Skip to main content
Log in

SAGES guidelines for the surgical treatment of gastroesophageal reflux (GERD)

  • SAGES Guidelines
  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

Gastroesophageal Reflux Disease (GERD) is an extremely common condition with several medical and surgical treatment options. A multidisciplinary expert panel was convened to develop evidence-based recommendations to support clinicians, patients, and others in decisions regarding the treatment of GERD with an emphasis on evaluating different surgical techniques.

Methods

Literature reviews were conducted for 4 key questions regarding the surgical treatment of GERD in both adults and children: surgical vs. medical treatment, robotic vs. laparoscopic fundoplication, partial vs. complete fundoplication, and division vs. preservation of short gastric vessels in adults or maximal versus minimal dissection in pediatric patients. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Recommendations for future research were also proposed.

Results

The panel provided seven recommendations for adults and children with GERD. All recommendations were conditional due to very low, low, or moderate certainty of evidence. The panel conditionally recommended surgical treatment over medical management for adults with chronic or chronic refractory GERD. There was insufficient evidence for the panel to make a recommendation regarding surgical versus medical treatment in children. The panel suggested that once the decision to pursue surgical therapy is made, adults and children with GERD may be treated with either a robotic or a laparoscopic approach, and either partial or complete fundoplication based on surgeon–patient shared decision-making and patient values. In adults, the panel suggested either division or non-division of the short gastric vessels is appropriate, and that children should undergo minimal dissection during fundoplication.

Conclusions

These recommendations should provide guidance with regard to surgical decision-making in the treatment of GERD and highlight the importance of shared decision-making and patient values to optimize patient outcomes. Pursuing the identified research needs may improve future versions of guidelines for the treatment of GERD.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

Abbreviations

EGD:

Esophagogastroduodenoscopy

EtD:

Evidence to decision tables

GERD:

Gastroesophageal reflux disease

GRADE:

Grading of recommendations assessment, development, and evaluation

PPI:

Proton pump inhibitor

RCT:

Randomized control trial

References

  1. Andrews J, Guyatt G, Oxman AD, Alderson P, Dahm P, Falck-Ytter Y, Nasser M, Meerpohl J, Post PN, Kunz R, Brozek J, Vist G, Rind D, Akl EA, Schünemann HJ (2013) GRADE guidelines: 14. Going from evidence to recommendations: the significance and presentation of recommendations. J Clin Epidemiol 66:719–725

    Article  PubMed  Google Scholar 

  2. El-Serag HB, Sweet S, Winchester CC, Dent J (2014) Update on the epidemiology of gastro-oesophageal reflux disease: a systematic review. Gut 63:871–880

    Article  PubMed  Google Scholar 

  3. Mauritz FA, van Herwaarden-Lindeboom MY, Stomp W, Zwaveling S, Fischer K, Houwen RH, Siersema PD, van der Zee DC (2011) The effects and efficacy of antireflux surgery in children with gastroesophageal reflux disease: a systematic review. J Gastrointest Surg 15:1872–1878

    Article  PubMed  PubMed Central  Google Scholar 

  4. Martigne L, Delaage PH, Thomas-Delecourt F, Bonnelye G, Barthelemy P, Gottrand F (2012) Prevalence and management of gastroesophageal reflux disease in children and adolescents: a nationwide cross-sectional observational study. Eur J Pediatr 171:1767–1773

    Article  PubMed  Google Scholar 

  5. Wileman SM, McCann S, Grant AM, Krukowski ZH, Bruce J (2010) Medical versus surgical management for gastro-oesophageal reflux disease (GORD) in adults. Cochrane Database Syst Rev:Cd003243

  6. Alonso-Coello P, Schünemann HJ, Moberg J, Brignardello-Petersen R, Akl EA, Davoli M, Treweek S, Mustafa RA, Rada G, Rosenbaum S, Morelli A, Guyatt GH, Oxman AD (2016) GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. 1: Introduction. BMJ 353:i2016

  7. Alonso-Coello P, Oxman AD, Moberg J, Brignardello-Petersen R, Akl EA, Davoli M, Treweek S, Mustafa RA, Vandvik PO, Meerpohl J, Guyatt GH, Schünemann HJ (2016) GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. 2: Clinical practice guidelines. BMJ 353:i2089

  8. Andrews JC, Schünemann HJ, Oxman AD, Pottie K, Meerpohl JJ, Coello PA, Rind D, Montori VM, Brito JP, Norris S, Elbarbary M, Post P, Nasser M, Shukla V, Jaeschke R, Brozek J, Djulbegovic B, Guyatt G (2013) GRADE guidelines: 15. Going from evidence to recommendation-determinants of a recommendation’s direction and strength. J Clin Epidemiol 66:726–735

