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GORD management in adults, treatment, inverstigation
1. Endoscopic and laparoscopic
management of GORD
Dr Dakshitha Wickramasinghe
MBBS MD(Surgery) DM MRCSEd PGCertMedEdu FMAS
Consultant Surgeon and Senior Lecturer in Surgery
4. • Indications — Upper endoscopy is indicated in patients with suspected GERD to evaluate alarm features or abnormal imaging if not performed within the last three
months. Upper endoscopy should also be performed to screen for Barrett’s esophagus in patients with risk factors. On upper endoscopy, biopsies should target any
areas of suspected metaplasia, dysplasia, or, in the absence of visual abnormalities, normal mucosa to evaluate for eosinophilic esophagitis [17]. (See 'Alarm
features' below and 'Risk factors for Barrett's esophagus' below and 'Abnormal upper gastrointestinal tract imaging' below.) (Related Pathway(s): Gastroesophageal
reflux disease: Identification of adults who require upper endoscopy.)
• Upper endoscopy is not required to make a diagnosis of GERD. However, upper endoscopy can detect esophageal manifestations of GERD (eg, Barrett’s metaplasia,
erosive esophagitis) and can rule out an upper gastrointestinal tract malignancy. Upper endoscopy can also rule out other etiologies in patients with GERD
symptoms that are refractory to a trial of proton pump inhibitor therapy. (See "Approach to refractory gastroesophageal reflux disease in adults", section on
'Diagnostic strategies and initial management' and "Medical management of gastroesophageal reflux disease in adults", section on 'Pretreatment evaluation'.)
• Alarm features — Alarm features that are suggestive of a gastrointestinal malignancy include:
• ●New onset of dyspepsia in patient ≥60 years
• ●Evidence of gastrointestinal bleeding (hematemesis, melena, hematochezia, occult blood in stool)
• ●Iron deficiency anemia
• ●Anorexia
• ●Unexplained weight loss
• ●Dysphagia
• ●Odynophagia
• ●Persistent vomiting
• ●Gastrointestinal cancer in a first-degree relative
5. • Endoscopic findings — Upper endoscopy may be normal in patients with GERD, or there may be evidence of esophagitis of varying degrees [18,19]. Among untreated GERD patients, approximately 30
percent will have endoscopic esophagitis. The severity and duration of symptoms correlate poorly with the severity of esophagitis.
• In contrast to infectious and medication-induced esophagitis which tend to be in the proximal esophagus, the ulcerations seen in peptic esophagitis are usually irregularly shaped or linear, multiple,
and are in the distal esophagus. (See "Medication-induced esophagitis", section on 'Endoscopy' and "Approach to the evaluation of dysphagia in adults", section on 'Infectious esophagitis'.)
• Other endoscopic findings in patients with longstanding GERD include peptic strictures, Barrett's metaplasia, and esophageal adenocarcinoma. (See "Complications of gastroesophageal reflux in
adults".)
• ●Grading the severity of esophagitis – Erosive esophagitis is graded according to its severity to guide management. Several endoscopic grading schemes have been devised to decrease inter-
operator variability of endoscopy in assessing the severity of peptic esophagitis. Of these, the Los Angeles classification is the most thoroughly evaluated classification for esophagitis and is the most
widely used. (See "Medical management of gastroesophageal reflux disease in adults", section on 'Recurrent symptoms'.)
• •Los Angeles classification – The Los Angeles classification grades esophagitis severity by the extent of mucosal abnormality, with complications recorded separately. In this grading scheme, a mucosal
break refers to an area of slough adjacent to more normal mucosa in the squamous epithelium with or without overlying exudate.
• -Grade A – One or more mucosal breaks each ≤5 mm in length (picture 1)
• -Grade B – At least one mucosal break >5 mm long, but not continuous between the tops of adjacent mucosal folds (picture 2)
• -Grade C – At least one mucosal break that is continuous between the tops of adjacent mucosal folds, but which is not circumferential (picture 3)
• -Grade D – Mucosal break that involves at least three-fourths of the luminal circumference (picture 4)
• •Savary-Miller classification – The Savary-Miller classification is historically the most widely referenced grading of esophagitis [20].
