Reply to “The importance of subgrouping refractory NERD patients according to esophageal pH-impedance testing”

Excerpt

According to Rome III, evidence of a symptom relationship with reflux events either by subjective outcome from a proton pump inhibitor (PPI) trial or through direct reflux monitoring is sufficient to diagnose gastroesophageal reflux disease (GERD) [1]. Consequently, hypersensitive esophagus (HE) has been considered within the realm of GERD, whereas functional heartburn (FH) has been defined as absence of evidence that reflux is the cause of the symptom [1]. Unsatisfactory response to a PPI trial is then mandatory to define FH, whereas a positive symptom–reflux association at reflux monitoring defines HE, a condition in which a favorable response to PPI trial confirms the diagnosis of GERD [1]. Accordingly, by definition, patients with FH do not respond to PPI therapy and no benefit from antireflux surgery can be predicted in them, whereas many patients with HE respond to PPI therapy [1], to laparoscopic fundoplication [2], or to selective serotonin reuptake inhibitors [3]. The aim of our study [4] was to establish whether patients with refractory GERD (heartburn and/or regurgitation persisting despite high-dose PPI therapy) as diagnosed by on-PPI impedance-pH monitoring can achieve GERD cure by laparoscopic fundoplication, with GERD cure being defined as 3-year postoperative off-PPI normal impedance-pH findings associated with persistent total or subtotal heartburn and/or regurgitation remission. Therefore, patients with FH as defined by PPI refractoriness and negative on-PPI impedance-pH findings were excluded. …