title: Refractory gastroesophageal reflux disease as diagnosed by impedance-pH monitoring can be cured by laparoscopic fundoplication.
abstract: BACKGROUND
  Some patients with typical (heartburn/regurgitation) symptoms of gastroesophageal reflux disease (GERD) are refractory to proton pump inhibitor (PPI) therapy. Impedance-pH monitoring can identify PPI-refractory patients who could benefit from laparoscopic fundoplication, but outcome data are scarce. We aimed to assess whether PPI-refractory GERD as diagnosed by impedance-pH monitoring can be cured by laparoscopic fundoplication.
  
  
  METHODS
  Forty-four consecutive GERD patients with heartburn/regurgitation refractory to high-dose PPI therapy entered a 3-year outcome assessment following robot-assisted laparoscopic fundoplication. Preoperative on-PPI impedance-pH diagnostic criteria consisted of positive symptom association probability (SAP)/symptom index (SI), and/or abnormal percentage esophageal acid exposure time (%EAET), and/or abnormal number of total refluxes. GERD cure was defined by 3-year postoperative off-PPI normal impedance-pH findings with persistent symptom remission.
  
  
  RESULTS
  Preoperatively, 24 of 38 (63 %) patients who completed the outcome assessment had a positive SAP/SI, 20 of 38 (53 %) for weakly acidic refluxes; 3 of 38 (8 %) patients had an abnormal %EAET, 11 of 38 (29 %) an abnormal number of total refluxes only. Postoperatively, heartburn/regurgitation recurred in 3 patients; abnormal impedance-pH findings were found in two of them, and they responded to PPI therapy. GERD cure was achieved in 34 of 38 (89 %) patients, 11 of 11 with an abnormal number of total refluxes as the only preoperative abnormal impedance-pH finding. Postoperatively, there was a significant decrease of the %EAET (1 vs. 0.1 %, P = 0.002) and of the number of total refluxes (68 vs. 8, P = 0.001), with the latter finding mainly due to a decrease in the number of weakly acidic refluxes.
  
  
  CONCLUSIONS
  Normal reflux parameters and persistent symptom remission at 3-year follow-up can be achieved with laparoscopic fundoplication in the majority of patients with PPI-refractory GERD as diagnosed by impedance-pH monitoring. On-PPI impedance-pH diagnostic criteria should include SAP/SI positivity, an abnormal %EAET, and an abnormal number of total refluxes. Weakly acidic refluxes have a major role in the pathogenesis of PPI-refractory GERD.
authors: Fisiopatologia Digestiva, Nuovo Ospedale S. Agostino, Viale Giardini, 1355-41100 Modena, Italy. marziofrazzoni@gmail.com
authors: Marzio
authors: M
authors: Frazzoni
authors: Micaela
authors: M
authors: Piccoli
authors: Rita
authors: R
authors: Conigliaro
authors: Raffaele
authors: R
authors: Manta
authors: Leonardo
authors: L
authors: Frazzoni
authors: Gianluigi
authors: G
authors: Melotti
mesh_terms: D000328:Adult; D050782:Esophageal pH Monitoring; D004947:Esophagus / Q000378:metabolism / Q000503:physiopathology*; D005260:Female; D005500:Follow-Up Studies; D018662:Fundoplication / Q000379:methods*; D005764:Gastroesophageal Reflux / Q000175:diagnosis* / Q000378:metabolism / Q000601:surgery; D006801:Humans; D006863:Hydrogen-Ion Concentration; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008365:Manometry; D008875:Middle Aged; D012189:Retrospective Studies; D012371:Robotics; D013997:Time Factors; D016896:Treatment Outcome