Surgical Endoscopy (2022) 36:9345–9354 and Other Interventional Techniques

https://doi.org/10.1007/s00464-022-09209-7

2021 SAGES ORAL

Review of SAGES GERD guidelines and recommendations

Cassandra Mohr1,5   · Hailie Ciomperlik1 · Naila Dhanani1 · Oscar A. Olavarria1 · Craig Hannon1 · William Hope2 ·
Scott Roth3 · Mike K. Liang4 · Julie L. Holihan1

Received: 7 August 2021 / Accepted: 7 February 2022 / Published online: 12 April 2022
© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2022

Abstract
Background  The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) developed evidence-based guide-
lines for the management of patients with gastroesophageal reflux disease (GERD). The aim of this study is to evaluate guide-
lines lacking agreement among experts (grades B–D) or lacking support from randomized controlled trials (levels II–III).
Methods  Six guidelines were chosen for evaluation. A retrospective review of a multicenter database of patients undergoing
fundoplication surgery for treatment of GERD between 2015 and 2020 was performed. Patients that underwent a concurrent
gastrectomy or were diagnosed with pre-operative achalasia were excluded. Demographics, pre-operative, intra-operative,
and post-operative variables were collected. Post-operative outcomes were evaluated based on selected SAGES guidelines.
Outcomes were assessed using multivariable regression or stratified analysis for each guideline.
Results  A total of 444 patients from four institutions underwent surgery for the management of GERD with a median (interquartile
range) follow-up of 16 (13) months. Guidelines supported by our data were (1) robotic repair has similar short-term outcomes to
laparoscopic repair, (2) outcomes in older patients are similar to outcomes of younger patients undergoing antireflux surgery, and
(3) following laparoscopic antireflux surgery, dysphagia has been reported to significantly improve from pre-operative values.
Guidelines that were not supported were (1) mesh reinforcement may be beneficial in decreasing the incidence of wrap herniation,
(2) a bougie has been found to be effective, and (3) the long-term effectiveness of fundoplication in obese individuals (BMI > 30)
has been questioned due to higher failure rates.
Conclusion  Many SAGES GERD guidelines not receiving Grade A or Level I recommendation are supported by large,
multicenter database findings. However, further studies at low risk for bias are needed to further refine these guidelines.
Graphical abstract

Extended author information available on the last page of the article

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9346 Surgical Endoscopy (2022) 36:9345–9354

Keywords  GERD · Guidelines · Fundoplication

Current studies show mixed results, with some finding no differences and others find-
RCTs have shown possible benefit with mesh reinforcement in reducing wrap hernia-

An RCT found lower post-operative dysphagia symptoms in patients that received an

Robot repair is more expensive but RCTs have not supported significant benefit over

RCTs have shown a wide range of post-operative dysphagia symptoms but most
The Society of American Gastrointestinal and Endoscopic
Surgeons (SAGES) Guidelines Committee published recom-
mendations for the surgical management of gastroesopha-

Studies have shown similar outcomes between patients > 65 and ≤ 65

geal reflux disease (GERD), last updated in February 2010.
The guidelines are a systematic review based on available
data and expert opinion, with each recommendation labeled
according to its strength of endorsement. Several of these
guidelines (Table 1) were given a lower level of endorse-
ment, either due to lack of certainty among experts (grades
B–D) or lack of support from randomized controlled trials

ing higher failure rates in obese patients

(level II–V).

are < 20% at one year post-operative

Several SAGES guidelines lack agreement among
experts. One is the use of mesh reinforcement for decreas-
ing the incidence of wrap herniation (grade B) [1]. Stud-
ies have suggested that mesh reinforcement does provide

intra-operative bougie
this benefit, including a randomized controlled trial which

laparoscopic repair
showed significantly lower recurrence rates for mesh rein-
forcement compared to suture reinforcement at 1 year fol-
low-up (8% vs. 26%, p = 0.001) [2]. Another area of disa-
greement is the benefits of robotic assistance compared to Comment

tion
laparoscopic assistance (grade B). Randomized controlled
trials comparing the two approaches have shown that robotic Mesh reinforcement may be beneficial in decreasing the incidence of wrap herniation

A 56 French bougie has been found to be effective but the evidence is limited (Grade
higher cost compared with conventional laparoscopy and similar short-term patient
repair is significantly more expensive with longer operating

