As for surgery, I would propose a short limb Roux-en Y gastric bypass 40/40cm

To treat non-acid reflux, already on PPI, we need to enhance barrier function of normal GOJ by following recommendations:

A) Weight loss and avoiding tight clothing i.e. waist belt

B) GABAB agonist Baclofen (start with 5mg PO tid, then increase gradually if necessary up to 20mg PO tid)

C) Endoscopic gastroplication

D) Finally surgical fundoplication

Could you please propose me some reference for fundoplication for non-acid reflux? Thank you. And what do you think for duodenal switch?

Dear Dimitrios

Thanks for the interest. The best study I can mention here done by Mainie et al, which has been published in Br J Sug 2006; 93:1483.

Duodenal Switch: I think duodenal switch preserves the physiologic food transit while creating an effective Roux-en-Y diversion to duodenal juice. If we think the biliary content are responsible for reflux symptoms supported by impedance studies, it is reasonable to consider duodenal switch.

Thank you dr Derakhshan

I believe that surgery must be confined to a very small number of selected patients. Often diet and lifestyle are poorly considered despite they may be of relevant help. Moreover, weight loss, the search and treatment of a metabolic syndrome and the use of prokinetics and buffer substances may be useful tools independently from acid, biliary, alimentary or gas refluxate. Finally, a good support may be given by pH-impedenzometry.

If Impedence monitoring identifies non acid reflux, then a significant symptom association might support a role for surgery particularly in the presence of volume regurgitation and/or a reversible cause for symptoms (eg hiatus hernia). Important to exclude other precipitating factors such as gastroparesis / delayed gastric emptying.