Commentary on the SAGES Guidelines for Surgical Treatment of Gastroesophageal Reflux Disease

The SAGES Guidelines Committee has created a document on the surgical management of gastroesophageal reflux disease (GERD) using the most rigorous methods of systematic review. From this standpoint, the information provided is of the highest quality and the recommendations rest on a solid foundation. All surgeons who care for patients with GERD can look to this document for guidance and support. As reflux disease continues to be a common malady, with well over US $1 billion spent on direct costs, and with an unknown but undoubtedly large amount spent on indirect costs, this is a topic worthy of comparative clinical effectiveness analysis. It must be remembered, however, that these Guidelines are written for the surgical management of GERD. Appropriate references are made to guidelines dealing with medical management, and an analysis of the extant controlled trials comparing medical with surgical management is presented. However, the Guidelines do not settle the controversy regarding whether medical or surgical therapy is superior. This is appropriate, since GERD is a protean disease in its patients and manifestations. No single treatment plan is appropriate for all patients. The indications for an operation are based specifically on the pathology of gastroesophageal reflux, not on the presence of a hiatal hernia. Therefore, the indications for an operation for a paraesophageal hernia are not a part of these Guidelines. However, the indications for an operation for GERD presented are clear, circumscribed, and comprehensive. The preoperative evaluation of the patient with GERD has been an area of confusion—which tests are needed and for whom? These Guidelines provide an evidence-based answer: enough testing to confirm pathologic reflux. Upper gastrointestinal endoscopy is mandatory to confirm mucosal injury as a result of acid reflux. This author believes that endoscopy is also important to rule out other, more sinister, pathologies such as Barrett’s esophagus or even adenocarcinoma. If no such injury is visualized, then 24-h esophageal pH monitoring is mandatory to confirm pathologic reflux. Interestingly, the authors did not find evidence supporting esophageal manometry and gastric emptying scintigraphy. In my opinion, manometry is important to rule out other esophageal motility disorders which may preclude an antireflux operation. As preoperative bloating in not uncommonly found in GERD patients, gastric emptying scintigraphy may identify patients with coexisting gastroparesis in whom concomitant pyloroplasty may be of benefit. In understanding the results of the studies on the comparative treatments for GERD, one must clearly keep in mind the goals of treatment. Much of the controversy regarding medical versus surgical management relates to which endpoints are emphasized: Symptomatic relief, reduction of esophageal acid exposure, reduction in medication use, patient satisfaction, and costs have all been applied as primary endpoints. These endpoints measure different, albeit related, things. The only patient-centered outcomes are symptomatic relief and satisfaction; however, these symptoms, whether occurring preoperatively or postoperatively, may not, in fact, be related to acid reflux. Reduction of acid exposure is the only physiologically objective endpoint, but many of the symptoms of GERD are related to reflux volume, such as regurgitation, or bile reflux, independent of the acid content of the refluxate. The resumption of the use of medications, primarily proton-pump inhibitors (PPIs), is almost always based on a physician or patient judging that postoperative symptoms are due to a failure of the operation rather V. Velanovich (&) Division of General Surgery, K-8, Henry Ford Hospital, 2700 West Grand Blvd., Detroit, MI 48202, USA e-mail: vvelano1@hfhs.org