Journal of Gastrointestinal Surgery

, Volume 21, Issue 9, pp 1544–1552 | Cite as

New Approaches to Gastroesophageal Reflux Disease

  • William Kethman
  • Mary HawnEmail author
Evidence-Based Current Surgical Practice



Gastroesophageal reflux disease (GERD) is the most common gastrointestinal disorder of the esophagus. It is a chronic, progressive disorder that presents most typically with heartburn and regurgitation and atypically with chest pain, dysphagia, chronic cough, globus, or sore throat. The mainstay for diagnosis and characterization of the disorder is esophagoduodenoscopy (EGD), high-resolution esophageal manometry, and symptom-associated ambulatory esophageal pH impedance monitoring. Additional studies that can be useful in certain clinical presentations include gastric scintigraphy and oral contrast upper gastrointestinal radiographic series.


Refractory GERD can be surgically managed with various techniques. In obese individuals, laparoscopic Roux-en-Y gastric bypass should be considered due to significant symptom improvement and lower incidence of recurrent symptoms with weight loss. Otherwise, laparoscopic Nissen fundoplication is the preferred surgical technique for treatment of this disease with concomitant hiatal hernia repair when present for either procedure. The short-term risks associated with these procedures include esophageal or gastric injury, pneumothorax, wound infection, and dysphagia. Emerging techniques for treatment of this disease include the Linx Reflux Management System, EndoStim LES Stimulation System, Esophyx® and MUSE™ endoscopic fundoplication devices, and the Stretta endoscopic ablation system. Outcomes after surgical management of refractory GERD are highly dependent on adherence to strict surgical indications and appropriate patient-specific procedure selection.


Advances Gastroesophageal reflux disease GERD Erosive esophagitis Nerd Functional heartburn Esophageal hypersensitivity Surgery Endoscopy 




Authors’ Contributions

William Kethman was substantially involved in the conception, drafting, and final approval of the intellectual content contained within this manuscript and he agrees to be accountable for all aspects of the work to ensure questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Mary Hawn was substantially involved in the conception, revision, and final approval of the intellectual content contained within this manuscript and she agrees to be accountable for all aspects of the work to ensure questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Compliance with Ethical Standards

