Laparoscopic Nissen Fundoplication (LNF)

LNF is the most widely performed surgical procedure for GERD, especially in patients with severe reflux or complications. This technique involves wrapping the top portion of the stomach (the fundus) around the lower esophagus to reinforce the lower esophageal sphincter (LES), preventing reflux. Studies show that LNF is effective in achieving symptom relief and healing esophagitis in children and adults; however, recurrence rates range from 8.7% to 27% (7, 8).

Advantages of LNF:

• Effective symptom relief: High success rates in alleviating GERD symptoms.
• Long-term resolution: Many patients experience sustained relief without the need for continuous medication.

Disadvantages of LNF:

• Surgical risks: Potential for complications such as bleeding, infection, and injury to surrounding organs.
• Recurrence: Some patients may experience recurrent symptoms years after surgery.

Endoscopic Anti-Reflux Mucosectomy (ARMS)

Introduced in the mid-2000s, ARMS employs an endoscopic mucosal resection technique to augment LES function by increasing its tone and modifying the esophagogastric junction structure. This procedure is less invasive than traditional fundoplication and is particularly beneficial for patients with mild to moderate GERD who cannot tolerate PPIs.

Advantages of ARMS:

• Minimally invasive: Reduced recovery time compared to traditional surgery.
• Lower complication rates: Fewer adverse events reported when compared to LNF.

Disadvantages of ARMS:

• Inconsistent outcomes: Response rates can vary, and not all patients benefit from the procedure (9).
• Limited indications: Best suited for select patient populations with specific clinical profiles.

Stretta Radiofrequency (SRF) Therapy

SRF is an endoscopic procedure that uses radiofrequency energy to remodel the LES. It aims to enhance the sphincter’s function and reduce reflux events without the need for significant surgical intervention.

Advantages of SRF:

• Outpatient procedure: Can often be done under sedation without the need for general anesthesia.
• Quick recovery: Patients typically resume normal activities shortly after the procedure.

Disadvantages of SRF:

• Variable effectiveness: Clinical outcomes can be inconsistent, and long-term data is limited (10, 11).
• Potential adverse effects: Risks include esophageal injury and the need for repeat procedures if symptoms recur.

The Role of Proton Pump Inhibitors (PPIs) in GERD Treatment

PPIs are the most common pharmacological treatment for GERD, effectively reducing gastric acid production. They work by irreversibly binding to the H+/K+-ATPase enzyme in gastric parietal cells, leading to decreased acid secretion (12).

Efficacy of PPIs

Research indicates that PPIs are highly effective in managing symptoms of erosive esophagitis, with healing rates upwards of 85% (13). However, a significant proportion of patients (up to 40%) report persistent symptoms despite optimal PPI therapy, leading to the recognition of PPI-refractory GERD (14).

Limitations and Risks of Long-term PPI Use

While PPIs offer substantial benefits, their long-term use raises concerns regarding potential side effects, including:

• Nutrient malabsorption: Increases in deficiencies of vitamin B12, calcium, and magnesium (15).
• Increased infection risk: Long-term PPI use is linked to heightened risks of Clostridium difficile infections and community-acquired pneumonia (16).
• Rebound acid hypersecretion: Symptoms may worsen upon discontinuation of PPIs, necessitating careful management strategies (17).

Novel Therapies and Future Directions in GERD Management

As the limitations of current GERD therapies become more apparent, alternative treatments are being explored. Potassium-competitive acid blockers (PCABs), such as vonoprazan, are emerging as promising options due to their ability to provide greater and more sustained acid suppression compared to PPIs (18).

Advances in Pharmacotherapy:

• PCABs: Vonoprazan has demonstrated superior efficacy in terms of acid control and symptom relief, particularly for patients with erosive esophagitis and those who are refractory to PPIs (19).
• Prokinetic agents: Medications like itopride have shown potential in enhancing gastrointestinal motility and improving GERD symptoms (20).

Future Directions:

Research continues into the long-term safety and effectiveness of these new therapies, and ongoing studies will likely refine treatment protocols to enhance GERD management.

FAQs

What is GERD?

GERD, or gastroesophageal reflux disease, is a chronic condition characterized by the backward flow of stomach contents into the esophagus, leading to symptoms like heartburn and regurgitation.

How is GERD diagnosed?

Diagnosis can involve a combination of clinical assessments, endoscopy, pH monitoring, and imaging studies to evaluate esophageal damage.

What are the treatment options for GERD?

Treatment options include lifestyle changes, medications such as PPIs, and surgical interventions like laparoscopic fundoplication.

Are there risks associated with long-term PPI use?

Yes, long-term use of PPIs can lead to nutrient malabsorption, increased risk of infections, and rebound acid hypersecretion.

What are the newer therapies for GERD?

Emerging treatments include potassium-competitive acid blockers and prokinetic agents, which offer alternative strategies for patients who do not respond well to traditional therapies.

References

1. The comparative study of Stretta radiofrequency and anti-reflux mucosectomy in the management of intractable gastroesophageal reflux disease: a single-center retrospective study from Korea. Retrieved from https://pubmed.ncbi.nlm.nih.gov/12138365/
2. Risk Factors for Recurrence of Gastroesophageal Reflux Disease After Laparoscopic Nissen Fundoplication in Patients With Severe Motor and Intellectual Disabilities. Retrieved from https://pubmed.ncbi.nlm.nih.gov/12116254/
3. Childhood gastroesophageal reflux disease: A comprehensive review of disease, diagnosis, and therapeutic management. Retrieved from https://doi.org/10.5409/wjcp.v14.i2.101175
4. Unraveling the Mystery of Persistent Positional Borborygmi. Retrieved from https://pubmed.ncbi.nlm.nih.gov/12144641/
5. Severe intestinal distension following HFNC-assisted awake intubation with conversion to open Nissen fundoplication: a case report. Retrieved from https://doi.org/10.1186/s12871-025-03166-z
6. Ventral Hernia and Obesity: A Contemporary Surgical Challenge. Retrieved from https://doi.org/10.7759/cureus.83126
7. Optimal Sequencing in Same-Day Bidirectional Endoscopy: A Tertiary US Healthcare Center Experience. Retrieved from https://doi.org/10.1007/s10620-025-08889-0