Patients with gastroesophageal reflux disease (GERD) who have failed medical therapy have developed complications of GERD (Barrett’s esophagus, peptic stricture) or have persistent pulmonary symptoms are candidates for antireflux surgery. Some patients may opt for surgery in spite of the success of medication for reasons such as inconvenience or expense of medication or quality of life. Preoperative evaluation must include esophagogastroduodenoscopy to evaluate esophagitis, metaplasia, dysplasia, hiatal hernia, esophageal shortening and stricture, and for biopsies as needed. Esophageal manometry is not essential but may help to demonstrate a defective lower esophageal sphincter and to assess esophageal motility. A 24-hour pH study to confirm exposure of the lower esophageal sphincter to acid pH is essential only if esophagogastroduodenoscopy does not show esophagitis and if manometry is normal, but some surgeons perform this preoperative investigation routinely. A barium swallow is useful when a large hiatal hernia is associated with a shortened esophagus. A gastric emptying study helps evaluate patients undergoing revisions where vagal nerve injury may be suspected.

The laparoscopic Nissen fundoplication, described here, is a minimal access technique very similar to the open Nissen fundoplication (see Chapter 51), an operation that has proved highly successful and durable. Partial fundoplication is reported to have significantly lower incidence of dysphagia, bloating, flatulence, and reoperation rate compared after 5 years with total fundoplication, while achieving equivalent control of GERD, but long-term data are still awaited. Techniques of partial fundoplication are described in Chapter 55 (laparoscopic esophagomyotomy). The minimally invasive management of paraesophageal hernias is covered in Chapter 54. In morbidly obese patients (BMI > 35 kg/m²) with GERD the Roux-en-Y gastric bypass is the procedure of choice as fundoplication has a high failure rate.