Laparoscopic Toupet fundoplication with duodenojejunostomy for the management of superior mesenteric artery syndrome with reflux symptoms

RATIONALE

The patient had symptoms of GERD and the reflux even caused the symptom of cough. Gaining weight is a risk factor for the treatment of reflux as it could exacerbated symptoms of reflux and the drug treatment is not effective. Surgical intervention becomes necessary when there is failure following conservative medical therapy or the patient.

PATIENT CONCERNS

The patient was not satisfied with the drug treatment.

DIAGNOSES

Superior mesenteric artery syndrome, gastroesophageal reflux disease.

INTERVENTIONS

Laparoscopic Toupet fundoplication with duodenojejunostomy.

OUTCOMES

The patient discharged from hospital 10 days after surgery without any postoperative complication. The patient achieved complete relief of symptoms and discontinuation of drug.

LESSONS SUBSECTIONS

Superior mesenteric artery (SMA) syndrome may manifest the symptoms of GERD such as heartburn, acid reflux and cough. It is necessary to complete examination to exclude superior mesenteric artery syndrome for these patients. Laparoscopic fundoplication with duodenojejunostomy provided an effective treatment for patients who failed drug treatment.

[Laparoscopic reoperation for recurred antireflux surgery of gastroesophageal reflux disease]

OBJECTIVE

To investigate the safety and effectiveness of laparoscopic reoperation for patients with gastroesophageal reflux disease (GERD) recurred form previous anti-reflux surgery.

METHODS

Totally 19 patients received laparoscopic reoperation for symptomatic and anatomic recurred GERD in Department of Gastroesophageal Reflux Disease, Rocket Force General Hospital from January 2008 to September 2015 were retrospectively analyzed. There were 12 male and 7 female patients. The average reoperation age was (48±14) years, the average duration of reoperation from original ones was (43±38) months. The patients underwent preoperative barium, endoscopy, manometry and 24-hour pH studies. Laparoscopic hiatal hernia repair plus fundoplication was carried out for reoperation. Gastroesophageal reflux related symptoms (reflux, heartburn, chest pain, chough, wheezing, chest tightness and globus sensation) before and after surgery were compared by a questionnaire. The patients' medication consumption, complications and satisfaction of the reoperation were investigated as well. The repeated measures analysis of variance was used for statistical comparison of data preoperatively and postoperatively.

RESULTS

No major complication and death occurred. Six cases (32%) had complications such as diarrhea, increased passing wind, flatulence, dysphagia and abdominal pain. The GERD related symptom score of reflux, heartburn, chest pain, chough, wheezing, chest tightness and globus sensation all significantly decreased (F: 25.0 to 56.7; P: 0.000 to 0.001) after the reoperation, with 68% good outcome of all the patients. After a follow-up of (33±22) months after reoperation, 1 case had partial recurrence at the 3(rd) month after reoperation. For all the patients, 12 cases felt very satisfied or satisfied with the reoperation.

CONCLUSION

Laparoscopic reoperation is generally effective with acceptable morbidity rates for patients with esophageal and extraesophageal symptoms recurred form previous hiatal repair and (or) fundoplication.

Early and Midterm Outcome After Laparoscopic Fundoplication and a Minimally Invasive Endoscopic Procedure in Patients with Gastroesophageal Reflux Disease: A Prospective Observational Study

BACKGROUND AND AIMS

Although the minimally invasive endoscopic Stretta procedure is being increasingly used as an alternative strategy to manage gastroesophageal reflux disease (GERD), the benefits of this procedure have to be further evaluated in clinical settings. This prospective observational study assessed the short-term and midterm outcomes associated with laparoscopic Toupet fundoplication (LTF) and the Stretta procedure.

PATIENTS AND METHODS

From January 2011 to January 2012, we allocated 80 patients to LTF and 85 to the Stretta procedure. Primary outcome measures, including symptom scores of heartburn, regurgitation, chest pain, belching, hiccup, cough, and asthma, as well as proton pump inhibitor (PPI) use, were analyzed at midterm follow-up (1-3 years).