Age should not be considered a contraindication for antireflux surgery in otherwise

weight patients. Nevertheless, others have reported equivalent outcomes in obese

The long-term effectiveness of fundoplication in obese individuals (BMI > 30) has
Following laparoscopic antireflux surgery, dysphagia has been reported to signifi-
acceptable operative candidates, as outcomes in this patient group are similar to
times [3–6]. Despite these differences, most studies have While robotic assistance can be safely and effectively used for fundoplication, its

been questioned due to higher failure rates (level II–III) compared with normal
yet to show superior outcomes with use of robotic assis-
tance over laparoscopic repair. Additionally, the impact of
age on outcomes of fundoplication surgery (grade C) lacks
expert certainty. Studies have found that elderly patients
Table 1  SAGES guidelines with limited evidence or expert agreement

(over 65 years old) can experience an improvement from

outcomes make it a less than ideal initial choice (Grade B)

fundoplication surgery similar to younger patients [7–9].

cantly improve from pre-operative values (level II–III)

The use of an intra-operative bougie has also not reached a
consensus (grade C). A randomized controlled trial found
that patients undergoing an intra-operative 56 French bou-

and normal weight individuals (level II–III)

gie placement, compared to patients that did not, reported
outcomes of younger patients (Grade C)

significantly lower post-operative dysphagia symptoms [10].

There was no significant difference in operative complica-
Guidelines with limited evidence support (level II–V)

tions between the bougie and no bougie group (7.4% vs.

Guideline with limited expert certainty (grade B–D)

11%, p = 0.41), with all complications deemed minor and

resolved laparoscopically.
There are various SAGES guidelines lacking support
from randomized controlled trials. One guideline in this
category explores the impact of antireflux surgery on dys-
(Grade B)
Description

phagia symptoms and whether or not patients significantly

improve from pre-operative symptoms (level II–III). Rand-
C)

omized controlled trials have shown a wide range of rates for

post-operative dysphagia following laparoscopic antireflux
surgery, but most have found dysphagia rates up to 1 year
post-operative as less than 20% and even lower rates (5–8%)
Guideline 1

Guideline 2

Guideline 3

Guideline 4

Guideline 5

Guideline 6
Guideline

for longer follow-up [11–15]. A final guideline lacking data

at low risk of bias compares higher failure rates of obese

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Surgical Endoscopy (2022) 36:9345–9354 9347

patients (BMI > 30) to non-obese patients (level II–III). The Table 2  Background and demographics
current research on antireflux surgery in obese patients has Patient variables N = 444
mixed results, with some studies showing higher failure rates
in obese patients [16, 17] and others finding no significant Age, year, mean ± SD 53.8 ± 13.1
differences in outcomes between obese and normal weight Ethnicity, n (%)
patients [18].  African American 40 (9%)
The aim of this study is to assess recommendations lack-  Asian 6 (1.4%)
ing the highest level of evidence or endorsement utilizing a  Hispanic 114 (25.7%)
large, multicenter database of patients undergoing surgery  White 219 (49.3%)
for GERD.  Other 65 (14.6%)
Gender, female, n (%) 297 (66.9%)
ASA status, n (%)
Methods  1 7 (1.6%)
 2 259 (58.3%)
A multicenter, retrospective review was conducted on all  3 175 (39.4%)
patients who underwent fundoplication surgery from June  4 3 (0.7%)
2015 to March 2020 at one of four institutions (2 private BMI, kg/m2, mean ± SD 29.7 ± 5.3
hospitals, 1 University hospital, and 1 safety-net hospital). COPD, n (%) 15 (3.4%)
All patients undergoing fundoplication surgery for GERD Diabetes mellitus, n (%) 48 (10.8)
were eligible for inclusion. Patients were excluded if they Current smoker, n (%) 40 (9%)
underwent a gastrectomy or were diagnosed with pre-oper- Previous abdominal surgeries, median 0
ative achalasia.  Yes, n (%) 195 (43.9%)
Patient variables collected include age, ethnicity, gen-
der, American Society of Anesthesiologists (ASA) status,
body mass index (BMI), chronic obstructive pulmonary t-test or Mann–Whitney U test. When appropriate, mul-
disease, current smoking, and number of previous abdomi- tivariable regression analysis was performed to evaluate
nal surgeries. Variables from pre-operative testing included variables associated with each outcome. Variables included
EGD, gastritis, LA Grade esophagitis, Hill Grade, Barrett’s in the multivariable analysis were chosen a priori and
esophagus. Pre-operative variables recorded were use of included center, age, ethnicity, gender, BMI, diabetes mel-
baseline medications (PPI or H2 blocker use) and self-report litus, COPD, prior surgery, and hiatal hernia. Other vari-
pre-operative symptoms (heartburn, dysphagia, epigastric ables included depending on the guideline were use of mesh,
pain, cough, and regurgitation). All centers used electronic surgical approach, fundoplication type, bougie usage, and
medical records and standardized templates with common pre-operative dysphagia. When there was evidence of col-
questions to review symptoms of dysphagia, heartburn, and linearity or interactions, variables were dropped for model
regurgitation before and after surgery. Operative variables stability. All statistics were performed using Stata v.16.
collected were fundoplication approach, mesh, bougie, fun-
doplication type, and intra-operative EGD. Outcome vari-
ables were surgical site infection, emergency department
visits, Dindo–Clavien outcomes [19], symptom recurrence at Results
last clinic visit (defined as heartburn, dysphagia, epigastric
pain, cough, and/or regurgitation), antacid use at last clinic A total of 444 patients from four institutions underwent sur-
visit, anatomic failure, and reoperation (any time post-oper- gery for the management of GERD with a median (inter-
ative). Post-operative imaging was performed selectively on quartile range) follow-up of 16 (13) months. Patient back-
patients with recurrent symptoms at any follow-up visit. ground and demographics are in Table 2. Many patients were
Additional independent variables were based on the obese (mean BMI 29.7), white (49.3%), and female (66.9%).
SAGES guideline being evaluated and included surgical Over one-third of patients were ASA status of 3–4 (40.1%)
reinforcement (mesh or suture), surgical assistance (robotic and almost half had previous abdominal surgeries (43.9%).
or laparoscopic), pre-operative dysphagia, patient age (over Results of pre-operative evaluation are in Table 3. Fifty-
65 years), patient BMI (over 30), and intra-operative bougie five patients (12.8%) had esophagitis identified on pre-
usage. Follow-up duration was defined as the most recent operative EGD while 209 (48.7%) patients had a Hill Grade
clinical evaluation. 2–4. Most patients were taking a PPI preoperatively (80.9%)
Categorial outcomes were assessed by Fisher exact test, or other antacid (18.2%). All patients reported heartburn
and continuous outcomes were assessed using two-tailed

