Minimally invasive treatment of gastro-esophageal reflux disease (GERD): a still debated issue

Gastro-esophageal reflux disease (GERD) is defined as a “condition which develops when the reflux of stomach contents causes troublesome symptoms and/or complications” (1). Currently, GERD prevalence ranged between 2.5% and 33.1% but it is increasing world-wide (2).

GERD is a functional disease, which involves anatomical barrier such as the esophago-gastric junction (including the intrinsic lower esophageal sphincter, the diaphragmatic crura, the phreno-esophageal ligaments and the acute angle of His) and functional barriers (including functional efficacy of esophago-gastric junction and of esophageal peristalsis to clear the refluxate from esophagus) (3,4). Impairment of one or more of these barriers can be responsible for the development of GERD and for this reason the diagnosis, the surgical strategies and the postoperative outcomes are still a debated topic in literature (5).

Undoubtedly, the introduction of minimally invasive approach for the surgical treatment of GERD provided several advantages such as the early postoperative recovery and the reduced postoperative pain, but the choice of the best surgical technique is still a debated issue (6).

The present series, focused on the minimally invasive surgical treatment of GERD, aims to provide an overview about the possibilities presently available to manage patients with GERD. The indication for surgery (Sacchi et al.) is not always so simple and often influences the postoperative results. The most employed surgical techniques such as Nissen and Toupet fundoplication (Ugliono et al. and Coletta et al.) are safe and feasible but required an adequate experience and volume of the surgical team and in some cases are responsible for important functional sequelae at long term follow up (7,8). For this reason, recently, new devices and surgical techniques have been proposed in order to treat GERD such as LINX (Botteri et al.) and the lower esophageal sphincter electrical stimulator (Paganini et al.) but long term follow up data are still lacking and it is difficult to draw definitive conclusions. As above mentioned, GERD is a complex disease and many structures, not only the esophago-gastric junction, are responsible for the development of reflux, so another debated topic is if and how to perform the hiatal repair in case of hiatal hernia (Balagué et al.). In the last two decades, several authors reported their experience with the absorbable or not absorbable mesh placement after the diaphragmatic crura approaching, but also in this case, standardized indication and surgical technique of choice are not yet available (9-11). Lastly, it is important to underline that only long term follow up is able to provide definitive information regarding the surgical results and that in this sense the recurrence rate (Ortenzi et al.) and patients’ quality of life (Alemanno et al.) are the best indicator of postoperative results.

I hope that this series could be of interest for the readers providing useful information about the most recent knowledge on GERD and I would thank the Laparoscopic Surgery journal for the opportunity to serve as guest editor for this series and all authors who have contributed with their articles in this project.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Laparoscopic Surgery for the series “Minimally Invasive Approach for the Treatment of Gastro-esophageal Reflux Disease”. The article did not undergo external peer review.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/ls-2020-gerd-09). The series “Minimally Invasive Approach for the Treatment of Gastro-esophageal Reflux Disease” was commissioned by the editorial office without any funding or sponsorship. Dr. AB served as the unpaid Guest Editor of the series. The author has no other conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Vakil N, van Zanten SV, Kahrilas P, et al. The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. Am J Gastroenterol 2006;101:1900-20. [Crossref] [PubMed]
2. Zhang S, Jiang Q, Mu X, et al. A comparison of the efficacy and safety of complementary and alternative therapies for gastroesophageal reflux disease: a protocol for network meta-analysis. Medicine (Baltimore) 2020;99:e21318. [Crossref] [PubMed]
3. Gyawali CP, Kahrilas PJ, Savarino E, et al. Modern diagnosis of GERD: the Lyon Consensus. Gut 2018;67:1351-62. [Crossref] [PubMed]
4. Liu L, Li S, Zhu K, et al. Relationship between esophageal motility and severity of gastroesophageal reflux disease according to the Los Angeles classification. Medicine (Baltimore) 2019;98:e15543. [Crossref] [PubMed]
5. Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol 2013;108:308-28. [Crossref] [PubMed]
6. Hillman L, Yadlapati R, Whitsett M, et al. Review of antireflux procedures for proton pump inhibitor nonresponsive gastroesophageal reflux disease. Dis Esophagus 2017;30:1-14. [Crossref] [PubMed]
7. Vakil N, Shaw M, Kirby R. Clinical effectiveness of laparoscopic fundoplication in a U.S. community. Am J Med 2003;114:1-5. [Crossref] [PubMed]
8. Richter JE. Gastroesophageal reflux disease treatment: side effects and complications of fundoplication. Clin Gastroenterol Hepatol 2013;11:465-71. [Crossref] [PubMed]
9. Targarona EM, Bendahan G, Balague C, et al. Mesh in the hiatus: a controversial issue. Arch Surg 2004;139:1286-96; discussion 1296. [Crossref] [PubMed]
10. Granderath FA, Schweiger UM, Kamolz T, et al. Laparoscopic Nissen fundoplication with prosthetic hiatal closure reduces postoperative intrathoracic wrap herniation: preliminary results of a prospective randomized functional and clinical study. Arch Surg 2005;140:40-8. [Crossref] [PubMed]
11. Watson DI, Thompson SK, Devitt PG, et al. Five year follow-up of a randomized controlled trial of laparoscopic repair of very large hiatus hernia with sutures versus absorbable versus nonabsorbable mesh. Ann Surg 2020;272:241-7. [Crossref] [PubMed]

Andrea Balla