RESULTS

Of the 165 patients, 125 patients following LTF (n=65) or the Stretta procedure (n=60) completed the designated 3-year follow-up and were included in the final analysis. At the end of the 3-year follow-up, the symptom scores were all significantly decreased compared with the corresponding values before the two procedures in both groups (P<.05). After LTF and the Stretta procedure, 47/65 (72.3%) and 41/60 (68.3%) patients, respectively, achieved complete PPI therapy independence (72.3% versus 68.3%, P=.627). Comparing with LTF, however, the Stretta procedure had less effect on improving typical symptoms of heartburn, regurgitation, and chest pain and reducing the rate of re-operation (11.8% versus 0%, P=.006).

CONCLUSIONS

LTF and the Stretta procedure were equally effective in controlling GERD symptoms and reducing PPI use. However, LTF can achieve more improvement on typical symptoms and has a lower rate of re-operation.

Comparison of Stretta procedure and toupet fundoplication for gastroesophageal reflux disease-related extra-esophageal symptoms

AIM: To compare the outcomes between the Stretta procedure and laparoscopic toupet fundoplication (LTF) in patients with gastroesophageal reflux disease (GERD)-related extra-esophageal symptoms.

METHODS: From January 2011 to February 2012, a total of 98 patients diagnosed with GERD-related extra-esophageal symptoms who met the inclusion criteria were enrolled in this study. All patients who either underwent the Stretta procedure or LTF treatment have now completed the 3-year follow-up. Primary outcome measures, including frequency and severity of extra-esophageal symptoms, proton pump inhibitor (PPI) use, satisfaction, and postoperative complications, were assessed. The results of the Stretta procedure and LTF therapy were analyzed and compared.

RESULTS: There were 47 patients in the Stretta group and 51 patients in the LTF group. Ninety patients were available at the 3-year follow-up. The total of the frequency and severity scores for every symptom improved in both groups (P < 0.05). Improvement in symptom scores of cough, sputum, and wheezing did not achieve statistical significance between the two groups (P > 0.05). However, the score for globus hysterics was different between the Stretta group and the LTF group (4.9 ± 2.24 vs 3.2 ± 2.63, P < 0.05). After the Stretta procedure and LTF treatment, 29 and 33 patients in each group achieved PPI therapy independence (61.7% vs 64.7%, P = 0.835). The patients in the LTF group were more satisfied with their quality of life than those in the Stretta procedure group (P < 0.05). Most complications resolved without intervention within two weeks; however, two patients in the LTF group still suffered from severe dysphagia 2 wk after the operation, and it improved after bougie dilation treatment in both patients.

CONCLUSION: The Stretta procedure and LTF were both safe and effective for the control of GERD-related extra-esophageal symptoms and the reduction of PPI use.

Gastroesophageal reflux disease related asthma: From preliminary studies to clinical practice

The diagnosis of asthma requires the presence of episodic respiratory difficulties characterized by variable and reversible airway obstruction. It has a high prevalence worldwide and is traditionally considered to be an allergic disease. Most cases are responsive to treatment with bronchodilators and anti-inflammatories, as recommended by national and international guidelines; however, approximately 10% of asthmatic patients are refractory even to optimal therapy. Gastroesophageal reflux disease (GERD) is a common disorder in asthmatic patients and the two disorders may be linked pathophysiologically. Here we review data from preliminary studies that suggest asthma could be induced or exacerbated by gastroesophageal reflux. The optimal strategies for the diagnosis of GERD-related asthma and its therapy are still debated. However, there is evidence to suggest that antireflux treatment is effective and practical for asthmatic patients with well-defined reflux disease.

[Establishment of a FVB/N mouse model of cardiac hypertrophy by isoprenaline]

OBJECTIVE

To investigate the condition of isoprenaline (ISO)-induced cardiac hypertrophy in the FVB/N mouse.

METHODS

ISO (30 mg/kg/d) was administered either by daily subcutaneous injection, or by continuous infusion via an implanted osmotic minipump. The mice in each mode of administration were randomly divided into two groups. For subcutaneous injection: the mice received ISO or saline through daily subcutaneous injection for 2 weeks. The mice for minipump: the mice received continuous infusion of ISO via an implanted osmotic minipump for 2 weeks, or received sham operation as the control to mimipump. The ratio of heart weight to tibia length (HW/TI), the diastolic left ventricular posterior wall thickness (dLVPW) were used to indicate cardiac hypertrophy. Interstitial fibrosis was examined with picrosirius red staining.

