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• W4249505624 abstract "We thank Dr Triadafilopoulos for his accurate and positive comments on our study. We agree with his critique that our study has limitations; notably in terms of short term follow-up, absence of a medical control group, and nongeneralizability of these data to the general community setting. In addition to the data from our study, there is other evidence that influenced our group to arrive at its decision that antireflux surgery is indicated for patients not responsive to medical therapy when non-acid reflux is suspected. Today the combined 24-hour pH-multichannel intraluminal impedance (MII) makes it possible to assimilate data that helps drive decisions to pursue antireflux surgery in these patients who undergo negative pH-monitoring studies. The ability to rely on objective parameters, as opposed to subjective data (ie, relying on the personal experience of the physician), is desirable. It is important to recognize that starting a fundoplication increases the lower esophageal sphincter pressure in long-term follow-up (World J Surg 2007;31:1099–1106) and decreases transient lower esophageal sphincter relaxations (Gut 2008;57:161–166). We postulated that MII could be the suitable tool to select and follow-up with gastroesophageal reflux disease patients before and after antireflux surgery. This is because of its ability to detect the physic movements into the esophagus. Thus, with a pre- and postoperative use of MII–pH, we showed that Nissen–Rossetti fundoplication was effective in controlling either acid or non-acid reflux (Surg Endosc 2008;22:2518–2523). This feature in controlling non-acid reflux was also found in achalasic patients after extended myotomy (Dis Esophagus 2008;21:664–667), suggesting that the total fundoplication itself creates an adequate barrier to prevent reflux when peristalsis is absent and myotomy has abolished the lower esophageal sphincter pressure. In our opinion, this is because of the elastic feature of the anterior gastric wall, which is able to dilate when the bolus passes through the wrap and increase the pressure for Laplace's law when the gastric fundus is distended, preventing reflux after a meal (Ann Surg 2005;241:614–621). The present study provided initial evidence to demonstrate that in a dedicated center, patients not responsive to medical treatment, if selected on the basis of the presence of reflux episodes or SI association at MII, benefit from surgery independently to the type of pH of the refluxate. This is consistent with a large experience in the pre-MII era of patients with a negative preoperative pH monitoring who benefited from a long term follow-up of antireflux surgery. At the same time, we agree that to definitively change the paradigm strategy in the entire community for the treatment of all gastroesophageal reflux disease patients nonresponsive to medical therapy, a multicenter randomized trial comparing medical treatment (standard of care) versus antireflux surgery is needed. We thank Dr Triadafilopoulos for this interesting commentary and we hope other centers will join such a study. Currently, we believe that in an experienced center for antireflux surgery, patients who underwent complete medical therapy without satisfaction should be selected for laparoscopic total fundoplication on the basis of presence of reflux episodes (acid and/or non-acid) when association with clinical symptoms can be proven at MII. A Closure Without a Closure: Impedance pH Monitoring Expanding the Indications for Antireflux SurgeryGastroenterologyVol. 138Issue 1PreviewDelGenio G, Tolone S, DelGenio F, et al. Prospective assessment of patient selection for antireflux surgery by combined multichannel intraluminal impedance pH monitoring. J Gastrointest Surg 2008;12:1491–1496. Full-Text PDF" @default.
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• W4249505624 date "2010-01-01" @default.
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• W4249505624 title "Reply" @default.
• W4249505624 doi "https://doi.org/10.1053/j.gastro.2009.11.028" @default.
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