Financial Support



  1. 1.
    Camilleri M, Dubois D, Coulie B, et al. Prevalence and socioeconomic impact of upper gastrointestinal disorders in the United States: results of the US Upper Gastrointestinal Study. Clin Gastroenterol Hepatol. 2005;3(6):543–552. Accessed December 1, 2016.
  2. 2.
    Labenz J, Nocon M, Lind T, et al. Prospective follow-up data from the ProGERD study suggest that GERD is not a categorial disease. Am J Gastroenterol. 2006;101(11):2457–2462. doi: 10.1111/j.1572-0241.2006.00829.x.CrossRefPubMedGoogle Scholar
  3. 3.
    Peery AF, Dellon ES, Lund J, et al. Burden of gastrointestinal disease in the United States: 2012 update. Gastroenterology. 2012;143(5):1179–1187.e3. doi: 10.1053/j.gastro.2012.08.002.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Dent J, El-Serag HB, Wallander M-A, Johansson S. Epidemiology of gastro-oesophageal reflux disease: a systematic review. Gut. 2005;54(5):710–717. doi: 10.1136/gut.2004.051821.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    El-Serag H, Becher A, Jones R. Systematic review: persistent reflux symptoms on proton pump inhibitor therapy in primary care and community studies. Aliment Pharmacol Ther. 2010;32(6):720–737. doi: 10.1111/j.1365-2036.2010.04406.x.CrossRefPubMedGoogle Scholar
  6. 6.
    Ismail-Beigi F, Horton PF, Pope CE. Histological consequences of gastroesophageal reflux in man. Gastroenterology. 1970;58(2):163–174. Accessed January 2, 2017.
  7. 7.
    Dunbar KB, Agoston AT, Odze RD, et al. Association of Acute Gastroesophageal Reflux Disease With Esophageal Histologic Changes. JAMA. 2016;315(19):2104–2112. doi: 10.1001/jama.2016.5657.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Vakil N, van Zanten S V., Kahrilas P, Dent J, Jones R, Global Consensus Group. The Montreal Definition and Classification of Gastroesophageal Reflux Disease: A Global Evidence-Based Consensus. Am J Gastroenterol. 2006;101(8):1900–1920. doi: 10.1111/j.1572-0241.2006.00630.x.CrossRefPubMedGoogle Scholar
  9. 9.
    Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2013;108(3):308–28; quiz 329. doi: 10.1038/ajg.2012.444.CrossRefPubMedGoogle Scholar
  10. 10.
    Zagari RM, Fuccio L, Wallander M-A, et al. Gastro-oesophageal reflux symptoms, oesophagitis and Barrett’s oesophagus in the general population: the Loiano-Monghidoro study. Gut. 2008;57(10):1354–1359. doi: 10.1136/gut.2007.145177.CrossRefPubMedGoogle Scholar
  11. 11.
    Hirano I, Richter JE. ACG Practice Guidelines: Esophageal Reflux Testing. Am J Gastroenterol. 2007;102(3):668–685. doi: 10.1111/j.1572-0241.2006.00936.x.CrossRefPubMedGoogle Scholar
  12. 12.
    Galindo G, Vassalle J, Marcus SN, Triadafilopoulos G. Multimodality evaluation of patients with gastroesophageal reflux disease symptoms who have failed empiric proton pump inhibitor therapy. Dis esophagus Off J Int Soc Dis Esophagus. 2013;26(5):443–450. doi: 10.1111/j.1442-2050.2012.01381.x.CrossRefGoogle Scholar
  13. 13.
    Nikaki K, Woodland P, Sifrim D. Adult and paediatric GERD: diagnosis, phenotypes and avoidance of excess treatments. Nat Rev Gastroenterol Hepatol. 2016;13(9):529–542. doi: 10.1038/nrgastro.2016.109.CrossRefPubMedGoogle Scholar
  14. 14.
    Montgomery M, Håkanson B, Ljungqvist O, Ahlman B, Thorell A. Twelve months’ follow-up after treatment with the EndoCinch endoscopic technique for gastro-oesophageal reflux disease: a randomized, placebo-controlled study. Scand J Gastroenterol. 2006;41(12):1382–1389. doi: 10.1080/00365520600735738.CrossRefPubMedGoogle Scholar
  15. 15.
