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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.


Ans Pauwels

Veerle Boecxstaens

Christopher Andrews

Stephen E. Attwood

Richard Berrisford

Raf Bisschops

Guy Boeckxstaens

Serhat Bor

Albert J. Bredenoord

Michele Cicala

Fernando Fornari

C. Prakash Gyawali

Jan G. Hatlebakk

Scott B. Johnson

Toni Lerut

Lars Lundell

Sandro Mattioli

Hiroto Miwa

Phillippe Nafteux

Taher Morai

John E. Pandolfino

Roberto Penagini

Thomas W. Rice

Philip R. Roelandt

Nathalie Rommel

Vincenzo Savarino

Daniel Sifrim

Hidekazu Suzuki

Radu Tutuian

Tim Vanuytsel

Marcelo F. Vela

David I. Watson

Frank Zerbib

Jan F. Tack


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.


Pauwels, A., Boecxstaens, V., Andrews, C., Attwood, S. E., Berrisford, R., Bisschops, R., …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.

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
Public URL
Publisher URL
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)


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