Which of the following patient scenarios would be best managed with anti-reflux surgery?

b.A patient with primarily respiratory manifestations of gastroesophageal reflux

c.A patient with increased acid exposure and a mechanically defective sphincter who responds well to medical therapy but requires continued long-term medication for continued relief

The first requirement for consideration of anti-reflux surgery is the objective demonstration of the presence of GERD by 24- hour pH monitoring. Secondly, the patient must have either symptoms or complications of the disease. Thirdly, the disease should be caused by defect appropriate to surgical therapy, i.e., a mechanically defective sphincter. Some patients with increased acid exposure and a mechanically defective sphincter, and who have no complications of the disease respond well to medical therapy, but they require long-term medication for continued relief. These patients should be given the option of surgery as a cost effective alternative. Atypical symptoms of reflux such as respiratory manifestations often respond well to anti-reflux surgery. When respiratory symptoms are combined with typical symptoms such as heartburn and regurgitation, the results of anti-reflux surgery are generally good. Complaints of epigastric pain, nausea, vomiting, and loss of appetite may be due to excessive duodenogastric reflux which occurs in about 11% of patients with gastroesophageal reflux disease. This problem is usually, but not invariably, confined to patients who have previous upper gastrointestinal surgery. The coexistence of these gastric symptoms in a patient who also has typical symptoms of GERD should prompt a thorough evaluation of the stomach using a bile probe, 24 hour pH monitoring or radionucleotide scanning. In such patients, the correction of only the incompetent cardia can result in a disgruntled individual who continues to complain of nausea and epigastric pain on eating.