Innovation in laparoscopic surgery to reduce the burden of gastroesophageal reflux disease on a global scale

Background. Gastroesophageal reflux disease (GERD) is the most common esophageal disorder worldwide, with a mean estimate of age-standardized prevalence ranging from 4.4 to 14.0 cases per 100.000 population. The global burden of GERD has increased by 18.1% from 1990 to 2017 as a result of ageing, increase in the proportion of younger patients, population growth, and the obesity epidemic. Overall, GERD is associated with life-time symptoms, impaired quality of life, and an estimated 0.7% disability rate while years lived with disability have increased by 67.1% [1]. In addition, GERD is a progressive condition that may lead to severe complications such as Barrett’s esophagus, esophageal adenocarcinoma, peptic stricture, and pulmonary fibrosis. Last but not least, data from the Globocan 2020 study show that 141.300 new adenocarcinoma cases are expected in 2040 [2].
Summary. Until now, therapy of GERD has largely relied on the use of PPI. Upfront therapy with proton-pump inhibitors (PPI) is ineffective in up to 40% of patients [3]. Therefore, GERD remains a chronic debilitating disease with a substantial burden of refractory symptoms and a negative impact on healthcare resource utilization and health-related quality of life. Last but not least, reflux-induced intestinal metaplasia and dysplasia may develop and have the potential to progress to Barrett’s adenocarcinoma despite symptomatic control with PPI. The scope of antireflux surgery (ARS) is to reconstruct the natural antireflux barrier provided by the diaphragmatic crura, the lower esophageal sphincter, and the gastroesophageal flap valve. Surprisingly, laparoscopic ARS has not been fully embraced by the medical community or the public, in part as a result of bad publicity and fear of adverse outcomes. Currently, it is estimated that ARS is offered to less than 1% of the patient population eligible for surgery [4]. The 360° Nissen fundoplication has dominated for a long time the scenario of surgical treatment and is considered the gold standard. However, over the past two decades, the partial fundoplications (Toupet and Dor) and the magnetic sphincter augmentation procedure (Linx) have emerged as alternative options to decrease the incidence of dysphagia and gas-bloat syndrome. Observational and randomized clinical studies have shown that the outcomes of partial fundoplication and Linx compare favorably with those of the Nissen [5]. Still, reflux control and anatomical integrity of partial fundoplications may fade away over time. It has been shown that concurrent repair of crural diaphragm and restoration of the gastroesophageal flap valve can augment the durability of ARS, reduce PPI dependency, and improve patient-reported outcomes and esophageal acid exposure.
Key messages. The global burden of GERD requires accurate planning of health-care services to enhance the quality of care and reduce variations in practice. Modern laparoscopic ARS should provide long-lasting symptom relief to be cost-effective. It should be performed in centers offering a comprehensive diagnostic pathway and a spectrum of techniques tailored to the individual disease phenotype. Targeting the individual components of EGJ competence may enable effective reflux control and decrease the incidence of side-effects. Close scrutiny of new surgical procedures and technologies is ongoing to optimize clinical outcomes and to provide a more personalized and durable antireflux therapy.

References
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