Surgical and endoscopic treatment of gastroesophageal reflux disease.

There is no evidence to advocate medical or surgical therapy as the best therapy for GERD. The decision to have antireflux surgery must be individualized. All patients taking long-term medications for GERD should receive advice on the safety and wisdom of staying on that therapy and information on antireflux surgery. Fundoplication should be considered in three circumstances [4]: 1. Patients who are intolerant of PPI therapy because of side effects should be considered for surgery. This situation will be less common now with five PPIs, however. 2. Patients who are poorly responsive to PPI therapy should be considered for surgery. This situation is probably not common, given the effectiveness of the currently available PPIs. It is more common in patients with atypical GERD. The gastroenterologist should be as certain as possible that the patient not only has GERD, but also that the patient's symptoms are reflux related. 3. Surgery should be considered when patients desire a permanent solution to free them of the need to take medications. These patients must be warned about the potential suboptimal results, including the frequent need for medication within a few years of having the procedure and the small but real possibility of becoming worse after the operation. Even in experienced hands, 1% to 2% of patients are worse after the procedure. A careful preoperative evaluation to ensure that the patient's symptoms are reflux related and that the right operative procedure is performed offers the patient the best opportunity for success. Widespread use of endoscopic therapy for GERD is probably still several years away. The best endoscopic therapy is yet to be determined, but it will need to be safe, effective, and easy to use.