Laparoscopic antireflux surgery

Laparoscopic antireflux surgical procedures were introduced into clinical practice a little more than a decade ago. Today, they constitute a well-established treatment modality for gastro-esophageal reflux disease. With the introduction of laparoscopy, there has been a significant increase in the number of antireflux procedures performed annually in the United States. This most likely indicates more willingness by patients and referring physicians to consider the less invasive approach, rather than a change in the indications of surgical therapy. The main indications for surgical treatment continue to be relapse on medical therapy, intolerance of medications or the patient's choice of not taking medications chronically. A key to successful outcome following antireflux surgical procedures is careful patient selection and work-up. The use of endoscopy, contrast studies, esophageal manometry and 24-h pH studies is of paramount importance. Typical of many laparoscopic operations, antireflux procedures evolved with time and underwent several technical refinements. There continues to be considerable debate on some of the technical aspects of these procedures and on the long-term difference in outcome between partial and complete fundoplication. The superiority of the laparoscopic approach over the open approach has been established, with short-term advantages observed. Long-term outcome between the open and laparoscopic approaches appears to be equivalent. Failures of surgical therapy can be broadly divided into 2 groups: 1) improper patient selection and work-up and 2) technical failures. Redo laparoscopic antireflux operations are technically challenging but feasible in experienced hands.