title: Modern medical and surgical management of difficult-to-treat GORD.
abstract: Approximately 30-40% of patients taking proton pump inhibitors (PPIs) for presumed gastro-oesophageal reflux (GOR) symptoms do not achieve adequate symptom control, especially when no oesophageal mucosal breaks are present at endoscopy and when extra-oesophageal symptoms are concerned. After failure of optimization of medical therapy, a careful work up is mandatory that aims at determining whether symptoms are related to GOR or not. Most patients with refractory symptoms do not have GOR-related symptoms. Some may have symptoms related to weakly acidic reflux and/or oesophageal hypersensitivity. Baclofen is currently the only antireflux compound available as add-on therapy to PPIs, but its poor tolerability limits its use in clinical practice. There is room for pain modulators in patients with hypersensitive oesophagus and functional heartburn. Antireflux surgery is a suitable option in patients responding to medical therapy who want to avoid taking medication or if persisting symptoms can be clearly attributed to poorly controlled GOR.
authors.affiliation: Gastroenterology and Hepatology Department, Saint André Hospital, CHU Bordeaux and Bordeaux Segalen University, Bordeaux, France.
authors.forename: Frank
authors.initials: F
authors.lastname: Zerbib
authors.affiliation: Barts and The London School of Medicine and Dentistry, Wingate Institute for Neurogastroenterology, Queen Mary University of London, UK.
authors.forename: Daniel
authors.initials: D
authors.lastname: Sifrim
authors.affiliation: Division of Gastroenterology, University Clinic of Visceral Surgery and Medicine, Bern University Hospital, Inselspital Bern, Bern, Switzerland.
authors.forename: Radu
authors.initials: R
authors.lastname: Tutuian
authors.affiliation: Department of Surgery, North Tyeneside Hospital, Durham University, Northumbria Healthcare, United Kingdom.
authors.forename: Stephen
authors.initials: S
authors.lastname: Attwood
authors.affiliation: Department of Surgery, Gastrocentrum, Karolinska University Hospital, Stockholm, Sweden.
authors.forename: Lars
authors.initials: L
authors.lastname: Lundell
keywords: Asthma; GORD; PPI; cough; surgery