Leading article Surgical management of refractory gastro-oesophageal reflux G. Zaninotto 1 and S. E. A. Attwood 2 1 Department of Surgical and Gastrointestinal Sciences, University of Padova, Unit` a Operativa Complessa General Surgery, Hospital Santi Giovanni e Paolo, Castello 6777, 30100 Venice, Italy, and 2 Department of Surgery, Northumbria Healthcare NHS Trust and Newcastle University, North Tyneside Hospital, Rake Lane, North Shields NE29 8NH, UK (e-mail: giovanni.zaninotto@unipd.it) Published online in Wiley InterScience (www.bjs.co.uk). DOI: 10.1002/bjs.6863 Surgery in the management of gastro- oesophageal reflux disease (GORD) is controversial; its availability and frequency show variability between, and even within, countries. GORD is a common chronic condition, with some 20 per cent of the population in Western countries experiencing symptoms of reflux at least once a week 1 . When gastric juice flows back into the oesophagus, it causes heart- burn and acid regurgitation (so-called ‘typical’ symptoms) and/or a vari- ety of symptoms often referred to as ‘atypical’. Atypical symptoms include cough, hoarseness, dental erosions and angina-like chest pain. The regur- gitated gastric contents may dam- age the oesophageal mucosa, inducing erosions, ulcers and even metaplastic change (Barrett’s oesophagus). Most patients with GORD are treated effectively by non-prescription medication or acid-suppressing drugs (proton pump inhibitors (PPIs)), or a combination of the two. Although effective 2 , surgery has a relatively marginal role. It is generally reserved for those few patients who are unwill- ing to take drugs or whose condition is considered ‘refractory’ to such treat- ments (patients whose symptoms or mucosal damage persist or are cured only partially by PPIs) 3 . When faced with a patient with refractory disease it falls to the surgeon to decide whether or not an antireflux procedure will confer benefit. As will be shown below, the present difficulty in defining the role of surgery in the management of refrac- tory GORD stems partly from the currently accepted Montreal defini- tion of GORD as ‘a condition that develops when the reflux of stomach contents causes troublesome symp- toms and/or syndromes’ 4 . According to this symptom-focused definition, all patients with typical or atypical symptoms related to acid or non- acid reflux have the disease. These patients may be prescribed a trial of medical therapy, even if their overall oesophageal exposure to gastric con- tents is normal. Four groups of refractory patients who might request surgery can be identified. The first group consists of poorly compliant patients, or those having an inappropriate PPI con- sumption because of poor timing and/or frequency of dosing. This is probably the largest group and these patients are the simplest to treat, either by correcting the medical treat- ment (enforcing compliance, modify- ing the timing and/or frequency of dosage) or, if necessary, by antireflux surgery. The second group contains patients whose refractory symptoms are dif- ferent to their initial symptoms. PPIs often resolve the severe heartburn felt in the initial stages of GORD but fail to reduce volume reflux and regur- gitation while stooping or straining. Cough (especially at night), episodes of wakening and choking, and poor sleep pattern are common refractory symptoms that prompt a patient to seek surgical intervention. The third group of patients have symptoms that are unresponsive to PPIs. The main reason is a persistence of alkaline or weakly acidic reflux of duodenal contents (bile and pancre- atic juice). In this situation PPIs have reduced gastric acid output, but are ineffective with respect to the alkaline component of the refluxate. The final group comprises those whose refractory symptoms are due to an altered sensitivity of the oesophageal mucosa. This results in an abnormal perception of other- wise normal events, often described as ‘acid-sensitive oesophagus’ or ‘func- tional heartburn’. Although no exact figure is available, it has been esti- mated that these last two groups account for 10–20 per cent of refrac- tory GORD. Without refractory symptoms, there is little evidence to promote antireflux surgery, except for Barrett’s oesophagus with severe reflux requiring progressively increas- ing doses of PPI, or when there is an associated large paraoesophageal her- nia (to prevent future strangulation or respiratory complications). For a surgeon to operate, some- thing more than a purely symptom- based definition of GORD is required; a trial of treatment by operation is not acceptable if the chance of success- ful outcome is minimal. An accurate definition of disease before surgery requires the measurement of acid reflux (by 24-h pH monitoring after suspension of PPI therapy) and exclu- sion of dysmotility disorders (achala- sia, diffuse oesophageal spasm). If acid exposure is abnormal, GORD may be regarded as present and surgery as justified, if symptoms warrant it. This diagnostic approach, however, does not deal satisfactorily with the last two of the four groups described above. In Copyright  2010 British Journal of Surgery Society Ltd British Journal of Surgery 2010; 97: 139–140 Published by John Wiley & Sons Ltd