    Article  PubMed  Google Scholar 

  9. (2015) GRADEpro GDT: GRADEpro Guideline Development Tool. [Software]. McMaster University, (developed by Evidence Prime, Inc.), http://gradepro.org

  10. Chen Y, Yang K, Marusic A, Qaseem A, Meerpohl JJ, Flottorp S, Akl EA, Schunemann HJ, Chan ES, Falck-Ytter Y, Ahmed F, Barber S, Chen C, Zhang M, Xu B, Tian J, Song F, Shang H, Tang K, Wang Q, Norris SL (2017) A Reporting tool for practice guidelines in health care: the RIGHT statement. Ann Intern Med 166:128–132

    Article  PubMed  Google Scholar 

  11. Alonso-Coello P, Oxman AD, Moberg J, Brignardello-Petersen R, Akl EA, Davoli M, Treweek S, Mustafa RA, Vandvik PO, Meerpohl J, Guyatt GH, Schunemann HJ, Group GW (2016) GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices 2: clinical practice guidelines. BMJ 353:i2089

    Article  PubMed  Google Scholar 

  12. McKinley SK, Dirks RC, Walsh D, Hollands C, Arthur LE, Rodriguez N, Jhang J, Abou-Setta A, Pryor A, Stefanidis D, Slater BJ (2021) Surgical treatment of GERD: systematic review and meta-analysis. Surg Endosc

  13. Schünemann H, Brożek J, Guyatt G, Oxman A, (Eds) (2013) GRADE handbook for grading quality of evidence and strength of recommendations. Updated October 2013. The GRADE Working Group. guidelinedevelopment.org/handbook.

  14. Slankamenac K, Graf R, Barkun J, Puhan MA, Clavien PA (2013) The comprehensive complication index: a novel continuous scale to measure surgical morbidity. Ann Surg 258:1–7

    Article  PubMed  Google Scholar 

  15. Esposito C, Montupet P, van Der Zee D, Settimi A, Paye-Jaouen A, Centonze A, Bax NK (2006) Long-term outcome of laparoscopic Nissen, Toupet, and Thal antireflux procedures for neurologically normal children with gastroesophageal reflux disease. Surg Endosc 20:855–858

    Article  CAS  PubMed  Google Scholar 

  16. Wang YH, Wintzell V, Ludvigsson JF, Svanstrom H, Pasternak B (2020) Association between proton pump inhibitor use and risk of fracture in children. JAMA Pediatr 174:543–551

    Article  PubMed  Google Scholar 

  17. Villamanan E, Ruano M, Lara C, Suarez-de-Parga JM, Armada E, Alvarez-Sala R, Perez E, Herrero A (2015) Reasons for initiation of proton pump inhibitor therapy for hospitalised patients and its impact on outpatient prescription in primary care. Rev Esp Enferm Dig 107:652–658

    CAS  PubMed  Google Scholar 

  18. Januszewicz W, Hartley J, Waldock W, Roberts G, Alias B, Hobson A, Wernisch L, di Pietro M (2019) Endoscopic measurement of gastric pH associates with persistent acid reflux in patients treated with proton-pump inhibitors for gastroesophageal reflux disease. United Eur Gastroenterol J 7:1389–1398

    Article  CAS  Google Scholar 

  19. Albassam AA, Mallick MS, Gado A, Shoukry M (2009) Nissen fundoplication, robotic-assisted versus laparoscopic procedure: a comparative study in children. Eur J Pediatr Surg 19:316–319

    Article  CAS  PubMed  Google Scholar 

  20. Anderberg M, Kockum CC, Arnbjornsson E (2007) Robotic fundoplication in children. Pediatr Surg Int 23:123–127

    Article  PubMed  Google Scholar 

  21. Copeland DR, Boneti C, Kokoska ER, Jackson RJ, Smith SD (2008) Evaluation of initial experience and comparison of the da Vinci surgical system with established laparoscopic and open pediatric Nissen fundoplication surgery. JSLS 12:238–240

    PubMed  PubMed Central  Google Scholar 

  22. Lehnert M, Richter B, Beyer PA, Heller K (2006) A prospective study comparing operative time in conventional laparoscopic and robotically assisted Thal semifundoplication in children. J Pediatr Surg 41:1392–1396

