In certain situations, surgery is an option in the management of gastro-oesophageal reflux disease (GORD; See Gastro-oesophageal reflux disease). However, due to the advances in medications used to treat GORD, anti-reflux surgery is now seldom needed or indicated. Proton pump inhibitors (PPIs) are a class of medication that effectively blocks production of acid in the stomach. PPIs include such drugs as Omeprazole, Pantoprazole and Esomeprazole. This treatment is usually very successful in managing the symptoms and preventing complications of gastro-oesophageal reflux disease. Nevertheless, in some situations surgery for gastro-oesophageal reflux disease is indicated. 

Indications when anti-reflux surgery can be considered include:

• Medication related:
  • Non-compliance to treatment
  • Intolerance of medical therapy
  • The desire not to take lifelong treatment in patients who are medication dependant
• High-volume reflux
• Failed optimal medical therapy
• Complications of GORD
  • Benign stricture
  • Severe oesophagitis
  • Barrett’s oesophagus (but not when high-grade dysplasia or carcinoma is present)

In patients who have failed medical therapy, it is vitally important to confirm that the symptoms are caused by gastro-oesophageal reflux disease. There are several conditions that can mimic GORD, and these need to be excluded prior to performing surgery.

Anti-reflux surgery is not a necessity when there are complications of GORD. In most situations, PPI therapy is sufficient to manage these. 

Pre-operative evaluation:

Depending on a patient’s particular set of symptoms, it is usually advisable to perform certain investigations before proceeding to anti-reflux surgery. Confirmation of gastro-oesophageal reflux and exclusion of mimic conditions with investigations is strongly advised. Such investigations may include:

• Gastroscopy with oesophageal biopsies
• 24 hour pH studies
• Oesophageal manometry
• Gastric emptying studies

Because of the risk of peri- and post-operative complications, the decision to have anti-reflux surgery should not be taken lightly and should be thoroughly discussed with your surgeon and gastroenterologist. This type of surgery is never an emergency - careful consideration and appropriate investigation are essential.