Abstract and Introduction
Gastroesophageal reflux is extremely common in Western countries. For selected patients, there is an established role for the surgical treatment of reflux, and possibly an emerging role for endoscopic antireflux procedures. Randomized trials have compared medical versus surgical management, laparoscopic versus open surgery and partial versus total fundoplications. However, the evidence base for endoscopic procedures is limited to some small sham-controlled studies, and cohort studies with short-term follow-up. Laparoscopic fundoplication has been shown to be an effective antireflux operation. It facilitates quicker convalescence and is associated with fewer complications, but has a similar longer term outcome compared with open antireflux surgery. In most randomized trials, antireflux surgery achieves at least as good control of reflux as medical therapy, and these studies support a wider application of surgery for the treatment of moderate-to-severe reflux. Laparoscopic partial fundoplication is an effective surgical procedure with fewer side effects, and it may achieve high rates of patient satisfaction at late follow-up. Many of the early endoscopic antireflux procedures have failed to achieve effective reflux control, and they have been withdrawn from the market. Newer procedures have the potential to fashion a surgical fundoplication. However, at present there is insufficient evidence to establish the safety and efficacy of endoscopic procedures for the treatment of gastroesophageal reflux, and no endoscopic procedure has achieved equivalent reflux control to that achieved by surgical fundoplication.
Gastroesophageal reflux is prevalent, affecting up to 40% of the general population of most Western countries, and recently it has become more common. The treatment of reflux includes both medical and surgical options. Treatment is usually incremental, commencing with lifestyle measures, followed by medical therapy. Nonsurgical therapy treats the effects of reflux; as the underlying reflux is not corrected, treatment usually continues indefinitely. However, surgical procedures aim to reconstruct an antireflux valve at the gastroesophageal junction, and thereby potentially cure reflux. Since the introduction of laparoscopic approaches, surgery has become more acceptable, and it is likely that some patients are now undergoing surgery at earlier stages in the course of their disease. In the future, if endoscopic (transoral) antireflux procedures can be shown to be effective, then early curative therapy may have a greater role.