The current indications for antireflux surgery can be summarized as follows:

On the other hand, patients who have symptoms not responsive to proper medical therapy, patients complaining of bloating, epigastric pain, a strange taste in their mouth, and patients with a normal preoperative ambulatory pH monitoring more likely than not will not be satisfied with their operation.

A proper preoperative work-up should include an accurate clinical history (including the evaluation of the response to PPI therapy), barium swallow, upper endoscopy, esophageal manometry, and ambulatory pH monitoring. Unfortunately, many physicians believe that GERD can be securely diagnosed based on the symptoms reported by the patient and the results of the endoscopy. However, many studies have shown that even typical symptoms such as heartburn and regurgitation have low accuracy, leading to a wrong diagnosis of GERD in 30–50 % of patients [7, 8]. For instance, Patti et al. [7] found that among 822 consecutive patients referred for esophageal function tests because of a clinical diagnosis of GERD (based on symptoms and endoscopic findings), abnormal reflux by pH monitoring was present in 70 % of patients only. Heartburn and regurgitation were equally frequent in both groups of patients with and without GERD, underlying that symptoms alone cannot distinguish between patients with and without pathologic reflux [7]. Many patients with a normal esophageal acid exposure had been treated with expensive medications on the assumption that gastroesophageal reflux was the cause of their symptoms, therefore masking other diagnoses such as irritable bowel syndrome, gallstone disease, and coronary artery disease. In addition, some patients who had been referred for antireflux surgery were found to have primary esophageal motility disorders such as achalasia. Heartburn is in fact experienced by about 40 % of patients with achalasia, but it is due to stasis and fermentation of food in the distal esophagus and not to real gastroesophageal reflux [9]. Unfortunately, these patients are frequently labeled as having “refractory GERD,” and they are treated for long time with PPIs or they might undergo an antireflux operation if esophageal function tests are not performed. Bello et al. recently analyzed the sensitivity and specificity of symptoms, endoscopy, barium esophagography, and manometry as compared to ambulatory 24 h pH monitoring in 138 patients referred for laparoscopic antireflux surgery (LARS) [10]. Four patients were excluded as were found to have achalasia. Of the remaining 134 patients, 56 (42 %) were found to have a normal pH monitoring and 78 (58 %) had a pathologic amount of reflux. When these two groups were compared, there was no difference in the incidence of symptoms, presence of reflux, and hiatal hernia on esophagogram, endoscopic findings, and esophageal motility. This study clearly indicated that 24 h pH monitoring should be routinely performed in the preoperative work-up of patients sus pected of having GERD in order to avoid unnecessary surgery [10]. The importance of demonstrating the presence of pathologic reflux on pH monitoring was clearly indicated by Campos and colleagues [11]. They showed that the three most important predictors of successful LARS are the presence of typical symptoms such as heartburn, a good relief of symptoms with PPI therapy, and the presence of a pathologic amount of reflux as shown by pH monitoring [11].

The technical steps of a laparoscopic fundoplication have been clearly identified [12]. They include:

As stressed by Dr. Horgan et al. in their analysis of failures of LARS [26], patients usually present because of (a) heartburn and/or regurgitation (suggestive of recurrent reflux due to an incompetent cardia), (b) dysphagia (suggestive of defective esophageal emptying), and (c) a combination of the two. If the patient is again taking PPI, it is important to assess the response as this has significant therapeutic implications.

The combination of these two tests usually identifies possible anatomic problems such as a herniated wrap or a wrong configuration of the fundoplication.

This test is important to assess the pressure and relaxation of the lower esophageal sphincter and the quality of the esophageal peristalsis. This is particularly essential if the patient complained preoperatively of severe dysphagia in addition to heartburn to rule out achalasia [10]. Finally, an achalasia-type picture can be caused by a too tight or long fundoplication [27].

If a patient experiences heartburn after a fundoplication, it is usually assumed that the operation has failed, and acid suppressing medications are prescribed [28]. Unfortunately, this approach is wrong in the majority of patients and exposes them to improper and costly medical therapy [29–31]. Many studies have, in fact shown that when patients with recurrent heartburn are tested by ambulatory pH monitoring, abnormal reflux is present in 23–39 % only [29–31]. Based on these data, objective evidence of abnormal esophageal acid exposure should always be documented by esophageal function tests before prescribing acid suppression medications or planning to redo a fundoplication.