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Table 3  Pre-operative evaluation Table 4  Operative details

Pre-operative evaluation N = 444 Operative variables N = 444

EGD esophagitis: LA Grade, n (%)* Approach, n (%)

 A 18 (4.2%)  Laparoscopic 372 (83.8%)
 B 21 (4.9%) Laparoscopic converted to open 2 (0.5%)
 C 13 (3%)  Robotic 70 (15.8%)
 D 3 (0.7%) Mesh, yes, n (%) 173 (39%)
EGD: Hill Grade, n (%)** Mesh type, n (%)
 I 6 (1.4%)  Biologic 170 (98.3%)
 II 86 (20%)  Biosynthetic 2 (1.2%)
 III 47 (11%)  Synthetic 1 (0.6%)
 IV 76 (17.7%) Bougie, yes, n (%) 75 (16.9%)
Barrett’s esophagus, n (%)*** 28 (6.5%) Fundoplication type, n (%)
Baseline medication, n (%)  Complete 154 (34.7%)
 PPI 359 (80.9%)  Partial Anterior 9 (2%)
 H2 blocker 81 (18.2%)  Partial Posterior 281 (63.3%)
Pre-operative symptoms, n (%) Intra-op EGD, yes, n (%) 373 (84%)
 Heartburn 444 (100%)
 Dysphagia 178 (40.1%)
 Pain 187 (42.1%) Table 5  Outcomes
 Cough 109 (24.5%)
Outcome variables N = 444
 Regurgitation 224 (50.5%)
Follow-up duration, median (IQR), months 16 (13)
*N = 429
Surgical site infection, n (%) 2 (0.5%)
**N = 379
Emergency department visit, n (%) 64 (14.4%)
***N = 91
Dindo–Clavien outcomes, n (%)
 1 4 (0.9%)
symptoms prior to undergoing surgery, often along with  2 13 (2.9%)
regurgitation (50.5%), dysphagia (40.1%), and pain (42.1%).  3 30 (6.8%)
Operative details are in Table 4. Most patients underwent  4–5 4 (0.9%)
laparoscopic fundoplication (83.8%), with partial fundopli- Symptom recurrence at last clinic visit, n (%)*
cation (65.3%), and intra-operative EGD (84%).  Heartburn 94 (22.2%)
Patient variables for fundoplication approach are in  Dysphagia 64 (15.1%)
Online Table 1. Patients that underwent a complete fun- Antacid use at last clinic visit, n (%)* 226 (53.3%)
doplication were significantly younger than patients that Anatomic failure, n (%) 71 (16%)
received a partial fundoplication (49.4 vs. 56.1, p < 0.001). Reoperation, n (%) 23 (5.2%)
Most patients in both groups had an ASA 2. However, ASA *N = 424
status was generally higher in patients undergoing partial
fundoplication (p = 0.011). Both groups had similar mean
BMI (29.2 vs. 29.8, p = 0.203). year with 38% of patients reporting heartburn symptoms
Post-operative outcomes are in Table 5. Most patients (p < 0.001) and 16.7% endorsing dysphagia (p = 0.067).
did not report symptom recurrence at their last clinic visit, Anatomic failure and reoperation are also significantly
with 77.8% experiencing resolution of heartburn symptoms more likely for patients that are followed for over a year
and 84.9% reporting no dysphagia symptoms. Some patients post-operative, with 30% of patients experiencing ana-
had an anatomic failure (16%), but few required reoperations tomic failure (p < 0.001) and 11.3% needing to undergo
(5.2%). reoperation (p < 0.001).
Post-operative outcomes for differing follow-up dura-
tions are in Table 6. Patients that followed up for over
a year were more likely to have visited the emergency
department for post-surgical complications (p < 0.001).
Rates of heartburn and dysphagia were also highest at last
clinical evaluation for patients that followed up for over a