• -Grade I – One or more non-confluent reddish spots, with or without exudate
• -Grade II – Erosive and exudative lesions in the distal esophagus that may be confluent, but not circumferential
• -Grade III – Circumferential erosions in the distal esophagus, covered by hemorrhagic and pseudomembranous exudate
• -Grade IV – Chronic complications such as deep ulcers, stenosis, scarring, or Barrett's metaplasia
• The Savary-Miller classification has its limitations. Specifically, grade IV esophagitis is ambiguous since it includes all complications. This has led to modifications that either offer subdivisions of grade
IV or relegate metaplasia to grade V. However, with so many proposed modifications, grades IV and V no longer have any consistent meaning.
7. Indications
• Poor symptom control
• Gastro intestinal (typical) –heart burn, volume reflux
• Non gastro intestinal (atypical) – Chronic cough, hoarseness, laryngitis, wheezing, asthma, chronic bronchitis,
aspiration, or dental erosion (if associated with reflux / abnormal pH studies)
• Intolerance of or noncompliance with medical therapy
• Respond but complications
• Young patients with hypotensive LES
• Complications of GERD – No need of pH testing
• LA grade C / D
• Peptic stricture
• biopsy-proven Barrett's esophagus ≥1 cm
• double-dose PPIs for over three months should serve as a warning that symptoms may
not be due to excess esophageal acid exposure but to another diagnosis, such as reflux
hypersensitivity, functional heartburn, a malignancy, or extraesophageal disease.
9. Patient selection
• Early uncomplicated disease — For patients with normal esophageal length and motility (ie, most patients with early, uncomplicated disease), the operation of
choice in the United States is probably a laparoscopic Nissen fundoplication [44,45]. Studies comparing partial fundoplication to the 360 degree Nissen
fundoplication have consistently reported less postoperative dysphagia with partial fundoplication but greater long-term durability with complete fundoplication
[46]. (See 'Comparison of partial with complete fundoplication' below.)
• Complicated disease — Fundoplication remains the standard of care for patients with GERD complicated by hiatal hernia >2 cm, severe (Los Angeles class C or D)
erosive esophagitis, and/or Barrett's esophagus [47]. Such complications are contraindications to less invasive procedures such as TIF or MSA.
• Decreased esophageal motility — For patients with normal esophageal length but decreased esophageal motility, a laparoscopic partial fundoplication (eg, Toupet)
or Hill procedure, rather than a complete (Nissen) fundoplication, should be performed. While an incomplete wrap is often recommended in patients with poor
esophageal motility [48,49], the results of at least one trial raised questions about this recommendation [40].
• Shortened esophagus — Patients with a shortened esophagus from chronic inflammation or altered anatomy present a unique challenge. Although opinions vary
regarding what constitutes adequate esophageal mobilization, it is generally accepted that increasing the intra-abdominal esophageal length can also be
facilitated by reduction of hiatal hernia, approximation of the diaphragmatic crura, or tethering of the distal esophagus below the diaphragm. The bulk of a
fundoplication may also keep the gastroesophageal junction within the abdomen.
• In 311 consecutive patients undergoing minimally invasive surgery for GERD and/or hiatal hernia, the distance between the endoscopically localized
gastroesophageal junction and the apex of the diaphragmatic hiatus after maximal thoracic esophagus mobilization was <1.5 cm in 31.8 percent of the patients
who had "true" shortened esophagus [50].
• If the intra-abdominal esophagus is <2 cm despite the surgeon's best efforts at esophageal mobilization, a Collis gastroplasty (esophageal-lengthening procedure)
combined with a fundoplication should be performed. A survey of about 1000 patients reported that, at four years, those who underwent a laparoscopic Collis
gastroplasty with fundoplication had similar symptom control, satisfaction, and quality of life to those who underwent fundoplication alone [51].
• Shortened esophagus is discussed in detailed elsewhere as it is more commonly encountered during paraesophageal hernia repair than pure antireflux surgery.
(See "Surgical management of paraesophageal hernia", section on 'Esophageal mobilization'.)
• Patients with obesity — Obesity is associated with GERD. For patients with severe obesity, Roux-en-Y gastric bypass (RYGB) is the bariatric procedure of choice for
surgical treatment of GERD. Several small series have reported a decrease in reflux symptoms as well as complete or partial regression of Barrett's esophagus with
RYGB [52-54]. (See "Laparoscopic Roux-en-Y gastric bypass", section on 'Gastroesophageal reflux disease' and "Barrett's esophagus: Surveillance and
management".)
