SAGES guidelines for the surgical treatment of gastroesophageal reflux (GERD)

Bethany J Slater; Rebecca C Dirks; Sophia K McKinley; Mohammed T Ansari; Geoffrey P Kohn; Nirav Thosani; Bashar Qumseya; Sarah Billmeier; Shaun Daly; Catherine Crawford; Anne P Ehlers; Celeste Hollands; Francesco Palazzo; Noe Rodriguez; Arianne Train; Eelco Wassenaar; Danielle Walsh; Aurora D Pryor; Dimitrios Stefanidis

doi:10.1007/s00464-021-08625-5

SAGES guidelines for the surgical treatment of gastroesophageal reflux (GERD)

Surg Endosc. 2021 Sep;35(9):4903-4917. doi: 10.1007/s00464-021-08625-5. Epub 2021 Jul 19.

Authors

Bethany J Slater¹, Rebecca C Dirks², Sophia K McKinley³, Mohammed T Ansari⁴, Geoffrey P Kohn^{5

6}, Nirav Thosani⁷, Bashar Qumseya⁸, Sarah Billmeier⁹, Shaun Daly¹⁰, Catherine Crawford¹¹, Anne P Ehlers¹², Celeste Hollands¹³, Francesco Palazzo¹⁴, Noe Rodriguez¹⁵, Arianne Train¹⁶, Eelco Wassenaar¹⁷, Danielle Walsh¹⁸, Aurora D Pryor¹⁹, Dimitrios Stefanidis²

Affiliations

¹ Department of Surgery, University of Chicago Medicine, 5841 S. Maryland Avenue, MC 4062, Chicago, IL, 606037, USA. bjslater1@gmail.com.
² Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.
³ Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.
⁴ School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada.
⁵ Department of Surgery, Monash University, Eastern Health Clinical School, Melbourne, VIC, Australia.
⁶ Melbourne Upper GI Surgical Group, Melbourne, VIC, Australia.
⁷ Center for Interventional Gastroenterology at UTHealth (iGUT), McGovern Medical School, UTHealth, Houston, TX, USA.
⁸ Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Fl, USA.
⁹ Department of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA.
¹⁰ Department of Surgery, University of California Irvine, Irvine, USA.
¹¹ Department of Surgery, Cambridge Health Alliance, Cambridge Massachusetts and Milford Regional Medical Center, Milford, MA, USA.
¹² Department of Surgery, University of Michigan, Ann Arbor, MI, USA.
¹³ Department of Surgery, Texas Tech University Health Sciences Center, Texas, USA.
¹⁴ Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
¹⁵ Department of Surgery, Florida Atlantic University, Florida, USA.
¹⁶ Department of Surgery, Winn Army Community Hospital, Fort Stewart, GA, USA.
¹⁷ Department of Surgery, Gelre Hospitals, Zutphen, Netherlands.
¹⁸ Department of Surgery, East Carolina University, Greenville, NC, USA.
¹⁹ Department of Surgery, Stony Brook University, Stony Brook, NY, USA.

PMID: 34279710
DOI: 10.1007/s00464-021-08625-5

Abstract

Background: Gastroesophageal Reflux Disease (GERD) is an extremely common condition with several medical and surgical treatment options. A multidisciplinary expert panel was convened to develop evidence-based recommendations to support clinicians, patients, and others in decisions regarding the treatment of GERD with an emphasis on evaluating different surgical techniques.

Methods: Literature reviews were conducted for 4 key questions regarding the surgical treatment of GERD in both adults and children: surgical vs. medical treatment, robotic vs. laparoscopic fundoplication, partial vs. complete fundoplication, and division vs. preservation of short gastric vessels in adults or maximal versus minimal dissection in pediatric patients. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Recommendations for future research were also proposed.

Results: The panel provided seven recommendations for adults and children with GERD. All recommendations were conditional due to very low, low, or moderate certainty of evidence. The panel conditionally recommended surgical treatment over medical management for adults with chronic or chronic refractory GERD. There was insufficient evidence for the panel to make a recommendation regarding surgical versus medical treatment in children. The panel suggested that once the decision to pursue surgical therapy is made, adults and children with GERD may be treated with either a robotic or a laparoscopic approach, and either partial or complete fundoplication based on surgeon-patient shared decision-making and patient values. In adults, the panel suggested either division or non-division of the short gastric vessels is appropriate, and that children should undergo minimal dissection during fundoplication.

Conclusions: These recommendations should provide guidance with regard to surgical decision-making in the treatment of GERD and highlight the importance of shared decision-making and patient values to optimize patient outcomes. Pursuing the identified research needs may improve future versions of guidelines for the treatment of GERD.

Keywords: Antireflux surgery; Fundoplication; GERD; Gastroesophageal reflux; Partial fundoplication; Proton pump inhibitor.

MeSH terms

Adult
Child
Esophagoplasty*
Fundoplication
Gastroesophageal Reflux* / surgery
Humans
Laparoscopy*
Treatment Outcome