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Table 6  Outcomes vs. follow-up duration

Outcome variables  < 30 days 1 month- 3 months 3 months- 1 year  > 1 year p-value
(N = 52) (N = 134) (N = 108) (N = 150)

Surgical site infection, n (%) 0 (0%) 0 (0%) 0 (0%) 2 (1.3%) 0.268

Emergency department visit, n (%) 2 (3.8%) 9 (6.7%) 19 (17.6%) 34 (22.7%)  < 0.001
Dindo–Clavien outcomes, n (%) 0.150
 1 1 (1.9%) 2 (1.5%) 0 (0%) 0 (0%)
 2 0 (0%) 6 (4.5%) 3 (2.8%) 4 (2.7%)
 3 1 (1.9%) 6 (4.5%) 13 (12%) 10 (6.7%)
 4–5 0 (0%) 2 (1.5%) 0 (0%) 2 (1.3%)
Symptom recurrence at last clinic visit, n (%)
 Heartburn 0 (0%) 17 (12.7%) 20 (18.5%) 57 (38%)  < 0.001
 Dysphagia 2 (3.8%) 24 (17.9%) 13 (12%) 25 (16.7%) 0.067
Antacid use at last clinic visit, n (%) 20 (38.5%) 69 (51.5%) 60 (55.6%) 77 (51.3%) 0.242
Anatomic failure, n (%) 1 (1.9%) 12 (9%) 13 (12%) 45 (30%)  < 0.001
Reoperation, n (%) 0 (0%) 3 (2.2%) 3 (2.8%) 17 (11.3%)  < 0.001

Table 7  Mesh vs. Suture reinforcement

Univariate analysis
Mesh vs. Suture reinforcement Mesh Suture p-value
(N = 173) (N = 271)

Dindo–Clavien outcomes, n (%)  < 0.001

 1 2 (1.2%) 1 (0.4%)
 2 11 (6.4%) 2 (0.7%)
 3 17 (9.8%) 13 (4.8%)
 4–5 3 (1.7%) 1 (0.4%)
Anatomic failure, n (%) 31 (17.9%) 40 (14.8%) 0.376
Reoperation, n (%) 6 (3.5%) 17 (6.3%) 0.193
Multivariable regression: anatomic failure
Variable Odds ratio 95% confidence interval p-value

