The selection of patients for surgery is a subject of great interest to internists and surgeons. Although there are good results from medical therapy with PPI's, there are definite indications for surgery.
GERD is a chronic disease which requires lifelong medical treatment in about one-third of patients. Symptom and disease recurrence can be avoided by increasing the dosage or changing medication. Patients with a defect in LES pressure, overall length and intra-abdominal length (pressure < 6 mmHg, overall length < 2 cm and intra-abdominal length < 1 cm) develop more frequent recurrence of GERD after one year of medical treatment compared to patients with normal sphincter function. Another reason for treatment failure is noncompliance to medical therapy. Furthermore, young patients with severe reflux disease and failure of LES function are optimal candidates for antireflux surgery. Those patients will require long-term treatment and may develop complications. Because of the chronicity of the disease, the inconvenience and cost of medical therapy increases. It has been suggested that surgery has a cost advantage over medical therapy in patients less than 49 years of age (Veterans Administration Cooperative Trial) and that the cost of laparoscopic surgery is the same as medical treatment with omeprazole after about 3-5 years. Antireflux surgery is also indicated for patients suffering from severe reflux who have a preference for surgical therapy.
A structural defect of the LES is often found in patients with Barrett's esophagus. Those patients are at risk of progression of the mucosal abnormality up the esophagus, formation of strictures, hemorrhage from a Barrett's ulcer and the development of adenocarcinoma. For these reasons, Barrett's needs constant surveillance and suppression of reflux, which is not guaranteed by medical therapy. Barrett's patients are therefore also optimal candidates for surgical treatment. In addition, evidence is accumulating that an antireflux procedure provides better protection against progression to cancer, since there is elimination of bile reflux, an important risk factor for the development of Barrett's cancer.
Last, but not least, patients with atypical reflux symptoms such as chronic respiratory symptoms (cough, recurrent pneumonia, episodes of nocturnal chocking and aspiration) and noncardiac chest pain will benefit from antireflux surgery.