Purpose: Traditionally patients with classic reflux symptoms but minimally abnormal esophageal pH studies have not been considered ideal surgical candidates. Endoluminal gastroplication (ELGP) has been shown to improve clinical outcome in patients with gastroesophageal disease (GERD) but it remains unclear if equally impressive improvements occur in this patient population. The aim of this study is to evaluate symptomatic outcome after ELGP in patients with reflux symptoms and minimally abnormal pH studies. Methods: Patients with GERD and minimally abnormal DeMeester scores defined as less than or equal to 30 were included. Between July 2001-July 2002, 23 patients who underwent ELGP for GERD met this criterion. All ELGPs were performed with 2 or 3 plications placed 1 to 2 cm below the gastroesophageal junction. Follow-up data included weight, BMI, heartburn frequency score (HFS), heartburn severity (HSV), heartburn symptom score (HSS), regurgitation frequency (RFS), and medication use; in 3 patients manometries, pH studies, and upper endoscopy findings were obtained at variable intervals after ELGP. Results: For the 23 patients, average age was 51 with 11 men, 12 women and average BMI 28. Nine of 23 patients had a history of previous surgical fundoplication. Only 1 patient was not on medication before or after the ELGP. On average at baseline patients reported only a 36% improvement in symptoms on medications. Average baseline lower esophageal sphincter pressure (LESP) was low at 17.4+/-8.6mmHg with DeMeester scores of 18.5+/-9.0. Mean follow up was 4.3 months. For all symptom scores, improvement occurred post-ELGP (all p<0.02): HFS (0-3) from 2.4 to 1.2, HSS (0-96) from 48 to 19, HSV (0-32) from 18 to 10, and RFS (0-3) from 1.9 to 0.6. After ELGP, 68% of patients were off medications, 9% had decreased usage of medications, and 23% had no change in medications. Extraesophageal symptoms also improved: 100% of nocturnal symptoms (5 of 5), 75% of atypical chest pain (3 of 4) and cough (3 of 4), and 50% of hoarseness (2 of 4) resolved. The trend after ELGP for manometry, pH study, and upper endoscopy data was improvement: LESP from 18 to 21.75 mmHg, % time pH<4 from 3.4 to 2.2, and DeMeester scores from 14.6 to 7.9. None of the 3 patients with post-ELGP endoscopies had Barrett's but esophagitis in one patient had healed after ELGP. Conclusions: ELGP significantly improves clinical outcome in patients with GERD and persistent symptoms on medical therapy even with minimally abnormal pH studies.