    Article  PubMed  Google Scholar 

  23. Muller-Stich BP, Reiter MA, Mehrabi A, Wente MN, Fischer L, Koninger J, Gutt CN (2009) No relevant difference in quality of life and functional outcome at 12 months’ follow-up-a randomised controlled trial comparing robot-assisted versus conventional laparoscopic Nissen fundoplication. Langenbecks Arch Surg 394:441–446

    Article  CAS  PubMed  Google Scholar 

  24. Higgins RM, Frelich MJ, Bosler ME, Gould JC (2017) Cost analysis of robotic versus laparoscopic general surgery procedures. Surg Endosc 31:185–192

    Article  PubMed  Google Scholar 

  25. Watson DI, Pike GK, Baigrie RJ, Mathew G, Devitt PG, Britten-Jones R, Jamieson GG (1997) Prospective double-blind randomized trial of laparoscopic Nissen fundoplication with division and without division of short gastric vessels. Ann Surg 226:642–652

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  26. O’Boyle CJ, Watson DI, Jamieson GG, Myers JC, Game PA, Devitt PG (2002) Division of short gastric vessels at laparoscopic nissen fundoplication: a prospective double-blind randomized trial with 5-year follow-up. Ann Surg 235:165–170

    Article  PubMed  PubMed Central  Google Scholar 

  27. Kinsey-Trotman SP, Devitt PG, Bright T, Thompson SK, Jamieson GG, Watson DI (2018) Randomized trial of division versus nondivision of short gastric vessels during nissen fundoplication: 20-year outcomes. Ann Surg 268:228–232

    Article  PubMed  Google Scholar 

  28. St Peter SD, Barnhart DC, Ostlie DJ, Tsao K, Leys CM, Sharp SW, Bartle D, Morgan T, Harmon CM, Georgeson KE, Holcomb GW 3rd (2011) Minimal vs extensive esophageal mobilization during laparoscopic fundoplication: a prospective randomized trial. J Pediatr Surg 46:163–168

    Article  PubMed  PubMed Central  Google Scholar 

  29. Yadlapati R, Vaezi MF, Vela MF, Spechler SJ, Shaheen NJ, Richter J, Lacy BE, Katzka D, Katz PO, Kahrilas PJ, Gyawali PC, Gerson L, Fass R, Castell DO, Craft J, Hillman L, Pandolfino JE (2018) Management options for patients with GERD and persistent symptoms on proton pump inhibitors: recommendations from an expert panel. Am J Gastroenterol 113:980–986

    Article  PubMed  PubMed Central  Google Scholar 

  30. Wiens E, Kovaltchouk U, Koomson A, Targownik LE (2019) The clinician’s guide to proton-pump inhibitor discontinuation. J Clin Gastroenterol 53:553–559

    Article  CAS  PubMed  Google Scholar 

  31. Surdea-Blaga T, Băncilă I, Dobru D, Drug V, Frățilă O, Goldiș A, Grad SM, Mureșan C, Nedelcu L, Porr PJ, Sporea I, Dumitrascu DL (2016) Mucosal protective compounds in the treatment of gastroesophageal reflux disease. a position paper based on evidence of the romanian society of neurogastroenterology. J Gastrointestin Liver Dis 25:537–546

    Article  PubMed  Google Scholar 

  32. Stefanidis D, Hope WW, Kohn GP, Reardon PR, Richardson WS, Fanelli RD (2010) Guidelines for surgical treatment of gastroesophageal reflux disease. Surg Endosc 24:2647–2669

    Article  PubMed  Google Scholar 

  33. Shaheen NJ, Weinberg DS, Denberg TD, Chou R, Qaseem A, Shekelle P (2012) Upper endoscopy for gastroesophageal reflux disease: best practice advice from the clinical guidelines committee of the American College of Physicians. Ann Intern Med 157:808–816

    Article  PubMed  Google Scholar 

  34. Seo HS, Choi M, Son SY, Kim MG, Han DS, Lee HH (2018) Evidence-based practice guideline for surgical treatment of gastroesophageal reflux disease 2018. J Gastric Cancer 18:313–327

    Article  PubMed  PubMed Central  Google Scholar 

  35. Rosen R, Vandenplas Y, Singendonk M, Cabana M, DiLorenzo C, Gottrand F, Gupta S, Langendam M, Staiano A, Thapar N, Tipnis N, Tabbers M (2018) Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the north american society for pediatric gastroenterology, hepatology, and nutrition and the european society for pediatric gastroenterology, hepatology, and nutrition. J Pediatr Gastroenterol Nutr 66:516–554

