ICARUS Recommendations for the Selection of Antireflux Surgery Candidates

A young male patient describes his symptoms to his doctor.
A working group of 35 international experts released the ICARUS guidelines on the selection of patients with gastroesophageal reflux disease for antireflux surgery.

To date, international consensus guidelines defining clinical criteria and additional technical examinations used in patient selection for antireflux surgery have not been straightforward.

Therefore, based on emerging evidence and a multidisciplinary consensus, a working group of 35 international experts (gastroenterologists, surgeons, and physiologists), with support from the International Society for Diseases of the Esophagus, released the ICARUS guidelines on the selection of patients with gastroesophageal reflux disease (GERD) for antireflux surgery. This report was published in Gut.

The ICARUS recommendations were developed using the Delphi method, an approach in which the consensus group provided 37 statements, elicited expert feedback, and completed 3 rounds of voting to reach consensus (defined as 80% agreement). The investigators also performed a systematic literature review focused on antireflux surgery, including the selection of adult patients, which is traditionally based on symptom patterns, response to proton pump inhibitors (PPIs), and esophageal monitoring.

Recommendations for Clinical Presentation and Comorbidities

ICARUS suggests that patients who report heartburn as their main GERD symptom and respond satisfactorily to PPIs are good candidates for antireflux surgery.

Patients with functional heartburn in which symptoms manifest without association to reflux events are considered poor candidates for antireflux surgery. Similarly, patients with eosinophilic esophagitis do not respond to antireflux surgery and should not be considered as candidates.

Patients with morbid obesity (defined as a body mass index >35 kg/m2) or substance abuse disorders should not be excluded from antireflux surgery as there is no evidence associating these factors with poorer outcomes.

Recommendations for Esophagogastroduodenoscopy

Endoscopy carried out within a year prior to surgical referral is considered mandatory for antireflux surgery. Preoperative endoscopy provides the information needed to grade dysplasia in Barrett’s esophagus, identify the possibility of a short esophagus, and assess the size and configuration of hiatal hernia.

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Interrupting PPI therapy for endoscopy assessment is considered unnecessary and unhelpful, and patients should be allowed to continue treatment.

Patients with GERD symptoms and endoscopic diagnosis of a hiatal hernia, Barrett’s esophagus, or erosive esophagitis (grade B or higher) are considered good candidates for antireflux disease. Patients with nonerosive esophagitis have a diminished response to medical treatments, and therefore should not be excluded from antireflux surgery. 

Routine biopsies obtained from the distal esophagus should not be required for patients considering antireflux surgery as eosinophils on biopsy does not necessarily confirm an eosinophil esophagitis diagnosis, nor does it exclude other esophageal diseases.

Recommendations for Barium Swallow

Patients suspected of having a hiatal hernia or a short esophagus should receive a mandatory barium swallow in their preoperative workup for antireflux surgery. Failure to identify a short esophagus or a hiatal hernia repair constructed under tension may be responsible 20% to 33% of surgical failures.

Patients with GERD symptoms and a sliding hiatal hernia on barium swallow are good candidates for antireflux surgery; patients identified with a large sliding hiatal hernia should be considered for surgery in the absence of a short esophagus.

Similarly, patients with GERD symptoms and a para-esophageal hernia on barium swallow should be considered for antireflux surgery in addition to para-esophageal hernia repair.

A short esophagus on barium swallow should not necessarily exclude the patient from antireflux surgery, but rather inform the best surgical procedure in this scenario.

Recommendations for Esophageal Manometry

The ICARUS guidelines recommend that esophageal manometry be a mandatory requirement in the selection of patients for antireflux surgery to rule out major esophageal motor disorders like achalasia, esophagogastric junction outflow obstruction, or absent contractility.

Recommendations for Reflux Monitoring

In patients with nonerosive esophagitis or short Barrett’s esophagus, pH monitoring (with or without impedance) should be mandatory before referral for antireflux surgery; pH monitoring should preferentially be documented off PPI therapy.

Patients with GERD symptoms and normal reflux exposure on pH-monitoring (and off PPI therapy) are considered poor candidates for antireflux surgery.

Response to baclofen therapy in patients with pathological reflux monitoring on PPIs does not enhance their eligibility for antireflux surgery.

Recommendations for Gastric Emptying

The ICARUS guidelines recommend that preoperative gastric emptying tests for solid food are unnecessary for patients being considered for antireflux surgery as no evidence suggests that assessment of gastric emptying is associated with surgical outcomes.


Based on these statements that generated consensus, recommendations can be made to guide clinicians and surgeons in their selection of patients for antireflux surgery.


Pauwels A, Boecxstaens V, Andrews CN, et al. How to select patients for antireflux surgery? The ICARUS guidelines (international consensus regarding preoperative examinations and clinical characteristics assessment to select adult patients for antireflux surgery) [published online August 2, 2019]. Gut. doi: 10.1136/gutjnl-2019-318260