RESULTS

ISO (30 mg/kg/d) administered by daily subcutaneous injection did not lead to cardiac hypertrophy or fibrosis in the FVB/N mice, and 50% of the mice died before the end point. The mice receiving ISO via minipumps showed significant increase in HW/TI [(10.60±0.40 ) mg/mm vs. (7.93±0.19) mg/mm,P<0.001] and dLVPW [(0.87±0.03) mm vs. (0.68±0.06)mm,P=0.0116]. ISO administered via minipumps did not induce cardiac fibrosis. All the mice in this group survived to the end point.

CONCLUSION

ISO (30 mg/kg/d) administered by continuous infusion via a minipump for 2 weeks can lead to significant cardiac hypertrophy.

Long-term outcomes of patients with refractory gastroesophageal reflux disease following a minimally invasive endoscopic procedure: a prospective observational study

BACKGROUND

Gastroesophageal reflux disease (GERD) is the most common digestive disease, affecting one third of the world's population. The minimally invasive endoscopic Stretta procedure is being increasingly used as an alternative strategy to manage refractory GERD. However, long-term benefits of this procedure have to be further evaluated in clinical settings. This prospective observational study was therefore conducted to evaluate the outcome of patients with refractory GERD 5 years after the Stretta procedure.

METHODS

A total of 152 patients with refractory GERD underwent the Stretta procedure in our department between April 2007 and September 2008. They were followed up for 5 years, during which the primary outcome measures including symptom scores of heartburn, regurgitation, chest pain, cough and asthma and the secondary outcome measures including proton pump inhibitor (PPI) use and patients' satisfaction were analysed at 6, 12, 24, 36, 48 and 60 months respectively.

RESULTS

Of the 152 patients, 138 completed the designated 5-year follow-up and were included in the final analysis. At the end of the 5-year follow-up, the symptom scores of heartburn (2.47 ± 1.22 vs. 5.86 ± 1.52), regurgitation (2.23 ± 1.30 vs. 5.56 ± 1.65), chest pain (2.31 ± 0.76 vs. 4.79 ± 1.59), cough (3.14 ± 1.43 vs. 6.62 ± 1.73) and asthma (3.26 ± 1.53 vs. 6.83 ± 1.46) were all significantly decreased as compared with the corresponding values before the procedure (P < 0.001). After the Stretta procedure, 59 (42.8%) patients achieved complete PPI therapy independence and 104 (75.4%) patients were completely or partially satisfied with the GERD symptom control. Moreover, no severe complications were observed except for complaint of abdominal distention in 12 (8.7%) patients after the Stretta procedure.

CONCLUSION

The Stretta procedure may achieve an effective and satisfactory long-term symptom control and considerably reduce the reliance on medication without significant adverse effects in adult patients with refractory GERD, thereby having profound clinical implications.

Long-term outcomes of patients with refractory gastroesophageal reflux disease following a minimally invasive endoscopic procedure: a prospective observational study

BACKGROUND

Gastroesophageal reflux disease (GERD) is the most common digestive disease, affecting one third of the world's population. The minimally invasive endoscopic Stretta procedure is being increasingly used as an alternative strategy to manage refractory GERD. However, long-term benefits of this procedure have to be further evaluated in clinical settings. This prospective observational study was therefore conducted to evaluate the outcome of patients with refractory GERD 5 years after the Stretta procedure.

METHODS

A total of 152 patients with refractory GERD underwent the Stretta procedure in our department between April 2007 and September 2008. They were followed up for 5 years, during which the primary outcome measures including symptom scores of heartburn, regurgitation, chest pain, cough and asthma and the secondary outcome measures including proton pump inhibitor (PPI) use and patients' satisfaction were analysed at 6, 12, 24, 36, 48 and 60 months respectively.

RESULTS

Of the 152 patients, 138 completed the designated 5-year follow-up and were included in the final analysis. At the end of the 5-year follow-up, the symptom scores of heartburn (2.47 ± 1.22 vs. 5.86 ± 1.52), regurgitation (2.23 ± 1.30 vs. 5.56 ± 1.65), chest pain (2.31 ± 0.76 vs. 4.79 ± 1.59), cough (3.14 ± 1.43 vs. 6.62 ± 1.73) and asthma (3.26 ± 1.53 vs. 6.83 ± 1.46) were all significantly decreased as compared with the corresponding values before the procedure (P < 0.001). After the Stretta procedure, 59 (42.8%) patients achieved complete PPI therapy independence and 104 (75.4%) patients were completely or partially satisfied with the GERD symptom control. Moreover, no severe complications were observed except for complaint of abdominal distention in 12 (8.7%) patients after the Stretta procedure.

