Review article: indications for anti-reflux surgery and endoscopic anti-reflux procedures

Gastro-oesophageal reflux disease is a motor disorder principally caused by defective function of the lower oesophageal sphincter. Proton pump inhibitor (PPI) drugs alleviate symptoms, heal oesophagitis and improve quality of life but do not address the underlying motor disorder, and prolonged treatment is often needed. The efficacy of anti-reflux operations is comparable to PPIs. Indications for surgical referral include ineffective medical therapy, intolerance to PPIs, the aspiration to avoid drugs and treatment of complications (particularly peptic stricture and respiratory diseases). Pre-operative assessment should include endoscopy, pH monitoring and oesophageal manometry. The efficacy of anti-reflux surgery is well established but endoscopic anti-reflux procedures currently have an uncertain role. These procedures are based on endoscopic suturing, injection of materials around the lower oesophageal sphincter and radio frequency ablation. Published series show that all procedures may be effective in selected patients. Although the mechanisms for this efficacy are unclear, they may include correction of the underlying motor defect, physical barrier to reflux and decreased oesophageal sensitivity caused by denervation. Comparative studies are needed before endoscopic anti-reflux procedures can be recommended outside of clinical trials.