Antireflux surgeries and hiatal repair: keys to success.

Abstract

Introduction: Gastroesophagealreflux is common and when medical therapy is ineffective alternative treatmentsshould be considered. Nissen fundoplication controls reflux but can be followedby side effects such as dysphagia and flatulence. To improve outcomes,modifications have been advocated.

Areas covered: Modificationsto Nissen fundoplication and newer procedures for gastroesophageal reflux aimto improve overall outcome. Randomised controlled trials (RCTs) and long-termoutcomes from large cohorts are prioritized to consider the optimal procedurefor reflux and hiatus hernia.

Expert opinion: Fundoplication an effective treatment for gastroesophagealreflux, with success rates of > 80% reported at 18-20 years follow-up. RCTsconfirm Nissen fundoplication delivers better reflux control than medication.However, some patients are troubled by side effects. Anterior and posteriorpartial fundoplication variants have been proposed as procedures that offer equallygood reflux control, but less side effects, and RCTs have confirmed this withfollow-up to 20 years. Which partial fundoplication is better is debated.Alternative laparoscopic or endoscopic approaches require expensive implants orequipment and deliver less reliable reflux control than partial fundoplication.Currently, level I evidence confirms that laparoscopic partial fundoplicationdelivers the optimal outcome in fit patients with reflux that is not well controlledby medication.