CONCLUSION

The Stretta procedure may achieve an effective and satisfactory long-term symptom control and considerably reduce the reliance on medication without significant adverse effects in adult patients with refractory GERD, thereby having profound clinical implications.

Stretta radiofrequency for gastroesophageal reflux disease-related respiratory symptoms: a prospective 5-year study

AIM

The aim of the present study was to prospectively evaluate the Stretta radiofrequency (RF) treatment for gastroesophageal reflux disease (GERD) -related respiratory symptoms over a 5-years follow-up period.

METHODS

A total of 132 patients underwent the Stretta procedure between April 2007 and February 2009; 122 of the patients (92.4%) completed the 5-year follow-up. Symptom scores and PPI usage were evaluated at baseline, 6 months, 1 year, 3 years and 5 years after treatment.

RESULTS

A total of 122 patients (age, 51.7 ± 13.0 years, M:F, 52: 70) were followed up for 5 years and their outcomes were analyzed. At 5 years after treatment, the symptom scores were significantly reduced (heartburn score, from 5.67 ± 1.52 to 2.41 ± 1.13; regurgitation score, from 5.43 ± 1.66 to 2.27 ± 1.33; chest pain score, from 4.45 ± 1.47 to 2.40 ± 0.88; cough score, from 6.62 ± 1.73 to 3.14 ± 1.43; and asthma score, from 6.83 ± 1.46 to 3.26 ± 1.53, P<0.001). Moreover, 56.6% of the patients were completely off PPIs.

CONCLUSION

Stretta RF significantly improves the symptoms and reduces PPI usage at 5 years. Therefore, it is a viable, effective, and minimally invasive endoluminal procedure for patients with GERD-related respiratory symptoms.

[Response rules of pressing pain on back section in Governor Vessel in patients with gastroesophageal reflux disease]

The response rules of pressing pain on the back section in the Governor Vessel in patients with gastro-esophageal reflux disease (GERD) were studied to provide references for the diagnosis and treatment of GERD. Seventy-six cases of GERD were included into an observation group while 30 healthy volunteers were recruited into a control group. A mechanical measurement device of pressing pain that could measure the pain threshold was adapted to observe the pressing pain on the back section in the Governor Vessel in GERD patients and healthy volunteers. The test area is from spinous process of the 1st thoracic vertebra to that of the 12th thoracic vertebra (T1 -T12), including acupoints and non-acupoints on the Governor Vessel. As a result, in the observation group the pain threshold of T5-T7 spinous process clearance, which was the location of Shendao (GV 11), Lingtai (GV 10) and Zhiyang (GV 9), was lower than that in the control group (all P < 0.05). This result indicated that there was significant pressing pain in T5-T7 spinous process clearance in patients with GERD, which could be taken as an important auxiliary diagnosis and a new thinking method in the treatment of GERD with acupuncture.

Laparoscopic Nissen fundoplication is more effective in treating patients with GERD-related chronic cough than Stretta radiofrequency

AIM

Chronic cough is the most common extra-esophageal manifestation of gastroesophageal reflux disease (GERD). This study aimed to retrospectively analyze outcomes in patients with GERD-related cough following laparoscopic Nissen fundoplication (LNF) and Stretta radiofrequency (RF) respectively.

METHODS

Medical charts of 83 patients with GERD-related cough that underwent LNF or Stretta RF between 2007 and 2012 were retrieved. Symptom scores (heartburn, regurgitation and cough) and proton pump inhibitors (PPIs) usages were evaluated.

RESULTS

A total of 83 patients with GERD-related cough underwent LNF (N.=35) and Stretta RF (N.=48), and were followed up 36.78 ± 16.12 months (range 13-55 months). During the follow-up, the post-treatment scores were statistically lower as compared with the pre-treatment scores in both groups, while the cough improvement after Stretta was significantly lower than that after LNF (P<0.001). Besides, 27 (77.1%) patients achieved complete PPI therapy independence after LNF, comparing with 27 (65.1%) after Stretta (P<0.05). No significant differences in post-treatment complications were observed except for the abdominal distention.

