade dysplasia can reduce the incidence of oesophageal cancer at 2 years. Surgery is very effective therapy and when combined with ablation therapy may be more effective than proton pump inhibitors at maintaining regression of metaplasia. The future to prevent oesophageal adenocarcinoma may be to detect high-grade dysplasia and use ablation therapy as the most cost-effective method of eradication