10. Laparascopic surgery
• Comparable safety, efficacy in symptom relief [58], and patient
satisfaction as well as shorter hospital stays and recuperative
times [59-64] and fewer incisional hernias over time [65].
• earning curve of laparoscopic fundoplication varies among
studies but ranges from 20 to 60
11. Nissen fundoplication
• xtensive mediastinal dissection should be performed, especially when a
hiatal hernia is present, to reduce >2 cm of esophagus to below the
diaphragm without tension. Reduction of hiatal hernia may also contribute
to the efficacy of antireflux surgery [71]. If the intra-abdominal esophagus
is <2 cm despite the surgeon's best efforts at esophageal mobilization, a
Collis gastroplasty should be performed
• The lower esophageal sphincter (LES) and fundus normally undergo
vagally mediated relaxation with swallowing. An incorrectly performed
fundoplication may prevent appropriate relaxation of the LES with
swallowing. It is therefore important that the fundus is the only part of the
stomach used for reinforcing the LES; the wrap is placed around the
esophagus, not the upper stomach, and the vagal nerves must not be
injured during dissection
12. Partial fundoplication
• A partial 270 degree posterior wrap (Toupet) is used for
patients with severe associated motor abnormalities. A partial
180 degree anterior wrap (Dor) has also been described
13. Magnetic sphincter augmentation
• LINX Reflux Management System
• sufficient attraction to increase the LES closure pressure but
permit food passage with swallowing
• reduced GERD symptoms and improved GERD-related quality
of life scores, cessation of PPI use, and substantial normalization
of objective GERD measurements
• Dysphagia can occur early or late (>30 days) after MSA
implantation by different mechanisms and is treated differently.
Device erosion occurs in 0.3 percent of patients at four years;
between 3 and 7 percent
16. Transoral incisionless fundoplication
• full-thickness serosa-to-serosa plication that is 3 to 5 cm in
length and 200 to 300 degrees in circumference (partial
fundoplication).
• Typical GERD symptoms, no or only low-grade erosive
esophagitis (grades A and B), and no or only small hiatal hernia
(≤2 cm). TIF is contraindicated in patients with high-grade
erosive esophagitis, Barrett's esophagus, atypical and
extraesophageal symptoms of GERD, scleroderma, or other
esophageal pathology or surgery
17. • In the latest trial (TEMPO), 63 patients with GERD refractory to PPI received
TIF versus maximum standard dose PPI therapy [92]. At six months, both
regurgitation and extraesophageal symptoms were eliminated in more TIF
than PPI patients (62 versus 5 percent); 90 percent of TIF patients were off
PPIs. After six months, all patients in the PPI (control) group elected to
cross over to TIF. At three years, 90 and 88 percent of patients reported
elimination of troublesome regurgitation and all atypical symptoms,
respectively [93]. At five years, troublesome regurgitation was eliminated in
80 percent of patients; 34 percent were on daily PPI therapy, and the
average total GERD health-related quality of life score improved from 22.2
(baseline) to 6.8
• meta-analysis of five randomized trials and 13 prospective studies, PPI use
after TIF increased over time
18. Failure
• ntireflux surgery has a failure rate of 10 to 15 percent
• Operative failure is usually defined as persistent, recurrent, or
new-onset symptoms.
• 5 to 10 percent of patients will need revisional surgery after
laparoscopic fundoplication [
• Increases with time
• 1, 5, 10 and 15 year rates of repeat antireflux surgery were 3.1,
9.3, 11.7, and 12.8 percent,
19. LONG-TERM EFFICACY
• Surgical versus medical therapy
• LOTUS trial, patients who underwent LARS had a slightly lower estimated five-year
remission rate compared with those treated medically (85 versus 92 percent); this
difference was not statistically significant
• Dysphagia, bloating, and flatulence were more common in patients treated with LAR
• LARS has not been shown to halt the progression from intestinal metaplasia (Barrett's
esophagus) to dysplasia
• REFLUX trial, which included only 246 patients with five years of follow-up, found that
patients undergoing a fundoplication (either a total or partial fundoplication per surgeon
preference, n = 127) were less likely to require antireflux medication at five years
compared with patients managed by medical therapy alon
• 015 Cochrane review of four trials found that, in the short and medium term, laparoscopic
fundoplication was associated with better GERD-specific quality of life and fewer
heartburn or reflux symptoms but a higher risk of adverse events (eg, dysphagia)
compared with medical therapy
21. Comparison of partial with complete
fundoplication
• Laparoscopic Toupet (posterior partial) fundoplication was compared with
laparoscopic Nissen (posterior complete) fundoplication in a systematic review
and meta-analysis of seven trials [137]. Toupet and Nissen fundoplication resulted
in similar reduction in esophageal acid exposure and reflux symptom control, but
Toupet fundoplication was associated with fewer cases of postoperative
dysphagia and dilation, gas-related symptoms, and reoperation. Another meta-
analysis of 13 trials reached a similar conclusion [138].