Suture Reference – 0.464

Mesh 0.78 0.40–1.51

SAGES guidelines SAGES guideline While robotic assistance can be safely

SAGES guideline Mesh reinforcement may be beneficial
in decreasing the incidence of wrap herniation (Grade B).
Outcome analysis is in Table 7. There were no significant
differences between mesh and suture reinforcement for
anatomic failure (17.9% vs. 14.8%, p = 0.376) or reopera-
tion (3.5% vs. 6.3%, p = 0.193). However, patients under-
going mesh reinforcement experienced significantly more
Dindo–Clavien outcomes (cumulative 19.1% vs. 6.3%,
p < 0.001). On regression analysis, there was no significant
difference in occurrence of wrap herniation (OR 0.78, 95%
CI 0.40–1.51, p = 0.464).
and effectively used for fundoplication, its higher cost com-
pared with conventional laparoscopy and similar short-term
patient outcomes make it a less than ideal initial choice
(Grade B). Outcome analysis is in Table 8. There were no
significant differences for any short-term outcomes col-
lected, including Dindo–Clavien outcomes (cumulative 5.7%
vs 12.1%, p = 0.480), heartburn symptom recurrence at last
clinic visit (22.1% vs. 22.3%, p = 0.963), or dysphagia symp-
toms at last clinic visit (19.1% vs. 14.4%, p = 0.321). On
regression analysis, robotic and laparoscopic assistance had
similar short-term outcomes, measured by Dindo–Clavien
complications (OR 1.48, 95% CI 0.16–13.66, p = 0.727).
SAGES guideline Age should not be considered a con-
traindication for antireflux surgery in otherwise acceptable

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Table 8  Robotic vs. laparoscopic assistance

Univariate analysis
Robotic vs. laparoscopic assistance Robotic Laparoscopic p-value
(N = 70) (N = 372)

Surgical site infection, n (%) 0 (0%) 1 (0.3%) 0.664

Emergency department visit, n (%) 8 (11.4%) 54 (14.5%) 0.495
Dindo–Clavien outcomes, n (%) 0.480
 1 0 (0%) 3 (0.8%)
 2 1 (1.4%) 11 (3%)
 3 2 (2.9%) 28 (7.5%)
 4–5 1 (1.4%) 3 (0.8%)
Symptom recurrence at last clinic visit, n (%)*
 Heartburn 15 (22.1%) 79 (22.3%) 0.963
 Dysphagia 13 (19.1%) 51 (14.4%) 0.321
Anatomic failure, n (%) 7 (10.3%) 64 (17.2%) 0.132
Reoperation, n (%) 3 (4.4%) 20 (5.4%) 0.706
Multivariable regression: Dindo–Clavien outcome
Variable Odds ratio 95% confidence interval p-value

Robotic Reference – 0.727

Laparoscopic 1.48 0.16–13.66

*Robotic, N = 68; laparoscopic, N = 354

Table 9  Patients > 65 vs. patients ≤ 65

Univariate analysis
Patients > 65 vs. patients ≤ 65  > 65 years  ≤ 65 years p-value
(N = 90) (N = 354)

Dindo–Clavien outcomes, n (%) 0.597

 1 0 (0%) 3 (0.8%)
 2 3 (3.3%) 10 (2.8%)
 3 9 (10%) 21 (5.9%)
 4–5 1 (1.1%) 3 (0.8%)
Symptom recurrence at last clinic visit, n (%)*
 Heartburn 5 (5.8%) 89 (26.3%)  < 0.001
 Dysphagia 12 (14%) 52 (15.4%) 0.741
Multivariable regression: Dindo–Clavien outcome
Variable Odds ratio 95% confidence interval p-value

Age 1.00 0.97–1.03 0.950

* > 65 years, N = 86; ≤ 65 years, N = 338

operative candidates, as outcomes in this patient group are
similar to outcomes of younger patients (Grade C). Outcome
analysis is in Table 9. Compared to younger patients, patients
over 65 years old had similar occurrence of Dindo–Clavien
outcomes (cumulative 14.4% vs. 10.3%, p = 0.597) and
dysphagia symptoms at last clinic visit (14% vs. 15.4%,
p = 0.741). Patients over 65 also reported significantly lower
heartburn symptom recurrence at last clinic visit compared
to their younger counterparts (5.8% vs. 26.3%, p < 0.001).
On regression analysis, patients over 65 years old did not
have significant differences in occurrence of Dindo–Clavien
complications compared to patients less than 65 (OR 1.00,
95% CI 0.97–1.03, p = 0.950).
SAGES guideline A 56 French bougie has been found
to be effective but the evidence is limited (Grade C). Out-
come analysis is in Table  10. Patients that received an

