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Multi-society consensus conference and guideline on the treatment of gastroesophageal reflux disease (GERD)

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Abstract

Background

Gastroesophageal reflux disease (GERD) is one of the most common diseases in North America and globally. The aim of this guideline is to provide evidence-based recommendations regarding the most utilized and available endoscopic and surgical treatments for GERD.

Methods

Systematic literature reviews were conducted for 4 key questions regarding the surgical and endoscopic treatments for GERD in adults: preoperative evaluation, endoscopic vs surgical or medical treatment, complete vs partial fundoplication, and treatment for obesity (body mass index [BMI] ≥ 35 kg/m2) and concomitant GERD. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Recommendations for future research were also proposed.

Results

The consensus provided 13 recommendations. Through the development of these evidence-based recommendations, an algorithm was proposed for aid in the treatment of GERD. Patients with typical symptoms should undergo upper endoscopy, manometry, and pH-testing; additional testing may be required for patients with atypical or extra-esophageal symptoms. Patients with normal or abnormal findings on manometry should consider undergoing partial fundoplication. Magnetic sphincter augmentation or fundoplication are appropriate surgical procedures for adults with GERD. For patients who wish to avoid surgery, the Stretta procedure and transoral incisionless fundoplication (TIF 2.0) were found to have better outcomes than proton pump inhibitors alone. Patients with concomitant obesity were recommended to undergo either gastric bypass or fundoplication, although patients with severe comorbid disease or BMI > 50 should undergo Roux-en-Y gastric bypass for the additional benefits that follow weight loss.

Conclusion

Using the recommendations an algorithm was developed by this panel, so that physicians may better counsel their patients with GERD. There are certain patient factors that have been excluded from included studies/trials, and so these recommendations should not replace surgeon–patient decision making. Engaging in the identified research areas may improve future care for GERD patients.

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Abbreviations

ARM:

Anti-reflux medication

ARS:

Anti-reflux surgery

CI:

Confidence interval

EGD:

Esophagogastroduodenoscopy

MSA:

Magnetic sphincter augmentation

GERD:

Gastroesophageal reflux disease

GRADE:

Grading of Recommendations Assessment, Development and Evaluation

HREM:

High-resolution esophageal manometry

KQ:

Key question

PRISMA:

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

QoL:

Quality of life

PPI:

Proton pump inhibitor

LES:

Lower esophageal sphincter

LA:

Los Angeles

Stretta procedure:

Radiofrequency treatment for GERD

RCT:

Randomized clinical trial

TIF:

Transoral incisionless fundoplication

RYGB:

Roux-en-Y gastric bypass

LNF:

Laparoscopic Nissen Fundoplication

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Acknowledgements

We would like to thank Jillian Kelly, the SAGES senior program coordinator, Holly Burt, the SAGES librarian, and the SAGES guideline committee members for their help with the creation of this guideline.

Funding

There was no funding for this manuscript.

Author information

Author notes

  1. Bethany J. Slater and Amelia Collings are co-first authors.

Authors and Affiliations

  1. University of Chicago Medicine, 5841 S. Maryland Avenue, MC 4062, Chicago, IL, USA

    Bethany J. Slater

  2. Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA

    Amelia Collings, Rebecca Dirks & Dimitrios I. Athanasiadis

  3. Division of Minimally Invasive and Gastrointestinal Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA

    Jon C. Gould

  4. Division of General & GI Surgery, Foregut Surgery, Oregon Health & Science University, Portland, OR, USA

    Alia P. Qureshi

  5. Department of Surgery, University of Wisconsin, Madison, WI, USA

    Ryan Juza & Anne Lidor

  6. Research Institute Against Digestive Cancer (IRCAD) and ICube Laboratory, Photonics Instrumentation for Health, Strasbourg, France

