LAUSR

At least once or twice per month, we see a patient with debilitating reflux symptoms. Usually it is a patient who describes volume regurgitation occurring on a daily basis, and frequently necessitating sleeping propped up in a recliner. These patients have cut out caffeine, alcohol, spicy foods, and late meals with friends. They take high doses of proton pump inhibitors religiously! When asked how long this has been going on, the answer is variable but, more often than not, many years, if not decades, have passed since the symptoms began. And it is not uncommon for these patients to admit that they themselves insisted on a referral to a surgeon, as they were tired of their poor quality of life with breakthrough symptoms on maximal medical therapy. So why the hesitation to obtain a surgical opinion? The evidence (described below) is often in favour of anti-reflux surgery. Perhaps the answer rests with a few high-profile publications on this topic. As an example, an Editorial published in the NEJM in 2019 [1] with the title ‘‘Think First, Cut Last’’ does not encourage surgical referrals for gastroesophageal reflux disease (GERD)! The evidence up to 2014 was nicely summarized in a systematic review which included 1972 patients across 7 randomized trials comparing medical and surgical therapy for GERD [2]. In this paper, the meta-analyses for healthand GERD-related quality-of-life showed a clear and significant pooled effect estimate in favour of fundoplication. Given that some of the trials included open fundoplication rather than laparoscopic surgery, and all but one trial involved PPI therapy, there should be no argument that this was a strong result. Fast forward to 2019 and Spechler et al.’s randomized trial of medical versus surgical therapy in refractory heartburn, published in the NEJM [3]. Again, surgery prevailed at 12 months with 67% of the patients in the surgical arm reporting more than 50% improvement in GERD-related quality-of-life, compared to 28% of those in the active medical arm. Yet, despite these striking results, the accompanying Editorial took an opposing slant, cautioning the reader to rule out functional dyspepsia, eosinophilic esophagitis, rumination, and achalasia, before accepting a diagnosis of refractory reflux! [1] The Editorial then offered advice on optimizing medical management and suggested that the results in Spechler et al.’s study may reflect a powerful placebo response. The bottom line is that laparoscopic fundoplication works. It creates a mechanical ‘flap-like’ valve between the stomach and the esophagus, which is independent of the constituent of the refluxate (i.e. acid or non-acid). Whilst it is true that effective and durable reflux control may come at the expense of an ‘over-competent’ barrier, with (shortterm) symptoms of dysphagia, gas bloat, and increased flatulence, an overwhelming 87–90% of patients report long-term satisfaction with the procedure [4]. Contrary to the NICE (National Institute for Health and Care Excellence) guidelines for reflux (updated in [5]), we suggest that there are six, not three, categories of patients with GERD who deserve a surgical opinion. The NICE guidelines include the following: