[GERD and complications: when is surgery necessary?]

Esophagitis, ulcer with potential for bleeding and peptic stenosis are typical complications of gastroesophageal reflux disease (GERD). Whereas GERD is frequent with symptom prevalence of 30 % in the normal population, ulcer and peptic stenosis have become very rare. Consequently surgical interventions due to these complications are only necessary in exceptional cases. After successful bougienage and response to adequate medical treatment, surgical indications for peptic stenosis or ulcer are not different to those for other forms of reflux disease. GERD patients with a "short esophagus" and axial hiatal hernia are difficult to treat either by medication or surgery. However, intrathoracic fundoplication may lead to acceptable results. Extraesophageal manifestations of GERD are caused by a severe reflux up to the cervical esophagus. The resulting laryngitis or pulmonary problems require antireflux surgery more often than in the absence of these symptoms. Long-standing reflux can lead to the development of Barrett mucosa, which represents a precancerous for esophageal adenocarcinoma and can be considered as a special complication of GERD. Retrospective data show that progression of Barrett mucosa or its malignant degeneration cannot be prevented by fundoplication. However, in a comparative study concerning low-grade neoplasia fundoplication leads to significantly more cases with regression than medication. High-grade neoplasia has to be removed in all cases. With regard to the prerequisite for correct indications the long-term results of endoscopic or surgical procedures are equal, but endoscopic mucosectomy is favoured due to its lower invasiveness. Indications for surgery by limited or radical esophagectomy are incomplete removal of neoplasia after mucosectomy, long Barrett's esophagus with multifocal lesions or suspicion of submucosal carcinoma.