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Table 10  Bougie efficacy
Univariate analysis
Bougie efficacy Bougie, yes
(N = 76)
Dindo–Clavien outcomes, n (%)
 1 0 (0%)
 2 0 (0%)
 3 3 (3.9%)
 4–5 1 (1.3%)
Symptom recurrence at last clinic visit, n (%)*
 Heartburn 13 (17.6%)
 Dysphagia 14 (18.9%)
Anatomic failure, n (%) 6 (7.9%)
Reoperation, n (%) 6 (7.9%)
Multivariable regression: post-operative dysphagia
Variable Odds ratio
Bougie, no Reference
Bougie, yes 1.10
*Bougie, yes, N = 74; Bougie, no, N = 350
intra-operative bougie had no significant differences in
post-operative Dindo–Clavien outcomes (cumulative 5.2%
vs. 12.4%, p = 0.295), heartburn symptoms at last clinic
visit (17.6% vs. 23.1%, p = 0.294), dysphagia symptoms at
last clinic visit (18.9% vs. 14.3%, p = 0.312), or reoperation
(7.9% vs. 4.6%, p = 0.241). However, the patients that had
an intra-operative bougie had significantly lower rates of
anatomic failure (7.9% vs. 17.7%, p = 0.034). On regression
analysis, usage of a bougie did not result in significantly
lower rates of post-operative dysphagia (OR 1.10, 95% CI
0.33–3.26, p = 0.859).
SAGES guideline Following laparoscopic antireflux
surgery, dysphagia has been reported to significantly
improve from pre-operative values (level II–III). A total of
178 patients reported dysphagia preoperatively. Of these
patients, 83.6% stated that their symptoms had resolved by
their last clinic visit. Prior to surgery, 266 patients reported
no dysphagia symptoms. Of these patients, 14.3% were
experiencing dysphagia symptoms at their last clinic visit.
There was no significant difference between the two groups
for prevalence of post-operative dysphagia (16.4% vs 14.3%,
p = 0.498).
SAGES guideline The long-term effectiveness of fun-
doplication in obese individuals (BMI > 30) has been ques-
tioned due to higher failure rates compared with normal
weight patients. Nevertheless, others have reported equiva-
lent outcomes in obese and normal weight individuals (level
II–III). Outcome analysis is in Table 11. The mean BMI for
patients with BMI > 30 was 34.2 while the mean BMI for
patients with BMI ≤ 30 was 25.8 (p < 0.001). There was no
Bougie, no p-value
(N = 368)
0.295
3 (0.8%)
13 (3.5%)
27 (7.3%)
3 (0.8%)
81 (23.1%) 0.294
50 (14.3%) 0.312
65 (17.7%) 0.034
17 (4.6%) 0.241
95% confidence interval p-value
– 0.859
0.33–3.26
significant difference for fundoplication type between the
two groups, with the majority receiving a partial fundopli-
cation (67.5% vs. 63.5%, p = 0.377). Post-operative results
were similar to non-obese patients for Dindo–Clavien out-
comes (cumulative 9.9% vs. 12.4%, p = 0.863), dysphagia
symptoms at last clinic visit (13.3% vs. 16.7%, p = 0.329),
anatomic failure (16.3% vs. 15.8%, p = 0.899), and reopera-
tion (5.4% vs. 5%, p = 0.835). Additionally, obese patients
were less likely to report heartburn symptoms at last clinic
visit when compared to non-obese patients (15.8% vs.
27.6%, p = 0.003). On regression analysis, obese patients did
not have significantly higher incidence of wrap herniation
(OR 1.00, 95% CI 0.95–1.06, p = 0.910).
Discussion
There is a lack of consensus and/or evidence at low risk for
bias to support several of the SAGES GERD guidelines.
Many studies cited on the management of GERD have small
sample size, limited follow-up, and heterogeneity in outcome
reporting [18]. In addition, variations in surgical technique
and reporting of surgical technique limits study generaliza-
bility. Our study provides multicenter data including surgical
details and outcomes details not available in many nation-
wide databases. It augments smaller randomized controlled
trials by providing real-world effectiveness data that can
increase the strength and generalizability of recommenda-
tions made. While randomized controlled trials are needed
whenever feasible often we need to simply rely on the best
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Table 11  Patients BMI > 30 vs. Patients BMI ≤ 30
Univariate analysis
Patients BMI > 30 vs. Patients BMI ≤ 30 BMI > 30
(N = 203)
BMI, kg/m2, mean 34.2
Fundoplication type, n (%)
 Complete 66 (32.5%)
 Partial 137 (67.5%)
Dindo–Clavien outcomes, n (%)
 1 1 (0.5%)
 2 6 (3%)
 3 11 (5.4%)
 4–5 2 (1%)
Symptom recurrence at last clinic visit, n (%)*
 Heartburn 31 (15.8%)
 Dysphagia 26 (13.3%)
Anatomic failure, n (%) 33 (16.3%)
Reoperation, n (%) 11 (5.4%)
Multivariable regression: recurrence
Variable Odds ratio
BMI 1.00
*BMI > 30, N = 196; BMI ≤ 30, N = 228
available data to guide treatment strategies. SAGES GERD
guidelines are currently in the process of being updated to
support more recent literature.
Three of the SAGES guidelines were not supported by
