Table 3

All statements with grading and references

StatementGrade of evidenceReferences
1. Patients with heartburn as the main symptom who respond satisfactorily to proton pump inhibitors (PPIs) are good candidates for antireflux surgery.A 18–25
2. Patients with regurgitation as the main symptom are good candidates for antireflux surgery, regardless of the response pattern to PPI therapy.B 8 26–29
3. Patients with reflux-hypersensitive oesophagus (normal acid exposure but positive symptom association with reflux events) are good candidates for antireflux surgery.C 3 4 30–36
4. Patients with functional heartburn (Rome III/IV criteria, who have no association of symptoms with documented episodes of reflux events) are poor candidates for surgery.B 3 34 37
5a. Patients with non-cardiac chest pain are good candidates for antireflux surgery only if symptoms can be attributed to reflux.C 38–46
5b. Patients with extra-oesophageal syndromes (asthma, chronic cough or laryngitis) are good candidates for antireflux surgery only if symptoms can be attributed to reflux.C 45 47–73
6. Patients with eosinophilic oesophagitis (EOO) on oesophageal biopsies are poor candidates for antireflux surgery.C 74–78
7. Patients with scleroderma (and/or other severe smooth muscle disease) are poor candidates for antireflux surgery.C 79–89
8. Patients with concomitant functional disorders such as dyspepsia and IBS are good candidates for antireflux surgery, only if symptoms can be attributed to reflux.B 90–95
9. Patients with a body mass index >35 kg/m2 are poor candidates for antireflux surgery.B 96–102
10. Patients with psychiatric illness (major depression or anxiety disorder) are good candidates for antireflux surgery only if symptoms can be attributed to reflux.C 103–106
11. Patients known with substance abuse (such as alcohol abuse and drug abuse) are poor candidates for antireflux surgery.D 97 107–114
12. Patients with dental erosions related to documented reflux are good candidates for antireflux surgery.D 115–123
13. Endoscopy is mandatory and has to be carried out in the last year prior to antireflux surgery.B 8 28 123
14. There is no need to wean the patient off PPI for an endoscopy in the preoperative workup for antireflux surgery.C 28 124–127
15. Patients with GORD symptoms and an endoscopic diagnosis of a hiatal hernia (HH) are good candidates for antireflux surgery.B 10 128–133
16a. Patients with GORD symptoms and unequivocal presence of reflux oesophagitis Los Angeles (LA) grade A or higher off PPI are good candidates for antireflux surgery.B 2 8 134–139
16b. Patients with GORD symptoms and unequivocal presence of reflux oesophagitis LA grade B or higher off PPI are good candidates for antireflux surgery.B
17. Patients with GORD symptoms without reflux oesophagitis during endoscopy performed off PPIs are poor candidates for antireflux surgery.B 3 32 134 141–143
18. Patients with GORD symptoms and Barrett’s oesophagus (non-dysplastic specialised intestinal metaplasia) on biopsies of the distal oesophagus are good candidates for antireflux surgery.B 22 144–154
19. In patients considered for antireflux surgery, biopsies of the oesophageal body should be obtained during endoscopy.C 75 77 155–161
20. In patients with suspicion of HH or short oesophagus, a barium swallow is mandatory in the preoperative workup for antireflux surgery.B 162–167
21. Patients with GORD symptoms and a small or medium size sliding HH on barium swallow are good candidates for antireflux surgery.B 58 133 168–170
22. Patients with GORD symptoms and a large sliding HH on barium swallow are good candidates for antireflux surgery in the absence of short oesophagus.B 92 162 166 171 203 204
23. Symptomatic patients with a para-oesophageal hernia on barium swallow are good candidates for antireflux surgery in addition to para-oesophageal hernia repair.C 172–176
24. Patients with GORD symptoms and a short oesophagus on barium swallow are poor candidates for antireflux surgery.C 162 164 165
25. Oesophageal manometry is mandatory to select patients for antireflux surgery.D 177–179
26. Patients with GERD symptoms and a hypercontractile oesophagus (Jackhammer and the previously described Nutcracker) oesophagus on manometry are good candidates for anti-reflux surgery if symptoms can be attributed to reflux.D 180–182
27. Patients with GORD symptoms and distal oesophageal spasm on manometry are poor candidates for antireflux surgery.D 183–185
28. In patients with GORD symptoms and hypocontractility of the oesophageal body on manometry, antireflux surgery should be tailored.D 186–189
29. Patients with GORD symptoms and severe hypocontractility or failed peristalsis on manometry are poor candidates for antireflux surgery.D 186 188 189
30. Oesophageal pH (±impedance) monitoring off therapy is mandatory to select patients with NERD for antireflux surgery.B 22 33 190–194
31. Oesophageal pH (±impedance) monitoring off therapy should be performed for selection for antireflux surgery of patients who have short Barrett’s oesophagus in the absence of erosive oesophagitis.B 190
32. Patients with GORD symptoms and normal reflux exposure on pH (±impedance) monitoring off PPI therapy are poor candidates for antireflux surgery.B 56
33a. Patients with GORD symptoms, a normal reflux exposure on pH (±impedance) monitoring off therapy and a positive symptom association are good candidates for antireflux surgery.C 31 35 56 195
33b. Patients with GORD symptoms, a normal reflux exposure on pH (± impedance) monitoring off therapy and a positive reflux symptom association are good candidates for anti-reflux surgery, only if symptoms respond to PPI therapy.B
34a. Patients with GORD symptoms and pathological reflux exposure on pH (±impedance) monitoring off therapy and a negative reflux symptom association are eligible for antireflux surgery.C 33 192 194
34b. Patients with GORD symptoms and pathological reflux exposure on pH (± impedance) monitoring off therapy and a negative reflux symptom association are eligible for antireflux surgery, only if symptoms respond to PPI therapy.C
35. Patients with pathological reflux exposure on pH (±impedance) monitoring on PPI who respond to baclofen therapy are good candidates for antireflux surgery.D 196 197
36. A gastric emptying test for solid food is necessary to select patients with GORD with concomitant dyspeptic symptoms for antireflux surgery.C 198–200
37. If the gastric emptying test is abnormal for solid food, patients should not undergo an antireflux surgery.C 198 199 201 202