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How to select patients for antireflux surgery? The ICARUS guidelines (international consensus regarding preoperative examinations and clinical characteristics assessment to select adult patients for antireflux surgery)
  1. Ans Pauwels1,
  2. Veerle Boecxstaens1,2,3,
  3. Christopher N Andrews4,
  4. Stephen E Attwood5,
  5. Richard Berrisford6,
  6. Raf Bisschops1,7,
  7. Guy E Boeckxstaens1,
  8. Serhat Bor8,
  9. Albert J Bredenoord9,
  10. Michele Cicala10,
  11. Maura Corsetti11,12,
  12. Fernando Fornari13,
  13. Chandra Prakash Gyawali14,
  14. Jan Hatlebakk15,
  15. Scott B Johnson16,
  16. Toni Lerut17,
  17. Lars Lundell18,
  18. Sandro Mattioli19,
  19. Hiroto Miwa20,
  20. Philippe Nafteux17,
  21. Taher Omari21,
  22. John Pandolfino22,
  23. Roberto Penagini23,
  24. Thomas W Rice24,
  25. Philip Roelandt1,7,
  26. Nathalie Rommel1,25,
  27. Vincenzo Savarino26,
  28. Daniel Sifrim27,
  29. Hidekazu Suzuki28,
  30. Radu Tutuian29,
  31. Tim Vanuytsel1,7,
  32. Marcelo F Vela30,
  33. David I Watson31,
  34. Frank Zerbib32,
  35. Jan Tack1,7
  1. 1 Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
  2. 2 Department of Surgical Oncology, Oncological and Vascular Access Surgery, Leuven, Belgium
  3. 3 Department of Oncology, KU Leuven, Leuven, Belgium
  4. 4 Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
  5. 5 Helath Services Research, Durham University, Durham, Durham, UK
  6. 6 Peninsula Oesophago-gastric Surgery Unit, Derriford Hospital, Plymouth, Plymouth, UK
  7. 7 Gastroenterology and Hepatology, University Hospital Gasthuisberg, Leuven, Belgium
  8. 8 Gastroenterology, Ege University School of Medicine, İzmir, Turkey
  9. 9 Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, Netherlands
  10. 10 Digestive Diseases, Universita Campus Bio Medico, Roma, Italy
  11. 11 Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
  12. 12 Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham, UK
  13. 13 Programa de Pós-Graduação: Ciências em Gastroenterologia e Hepatologia, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
  14. 14 Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
  15. 15 Gastroenterology, Haukeland Sykehus, University of Bergen, Bergen, Norway
  16. 16 Department of Cardiothoracic Surgery, University of Texas Health Science Center, San Antonio, USA
  17. 17 Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
  18. 18 Department of Surgery, Karolinska, Stockholm, Sweden
  19. 19 Department of Medical and Surgical Sciences, Universita degli Studi di Bologna, Bologna, Emilia-Romagna, Italy
  20. 20 Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
  21. 21 Department of Gastroenterology, Flinders University, Adelaide, Australia
  22. 22 Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, USA
  23. 23 Department of Pathophysiology and Transplantation, Ospedale Maggiore Policlinico, Milano, Lombardia, Italy
  24. 24 Thoracic Surgery, Emeritus Staff Cleveland Clinic, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, USA
  25. 25 Neurosciences, KU Leuven, Leuven, Belgium
  26. 26 Internal Medicine and Medical Specialties, Universita di Genoa, Genoa, Italy
  27. 27 Barts and The London School of Medicine and Dentistry, Queen Mary University London, London, UK
  28. 28 Gastroenterology and Hepatology, Tokai University School of Medicine, Isehara, Kanagawa, Japan
  29. 29 Gastroenteroloy, Tiefenauspital Bern, Bern, Switzerland
  30. 30 Gastroenterology, Mayo Clinic, Scottsdale, Arizona, USA
  31. 31 Department of Surgery, Flinders Medical Centre, Flinders University, Adelaide, South Australia, Australia
  32. 32 Department of Gastroenterology, Bordeaux University Hospital, Université de Bordeaux, Bordeaux, France
  1. Correspondence to Professor Jan Tack, Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven 3000, Belgium; jan.tack{at}


Objective Antireflux surgery can be proposed in patients with GORD, especially when proton pump inhibitor (PPI) use leads to incomplete symptom improvement. However, to date, international consensus guidelines on the clinical criteria and additional technical examinations used in patient selection for antireflux surgery are lacking. We aimed at generating key recommendations in the selection of patients for antireflux surgery.

Design We included 35 international experts (gastroenterologists, surgeons and physiologists) in a Delphi process and developed 37 statements that were revised by the Consensus Group, to start the Delphi process. Three voting rounds followed where each statement was presented with the evidence summary. The panel indicated the degree of agreement for the statement. When 80% of the Consensus Group agreed (A+/A) with a statement, this was defined as consensus. All votes were mutually anonymous.

Results Patients with heartburn with a satisfactory response to PPIs, patients with a hiatal hernia (HH), patients with oesophagitis Los Angeles (LA) grade B or higher and patients with Barrett’s oesophagus are good candidates for antireflux surgery. An endoscopy prior to antireflux surgery is mandatory and a barium swallow should be performed in patients with suspicion of a HH or short oesophagus. Oesophageal manometry is mandatory to rule out major motility disorders. Finally, oesophageal pH (±impedance) monitoring of PPI is mandatory to select patients for antireflux surgery, if endoscopy is negative for unequivocal reflux oesophagitis.

Conclusion With the ICARUS guidelines, we generated key recommendations for selection of patients for antireflux surgery.

  • anti-reflux surgery
  • patient selection
  • delphi process

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  • AP and VB contributed equally.

  • Contributors AP, VB, TV, NR and PhR contributed to the reviewing list of publications. AP and VB drafted all the statements, tracked the voting process and wrote the manuscript. TV, NR, PhR and JT contributed to the revision of the statements and involved in the voting process. JT contributed to the study concept and design. All the other authors also contributed to the revision of the statements and involved in the voting process. All authors contributed to the critical revision of the manuscript for important intellectual content and approval of the final manuscript.

  • Funding JT is supported by a Methusalem Grant from Leuven University. AP is funded by a personal grant from the Research Foundation Flanders (FWO). PhR is supported by Clinical Mandate from the Belgian Foundation against Cancer (Stichting tegen Kanker).

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent for publication Not required.

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