While antireflux surgery is often proposed to patients with proton pump inhibitor-refractory GERD, a subgroup of patients remains symptomatic or experiences late complications of surgery, such as dyspepsia or dumping syndrome. “To select patients who will benefit most from surgery, and to minimize complication risk, we believe good selection of patients is pivotal,” explains Jan Tack, MD, PhD. With no international consensus guidelines on the clinical criteria and additional technical examinations used in patient selection for antireflux surgery, Dr. Tack and 34 other expert gastroenterologists, surgeons, and physiologists developed 37 statements for the International Consensus Regarding Preoperative Examinations and Clinical Characteristics Assessment to Select Adult Patients for Antireflux Surgery (ICARUS) Guidelines. Published in Gut, the guidelines aimed at summarizing knowledge on selection criteria.

Patient Characteristics

We believe the best candidates for anti-reflux surgery are those that experience typical reflux symptoms, and who have a response of their symptoms with acid suppressive therapy,” says Dr. Pauwels. “Patients with a hiatal hernia, patients with esophagitis grade B or higher, and patients with Barrett’s esophagus are good candidates for anti-reflux surgery (Table).”

In explaining why patients who respond well to medication are good candidates for surgery, Dr. Pauwels says that these patients have symptoms that are most likely caused by acid reflux and therefore highly likely to respond well to anti-reflux surgery, which “creates an extra barrier through which reflux of any acidity cannot occur. Of course, a patient who responds well to medication also has the option of long-term medical therapy, but not everyone wants to do this.”

Confirmatory Procedures

Although the exact timing of endoscopy has not been studied and is therefore not well defined, the guidelines recommend that it be performed in all patients considered for anti-reflux surgery, as the procedure aids in confirming hiatal hernia, esophagitis grade B or higher, or Barrett’s esophagus. Dr. Tack notes that grade A esophagitis is commonly seen upon endoscopy in asymptomatic patients, which alone does not make a patient suitable for anti-reflux surgery. While biopsies are not always necessary to take during endoscopy, the guidelines recommend doing so with signs of suspicion of eosinophilic esophagitis.

With the need to establish anatomy in order to optimize a surgical intervention, barium x-ray is recommended to be obtained in patients with suspicion of a hiatal hernia or short esophagus. For ruling out major motility disorders, esophageal manometry is needed, according to Dr. Tack. “Some patients with achalasia have symptoms of heartburn, and sending them for anti-reflux surgery would obviously not be beneficial,” she adds. 

The guidelines recommend that reflux monitoring (pH or pH-impedance monitoring) be performed in all patients undergoing surgery, preferably when they are off PPI therapy. “In this way, objective reflux can be documented,” notes Dr. Pauwels. “Patients without increased reflux parameters and without any symptom correlation are not likely to benefit from anti-reflux surgery.”

Postop & Beyond

With no evidence to suggest that delayed gastric emptying for solids is associated with poor outcomes after anti-reflux surgery, the ICARUS panel suggests that routine gastric emptying testing is not needed for patients who may be referred for anti-reflux surgery.

“The current guideline was built both on the expertise of the multidisciplinary panel and on a thorough review of the literature,” explains Dr. Tack. “Nevertheless, we identified many areas of uncertainty. Ongoing and planned research, presumably using large case series studied in a uniform way, have the potential to fill these gaps in our knowledge. Scientific organizations, such as the International Society for Diseases of the Esophagus, could initiate and support such effort.” In the meantime, he suggests that clinicians be aware of the ICARUS recommendations of good candidates and the identification of those who are not good candidates when considering anti-reflux surgery in a given patient. “They should also make sure all recommended examinations have been performed and give a result that confirms the patient as being eligible for surgery,” he adds.