[Surgery of reflux esophagitis--a renaissance]

Gastroesophageal reflux disease (GERD) has a high prevalence of 40% in Western countries. A dysfunction of the lower esophageal sphincter of unknown origin is the main etiology. Less common pathophysiological reasons are disorders of esophageal motility, delayed gastric emptying, gastric acid hypersecretion and bile reflux. As causal surgical therapy for these disorders fundoplication has been developed 50 years ago. This technique uses a wrap of gastric fundus around the distal esophagus as reflux barrier. Because of severe postoperative complications (dysphagia, gas bloat syndrome, gastric ulcer) and recurrence after fundoplication, medical therapy became the treatment of choice with the development of H2-receptor antagonists and proton pump inhibitors in the 1970s. However, after improvement of surgical technique and introduction of laparoscopic fundoplication in 1991 surgery offers a secure and effective causal therapy. Randomized controlled trials proof the superiority of fundoplication versus medical therapy in regard of long term results, recurrence and cost effectiveness as well as the superiority of laparoscopic versus conventional open fundoplication in regard of recovery and cost effectiveness with equal long term results. Therefore, laparoscopic fundoplication by an experienced laparoscopic surgeon is the surgical therapy of choice. However the high prevalence of GERD requires careful selection of patients for surgery. A thorough preoperative evaluation including upper gastrointestinal endoscopy with biopsy, esophageal manometry and 24 h-pH monitoring as well as upper gastrointestinal contrast study is essential. Today the indication for fundoplication is seen in young symptomatic patients, requiring a long-term medical therapy, in hiatal hernia with threatening complications as well as in complications of severe GERD, especially Barrett-esophagus. At present the advantages of total (Nissen) or partial (Toupet) wrap as well as the benefit of dissection of the short gastric vessels for total fundoplication are still unclear, especially concerning long-term results. To answer these technical questions further randomized controlled trials with long-term follow-up have to be performed.