CONCLUSION

Even though laparoscopic Nissen fundoplication and Stretta are capable of controlling GERD-related cough effectively and safely in selected patients, laparoscopic Nissen fundoplication could improve more in symptoms and PPI elimination.

Gastroesophageal reflux in chronic cough and cough syncope and the effect of antireflux treatment: case report and literature review

OBJECTIVE

This study aimed to evaluate the efficacy of antireflux treatment on gastroesophageal reflux (GER)-related cough syncope.

METHODS

The method used was a retrospective review of the outcomes of antireflux treatment with proton pump inhibitor (PPI), Stretta radiofrequency (SRF), or laparoscopic fundoplication (LF) of 8 patients with chronic cough and cough syncope that was clinically evaluated to be GER related over a period of 2 to 5 years.

RESULTS

In the 8 selected cases, the typical GER symptoms disappeared in 7 cases and were significantly eased in 1 case. The chronic cough diminished to mild and occasional occurrence in 6 cases and was completely relieved in 2 cases. Meanwhile, the cough syncope disappeared in all cases. Seven of the patients resumed physical and social functions after the antireflux treatments, except for 1 person, who had a stroke due to other causes.

CONCLUSION

For chronic cough and cough syncope of unknown cause, the GER assessment could be valuable. In treating well-selected GER-related chronic cough and cough syncope, PPI, SRF, and LF can be considered. Moreover, satisfactory restoration of physical and social functions could be achieved after effective antireflux therapy.

Prevalence and genetic characterization of Toxoplasma gondii infection in bats in southern China

Toxoplasma gondii can infect a wide variety of warm-blooded animals, including bats. Limited information on T. gondii infection in bats is available in China. The objective of the present study was to determine prevalence and genetic diversity of T. gondii infection in bats in southern China. A total of 608 bats representing 12 species, including 120 Aselliscus stoliczkanus, 59 Myotis chinensis, 11 Miniopterus schreibersii, 53 Rhinolophus affinis, 32 Rhinolophus pusillus, 81 Hipposideros armiger, 28 Hipposideros fulvus, 32 Cynopterus brachyotis, 14 Cynopterus sphinx, 45 Eonycteris spelaea, 109 Hipposideros larvatus, and 24 Taphozous melanopogon, were collected from Yunnan and Guangxi provinces, southern China. They were examined for the presence of T. gondii DNA by amplification of the B1 gene using a nested PCR, and the positive samples were genotyped at 11 genetic loci (SAG1, 5'- and 3'-SAG2, alternative SAG2, SAG3, BTUB, GRA6, c22-8, c29-2, L358, PK1 and Apico) using multilocus polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) technology. Fifty-nine (9.7%) of these bats were detected positive by PCR but only five of these positive DNA samples were completely typed at all loci; of which 4 samples, 2 from A. stoliczkanus, and 2 from H. larvatus, belonged to ToxoDB Genotype #10, and the other one from H. larvatus was identified as ToxoDB Genotype #9 (http://toxodb.org/toxo/). To our knowledge, this is the first report of molecular detection and genetic characterization of T. gondii infection in bats in China. The results show that these bats are potential reservoirs for T. gondii transmission, which may pose a threat to human health.

Acute hyperglycemia together with hematoma of high-glucose blood exacerbates neurological injury in a rat model of intracerebral hemorrhage

Recent evidence suggests that admission hyperglycemia has deleterious effects on the survival and functional outcome of patients with intracerebral hemorrhage (ICH). In this study, we first induced acute hyperglycemia in male adult Sprague-Dawley rats by intraperitoneal injection of 50% glucose (6 mL/kg), and created the ICH model thereafter by delivering autologous whole blood or homologous normal-glucose blood into the right basal ganglia. Twenty-four hours later, we assessed the neurological injury, evaluated the hematoma and brain water content, and investigated autophagy. We found elevations of neurological deficit scores, brain water content, and microtubule-associated protein light chain-3 (LC3) and beclin-1 protein levels, and decreased SQSTM1/ p62 levels after ICH with normal-glucose blood (without hyperglycemia). Acute hyperglycemia with ICH of high-glucose blood hematoma was associated with significantly increased forelimb-use asymmetry test scores, brain water content and SQSTM1/p62 protein levels, and evident decreases in the ratio of LC3-II/LC3-I and beclin-1 protein levels. On the other hand, acute hyperglycemia and ICH with normal-glucose blood hematoma only slightly increased the neurological deficit scores and brain water content (P >0.05). In conclusion, the autophagy pathway was activated after ICH, and acute hyperglycemia with hematoma of high-glucose blood exacerbates the neurological injury, and reduces autophagy around the hematoma.

