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Redefining Success After Antireflux Surgery: From Acid Control to Mucosal Recovery
Letter/Communication   Open access   Peer reviewed

Redefining Success After Antireflux Surgery: From Acid Control to Mucosal Recovery

Shahin Ayazi, Giulia Nezi and John C Lipham
Journal of gastrointestinal surgery, Forthcoming
22 Jul 2026
DOI: https://doi.org/10.1016/j.gassur.2026.102528
PMID: 42486254
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url
https://doi.org/10.1016/j.gassur.2026.102528View
Published, Version of Record (VoR) Open Access via Drexel Libraries Read and Publish Program 2026 Open CC BY V4.0

Abstract

Progress in antireflux surgery has been driven not only by refinements in operative technique, but also by advances in esophageal physiology that have transformed the objective assessment of reflux disease. For more than five decades, normalization of esophageal acid exposure has served as the principal physiologic benchmark of success after antireflux surgery. As new tools emerge to assess epithelial integrity and mucosal recovery, it is worth reconsidering whether correction of reflux burden alone fully captures therapeutic success. In 1974 and 1976, landmark studies presented at the American Surgical Association and subsequently published by Tom R. DeMeester and colleagues fundamentally reshaped the understanding of gastroesophageal reflux disease (Fig. 1) [1], [2]. The introduction of ambulatory 24-hour esophageal pH monitoring transformed reflux from a symptom-based diagnosis into an objectively measurable physiologic disorder. These investigations established the relationship between abnormal acid exposure, lower esophageal sphincter incompetence, and reflux-induced mucosal injury, shifting postoperative assessment from symptom relief toward normalization of reflux burden. Subsequent studies validated ambulatory pH monitoring, established normal physiologic thresholds, and demonstrated that successful fundoplication restored normal reflux physiology [3], [4]. Together, these advances established normalization of esophageal acid exposure as the reference standard for assessing antireflux surgery.

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