    Lundell LR, Dent J, Bennett JR, et al. Endoscopic assessment of oesophagitis: clinical and functional correlates and further validation of the Los Angeles classification. Gut. 1999;45(2):172–180. Accessed January 2, 2017.
  16. 16.
    Stefanidis D, Hope WW, Kohn GP, et al. Guidelines for surgical treatment of gastroesophageal reflux disease. Surg Endosc. 2010;24(11):2647–2669. doi: 10.1007/s00464-010-1267-8.CrossRefPubMedGoogle Scholar
  17. 17.
    Bortoli N de, Martinucci I, Bertani L, et al. Esophageal testing: What we have so far. World J Gastrointest Pathophysiol. 2016;7(1):72. doi: 10.4291/wjgp.v7.i1.72.
  18. 18.
    Leggett CL, Gorospe EC. Application of confocal laser endomicroscopy in the diagnosis and management of Barrett’s esophagus. Ann Gastroenterol Q Publ Hell Soc Gastroenterol. 2014;27(3):193–199. Accessed December 1, 2016.
  19. 19.
    Trindade AJ, Smith MS, Pleskow DK. The new kid on the block for advanced imaging in Barrett’s esophagus: a review of volumetric laser endomicroscopy. Therap Adv Gastroenterol. 2016;9(3):408–416. doi: 10.1177/1756283X16639003.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Kahrilas PJ, Shaheen NJ, Vaezi MF, American Gastroenterological Association Institute, Clinical Practice and Quality Management Committee. American Gastroenterological Association Institute technical review on the management of gastroesophageal reflux disease. Gastroenterology. 2008;135(4):1392–1413, 1413-5. doi: 10.1053/j.gastro.2008.08.044.CrossRefPubMedGoogle Scholar
  21. 21.
    Subramanian CR, Triadafilopoulos G. Refractory gastroesophageal reflux disease. Gastroenterol Rep. 2014. doi: 10.1093/gastro/gou061.
  22. 22.
    Ali T, Roberts DN, Tierney WM. Long-term safety concerns with proton pump inhibitors. Am J Med. 2009;122(10):896–903. doi: 10.1016/j.amjmed.2009.04.014.CrossRefPubMedGoogle Scholar
  23. 23.
    Sheen E, Triadafilopoulos G. Adverse effects of long-term proton pump inhibitor therapy. Dig Dis Sci. 2011;56(4):931–950. doi: 10.1007/s10620-010-1560-3.CrossRefPubMedGoogle Scholar
  24. 24.
    Wileman SM, McCann S, Grant AM, Krukowski ZH, Bruce J. Medical versus surgical management for gastro-oesophageal reflux disease (GORD) in adults. Cochrane database Syst Rev. 2010;(3):CD003243. doi: 10.1002/14651858.CD003243.pub2.Google Scholar
  25. 25.
    Attwood SEA, Lundell L, Ell C, et al. Standardization of surgical technique in antireflux surgery: the LOTUS Trial experience. World J Surg. 2008;32(6):995–998. doi: 10.1007/s00268-007-9409-4.CrossRefPubMedGoogle Scholar
  26. 26.
    Who is a Candidate for Bariatric Surgery? - American Society for Metabolic and Bariatric Surgery.
  27. 27.
    Labenz J, Jaspersen D, Kulig M, et al. Risk factors for erosive esophagitis: a multivariate analysis based on the ProGERD study initiative. Am J Gastroenterol. 2004;99(9):1652–1656. doi: 10.1111/j.1572-0241.2004.30390.x.CrossRefPubMedGoogle Scholar
  28. 28.
    Sutherland V, Kuwada T, Gersin K, Simms C, Stefanidis D. Impact of Bariatric Surgery on Hiatal Hernia Repair Outcomes. Am Surg. 2016;82(8):743–747. Accessed February 5, 2017.
  29. 29.
    Pallati PK, Shaligram A, Shostrom VK, Oleynikov D, McBride CL, Goede MR. Improvement in gastroesophageal reflux disease symptoms after various bariatric procedures: Review of the Bariatric Outcomes Longitudinal Database. Surg Obes Relat Dis. 2014;10(3):502–507. doi: 10.1016/j.soard.2013.07.018.CrossRefPubMedGoogle Scholar
  30. 30.
    Bonavina L, Saino G, Bona D, et al. One Hundred Consecutive Patients Treated with Magnetic Sphincter Augmentation for Gastroesophageal Reflux Disease: 6 Years of Clinical Experience from a Single Center. J Am Coll Surg. 2013;217(4):577–585. doi: 10.1016/j.jamcollsurg.2013.04.039.CrossRefPubMedGoogle Scholar
