Indications for EARTh and LARS in patients with refractory GERD

Background and Aim: For patients who poorly respond to acid-suppressive therapies (AST), laparoscopic anti-reflux surgery (LARS) and endoscopic anti-reflux therapy (EARTh) are considered therapeutic options. We aimed to determine the frequency of cases in which LARS and EARTh were indicated. Methods: We evaluated 284 patients with refractory GERD who underwent impedance-pH monitoring (MII-pH) over the past 12 years. Based on symptom profile, endoscopic findings, and distinct patterns on MII-pH, patients were categorized into erosive reflux disease (ERD), non-erosive reflux disease (NERD), reflux hypersensitivity (RH), and functional heartburn (FH). Reflux burden (RB) was defined using MII-pH parameters (acid exposure time (AET) and total reflux events (TRE)) according to Lyon consensus 2.0. Results: RB was found in 193 patients (68%). There were no differences in age, BMI, or reflux symptom scores between patients with and without RB, but RB was more frequent in males, reflux esophagitis (RE), large hiatal hernia (HH), and Barrett's esophagus (BE). In multivariate analysis, reflux esophagitis (OR 2.96, p=0.01), HH (OR 4.18, p=0.01), and AST administration (OR 1.91, p=0.03) were independent factors associated with RB. Among patients with RB with positive symptom correlation, those with severe RE or large HH were ideal candidates for LARS (48 cases (17%)), and those with mild RE and small HH were for EARTh (99 cases (34%)). Conclusions: Patient selection for LARS and EARTh needs to be carefully considered.