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As life expectancy increases, the number of elderly patients presenting with surgically correctable diseases will increase. However, elderly patients are often medically managed despite refractory symptoms due to fear of surgical morbidity and mortality [27]. There has been reluctance to refer elderly patients for lapa-roscopic surgery until complications develop, sometimes despite the presence of continued symptoms on appropriate medical therapy [82]. However, many elderly patients are not satisfied with medical therapy due to continued symptoms and the cost of medications. They may also not like the inconvenience of lifestyle modifications or are concerned with the possible effects of long-term medication usage [82].

Underlying chronic diseases are more common in the elderly, increasing their operative risk, and age above 70 is a predictor of increased postoperative complications and in-hospital mortality, as well as longer hospital stay [56]. Laparoscopic procedures have the benefit of shorter hospitalization, earlier ambulation, decreased postoperative pain, lower wound-related morbidity, and more rapid return to normal activities [56], [83]. The healthy elderly patient should not be refused surgery solely based on age but careful pre-operative examination is necessary. Endoscopy needs to be performed to exclude BE with dysplasia or early cancer, and manometry can identify a weak esopha-geal pump. pH monitoring is needed in symptomatic individuals without esophagitis to confirm the diagnosis, and in those with intractable esophagitis to exclude pill-induced esophagitis. In patients with severe bloating, nausea, or vomiting, an emptying study can rule out gastroparesis [10].

Surgery should be considered for patients with a mechanically defective cardia (LES pressure < 6 mm Hg), short overall LES length, or short intraabdominal

LES segment [50]. Surgical intervention restores the LES pressure and abolishes acid/alkaline reflux into the esophagus [84]. Other indications for surgery, include failed medical treatment, recurrence of symptoms after stopping treatment, and intolerable side effects from medical therapy [3], [28], [82]. Surgical therapy should also be considered for patients with respiratory complications such as recurrent aspiration pneumonia, laryngitis, or asthma due to GERD [13]. For asthma, around 70% have had improvement of symptoms, and there are also some reports of improvement in chronic cough [18]. The best surgical candidates are those who receive symptom relief with medication, require large doses of medication to control their symptoms, and have poorly responding aspiration symptoms [72].

Several studies have found no significant differences in intraoperative or post-operative complications between elderly and young groups [13], [27], [56], [82]. The laparoscopic procedure has a morbidity rate of 8-20% and a mortality rate of less than 1% [13]. Mortality rate does not differ by age group [82]. The mean hospital stay, reported in several studies, is 2 days in an elderly population [56], [82]. A summary of efficacy by Richardson found an 85-95% success rate, with up to 93% having no heartburn or regurgitation one year post-op [28]. Surgical follow-up studies have claimed symptom resolution in 77-97% of cases and healing of esopha-gitis in 75-90% [6], [13], [27]. Trus etal found that elderly and young patients were equal with respect to postoperative improvement in symptom scores [82]. Objective measurements of reflux (using 24 h pH probes), were equal in both groups, both pre-operatively and postoperatively. Additionally, at 1 year post-op, total time of pH < 4 was similar in the 2 groups. A study with 2 years of follow-up found only 10% of patients were on PPI's after surgery for typical GERD symptoms [83]. An additional 5.7% of the study patients had required repeat fundoplication for heartburn, dysphagia, or bloating. A longer term follow-up study of fundoplication (69 months), showed disappointing recurrences in heartburn, esophagitis, and decreased LES pressure [20]. Quality of life one year after lap surgery is similar to those of normal healthy individuals [28].

Sonnenberg et al showed the cost of a Nissen procedure to be equivalent to 14.5 years of therapy with a PPI, so that medical therapy may be more cost effec tive [35]. However, other investigators have found that surgery becomes more cost-effective than PPI therapy between 4-10 year of treatment [28]. This will make the option of surgery even more applicable as life expectancy continues to increase.

Worries exists about surgical complications in the elderly due to emergent intervention, presence of com-orbid conditions, decreased functional reserve, and severity of the primary disease. However, elective operations with careful pre-op assessment and peri-op management are safe and successful [27], [82]. In the elderly population, anti-reflux surgery is a safe, well tolerated, and efficacious alternative to continued medical therapy [27]. Weber comments on the future role of laparoscopic reflux surgery [56]. As surgeons become more experienced with these procedures, the initial hesitation in offering surgery to elderly patients is decreasing. Based on a decade of experience with lapa-roscopy, even octogenarians seem to benefit from these procedures. Finally, the proven efficacy and safety of this procedure needs to be communicated to PCP's to prevent delay in referral of elderly patients with persistent reflux symptoms for surgical management.

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