Your patient has “refractory” GERD and there can be several reasons for this:

Symptoms may not be all due to gastro-esophageal reflux. For example, this patient may have “visceral hypersensitivity.” The symptoms may also be associated with other “functional” issues such as irritable gut or depressive illness. My usual approach is to either investigate further with 24-hr pH studies and manometry — which usually confirms that ongoing acid reflux is not the problem — or, if I’m confident on clinical grounds, I might try low dose amitriptyline (10-20 mg at bedtime).

Other diagnoses to consider include candida esophagitis and eosinophilic esophagitis.

Laparoscopic fundoplication is an alternative to ongoing PPI therapy. If the indications are right — in other words, there are no other confounding clinical issues — it can be considered, mostly in patients who can’t afford long-term PPIs, or in the very young where long-term medical therapy may not be optimal. In expert hands, success rate is very high (around 90%+). Immediate complications are perioperative issues and dysphagia, which is usually not long-lasting.

My overall feeling is that PPI therapy is so effective and safe that it’s not very often that I recommend a surgical approach.

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