Fundoplication may be considered in certain patients with symptomatic reflux gastritis associated with esophagitis or refractory to maximal medical therapy. Esophagitis with stricture and paraesophageal hernia are other common indications. A preliminary trial of repeated dilatations should be instituted when there is evidence of a stricture of the lower end of the esophagus prior to fundoplication.
Substernal pain, especially in the recumbent position, difficulty in swallowing, and recurrent bouts of aspiration pneumonia are commonly associated with gastroesophageal reflux. Esophagoscopy should be performed to assess for presence of hiatal hernia, esophagitis, esophageal stricture or mass, and Barrett’s esophagus. Esophageal motility must be assessed by either manometry or video barium esophagram demonstrating normal motility. In the absence of erosive esophagitis, 24-hour pH monitoring should be performed to provide objective evidence of acid reflux.
Surgical procedures are designed to prevent acid peptic reflux and to restore normal sphincteric function. When reflux esophagitis is associated with duodenal ulcer, either parietal cell vagotomy or truncal vagotomy and pyloroplasty should be considered.