Guidelines of the previous consensus conference and recent developments

This article reviews the major changes that have occurred since the last Canadian consensus conference on gastroesophageal reflux disease (GERD), which was held four years ago. There were developments in the understanding of the pathophysiology of this disease and improvements in the methods of its investigation and management. Esophageal and extraesophageal complications have also been better defined. Since 1992 new knowledge on nitric oxide has been gained and several new inflammatory cytokines have been developed. Improved understanding of the mechanism of the hypersensitive esophagus helped to explain the presence of clinical symptoms with normal endoscopic findings. This also improved interpretation of the role of 24 h pH monitoring and 24 h pH with motility recording. There is better understanding of the role of H2 receptor antagonists and prokinetics and an increasing confidence in the long term safety of proton pump inhibitors (PPIs). The most important changes occurred in surgery with the introduction of laparoscopic fundoplication. Patients with Barrett's esophagus who are too ill for esophagectomy may now be enrolled in surveillance because it is possible to deal with dysplasia and small cancers with photodynamic therapy. As an introductory lecture to the consensus conference, this article also deals with the subject of health economics and discusses the necessity and the dangers involved in devising treatment guidelines. It indicates that guidelines change with advancing knowledge, and emphasizes that physicians' primary duty is toward their patients. Therefore, guidelines devised here should be adjusted to the individual needs of patients. Organizational aspects of the present conference are also described.