ARTICLEManagement Options for Patients With GERD and Persistent Symptoms on Proton Pump Inhibitors: Recommendations From an Expert PanelYadlapati, Rena MD, MSHS1; Vaezi, Michael F. MD, PhD2; Vela, Marcelo F. MD3; Spechler, Stuart J. MD4; Shaheen, Nicholas J. MD, MPH5; Richter, Joel MD6; Lacy, Brian E. MD, PhD7; Katzka, David MD8; Katz, Philip O. MD9; Kahrilas, Peter J. MD10; Gyawali, Prakash C. MD11; Gerson, Lauren MD, MSc12,†; Fass, Ronnie MD13; Castell, Donald O. MD14; Craft, Jenna MPH10; Hillman, Luke MD15; Pandolfino, John E. MD, MS10Author Information 1Anschutz Medical Campus, University of Colorado, Aurora, CO, USA. 2Vanderbilt Medical Center, Nashville, TN, USA. 3Mayo Clinic, Scottsdale, AZ, USA. 4Baylor Health Care System, Dallas, TX, USA. 5University of North Carolina, Chapel Hill, NC, USA. 6University of South Florida, Tampa, FL, USA. 7Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. 8Mayo Clinic, Rochester, MN, USA. 9Weill Cornell Medical Center, New York, NY, USA. 10Northwestern University, Chicago, IL, USA. 11Washington University, St. Louis, MO, USA. 12California Pacific Medical Center, San Francisco, CA, USA. 13Metro Health Medical Center, Cleveland, OH, USA. 14Medical University of South Carolina, Charleston, SC, USA. 15University of Wisconsin, Madison, WI, USA. †Deceased. Correspondence: R.Y. (email: Rena.firstname.lastname@example.org) SUPPLEMENTARY MATERIAL accompanies this paper at http://links.lww.com/AJG/A240, http://links.lww.com/AJG/A241 Received 20 November 2017; accepted 10 February 2018; Published online 24 April 2018 American Journal of Gastroenterology: July 2018 - Volume 113 - Issue 7 - p 980-986 doi: 10.1038/s41395-018-0045-4 Buy SDC Metrics Abstract BACKGROUND: The aim of this study was to assess expert gastroenterologists' opinion on treatment for distinct gastroesophageal reflux disease (GERD) profiles characterized by proton pump inhibitor (PPI) unresponsive symptoms. METHODS: Fourteen esophagologists applied the RAND/UCLA Appropriateness Method to hypothetical scenarios with previously demonstrated GERD (positive pH-metry or endoscopy) and persistent symptoms despite double-dose PPI therapy undergoing pH-impedance monitoring on therapy. A priori thresholds included: esophageal acid exposure (EAE) time >6.0%; symptom-reflux association: symptom index >50% and symptom association probability >95%; >80 reflux events; large hiatal hernia: >3 cm. Primary outcomes were appropriateness of four invasive procedures (laparoscopic fundoplication, magnetic sphincter augmentation, transoral incisionless fundoplication, radiofrequency energy delivery) and preference for pharmacologic/behavioral therapy. RESULTS: Laparoscopic fundoplication was deemed appropriate for elevated EAE, and moderately appropriate for positive symptom-reflux association for regurgitation and a large hiatal hernia with normal EAE. Magnetic sphincter augmentation was deemed moderately appropriate for elevated EAE without a large hiatal hernia. Transoral incisionless fundoplication and radiofrequency energy delivery were not judged appropriate in any scenario. Preference for non-invasive options was as follows: H2RA for elevated EAE, transient lower esophageal sphincter relaxation inhibitors for elevated reflux episodes, and neuromodulation/behavioral therapy for positive symptom-reflux association. CONCLUSION: For treatment of PPI unresponsive symptoms in proven GERD, expert esophagologists recommend invasive therapy only in the presence of abnormal reflux burden, with or without hiatal hernia, or regurgitation with positive symptom-reflux association and a large hiatus hernia. Non-invasive pharmacologic or behavioral therapies are preferred for all other scenarios. © The American College of Gastroenterology 2018. All Rights Reserved.