    Article  PubMed  PubMed Central  Google Scholar 

  36. Richter JE, Pandolfino JE, Vela MF, Kahrilas PJ, Lacy BE, Ganz R, Dengler W, Oelschlager BK, Peters J, DeVault KR, Fass R, Gyawali CP, Conklin J, DeMeester T (2013) Utilization of wireless pH monitoring technologies: a summary of the proceedings from the esophageal diagnostic working group. Dis Esophagus 26:755–765

    Article  CAS  PubMed  Google Scholar 

  37. Randel A (2014) AAP releases guideline for the management of gastroesophageal reflux in children. Am Fam Physician 89:395–397

    PubMed  Google Scholar 

  38. Patti MG, Vela MF, Odell DD, Richter JE, Fisichella PM, Vaezi MF (2016) The intersection of GERD, aspiration, and lung transplantation. J Laparoendosc Adv Surg Tech A 26:501–505

    Article  PubMed  PubMed Central  Google Scholar 

  39. Muthusamy VR, Lightdale JR, Acosta RD, Chandrasekhara V, Chathadi KV, Eloubeidi MA, Fanelli RD, Fonkalsrud L, Faulx AL, Khashab MA, Saltzman JR, Shaukat A, Wang A, Cash B, DeWitt JM (2015) The role of endoscopy in the management of GERD. Gastrointest Endosc 81:1305–1310

    Article  PubMed  Google Scholar 

  40. Kahrilas PJ, Altman KW, Chang AB, Field SK, Harding SM, Lane AP, Lim K, McGarvey L, Smith J, Irwin RS (2016) Chronic cough due to gastroesophageal reflux in adults: CHEST guideline and expert panel report. Chest 150:1341–1360

    Article  PubMed  PubMed Central  Google Scholar 

  41. Iwakiri K, Kinoshita Y, Habu Y, Oshima T, Manabe N, Fujiwara Y, Nagahara A, Kawamura O, Iwakiri R, Ozawa S, Ashida K, Ohara S, Kashiwagi H, Adachi K, Higuchi K, Miwa H, Fujimoto K, Kusano M, Hoshihara Y, Kawano T, Haruma K, Hongo M, Sugano K, Watanabe M, Shimosegawa T (2016) Evidence-based clinical practice guidelines for gastroesophageal reflux disease 2015. J Gastroenterol 51:751–767

    Article  PubMed  Google Scholar 

  42. Hunt R, Armstrong D, Katelaris P, Afihene M, Bane A, Bhatia S, Chen MH, Choi MG, Melo AC, Fock KM, Ford A, Hongo M, Khan A, Lazebnik L, Lindberg G, Lizarzabal M, Myint T, Moraes-Filho JP, Salis G, Lin JT, Vaidya R, Abdo A, LeMair A (2017) World gastroenterology organisation global guidelines: GERD global perspective on gastroesophageal reflux disease. J Clin Gastroenterol 51:467–478

    Article  PubMed  Google Scholar 

  43. Huerta-Iga F, Tamayo-de la Cuesta JL, Noble-Lugo A, Hernández-Guerrero A, Torres-Villalobos G, Ramos-de la Medina A, Pantoja-Millán JP (2013) The Mexican consensus on gastroesophageal reflux disease. Part II. Rev Gastroenterol Mex 78:231–239

    CAS  PubMed  Google Scholar 

  44. Huerta-Iga F, Bielsa-Fernández MV, Remes-Troche JM, Valdovinos-Díaz MA, Tamayo-de la Cuesta JL (2016) Diagnosis and treatment of gastroesophageal reflux disease: recommendations of the Asociación Mexicana de Gastroenterología. Rev Gastroenterol Mex 81:208–222

    CAS  PubMed  Google Scholar 

  45. Fuchs KH, Babic B, Breithaupt W, Dallemagne B, Fingerhut A, Furnee E, Granderath F, Horvath P, Kardos P, Pointner R, Savarino E, Van Herwaarden-Lindeboom M, Zaninotto G (2014) EAES recommendations for the management of gastroesophageal reflux disease. Surg Endosc 28:1753–1773

    Article  PubMed  Google Scholar 

  46. Fock KM, Talley N, Goh KL, Sugano K, Katelaris P, Holtmann G, Pandolfino JE, Sharma P, Ang TL, Hongo M, Wu J, Chen M, Choi MG, Law NM, Sheu BS, Zhang J, Ho KY, Sollano J, Rani AA, Kositchaiwat C, Bhatia S (2016) Asia-Pacific consensus on the management of gastro-oesophageal reflux disease: an update focusing on refractory reflux disease and Barrett’s oesophagus. Gut 65:1402–1415

