GERD was defined according to the Montreal Consensus as “a condition which develops when the reflux of stomach contents causes troublesome symptoms and/or complications.” Symptoms were considered “troublesome” if they adversely affected an individual’s well-being [5].

From a surgical perspective, GERD is the failure of the antireflux barrier, allowing abnormal reflux of gastric contents into the esophagus [6]. It is a mechanical disorder, which is caused by a defective lower esophageal sphincter (LES), a gastric emptying disorder, or failed esophageal peristalsis. These abnormalities result in a spectrum of disease, ranging from symptoms only, such as “heartburn,” to esophageal tissue damage with or without subsequent complications including malignancy or airway disease. While the exact nature of the antireflux barrier is incompletely understood, the current view is that the LES, the diaphragmatic crura, and the phrenoesophageal ligament are key components [7, 8].

Guidelines for surgical treatment of gastroesophageal reflux disease

https://www.giejournal.org/article/S0016-5107(10)00142-2/pdf

Esophagogastric junction distensibility assessed with an endoscopic functional luminal imaging probe (EndoFLIP)

Background
The prevalence of gastroesophageal reflux disease (GERD) has increased in the last decades and it is now one of the most common chronic diseases. Throughout time our insight in the pathophysiology of GERD has been characterized by remarkable back and forth swings, often prompted by new investigational techniques. Even today, the pathophysiology of GERD is not fully understood but it is now recognized to be a multifactorial disease. Among the factors that have been shown to be involved in the provocation or increase of reflux, are sliding hiatus hernia, low lower esophageal sphincter pressure, transient lower esophageal sphincter relaxation, the acid pocket, obesity, increased distensibility of the esophagogastric junction, prolonged esophageal clearance, and delayed gastric emptying. Moreover, multiple mechanisms influence the perception of GERD symptoms, such as the acidity of the refluxate, its proximal extent, the presence of gas in the refluxate, duodenogastroesophageal reflux, longitudinal muscle contraction, mucosal integrity, and peripheral and central sensitization. Understanding the pathophysiology of GERD is important for future targets for therapy as proton pump inhibitor-refractory GERD symptoms remain a common problem.

Purpose
In this review we provide an overview of the mechanisms leading to reflux and the factors influencing perception, in the light of historical developments. It is clear that further research remains necessary despite the recent advances in the understanding of the pathophysiology of GERD.

Pathophysiology of gastroesophageal reflux disease: new understanding in a new era.

Objective:
The purpose of this prospective study was to compare the subjective and objective outcome of laparoscopic (LNF) and conventional Nissen fundoplication (CNF) up to 5 years after surgery as obtained in a multicenter randomized controlled trial.

Five-year subjective and objective results of laparoscopic and conventional Nissen fundoplication: a randomized trial.

Meta-Analysis of Randomized Clinical Trials Comparing Open and Laparoscopic Anti-Reflux Surgery

Meta-analysis of randomized clinical trials comparing open and laparoscopic anti-reflux surgery

Little is known about the effect of achalasia and gastroesophageal reflux disease (GERD) on compliance of the esophageal body and the lower esophageal sphincter (LES). Twenty-two patients with achalasia, 14 with GERD, and 14 asymptomatic volunteers were assessed. Recording apparatus consisted of a specially developed PVC bag tied to a compliance catheter, a barostat, and a polygraph. Intrabag pressures were increased incrementally while the bag volume was recorded. In each subject, pressure-volume graphs were constructed for both the esophageal body and LES and the compliance calculated. In achalasia, compliance of the esophageal body was significantly higher (P < 0.01) than in controls, whereas LES compliance was similar. Patients with GERD had a highly compliant LES in comparison to both controls and to patients with achalasia (P < 0.01 and P < 0.001, respectively); however there was no difference in their esophageal body compliance. In conclusion, foregut motility disorders can cause changes in organ compliance that are detectable using a barostat and a suitably designed compliance bag. Further measurement of compliance may provide clues to the pathogenesis of these disorders.

Compliance measurement of lower esophageal sphincter and esophageal body in achalasia and gastroesophageal reflux disease.

Prospective study of symptoms and gastro-oesophageal reflux 10 years after posterior partial fundoplication.

Editor,—We read with interest the recent paper by Kahrilas et al on the effect of hiatus hernia on gastro-oesophageal junction pressure ( Gut 1999; 44 :476–482). These authors used a novel technique that combined vector manometry, fluoroscopy, and endoscopic tagging of anatomical landmarks to map the differences in pressure profile between patients with and without hiatus hernia. Analysis of the vector profiles, taken at end expiration, revealed two distinct high pressure zones in each of the seven patients with hiatus hernia. These were thought to represent an axial separation of the internal and external components of the lower oesophageal sphincter (LOS). When these high pressure zones were repositioned …

https://gut.bmj.com/content/gutjnl/46/5/740.1.full.pdf

Vector manometry and LOS dynamics

Background:

The relationship between symptom severity and objective evidence of gastro-oesophageal reflux disease (GORD) after medical and surgical treatment has recently been questioned. This study aimed to compare the symptomatic and physiological response (as measured by pHmetry) to the treatment of GORD by proton pump inhibitors (PPIs) and by laparoscopic antireflux surgery, and to examine the relationship between the patient's subjective and objective response to treatment of GORD.



Methods:

Seventy patients underwent 24-h oesophageal pH measurement and DeMeester symptom assessment (for heartburn and regurgitation, grade 0–3) while off medical treatment, while taking PPIs and after laparoscopic fundoplication.



Results:

The median percentage total time with oesophageal pH < 4 off treatment, during medical treatment and after fundoplication was 9·5, 4·3 and 0·5 per cent respectively. After medical treatment 30 patients became asymptomatic although 18 of these still had pathological reflux on pH testing. Of the 19 patients who remained symptomatic after surgery only two had pathological acid reflux.



Conclusion:

The symptomatic response of patients to either PPIs or antireflux surgery is a poor indicator of successful treatment in terms of reduced lower oesophageal acid exposure. A high proportion of patients whose symptoms are improved by PPIs still have pathological levels of acid reflux. Conversely, most patients who complain of reflux symptoms after antireflux surgery have no evidence of residual reflux on pHmetry. Copyright © 2004 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Relationship between symptom response and oesophageal acid exposure after medical and surgical treatment for gastro‐oesophageal reflux disease

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Papers

Compliance measurement of lower esophageal sphincter and esophageal body in achalasia and gastroesophageal reflux disease.

Prospective study of symptoms and gastro-oesophageal reflux 10 years after posterior partial fundoplication.

Vector manometry and LOS dynamics

Relationship between symptom response and oesophageal acid exposure after medical and surgical treatment for gastro‐oesophageal reflux disease