The Durability of Antireflux Surgery

Patients who have mild, nonerosive gastroesophageal reflux disease (GERD) have many valid treatment options, but patients with severe erosive GERD (those with endoscopy showing large esophageal mucosal breaks extending between mucosal folds) have only 2: take proton pump inhibitors (PPIs) indefinitely or have antireflux surgery with fundoplication. No medication other than PPIs (and potassium-competitive acid blockers, which are not available in the United States) reliably heals reflux esophagitis; once healed, that esophagitis will return quickly and severely in most cases if PPIs are stopped. Endoscopic antireflux treatments and other antireflux devices generally have been used to treat only milder forms of GERD, and their efficacy for healing severe erosive esophagitis has not been established. Increasing awareness that patients taking PPIs often have persistent GERD symptoms even though their esophagitis has healed and recent concerns regarding serious potential consequences of long-term PPI therapy have stimulated renewed interest in antireflux surgery. One key and contentious issue is the durability of fundoplication.