Secrets for successful laparoscopic antireflux surgery: predictors

Vic Velanovich


Gastroesophageal reflux disease (GERD) is a common malady. It is a protean disease with many manifestations. Most patients seek medical attention due to symptoms. When a surgical remedy is contemplated, it is incumbent upon the surgeon to identify those patients in whom antireflux surgery (ARS) will lead to elimination of pathologic reflux and symptomatic improvement. There are many patient-related factors and technical factors which can predict success or failure of ARS. These predictors can be divided into proper diagnosis of GERD-like symptoms, GERD-related patient factors, non-GERD related patient factors, and operation-related factors. Proper diagnosis includes insuring that the GERD-like symptoms are in fact related to pathologic reflux and not some other disease or psychological process. GERD-related patient factors include differentiating between typical and atypical symptoms, as well as upright and supine reflux. This also includes assessing for reflux related complications, such as ulcers, strictures and neoplasia. Non-GERD-related patient factors include other gastrointestinal disorders such as irritable bowel syndrome (IBS), gastroparesis and peptic ulcer disease. Psychological disorders, such as anxiety and depression, can also affect the outcomes of ARS. Lastly, technical aspects, such as the type and geometry of the fundoplication, hiatal closure, division of the short gastric vessels and addition of a pyloroplasty can affect success. Attention to these details will place the surgeon in the best position to insure a favorable outcome of an antireflux operation.