Surgical treatment of GERD: facts, discrepancies and recommendations

50 years have passed since Rudolf Nissen presented his publication in the „Schweizerische medizinische Wochenschrift: Eine einfache Operation zur Beeinflussung der Refluxoeophagitis” [1]. – Time to reanalyse the position of antireflux surgery and to reflect on its evolution over the past 50 years! Despite good results in many patients with severe reflux disease, antireflux surgery went out of fashion for decades due to the lack of appropriate diagnostic tools, a lack of basic knowledge about GERD, and an overcorrection of the lower esophageal sphincter with the original Nissen technique with a high rate of postoperative dysphagia. In most hospitals in Europe, it was therefore performed only on rare occasions. Intensive research on upper GI pathophysiology during the seventies and eighties of the past century lightened the darkness: Development of water-perfused (and later solid state-) catheters shed new light on upper GI motility and computers have enabled a better evaluation of motility studies. The importance of a defective lower esophageal sphincter (LES) , weak esophageal peristalsis and transient LES relaxations in GERD patients was discovered [2]. Ambulatory 24h pH-monitoring [3] allowed a simple quantification of acid reflux with widespread use. Moreover, bile reflux studies and later, the Bilitec detection system [4] showed the correlation of duodenogastric reflux with severe grades of the disease [5]. At the same time, the role of the composition of the refluxate in inflammation and development of metaplasia, dysplasia and cancer formation were shed light upon [6, 7]. Nowadays, combined pH-esophageal impedance measurement is moving towards widespread use and its efficacy is being evaluated. This new tool offers the possibility to discriminate between acid and non-acid reflux, and makes it easy to diagnose a hypersensitive esophagus and – for the first time – to rule out reflux. In the late eighties, a peak in GERD research developed parallel to the evolution of minimal invasive surgery. With good results in the initial series [8], the distribution of this technique made antireflux surgery more attractive for patients and also for surgeons aiming to specialize in GERD. The absolute number of fundoplications in Austria increased dramatically [9] in the nineties. Medical technical companies provided diagnostic units for esophageal manometry and ambulatory pH-monitoring at an affordable price for smaller hospitals and therefore played an important role in the widespread distribution of basic “GERD detection units”. Within a few years, it was ethically almost impossible to seriously perform fundoplications without preoperative functional workup.