How to select patients for anti-reflux surgery? The ICARUS guidelines (International Consensus regarding preoperative examinations and clinical characteristics assessment to select adult patients for AntiReflUx Surgery)

Pauwels, Ans; Boecxstaens, Veerle; Andrews, Christopher; Attwood, Stephen E.; Berrisford, Richard; Bisschops, Raf; Boeckxstaens, Guy; Bor, Serhat; Bredenoord, Albert J.; Cicala, Michele; Corsetti, Maura; Fornari, Fernando; Gyawali, C. Prakash; Hatlebakk, Jan G.; Johnson, Scott B.; Lerut, Toni; Lundell, Lars; Mattioli, Sandro; Miwa, Hiroto; Nafteux, Phillippe; Morai, Taher; Pandolfino, John E.; Penagini, Roberto; Rice, Thomas W.; Roelandt, Philip R.; Rommel, Nathalie; Savarino, Vincenzo; Sifrim, Daniel; Suzuki, Hidekazu; Tutuian, Radu; Vanuytsel, Tim; Vela, Marcelo F.; Watson, David I.; Zerbib, Frank; Tack, Jan F.

Abstract

Objective: Anti-reflux surgery can be proposed in patients with gastro-esophageal reflux disease, especially when proton pump inhibitor 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 anti-reflux surgery are lacking. We aimed at generating key recommendations in the selection of patients for anti-reflux 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 esophagitis LA grade B or higher and patients with Barrett’s esophagus are good candidates for anti-reflux surgery. An endoscopy prior to anti-reflux surgery is mandatory and a barium swallow should be performed in patients with suspicion of a HH or short esophagus. Esophageal manometry is mandatory to rule out major motility disorders. Finally, esophageal pH (+/- impedance) monitoring off PPI is mandatory to select patients for anti-reflux surgery, if endoscopy is negative for unequivocal reflux esophagitis.
Conclusion: With the ICARUS guidelines, we generated key recommendations for selection of patients for anti-reflux surgery.

Citation

Pauwels, A., Boecxstaens, V., Andrews, C., Attwood, S. E., Berrisford, R., Bisschops, R., Boeckxstaens, G., Bor, S., Bredenoord, A. J., Cicala, M., Corsetti, M., Fornari, F., Gyawali, C. P., Hatlebakk, J. G., Johnson, S. B., Lerut, T., Lundell, L., Mattioli, S., Miwa, H., Nafteux, P., …Tack, J. F. (2019). How to select patients for anti-reflux surgery? The ICARUS guidelines (International Consensus regarding preoperative examinations and clinical characteristics assessment to select adult patients for AntiReflUx Surgery). Gut, 68(11), 1928-1941. https://doi.org/10.1136/gutjnl-2019-318260

• Journal Article Type: Article
• Acceptance Date: May 30, 2019
• Online Publication Date: Aug 2, 2019
• Publication Date: 2019-11
• Deposit Date: Jun 5, 2019
• Publicly Available Date: Jun 6, 2019
• Journal: Gut
• Print ISSN: 0017-5749
• Electronic ISSN: 1468-3288
• Publisher: BMJ Publishing Group
• Peer Reviewed: Peer Reviewed
• Volume: 68
• Issue: 11
• Pages: 1928-1941
• DOI: https://doi.org/10.1136/gutjnl-2019-318260
• Public URL: https://nottingham-repository.worktribe.com/output/2148120
• Publisher URL: https://gut.bmj.com/content/early/2019/08/01/gutjnl-2019-318260
• Additional Information: This article has been accepted for publication in Gut following peer review, and the Version of Record can be accessed online at 10.1136/gutjnl-2019-318260 . © Authors (or their employer(s)). Reuse of this manuscript version (excluding any databases, tables, diagrams, photographs and other images or illustrative material included where a another copyright owner is identified) is permitted strictly pursuant to the terms of the Creative Commons Attribution-Non Commercial 4.0 International (CC-BY-NC 4.0) http://creativecommons.org
• Contract Date: Jun 5, 2019