    María Rita Rodríguez-Luna

  7. Saint Louis University, St Louis, MO, USA

    Claire Wunker

  8. Department of Surgery, Monash University, Melbourne, VIC, Australia

    Geoffrey P. Kohn

  9. Department of Surgery, Prisma Health, Greenville, SC, USA

    Shanu Kothari

  10. Virginia Mason Medical Center, Seattle, WA, USA

    Elizabeth Carslon & Donald Low

  11. University of Arizona Health Sciences, Tucson, AZ, USA

    Stephanie Worrell

  12. Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada

    Ahmed M. Abou-Setta

  13. School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada

    Mohammed T. Ansari

  14. Department of Surgery, University of California, Irvine, Orange, CA, USA

    Shaun Daly

  15. Washington University in St. Louis, St. Louis, MO, USA

    Francesca Dimou

  16. Department of Surgery, University of Nebraska Medical Center, Omaha, USA

    Ivy N. Haskins

  17. Department of Surgery, New York Presbyterian/Queens, Queens, USA

    Julie Hong

  18. Massachusetts General Hospital, Boston, MA, USA

    Kumar Krishnan

  19. Section of Thoracic Surgery, Department of Cardiovascular Surgery, Intermountain Healthcare, Salt Lake City, UT, USA

    Virginia Litle

  20. Department of General Surgery, Geisinger School of Medicine, Geisinger Medical Center, Danville, PA, USA

    Anthony Petrick

  21. Department of Surgery, University of California San Francisco School of Medicine, San Francisco, CA, USA

    Ian S. Soriano

  22. McGovern Medical School, Center for Interventional Gastroenterology at UTHealth, Houston, TX, USA

    Nirav Thosani

  23. Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA

    Amy Tyberg

  24. Division of Gastrointestinal Surgery, Tampa General, Tampa, FL, USA

    Vic Velanovich

  25. Endocrine, Metabolic and Bariatric Unit, General Surgery Department, Vall d’Hebron University Hospital, Center of Excellence for the EAC-BC, Universitat Autònoma de Barcelona, Barcelona, Spain

    Ramon Vilallonga

  26. Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA

    Jeffrey M. Marks

Authors
  1. Bethany J. Slater
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  2. Amelia Collings
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  3. Rebecca Dirks
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  4. Jon C. Gould
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  8. Claire Wunker
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  9. Geoffrey P. Kohn
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  10. Shanu Kothari
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  11. Elizabeth Carslon
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  12. Stephanie Worrell
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  13. Ahmed M. Abou-Setta
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  15. Dimitrios I. Athanasiadis
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  16. Shaun Daly
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  21. Anne Lidor
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  22. Virginia Litle
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  23. Donald Low
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  25. Ian S. Soriano
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  27. Amy Tyberg
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  28. Vic Velanovich
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  29. Ramon Vilallonga
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  30. Jeffrey M. Marks
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Corresponding author

Correspondence to Bethany J. Slater.

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Disclosure

BS—Consultant for Hologic and Cook Medical, AC, APQ, MRR, SK, EC, SW, AAS, MTA, DIA, SD, FD, JH, KK, AL, MD, VL, DL, AP,CW,GPK, RV, AT—no conflicts of interest, RD—Personal stock in Johnson and Johnson, JCG—Preceptor for Ethicon/J + J, Speaker for BD, RJ—Speaker for Medtronic, Intuitive Surgical, and Aspire Medical, Consultant for Intuitive Surgical, Expert Review for BSPH Law, INH—Royalty for uptoDate. ISS—Proctor for Intuitive Surgical, NT—Consultant for Boston Scientific Corp, Pentax America, Ambu, Biotex Inc, Speaker for Abbvie, Royalty for UpToDate, Creatorship Rights for ROSEAID inc, VV—Advisory board and speaker for Integra Biosciences, Consultant for Innocoll Pharmaceuticals, Inc., and Proctor for Linx/Johnson & Johnson, JMM—Consultant for Boston Scientific, and US Endoscopy.

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Slater, B.J., Collings, A., Dirks, R. et al. Multi-society consensus conference and guideline on the treatment of gastroesophageal reflux disease (GERD). Surg Endosc 37, 781–806 (2023). https://doi.org/10.1007/s00464-022-09817-3

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