• ●A 180° laparoscopic anterior fundoplication was compared with Nissen
fundoplication in a 2017 systematic review and meta-analysis of six randomized
trials [139]. Anterior and Nissen fundoplications were equivalent in reflux control
and patient satisfaction. While anterior fundoplication resulted in a lower
incidence of postoperative dysphagia, Nissen fundoplication required fewer
reoperations for recurrent symptoms.
• ●Based on poor-quality studies, a 2014 systematic review and meta-analysis of
two trials and 12 retrospective studies failed to demonstrate superiority of either
complete or partial fundoplication [140].
22. Comparison of anterior with posterior
fundoplication
• The laparoscopic anterior fundoplication (LAF; 90 to 180° wrap)
was proposed as an alternative to the laparoscopic posterior
fundoplication (LPF; 180 to 360° wrap) to reduce
postfundoplication symptoms but was reported to have higher
rates of recurrence of reflux [46,141-145].
• ●A meta-analysis of nine randomized trials totaling 840 patients
associated LPF with better heartburn control but LAF with lower
risk of postoperative dysphagia [146]. Similar patient
satisfaction scores and reoperation rates were associated with
LAF and LPF.
23. Comparison of fundoplication with other
surgical options
• Newer minimally invasive antireflux procedures (eg, magnetic sphincter augmentation [MSA] or
transoral incisionless fundoplication [TIF]) have not been around long enough to report long-term
efficacy and adverse effect data. As such, there is insufficient evidence to recommend them as
alternatives to fundoplication for severe GERD [3,124]. Nevertheless, such minimally invasive
procedures may be suitable for patients who wish to avoid potential adverse effects of
fundoplication (eg, dysphagia, gas bloating) but do not desire to continue lifelong medical therapy
for GERD [85].
• ●MSA has not been compared with fundoplication in randomized trials. In a meta-analysis of seven
observational studies, both procedures were safe and effective in symptom control with up to one
year of follow-up [147]; MSA was associated with fewer gas bloat symptoms and increased ability to
vomit and belch [148]. In a propensity score matched retrospective study, MSA and Toupet (partial)
fundoplication had similar GERD control and side effect profiles [149]. (See "Magnetic sphincter
augmentation (MSA)", section on 'MSA versus fundoplication'.)
• ●TIF has not been directly compared with fundoplication in any randomized trial either. In a network
meta-analysis of TIF versus laparoscopic fundoplication versus PPI therapy, laparoscopic
fundoplication was associated with greater sphincter augmentation than TIF. Quality-of-life
improvement scores were actually higher with TIF, but the follow-up period was shorter [150].
24. Radiofrequency treatment for
gastroesophageal reflux disease
• Radiofrequency (RF) energy induces collagen contraction and has been shown to have
therapeutic benefits in patients with cardiac arrhythmias, joint laxity, benign prostatic
hyperplasia, and sleep-disordered breathing. Although the precise mechanisms of benefit
in gastroesophageal reflux disease (GERD) are unclear, RF treatment appears to reduce
postprandial transient lower esophageal sphincter relaxations and decrease compliance of
the gastroesophageal junction, may decrease esophageal acid sensitivity by inducing
healing of esophageal erosive disease, and may improve gastroparesis
• One theory is that RF treatment improves symptoms of GERD through radiofrequency
ablation of sensory neurons of the distal esophagus, leading to hyposensitization without
an effect on pH. In a study of 13 patients undergoing pH monitoring and Bernstein acid
perfusion testing, esophageal acid sensitivity was decreased six months after RF treatmen
• improved GERD symptoms and decreased gastroesophageal junction (GEJ) compliance
three months after the initial procedure. In this trial, the administration of sildenafil, an
esophageal smooth muscle relaxant, normalized GEJ compliance again to pre-procedure
levels, arguing against GEJ fibrosis as the underlying mechanism.
