Table 4 - Physiologic and anatomic goals of anti-reflux surgery

Restore lower sphincter pressure without overwhelming esophageal peristalsis Establish sufficient overall length of the lower esophageal sphincter (approx. 3 cm) Establish abdominal position of the lower esophageal sphincter (approx. 2 cm) Preserve the ability to belch and vomit Avoid vagal nerve injury Correct the associated diaphragmatic herniation

What are the key features of pathologic GERD that the physician and surgeon must focus upon in determining the candidacy of a patient for anti-reflux surgery? The most important feature is determining medical recalcitrancy of the patient's GERD condition. This is a rather "loose" definition primarily based upon the patient's interest/willingness to continue medical therapy and the possible development of significant "GERD-related" complications (persistent esophagitis, bleeding, ulceration, stricture formation). Once the patient with recalcitrant GERD is identified, it is important to quantitate the severity of the patient's disease and the pathophysiologic vagaries of his or her condition prior to launching a course of surgical management. We emphasize that the primary mandate for the surgeon performing anti-reflux surgery is to utilize a "tailored" reconstruction of the anti-reflux mechanism based upon the individual patient's pathophysiologic GERD condition.

A variety of tests aimed at determining the leading components to the GERD pathophysiology must be utilized. These tests have been generally described earlier within the Diagnostic Section of this Clinical Update. They are also identified in Table 1.

It is important to recognize that the primary goal of surgery for GERD is aimed at restoring near normal competency of the lower esophageal sphincter mechanism (Table 4). This should be accomplished without the development of adverse trade-offs related to the surgical reconstruction. This requires reconstruction which takes the integrity of the esophageal peristaltic pump into account. Creation of an anti-reflux barrier which burdens normal esophageal transit into the stomach is unacceptable. Esophageal manometric testing is therefore a vital component to any preoperative anti-reflux surgical evaluation. Without this assessment, the risk for development of significant postoperative dysphagia is increased among those patients who may receive too long or too tight an anti-reflux repair. Likewise, barium esophagram/ upper gastrointestinal contrast roentgenographic series and esophagogastroduodenoscopy are important diagnostic tools providing roadmaps for the surgical reconstruction and identification of significant associated pathologic conditions masquerading as GERD. Prolonged 24-hour intra-esophageal pH testing and nuclear scintigraphic assessment of esophagogastric transit are also useful studies that should be selectively applied when uncertainty exists regarding the patient's diagnosis or the severity of the disease. These studies are also useful in identifying recurrent or atypical symptoms experienced by the patient. When patients whose primary pathologic mechanism related to GERD sur-rounds a defective lower esophageal sphincter mechanism, the results of anti-reflux surgery are usually gratifying.

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