Preoperative diagnostic workup before antireflux surgery: an evidence and experience-based consensus of the Esophageal Diagnostic Advisory Panel

J Am Coll Surg. 2013 Oct;217(4):586-97. doi: 10.1016/j.jamcollsurg.2013.05.023. Epub 2013 Aug 21.


Background: Gastroesophageal reflux disease (GERD) is a very prevalent disorder. Medical therapy improves symptoms in some but not all patients. Antireflux surgery is an excellent option for patients with persistent symptoms such as regurgitation, as well as for those with complete symptomatic resolution on acid-suppressive therapy. However, proper patient selection is critical to achieve excellent outcomes.

Study design: A panel of experts was assembled to review data and personal experience with regard to appropriate preoperative evaluation for antireflux surgery and to construct an evidence and experience-based consensus that has practical application.

Results: The presence of reflux symptoms alone is not sufficient to support a diagnosis of GERD before antireflux surgery. Esophageal objective testing is required to physiologically and anatomically evaluate the presence and severity of GERD in all patients being considered for surgical intervention. It is critical to document the presence of abnormal distal esophageal acid exposure, especially when antireflux surgery is considered, and reflux-related symptoms should be severe enough to outweigh the potential side effects of fundoplication. Each testing modality has a specific role in the diagnosis and workup of GERD, and no single test alone can provide the entire clinical picture. Results of testing are combined to document the presence and extent of the disease and assist in planning the operative approach.

Conclusions: Currently, upper endoscopy, barium esophagram, pH testing, and manometry are required for preoperative workup for antireflux surgery. Additional studies with long-term follow-up are required to evaluate the diagnostic and therapeutic benefit of new technologies, such as oropharyngeal pH testing, multichannel intraluminal impedance, and hypopharyngeal multichannel intraluminal impedance, in the context of patient selection for antireflux surgery.

Keywords: BE; Barrett esophagus; GERD; HMII; LA; LES; LPR; Los Angeles; MII; PPI; SAP; SI; gastroesophageal reflux disease; hypopharyngeal multichannel intraluminal impedance; laryngopharyngeal reflux; lower esophageal sphincter; multichannel intraluminal impedance; proton pump inhibitor; symptom association probability; symptom index.

Publication types

  • Consensus Development Conference

MeSH terms

  • Endoscopy
  • Esophageal pH Monitoring
  • Gastric Emptying
  • Gastroesophageal Reflux / diagnosis*
  • Gastroesophageal Reflux / physiopathology
  • Gastroesophageal Reflux / surgery*
  • Humans
  • Manometry
  • Patient Selection*
  • Preoperative Care*
  • Radiographic Image Enhancement