Is a patient with a positive distal esophagus acid exposure and DeMeester score of 26, but no pathological reflux and no symptoms, indicated for Endoscopic Gastric Fundoplication?

Endoscopic Gastric Fundoplication Is Not Indicated for This Patient

Endoscopic gastric fundoplication is not indicated for this patient with positive distal esophagus acid exposure and elevated DeMeester score but no pathological reflux and no symptom correlation. 1

Assessment of pH Study Results

The patient's pH study shows:

• Duration of only 17:38:18 hours (incomplete study, should be 24-72 hours)
• Positive distal esophagus acid exposure of 8.3%
• DeMeester score of 26
• No pathological reflux
• No symptom correlation

Interpretation of These Findings

This represents a contradictory picture:

• The acid exposure time (8.3%) and DeMeester score (26) suggest GERD
• However, the lack of pathological reflux and symptom correlation argues against GERD
• The incomplete study duration (17:38 hours vs. intended 72 hours) makes these results unreliable

Criteria for Anti-Reflux Procedures

According to current guidelines, candidacy for invasive anti-reflux procedures requires:

1. Confirmatory evidence of pathologic GERD 1
2. Exclusion of achalasia
3. Assessment of esophageal peristaltic function

The patient fails to meet the first criterion as:

• There is no symptom correlation with reflux episodes
• The study reports "no pathological reflux" despite elevated numbers
• The pH study was incomplete and therefore unreliable

Importance of Symptom Correlation

The British Society of Gastroenterology guidelines emphasize that:

• Patients should have a positive symptom association on both the Symptom Association Probability (SAP) and Symptom Index (SI) with reflux episodes as selection criteria for anti-reflux surgery 1
• This patient has "no symptoms relation" which is a strong contraindication

Outcomes Research

Research demonstrates poor outcomes when anti-reflux procedures are performed without proper confirmation of GERD:

• Patients with normal preoperative pH findings but undergoing fundoplication have significantly worse outcomes (40% continued to have GERD symptoms vs. 8.1% in those with abnormal pH studies) 2
• The odds ratio for poor outcome was 9.02 for patients with normal preoperative pH studies 2

Recommendations

1. Repeat the pH study for the full intended duration (72 hours)
2. Ensure proper symptom recording during the study to establish correlation
3. Consider pH-impedance monitoring to detect non-acid reflux if symptoms persist but acid reflux is not confirmed
4. Only consider anti-reflux procedures if:
   • Complete pH study confirms pathological reflux
   • There is a positive symptom association with reflux events
   • Other causes of symptoms have been excluded

Common Pitfalls to Avoid

• Relying on incomplete pH studies: The 17-hour study is insufficient for proper diagnosis
• Overvaluing isolated numbers: Despite elevated DeMeester score, the lack of symptom correlation is a critical finding
• Performing invasive procedures without proper indication: This leads to poor outcomes and patient dissatisfaction
• Ignoring symptom correlation: The AGA guidelines emphasize that symptom correlation is essential for selecting patients for anti-reflux procedures 1

In summary, this patient should not undergo endoscopic gastric fundoplication based on the current study results. A complete pH study with proper symptom correlation is necessary before considering any anti-reflux procedure.