    Article  PubMed  Google Scholar 

  47. Farrell B, Pottie K, Thompson W, Boghossian T, Pizzola L, Rashid FJ, Rojas-Fernandez C, Walsh K, Welch V, Moayyedi P (2017) Deprescribing proton pump inhibitors: evidence-based clinical practice guideline. Can Fam Physician 63:354–364

    PubMed  PubMed Central  Google Scholar 

  48. Davies I, Burman-Roy S, Murphy MS (2015) Gastro-oesophageal reflux disease in children: NICE guidance. BMJ 350:g7703

    Article  PubMed  PubMed Central  Google Scholar 

  49. Indonesian Society of Gastroenterology (2014) National consensus on the management of gastroesophageal reflux disease in Indonesia. Acta Med Indones 46:263–271

    Google Scholar 

  50. Rickenbacher N, Kötter T, Kochen MM, Scherer M, Blozik E (2014) Fundoplication versus medical management of gastroesophageal reflux disease: systematic review and meta-analysis. Surg Endosc 28:143–155

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

We would like to thank Sarah Colon, the SAGES senior program coordinator, Holly Burt, the SAGES librarian, and the SAGES guideline committee members for their help with the creation of this guideline.

Author information

Authors and Affiliations

Authors

Contributions

Description of roles: BJS—conception and design, acquisition of data, analysis and interpretation of data, writing and editing of article. RCD—conception and design, acquisition of data, analysis and interpretation of data, writing and editing of article. SKM—conception and design, acquisition of data, analysis and interpretation of data, writing and editing of article. MTA—Analysis of data and methodology. GPK—panel member, editing of article. NT—panel member, editing of article. BQ—panel member, editing of article. SB—panel member, editing of article. SD—panel member, editing of article. CC—panel member, editing of article. APE—panel member, editing of article. CH—panel member, editing of article. FP—panel member, editing of article. NR—panel member, editing of article. AT—panel member, editing of article. EW—panel member, editing of article. DW—conception and design, acquisition of data, analysis and interpretation of data, editing of article—panel member, editing of article. ADP—Oversight, final editing. DS—development of key questions, formulation of recommendations, selection and guidance of expert panel, editing of the manuscript.

Corresponding author

Correspondence to Bethany J. Slater.

Ethics declarations

Disclosures

Bethany J. Slater—Consultant for Bolder Surgical, not relevant for this manuscript. Rebecca C. Dirks—Equity in Johnson & Johnson, not relevant for this manuscript. Nirav Thosani—Consultant for Boston Scientific Corporation, and Pentax of America; Research Support Pentax of America, and Endogastric Solutions, Royalty—UpToDate, Advisory Board member—ColubrisMx Endoluminal Surgical System, Speaker—Abbvie, Endoluminal Surgical System, Speaker—Abbvie, Not relevant for this manuscript. Aurora D. Pryor—receives honoraria for speaking from Ethicon, Gore, Medtronic, Merck, and Stryker, not relevant for this manuscript. Dimitrios Stefanidis—Dr. Stefanidis is part of the PREVENT Trial with Becton Dickinson, and his institution receives compensation for participation. Dr. Stefanidis receives research support for ExplORer and Intuitive. Sophia K. McKinley, Mohammed T. Ansari, Geoffrey P. Kohn, Bashar Qumseya, Sarah Billmeier, Shaun Daly, Catherine Crawford, Anne P. Ehlers, Celeste Hollands, Francesco Palazzo, Noe Rodriguez, Arianne Train, Eelco Wassenaar, and Danielle Walsh declare that they have no disclosures.

Conflict of interest

Bethany J. Slater, Rebecca C. Dirks, Sophia K. McKinley, Mohammed T. Ansari, Geoffrey P. Kohn, Nirav Thosani, Bashar Qumseya, Sarah Billmeier, Shaun Daly, Catherine Crawford, Anne P. Ehlers, Celeste Hollands and Francesco Palazzo declares that there is no relevant conflict of interest with the submitted work.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 131 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Slater, B.J., Dirks, R.C., McKinley, S.K. et al. SAGES guidelines for the surgical treatment of gastroesophageal reflux (GERD). Surg Endosc 35, 4903–4917 (2021). https://doi.org/10.1007/s00464-021-08625-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-021-08625-5

Keywords

Navigation