Updated GERD Guidelines Recommend Posterior Partial Fundoplication

Sheraz Markar, MSc, PhD

New European-based updated guidelines call for the use of posterior partial fundoplication as the surgical option for patients with gastroesophageal reflux disease (GERD).

Surgery is an option for patients with GERD who wish to avoid medication, as well as for patients with persistent symptoms despite medication. The most established antireflux operation is laparoscopic Nissen, which is also associated with dysphagia in approximately 13% of patients beyond 1 year following surgery. While partial fundoplications are an alternative, there are concerns about their long-term effectiveness for reflux control.

With several options available for surgical management of adult patients with GERD, previous guidelines and systematic reviews have focused on the effects of total fundoplication compared to the pooled effects of different techniques of partial fundoplication.

An international, multidisciplinary panel of surgeons, gastroenterologists, and a patient representative, led by Sheraz Markar, MSc, PhD, Nuffield Department of Surgery, University of Oxford, developed evidence-informed, trustworthy, pertinent recommendations for the use of total, posterior partial, and anterior partial fundoplications for the management of adult patients with GERD.

Partial Fundoplication

The new recommendations call for posterior partial fundoplication over total posterior or anterior 90° fundoplication in adult patients with GERD and anterior >90° fundoplication as an alternative.

“We suggest posterior partial fundoplication over total posterior or anterior 90° fundoplication in adult patients with gastroesophageal reflux disease,” the authors wrote. “Anterior >90° fundoplication is suggested as an alternative, although relevant comparative evidence is limited (weak recommendation).”

While total fundoplication is the most frequently performed antireflux surgery in Europe, the authors suggest offering posterior partial fundoplication in their services to reduce the risk of short-term complications and long-term dysphagia, as well as lowering the risk of major complications and reoperations.

The reccomendations also might have an impact on future studies.

“Researchers in the field of antireflux surgery are advised to collect and report a minimum of critical and important outcomes, including major and minor complications, ideally graded using the Clavien-Dindo classification; heartburn; regurgitation; dysphagia; gas-bloat; ability to belch; reoperation; use of antacids; and, importantly, quality of life,” the authors wrote.

The Panel

The updated reccomendations are based on 43 reports from the original review, with 8 additional reports. The final updated recommendations included 49 reports of 31 randomized trials.

In the updated systematic review, network meta-analysis, and evidence appraisal, the investigators used the GRADE approach and the Confidence in Network Meta-Analysis methodologies.

The team reached a unanimous consensus using an evidence-to-decision framework to select among multiple interventions and a Delphi process to formulate the recommendations.

“This rapid guideline was developed in line with highest methodological standards and provides evidence-informed recommendations on the surgical management of GERD,” the authors wrote. “It provides user-friendly decision aids to inform healthcare professionals' and patients' decision making.

There is a planned update to these guidelines expected in 2028.

The study, “UEG and EAES rapid guideline: Update systematic review, network meta-analysis, CINeMA and GRADE assessment, and evidence-informed European recommendations on surgical management of GERD,” was published online in the United European Gastroenterology Journal.