  31. 31.
    Ganz RA, Peters JH, Horgan S, et al. Esophageal Sphincter Device for Gastroesophageal Reflux Disease. N Engl J Med. 2013;368(8):719–727. doi: 10.1056/NEJMoa1205544.CrossRefGoogle Scholar
  32. 32.
    Rodríguez L, Rodriguez PA, Gómez B, Netto MG, Crowell MD, Soffer E. Electrical stimulation therapy of the lower esophageal sphincter is successful in treating GERD: long-term 3-year results. Surg Endosc. 2016;30(7):2666–2672. doi: 10.1007/s00464-015-4539-5.CrossRefPubMedGoogle Scholar
  33. 33.
    Pandolfino JE, Krishnan K. Do endoscopic antireflux procedures fit in the current treatment paradigm of gastroesophageal reflux disease? Clin Gastroenterol Hepatol. 2014;12(4):544–554. doi: 10.1016/j.cgh.2013.06.012.CrossRefPubMedGoogle Scholar
  34. 34.
    Auyang ED, Carter P, Rauth T, Fanelli RD, SAGES Guidelines Committee. SAGES clinical spotlight review: endoluminal treatments for gastroesophageal reflux disease (GERD). Surg Endosc. 2013;27(8):2658–2672. doi: 10.1007/s00464-013-3010-8.CrossRefGoogle Scholar
  35. 35.
    Triadafilopoulos G. Stretta: a valuable endoscopic treatment modality for gastroesophageal reflux disease. World J Gastroenterol. 2014;20(24):7730–7738. doi: 10.3748/wjg.v20.i24.7730.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Jobe BA, O’Rourke RW, McMahon BP, et al. Transoral endoscopic fundoplication in the treatment of gastroesophageal reflux disease: the anatomic and physiologic basis for reconstruction of the esophagogastric junction using a novel device. Ann Surg. 2008;248(1):69–76. doi: 10.1097/SLA.0b013e31817c9630.CrossRefGoogle Scholar
  37. 37.
    Kim HJ, Kwon C-I, Kessler WR, et al. Long-term follow-up results of endoscopic treatment of gastroesophageal reflux disease with the MUSE™ endoscopic stapling device. Surg Endosc. 2016;30(8):3402–3408. doi: 10.1007/s00464-015-4622-y.CrossRefPubMedGoogle Scholar
  38. 38.
    Inoue H, Ito H, Ikeda H, et al. Anti-reflux mucosectomy for gastroesophageal reflux disease in the absence of hiatus hernia: a pilot study. Ann Gastroenterol Q Publ Hell Soc Gastroenterol. 2014;27(4):346–351. Accessed November 30, 2016.Google Scholar
  39. 39.
    Robinson B, Dunst CM, Cassera MA, Reavis KM, Sharata A, Swanstrom LL. 20 years later: laparoscopic fundoplication durability. Surg Endosc. 2015;29(9):2520–2524. doi: 10.1007/s00464-014-4012-x.CrossRefGoogle Scholar
  40. 40.
    Cowgill SM, Gillman R, Kraemer E, Al-Saadi S, Villadolid D, Rosemurgy A. Ten-year follow up after laparoscopic Nissen fundoplication for gastroesophageal reflux disease. Am Surg. 2007;73(8):748-52-3. Accessed December 2, 2016.
  41. 41.
    Spechler SJ, Lee E, Ahnen D, et al. Long-term Outcome of Medical and Surgical Therapies for Gastroesophageal Reflux Disease. JAMA. 2001;285(18):2331. doi: 10.1001/jama.285.18.2331.CrossRefPubMedGoogle Scholar
  42. 42.
    Lundell L, Miettinen P, Myrvold HE, et al. Comparison of Outcomes Twelve Years After Antireflux Surgery or Omeprazole Maintenance Therapy for Reflux Esophagitis. Clin Gastroenterol Hepatol. 2009;7(12):1292–1298. doi: 10.1016/j.cgh.2009.05.021.CrossRefPubMedGoogle Scholar
  43. 43.
    Ip S, Tatsioni A, Conant A, et al. Predictors of Clinical Outcomes Following Fundoplication for Gastroesophageal Reflux Disease Remain Insufficiently Defined: A Systematic Review. Am J Gastroenterol. 2009;104(3):752–758. doi: 10.1038/ajg.2008.123.CrossRefPubMedGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2017

Authors and Affiliations

  1. 1.Department of SurgeryStanford UniversityStanfordUSA

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