Data on symptom association analysis in patients undergoing endoscopic therapy is useful to better define a successful therapeutic approach

We read the article by Witteman et al. ( 1 ) on the efficacy of EsophyX-2 Transoral Incisionless Fundoplication (TIF) in patients with gastro esophageal reflux disease (GERD). The authors randomized 60 proton pump inhibitor (PPI)-responder patients to TIF (n=40) vs. continuative PPI-therapy (n=20). Subjects underwent symptomatic clinical assessment, endoscopy, manometry, and impedance-pH monitoring off-PPI. The latter test was carried out in order to objectively prove the presence of pathological acid exposure time (AET) at baseline. Then, the same tests were repeated at 6 and 12 months after surgical and medical therapies. At 6 months follow-up, TIF significantly improved quality of life and reflux symptoms than the PPI group, whereas AET, total number of reflux events (NREs), and esophagitis relief were similar in both the groups. This study provides interesting data on the potential use of endotherapy for symptomatic relief in GERD, even if only in the short term, but given the mild effect of this technique on AET and NREs, we believe that the interpretation of their findings would have improved if the results of symptom association analysis (SAA) before and after TIF were also reported. In fact, even if the presence of a pathological reflux was an inclusion criteria, it is unclear which and how many symptoms were associated to reflux. Actually impedance-pH monitoring allows to measure all kind of reflux events, thus increasing the diagnostic yield of traditional reflux monitoring (pH-metry) by using the reflux-SAA ( 2–4 ). Indeed, several recent studies have shown that GERD patients, in parti cular those with non-erosive reflux disease, have frequently a normal AET ( 2–6 ), but a positive SAA. Moreover, recent data suggests a role of impedancedetected SAA in predicting the outcome in GERD patients treated with medical or surgical therapy ( 6 ). Thus, providing this information may be useful to understand whether a particular group of patients should be treated with alternative surgical or endoscopic therapies, and if the benefit of this technique can be associated to a reduction of reflux-symptom association rather than to a change in AET or number of reflux episodes. So, data concerning the SAA should be investigated and reported also pre- and post-operatively in all studies evaluating the efficacy of any anti-reflux procedure in GERD patients. This would clarify the role of SAA in determining the indication of surgical or endoscopic therapies and would help to understand its role as a parameter to define an anti-reflux successful approach