25. Good candidate
• Suffer from frequent heartburn, regurgitation, or both.
• ●Have adequate esophageal peristalsis and normal relaxation of the lower
esophageal sphincter (ie, patients with features of achalasia are not candidates
for RF treatment) (see "Achalasia: Pathogenesis, clinical manifestations, and
diagnosis").
• ●Have a 24-hour pH study demonstrating pathologic acid reflux (total acid
exposure time greater than 4 percent, or a DeMeester composite score >14.7).
• ●Have nonerosive reflux disease, have grade I or II esophagitis by Savary-Miller
criteria (or LA Grade A or B), or have higher grades of esophagitis healed by drug
therapy (see "Clinical manifestations and diagnosis of gastroesophageal reflux in
adults", section on 'Endoscopic findings').
• ●Have unsatisfactory control of GERD despite high dose proton pump inhibitor
(PPI) therapy (ie, typically, twice daily dosing).
26. Contraindications
• More than 3 cm long hiatal hernia detected endoscopically or
radiographically
• ●Significant dysphagia
• ●Grade III or IV esophagitis by Savary-Miller criteria that has not
been healed after two months of medical therapy
• ●Inadequate esophageal peristalsis and incomplete lower
esophageal sphincter relaxation in response to a swallow
27. TECHNIQUE
• Radiofrequency (RF) treatment for GERD is performed endoscopically (picture 1). The four-channel radiofrequency
generator and catheter system delivers pure sine-wave energy (465 kHz, 2 to 5 watts per channel, 80 volts maximum at
100 to 800 ohms). Each needle tip incorporates a thermocouple that automatically modulates power output to maintain
a desired target (muscle) tissue temperature. Maintaining lesion temperatures below 100°C minimizes the collateral
tissue damage due to vaporization and high impedance values. Temperature is similarly monitored with a thermocouple
at each needle base, and power delivery ceases if the mucosal temperature exceeds 47°C.
• Patients are prepared in a manner similar to that for standard esophagogastroduodenoscopy (EGD). Intravenous access
is obtained, and heart rate, blood pressure, and oxygen saturation are monitored. Patients typically require high doses
of midazolam (5 to 7 mg) and either fentanyl (100 to 150 mcg) or meperidine (100 to 125 mg) during treatment. There
is mild discomfort due to catheter passage in 25 percent of cases; mild-to-moderate discomfort is also experienced with
RF delivery in 50 to 70 percent of cases. In those cases, additional medication is generally provided. Alternatively,
intravenous propofol may be used. (See "Anesthesia for gastrointestinal endoscopy in adults".)
• An esophagogastroduodenoscopy (EGD) is then performed, and the distance from the incisors to the squamocolumnar
junction (z-line) is measured. The endoscope is removed, and the RF catheter is passed transorally and positioned 2 cm
above the z-line according to the distance measured during EGD (figure 1 and figure 2). The four needle electrodes are
deployed to a preset length of 5.5 mm, and RF delivery is commenced. Each electrode delivers RF energy for 90 seconds
to achieve a target temperature of 85°C. Additional lesion sets are created by rotating and changing the linear position
of the catheter to create several rings of lesions 2 cm above and below cardia. The catheter is then removed and the
EGD repeated. Patients receive 56 lesions placed over a period of 35 minutes (figure 3 and figure 4).
28. Efficacy
• Multiple studies have examined the efficacy of radiofrequency (RF) treatment for gastroesophageal reflux disease (GERD). Overall, 55 to 83 percent patients have
reported satisfactory symptom control or cessation of proton pump inhibitor (PPI) use in studies with follow-up intervals ranging from approximately 6 to 33
months [8-14].
• In a systematic review and meta-analysis of 28 studies of over 2400 patients with GERD, scores for health-related quality of life and heartburn were improved in
patients who underwent radiofrequency treatment (Stretta) compared with patients in a sham treatment group [15]. The rate of PPI use was lower in patients who
underwent radiofrequency treatment compared with rate of preprocedure PPI use (49 versus 97 percent). Radiofrequency treatment reduced esophageal acid
exposure, but it did not significantly improve LES basal pressure.
