What surgical options are used for GERD with refractory regurgitation?

• A. Medical therapy only.
• B. Pyloroplasty alone.
• C. Esophagectomy.
• D. Laparoscopic Nissen fundoplication or partial fundoplication (Toupet) or newer anti-reflux procedures; tailored to patient.

Answer: (D)

When GERD with regurgitation remains troublesome despite medical therapy, the surgical aim is to restore a competent barrier at the junction where the stomach meets the esophagus so reflux is minimized while swallowing stays smooth. The most effective and commonly used options are laparoscopic fundoplication procedures, which wrap part or all of the stomach around the lower esophagus to reinforce the valve mechanism. A full 360-degree wrap (Nissen) provides strong reflux control, while a partial wrap (Toupet, about 270 degrees) can be gentler on the esophagus and is often chosen when esophageal motility is reduced, to lessen the risk of postoperative dysphagia. Newer anti-reflux techniques may also be considered, but all are tailored to the individual patient’s anatomy, esophageal function, and any hiatal hernia present.

Other options listed aren’t appropriate for addressing refractory reflux on their own. Medical therapy alone would not resolve symptoms that persist despite optimization of medications. Pyloroplasty alone doesn’t fix the reflux barrier at the GEJ and isn’t a standard treatment for GERD with regurgitation. Esophagectomy is a major operation reserved for severe disease such as cancer or end-stage conditions, not for purely reflux-related symptoms. The best approach combines a minimally invasive anti-reflux procedure with careful patient-specific tailoring to optimize outcomes.