Dear sir. According to newer guidelines. .

PPI therapy should be initiated at once a day dosing, before the first meal of the day. (Strong recommendation, moderate level of evidence). For patients with partial response to once daily therapy, tailored therapy with adjustment of dose timing and/or twice daily dosing should be considered in patients with night-time symptoms, variable schedules, and/or sleep disturbance. (Strong recommendation, low level of evidence).

Non-responders to PPI should be referred for evaluation. (Conditional recommendation, low level of evidence, should rule out refractory GERD section).

 In patients with partial response to PPI therapy, increasing the dose to twice daily therapy or switching to a different PPI may provide additional symptom relief. (Conditional recommendation, low level evidence)

. Surgical therapy is generally not recommended in patients who do not respond to PPI therapy. (Strong recommendation, high level of evidence

Surgery can be offered to Chronic cases or those who are fed up with medical management or those who can not afford long term PPI.

good Amit,Interesting nobody else has responded about their own practices.

Surgical therapy must be recommended only in cases of refractory GERD that don´t respond to continuous PPis therapy

Thanks Dr Luis,as per the literature those who respond well to PPIs will do well with Fundoplication.!

Dear Prasanna

PPI are excellent but when pt start to experience severe heartburn or regurgitation ie volume reflux interfering with their daily activity or sleep then one should consider surgery. There are patients who are dependent on high dose PPI, or are intolerant or those who do not wish to take medication life long should also be considered for surgery. Oesophageal manometry prior to surgery is important to demonstrate an incompetent lower oesophageal sphincter and normal oesophageal peristalsis. Patients always ask me what are the long term effects of PPI bearing in mind that acid in the stomach is a 'friend' not 'foe' .

Dhiren,

Thankyou,Extr esophageal symptoms  and sideeffects to PPIs are some of the main indications in our practice.In Indian scenario you may recall one would like to continue non surgical management as long as their life style does not interfere as you mentioned.

It is not necessary to operate, if you can control well the disease, taking only 1 pill/day....

I base my recommendations on a number of factors. Regarding the chronic PPI medical tx of reflux, this must be regarded as essentially band-aid therapy that does nothing more than alter the gastric caustic contents, and does nothing to address the underlying cause of the the disease which is chronic progressive degeneration of the lower esophageal sphincter mechanism. Understanding that the sphincter mechanism is actually a dual mechanism made up of the intrinsic esophageal sphincter and the extrinsic or crural sphincter that coordinate efforts via the vagal nuclei, ultimately therapy should be directed toward the correction of the sphincter defect. I divide treatment options based upon this principle. If there is a larger than 3 cm hiatal hernia, the dominant sphincter defect is extrinsic and surgery is the necessary first step. If the hiatal hernia is under 3 cm, then the primary target should be the intrinsic sphincter,  in which case Stretta is the best and most selective option. Severity of symptoms is another important factor. As I always ask my patients, how much time do you have?  This refers to how quickly they need to feel better.  Surgical options are more immediate, whilst sphincter regeneration techniques like Stretta take longer.  Both have demonstrated long term durability and regression of Barrett's tissue. If one fails, the other can be employed to further reinforce the sphincter mechanism. Finally, regardless of the therapy selected, patients cannot be allowed to return to prior reflux risky behaviors and life long lifestyle changes must be emphasized.

Many interesting points have come up so far and I entirely agree, however I note that patient's age has not been brought into this discussion so far. Although I am not aware of any study specifically mentioning any cut-off age, I always thought age is an important factor to take into consideration when deciding on anti-reflux surgery.

A young professional (in 20s or 30s) with significant GERD symptoms, affecting his/her work commitments and quality of life, in my humble opinion should be counselled towards anti-reflux surgery early in life (if he/she fits the criteria) and not persuaded towards taking PPIs for decades! It is a completely different situation of course if the patient is in late 50s or 60s.

We now have enough long-term results on laparoscopic anti-reflux surgery and there are no doubts on its safety, durability and efficacy. It is an excellent procedure. Although patients may (quite rightly) feel apprehensive about going through an operation, I feel with adequate counselling, we could alleviate their fears and give them a lasting cure for their illness. 

Recurrence or persistent symptoms despite high dose medication, volume regurgitation and side effects or patient wishes against long term medication are the main reasons