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Introduction: In well-selected cases laparoscopic Nissen fundoplication (LNF) provides symptomatic control as high 90% in GERD. Recently, the use of combined 24-h pH-multichannel intraluminal impedance (MII-pH) has allowed studying non-acid reflux (NAR) episodes, an important factor in refractory GERD. However, the information regarding the effects of LNF on NAR is limited. Aim: To prospectively evaluate acid and NAR episodes before and at 1, 3 and 6 months after LNF in patients with typical symptoms of GERD. Material and Methods: We prospectively assessed and reviewed collected data from 14 consecutive patients (5 male and 9 female; mean age 46 ± 12 years) who underwent anti-reflux surgery (LNF) between August 2009 and August 2010. All subjects had heartburn and/or regurgitation and evidence of hiatal hernia and a positive symptom response to proton pump inhibitor (PPI) therapy. Nine patients had evidence of erosive GERD during endoscopy. Before surgery all subjects underwent a symptomatic evaluation using a 5 point type Likert scale for esophageal symptoms, stationary esophageal manometry using a solid state catheter and a 24-h MII-pH using a six impedance 1-pH catheter (Sandhill Scientific, Littleton, CO, USA). The design of the catheter allowed recording impedance data at 3,5,7,9,15 and 17 cm above the LES. Patients were asked to discontinue PPI and histamine blockers one week before the baseline evaluation. MII-pH and esophageal manometry was performed 1, 3 and 6 months after LNF. Reflux episodes (acid and NAR), % of time of pH<4, JDM score, proximal extent episodes and symptoms index were calculated according to standard definitions. Results: At baseline 7/14 (50%) of subjects had a hypotensive LES and 12/14 (85%) had normal esophageal peristalsis, 2 subjects had criteria for ineffective peristalsis. The mean LES pressure was 10.9 ± 3.3 mmHg. All patients underwent LNF without perioperative complications by a single surgeon (ARDLM) in a standard fashion using 5 upper abdominal ports. A 2-cm loose fundoplication calibrated over a 36 French bougie was performed with extensive transhiatal mobilization of the esophagus and division of short gastric vessels.Successful symptom control reflux after LNF was achieved at 1 and 3 months for all but one patient (92%). Patients declared their symptoms improved in 8/14 (57%), normalized in 4/14 (28%) and unchanged in 2/14 (14%) at 6 months. The 24-h MII-pH confirmed the postoperative reduction of acid and non-acid reflux episodes at 1, 3 and 6 months (Table 1).CONCLUSION: MII-pH provides an objective means for evaluating the effectiveness of LNF in controlling acid and nonacid reflux episodes. Selection of patients before LNF surgery is an important task and guarantees successful symptom control at 6 months.

MII-pH parameter	Baseline (n=14)	1 month (n=13)	3 months (n=13)	6 months (n=12)
% time pH < 4	9.05 ± 5	0.26 ± 0.33*	0.4 ± 0.8*	0.3 ± 1.2*
Reflux episodes > 5 min	4.7 ± 3	0.2 ± 0.44*	0.44 ± 0.98*	0.74 ± .82*
Longest reflux episode (min)	33.9 ± 28	2.26 ± 2.78*	3.16 ± 4.2*	2.85 ± 3.1*
Number reflux episodes	68 ± 13	2.22 ± 1.78*	1.5 ± 2.23*	1.8 ± 4.7*
DeMeester score	32 ± 17.8	1.51 ± 1.18*	2.4 ±3.08*	1.98 ± 2.1*
% bolus exposure	5.3 ± 3.2	0.30 ± 0.39*	0.04 ± 0.8*	0.8 ± 0.51*
All reflux episodes total	86 ± 42	44 ± 24*	34 ± 12*	30 ± 16*
Acid reflux episodes total	53 ± 33	4.18 ± 3.9*	2 ± 2.82*	2.4 ± 3.1*
Non-acid reflux episodes total	33 ± 30	19 ± 22*	17 ± 4*	19 ± 21*
% Symptom Index (heartburn)	72 ± 31	22 ± 18*	16 ± 6*	25 ± 14*

*p<0.05 compared to baseline values