Is endoscopic gastric fundoplication indicated for a patient with non-acid reflux, normal acid exposure, and positive symptom-reflux correlation for regurgitation and chest pain?

Endoscopic Gastric Fundoplication is Indicated for Non-Acid Reflux with Positive Symptom-Reflux Correlation

Endoscopic gastric fundoplication is indicated for this patient with non-acid reflux, normal acid exposure, and positive symptom-reflux correlation for regurgitation and chest pain. 1

Assessment of Current Findings

The patient's 24-hour pH and impedance study shows:

• Normal acid exposure (normal DeMeester score and total acid exposure time)
• Increased number of impedance events (>140), primarily non-acidic
• Reflux events extending to the upper esophagus
• Positive symptom-reflux correlation for regurgitation (based on SI)
• Correlation between chest pain and non-acid reflux

Rationale for Endoscopic Anti-Reflux Procedure

Evidence Supporting Intervention

1. Non-acid reflux with symptom correlation: The 2022 AGA Clinical Practice Update recommends anti-reflux procedures for patients with regurgitation-predominant GERD, which applies to this patient with positive symptom-reflux correlation for regurgitation 1

2. Objective evidence of pathologic reflux: The patient meets the candidacy criteria for invasive anti-reflux procedures with:

   • Confirmatory evidence of pathologic reflux (increased number of impedance events)
   • Positive symptom-reflux correlation 1

3. Type of procedure: Transoral incisionless fundoplication (endoscopic gastric fundoplication) is specifically mentioned as "an effective endoscopic option in carefully selected patients" 1

Procedure Selection Algorithm

For patients with proven GERD and regurgitation-predominant symptoms:

1. Endoscopic option (appropriate for this patient):

   • Transoral incisionless fundoplication - indicated for patients with:
     • Normal acid exposure but abnormal non-acid reflux
     • Positive symptom correlation
     • Absence of large hiatal hernia 1

2. Surgical options (alternative considerations):

   • Laparoscopic fundoplication - often utilized in non-obese patients
   • Magnetic sphincter augmentation - another option, often combined with crural repair for hiatal hernia 1

Expected Outcomes

Anti-reflux procedures have been shown to effectively control both acid and non-acid reflux:

• Laparoscopic fundoplication improves both acid and weakly acidic reflux parameters compared to PPI therapy 2
• Total fundoplication controls both acid and non-acid reflux as demonstrated by pre- and post-operative pH-impedance monitoring 3
• High symptom remission rates (96%) have been reported for chest pain when it correlates with reflux episodes 4

Important Considerations and Potential Pitfalls

1. Evaluation of esophageal motility: Before proceeding with any anti-reflux procedure, assessment of esophageal peristaltic function is necessary to exclude achalasia and determine the appropriate type of fundoplication 1

2. Objective vs. subjective outcomes: Evaluation of endoscopic anti-reflux treatments should not be based exclusively on subjective criteria (symptom improvement) but should be confirmed by objective examinations 5

3. Follow-up monitoring: Post-procedure pH-impedance monitoring should be considered to verify reduction in non-acid reflux events and correlation with symptom improvement 3

4. Patient selection: The British Society of Gastroenterology guidelines emphasize that reflux monitoring with pH/impedance is valuable in identifying patients with non-acid reflux who might benefit from anti-reflux procedures 1

In conclusion, this patient's clinical presentation with normal acid exposure but increased non-acid reflux events and positive symptom correlation makes them an appropriate candidate for endoscopic gastric fundoplication, which has demonstrated effectiveness in managing regurgitation-predominant symptoms and non-acid reflux.