our study. Obese patients (BMI > 30) had similar post-
operative outcomes to patients with BMI ≤ 30, including
wrap herniation. Prior research has shown mixed results
of fundoplication surgery for GERD among obese patients
[16–18, 20]. However, even among the studies demonstrat-
ing similar outcomes between obese and non-obese patients,
obese patients were reported technically more challenging
and required longer operative duration [20]. It is possible
that the differences among these studies were due to differ-
ences in surgeon experience given that fundoplication with
obese patients is technically more complex. Alternatively,
there could be selection bias as surgeons selectively chose
which obese patients to operate on versus not operate on.
Another unexpected finding was the lack of benefit from
an intra-operative bougie in reducing post-operative dys-
phagia [10]. This may be due to experienced surgeons no
longer needing a bougie to gauge an appropriate wrap size.
Another possible reason for these findings could be the shift
in preference toward a partial fundoplication approach over
a complete fundoplication, rendering an intra-operative
bougie less important. Our findings also differed from the
randomized controlled trial evaluating the use of mesh [2],
as we found similar hernia recurrence but higher incidence
13
Surgical Endoscopy (2022) 36:9345–9354
BMI ≤ 30 p-value
(N = 241)
25.8  < 0.001
0.377
88 (36.5%)
153 (63.5%)
0.863
2 (0.8%)
7 (2.9%)
19 (7.9%)
2 (0.8%)
63 (27.6%) 0.003
38 (16.7%) 0.329
38 (15.8%) 0.889
12 (5%) 0.835
95% confidence interval p-value
0.95–1.06 0.910
of Dindo–Clavien complications in patients repaired with
mesh compared to those without. Surgeons may have chosen
mesh reinforcement for the more complex cases, leading
to a higher incidence of Dindo–Clavien outcomes in this
group. However, the similar anatomic failure rates between
patients with and without mesh reinforcement requires fur-
ther evaluation. This indicates that use of mesh may not be
as beneficial to fundoplication surgery as previously thought.
The type of mesh used also needs to be taken into considera-
tion. The majority of mesh used in our study was biologic
mesh (98.3%). Thus far, biologic mesh has had less reported
complications compared to synthetic mesh [21]. However,
there has not been sufficient evidence to support biologic
mesh in improving long-term hernia recurrence rates [22].
We acknowledge several limitations to our study. Most
importantly, our study is limited in that it is a retrospec-
tive review. Therefore, the decision for mesh placement,
bougie placement, and partial/complete wrap is indi-
vidualized based on surgeon preference and the rea-
soning is not retrievable through chart review. Another
piece of information that was not retrieved through chart
review is OR duration. This is especially relevant when
comparing robotic to laparoscopic assistance, as ran-
domized controlled trials have found robotic assistance
to be more expensive and associated with longer operat-
ing times [3–6]. It is possible the longer operating times
associated with robotic assistance will improve over time
Surgical Endoscopy (2022) 36:9345–9354 9353
with improved team dynamics, surgeon experience, and
advancement in technology. However, even though our
study is lacking data for operative duration, it aligns with
current literature in finding a lack of superior post-opera-
tive outcomes offered by robotic assistance. Randomized
trials are needed to guide the role of robotic surgery in
the surgical management of GERD; however, at present it
appears robotic fundoplication is safe and feasible but may
came with longer operative duration and higher healthcare
costs [23].
Like all non-randomized trials, there is substantial risk
for selection bias. To account for hernia complexity from
patient and anatomic differences, we integrated BMI, ASA
status, and Hill Grade into our regression analysis. Patient
differences were also taken into consideration regarding
comparison based on age (> 65 vs. ≤ 65). However, there is
likely selection bias due to surgeons preferentially taking
healthier > 65-year-old patients to the OR. We attempted
to account for this by including variables that encompass
comorbid conditions such as BMI and ASA status. A
similar argument can be made when comparing obese to
non-obese patients and, consequently, we also attempted
to account for comorbid conditions in our regression
analysis.
Another limitation of our study involves our analysis of
post-operative outcomes. Regarding anatomic failure rates,
incidence is likely underreported as none of the sites rou-
tinely perform post-operative imaging. Imaging was only
