Laparoscopic antireflux surgery.

The availability of proton pump inhibitors and laparoscopic antireflux surgery has ushered in a new era in the management of chronic gastroesophageal reflux disease. Proton pump inhibitors allow physicians to treat nearly all patients with chronic gastroesophageal reflux with successful medical treatment. Laparoscopic antireflux surgery offers patients an opportunity to abandon their medications with an operation that is well tolerated. The major indication for antireflux surgery is failure of medical therapy. However, many patients with long-term medical therapy requirements are candidates, too. Several factors influence the decision to choose antireflux surgery, including patients' ages, costs of medications, types of symptoms the patients may have (for example, heartburn as opposed to chest pain or asthma), or complications such as Barrett's esophagus, metaplasia, or stricture formation. A through preoperative evaluation of patients being considered for antireflux surgery is essential. All patients should have an upper endoscopy and esophageal manometry. Selected patients, particularly those with nonerosive esophagitis, atypical reflux symptoms, or those in whom the diagnosis is in doubt, should have ambulatory esophageal pH monitoring. Barium swallow is helpful in evaluating patients with Barrett's esophagus, esophageal strictures, and in elderly patients who have a new onset of esophageal symptoms. Gastric testing infrequently identifies patients with significant abnormalities; however, in patients with symptoms of gastric disease it may change the type of surgery that is performed. The results of laparoscopic antireflux surgery are excellent in properly selected patients. Complications are rare and usually easily managed in the postoperative setting. The keys to successful antireflux surgery are a thorough evaluation of the patient, a thorough discussion of the advantages and disadvantages of antireflux surgery with the patient, and a skilled surgeon. Following these principles, antireflux surgery should be very successful in the great majority of patients for whom it is considered.