• The efficacy of RF treatment was also examined in a meta-analysis of 18 randomized trials, cohort studies, and reviews with 1441 patients performed over a 10-year
span [16]. RF treatment improved heartburn scores (decrease in mean heartburn score in the pooled analysis from 3.55 to 1.19) and quality of life. Esophageal acid
exposure was lower following the procedure compared with baseline (DeMeester score of 28.5 versus 44.4) but did not normalize. There was also a trend toward
improved lower esophageal sphincter pressure. In a subsequent meta-analysis of 10 trials including 516 patients with GERD, radiofrequency treatment resulted in
greater improvement in health-related quality of life (HRQL) and heartburn scores compared with PPI [17]. Compared with transoral incisionless fundoplication
(TIF), radiofrequency treatment resulted in greater reduction in esophageal acid exposure but was less effective at increasing LES pressure.
• Studies with long-term follow-up have found radiofrequency treatment to be effective [18-21]. The durability of radiofrequency treatment was assessed in 26
patients who were followed for eight years [18]. At eight years, 77 percent of patients were completely off PPIs [18]. In a study with 217 patients with refractory
GERD who underwent RF treatment, normalization of GERD health-related quality of life (the primary outcome) was seen in 72 percent of patients at 10 years [19].
Secondary outcomes were 50 percent reduction or elimination of PPIs, and 60 percent or greater improvement in satisfaction at 10 years. A 50 percent or greater
reduction in PPI use occurred in 64 percent of patients (41 percent eliminating PPIs entirely), and a 60 percent or greater increase in satisfaction occurred in 54
percent of patients [19]. A prospective study evaluated the outcomes of 138 patients with refractory GERD who were followed for five years after RF treatment [20].
At the end of the five-year follow-up, all symptom scores (heartburn, regurgitation, chest pain, cough, and asthma) had decreased. In addition, 59 patients (43
percent) achieved complete PPI therapy independence, and 104 patients (75 percent) were completely or partially satisfied with their GERD symptom control [20].
In a case series including 50 patients who were followed for a median of 771 days, radiofrequency treatment was associated with improvement in post-procedure
GERD-HRQL scores [21].
29. Comparison with surgical treatment
• One group stratified patients to either endoscopic therapy or laparoscopic fundoplication [9,22,23]. Patients were
offered RF treatment if they did not have a hiatal hernia greater than 2 cm, had a lower esophageal pressure of at least
8 mmHg, and did not have Barrett's esophagus. At six months, the quality of life scores were similar in both groups, and
both groups were satisfied with their procedures (89 percent of RF treated patients and 96 percent of fundoplication
patients). Fifty-eight percent of RF patients and 97 percent of fundoplication patients were off of proton pump
inhibitors (PPI) and an additional 31 percent of RF patients had reduced their PPI dose significantly. The mean hospital
cost for RF treatment was $1808, whereas it was $5715 for fundoplication.
• ●In a non-randomized cohort of 32 patients referred to a surgical practice who underwent RF treatment with an
average follow-up of 53 months, 19 patients (59 percent) subsequently required anti-reflux surgery [24]. Those not
undergoing surgery showed a significant improvement in their GERD satisfaction scores from 3.1 to 1.5, but had
significantly lower pre-procedure heartburn scores (2.4) than those who proceeded to surgery. The RF treatment was
effective in reducing symptoms in 40 percent of patients.
• ●A non-randomized study prospectively evaluated outcomes of 215 patients with refractory GERD five years after
laparoscopic Nissen fundoplication (LNF) or RF treatment [25]. At the end of the five-year follow-up, the post-treatment
symptoms scores for regurgitation, heartburn, chest pain, belching, hiccup, cough, and asthma were lower compared
with the pre-treatment scores in both groups. However, the symptom improvements after RF treatment were lower than
those after LNF. After LNF, 81 patients (91 percent) achieved complete PPI therapy independence, compared with 47
patients (51 percent) after RF treatment.
• ●In an observational study including 226 patients with GERD, there were no significant differences in acid exposure time
at one year following radiofrequency treatment (Stretta) compared with Toupet fundoplication [26]. However,
radiofrequency treatment was associated with higher post-procedure DeMeester score and lower LES pressure
compared with fundoplication.