obtained for patients with clinical symptoms. Any anatomic
failure was clinically apparent and validated by radiographic
imaging. Additionally, due to our analysis including four dif-
ferent centers and several surgeons, there may have been var-
iation in reporting. This includes variables such as symptom
reporting. We categorized “GERD” and “reflux” symptoms
into heartburn, dysphagia, pain, cough, and regurgitation
while conducting our data collection. However, these terms
may be used interchangeably or grouped together in report-
ing so this should be taken into consideration. Regardless,
our focus in post-operative symptom analysis was whether
the patient was reported to have clinically significant post-
operative symptoms and we believe this information was
captured overall. Further, the four institutions collaborating
have a history of working together in clinical and research
projects and used similar nomenclature and definitions when
documenting and reporting in their medical records as well
us utilized similar protocols for peri-operative care. Finally,
although we reported a median 1-year follow-up, longer
follow-up is needed. Most randomized trials and case series
on this subject report 1 year or less of follow-up; in fact, over
90% of the studies reported in the SAGES guidelines had
1 year or less of follow-up. Even among prospective studies,
achieving follow-up of greater than 1 year for most patients
is uncommon in the United States.
Conclusion
This multicenter review of GERD treatment supported
many of the SAGES guidelines, including: (1) robotic
assistance is more expensive with similar short-term out-
comes to laparoscopic assistance, (2) outcomes in older
patients are similar to outcomes of younger patients
undergoing antireflux surgery, and (3) dysphagia has been
reported to significantly improve from pre-operative val-
ues. Guidelines that were not supported were (1) mesh
reinforcement may be beneficial in decreasing the inci-
dence of wrap herniation, (2) a bougie has been found to
be effective, and (3) the long-term effectiveness of fun-
doplication in obese individuals (BMI > 30) has been ques-
tioned due to higher failure rates. Further studies at low
risk for bias are needed to refine these guidelines.
Supplementary Information  The online version contains supplemen-
tary material available at https://d​ oi.o​ rg/1​ 0.1​ 007/s​ 00464-0​ 22-0​ 9209-7.
Funding  No funding was provided.
Declarations 
Disclosures  Cassandra Mohr, Hailie Ciomperlik, Dr. Naila Dhanani,
Dr. Oscar A. Olavarria, Craig Hannon, Dr. William Hope, Dr. Scott
Roth, Dr. Mike K. Liang, and Dr. Julie L. Holihan have no conflicts of
interest or financial ties to disclose.
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Authors and Affiliations
Cassandra Mohr1,5   · Hailie Ciomperlik1 · Naila Dhanani1 · Oscar A. Olavarria1 · Craig Hannon1 · William Hope2 ·
Scott Roth3 · Mike K. Liang4 · Julie L. Holihan1
* Cassandra Mohr
cassandra.a.mohr@uth.tmc.edu
1 Department of Surgery, HCA Healthcare Kingwood,
Department of Surgery, McGovern Medical School,
Houston, TX, USA
2 Department of Surgery, Lyndon B. Johnson Hospital, 5656
Department of Surgery, New Hanover Regional Medical
Center, Wilmington, NC, USA
13
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symptomatic outcome after laparoscopic fundoplication. Surg
Laparosc Endosc Percutan Tech. https://​doi.​org/​10.​1097/​00129​
689-​20060​8000-​00001
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will fail laparoscopic Nissen fundoplication? Preoperative predic-
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s00464-​007-​9490-7
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gical complications: a new proposal with evaluation in a cohort
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Obesity does not adversely affect the outcome of laparoscopic
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hiatal hernias: what does the evidence say. Ann Laparosc Endosc
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versus mesh-augmented hiatus hernia repair: a systematic review
and meta-analysis of randomized controlled trials. Ann Surg.
https://​doi.​org/​10.​1097/​SLA.​00000​00000​004902
23. Dhanani NH, Olavarria OA, Bernardi K, Lyons NB, Holihan JL,
Loor M, Haynes AB, Liang MK (2021) The evidence behind
robot-assisted abdominopelvic surgery: a systematic review. Ann
Intern Med. https://​doi.​org/​10.​7326/​M20-​7006
Publisher's Note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.
3
Department of Surgery, University of Kentucky, Lexington,
KY, USA
4
University of Houston, Kingwood, TX, USA
5
Kelley St, Houston, TX 77026, USA