There is a tremendous number of people suffering from gastroesophageal reflux disease (GERD) in North America: 36% have monthly symptoms, 7 % have daily symptoms and 3% have severe disease. Medical management is successful for most patients, but there remains a significant number who have persistent symptoms (e.g. heartburn, regurgitation) despite maximal medical therapy. This is the most common indication for antireflux surgery. Other reasons to consider antireflux surgery include failure of medical therapy to control the complications of GERD: esophagitis, bleeding, stricture, aspiration, asthma, pneumonia. Still other patients may have complete or near-complete resolution of their symptoms if they adhere strictly to their dietary and lifestyle restrictions and medical regimen, but prefer antireflux surgery rather than face a lifetime of these inconveniences. The high success rate (>90%) and low morbidity (<5%) make laparoscopic antireflux surgery a very good alternative for these patients.

Indications for Laparoscopic Antireflux Surgery
1. Failure of Medical Therapy
    a. To control symptoms
    b. To prevent complications
2. Inability to tolerate medical therapy
3. Inability to finance medical therapy
4. Patient preference

Patient selection and proper surgical technique is the key to achieving excellent results. How can we select the best candidates? One must assure that the patient actually has abnormal GER and that their symptoms are the result of GER. Three important factors can predict a successful outcome after antireflux surgery. First is a history of typical symptoms, i.e. classic heartburn and regurgitation brought on by certain foods, postural changes, etc. Excellent results can be expected in greater than 90% of patients with typical symptoms versus 75-80% with atypical symptoms. Atypical symptoms include chest pain, hoarseness, chronic cough, throat clearing, asthma and recurrent pneumonia. Although GERD can and frequently does cause atypical symptoms, a direct causal relationship can be more difficult to establish. The second and equally important factor in patient selection is an appropriate response to acid suppressing medicines. A patient with symptoms caused by acid reflux should respond (even if incompletely or transiently) to acid suppression therapy. If not, a 24-hour pH monitor can document abnormal esophageal acid exposure, which is the third predictive factor for a successful antireflux surgery.

Factors that predict successful antireflux surgery
1. Typical symptoms
2. Response to medical therapy
3. Abnormal 24 hour pH monitor

Adhering to proper surgical principles is also important to achieve excellent relief of GERD symptoms, while minimizing untoward effects of the wrap. These include

1. Complete mobilization and reduction of the hiatal hernia, if present
2. Closure of the diaphragmatic hiatus to prevent recurrence of the hernia
3. Creation of a short, "loose" wrap to prevent postoperative dysphagia while still curing reflux. This usually requires division of the short gastric vessels.

In summary, patients most likely to benefit from antireflux surgery are those with typical symptoms, a response with medical therapy and/or an abnormal pH probe. Improvements in the surgical approach (laparoscopy) and in the surgical technique (short, loose wrap) have justifiably increased its use dramatically over the past decade. The excellent results and minimal morbidity after laparoscopic antireflux surgery make it a very good alternative to the inconveniences of medical management in many patients.