Gastroesophageal reflux in bronchiectasis and the effect of anti-reflux treatment

BACKGROUND

Bronchiectasis is a progressive and fatal disease despite the available treatment regimens. Gastroesophageal reflux (GER) may play an important role in the progression of bronchiectasis. However, active anti-reflux intervention such as Stretta radiofrequency (SRF) and/or laparoscopic fundoplication (LF) have rarely been used to treat Bronchiectasis.

CASE PRESENTATION

Seven patients' clinical outcomes for treating GER-related deteriorated bronchiectasis were retrospective reviewed. All patients were treated by SRF and/or LF, and had follow-up periods ranging from one to five years. Typical GER symptoms, respiratory symptoms, medication consumption and general health status were assessed during the follow-ups. At the latest follow-up all patients were alive. The typical GER symptoms disappeared in five people and were significantly improved in the other two. Two had complete remissions of both respiratory symptoms and bronchiectasis exacerbations; four had significantly improved respiratory symptoms to mild/moderate degrees as well as reduced or zero bronchiectasis exacerbations, which allowed them to resume the physical and social functions; one's respiratory symptoms and bronchiectasis exacerbations were not much improved, yet she was in stable condition and satisfied with the results.

CONCLUSIONS

Potentially, GER plays an important role in some patients with bronchiectasis, and active anti-reflux treatments can be beneficial. Future clinical studies are suggested to clarify GER's role in bronchiectasis and to further determine whether anti-reflux interventions for GER can improve the outcomes of patients with bronchiectasis.

Dynamic QTL analysis for fruit lycopene content and total soluble solid content in a Solanum lycopersicum x S. pimpinellifolium cross

Fruit lycopene content and total soluble solid content are important factors determining fruit quality of tomatoes; however, the dynamic quantitative trait loci (QTL) controlling lycopene and soluble solid content have not been well studied. We mapped the chromosomal regions controlling these traits in different periods in F(2:3) families derived from a cross between the domestic and wild tomato species Solanum lycopersicum and S. pimpinellifolium. Fifteen QTLs for lycopene and soluble solid content and other related traits analyzed at three different fruit ripening stages were detected with a composite interval mapping method. These QTLs explained 7-33% of the individual phenotypic variation. QTLs detected in the color-changing period were different from those detected in the other two periods. On chromosome 1, the soluble solid content QTL was located in the same region during the color-changing and full-ripe periods. On chromosome 4, the same QTL for lycopene content was found during the color-changing and full-ripe periods. The QTL for lycopene content on chromosome 4 co-located with the QTL for soluble solid content during the full-ripe period. Co-location of lycopene content QTL and soluble solid content QTLs may be due to pleiotropic effects of a single gene or a cluster of genes via physiological relationships among traits. On chromosome 9, the same two QTLs for lycopene content at two different fruit ripening periods may reflect genes controlling lycopene content that are always expressed in tomato fruit development.

Anti-reflux procedure for difficult-to-treat asthmatic children, case report and literature review

Gastroesophageal reflux disease (GERD) is a commonly encountered condition in children, which at times causes respiratory distress, such as asthmatic symptoms, and results in serious morbidity and even mortality. The complexity is sometimes so obscure, that it can cause paradoxical diagnoses and treatment. Here we present two cases of children with difficult-to-treat asthmatic symptoms, which were eventually found to be related to GERD. The two children were treated with anti-reflux procedures and both became symptom free. Literature was also reviewed to shed a light into this complex disease.

Anti-reflux procedure for difficult-to-treat asthmatic children, case report and literature review

Gastroesophageal reflux disease (GERD) is a commonly encountered condition in children, which at times causes respiratory distress, such as asthmatic symptoms, and results in serious morbidity and even mortality. The complexity is sometimes so obscure, that it can cause paradoxical diagnoses and treatment. Here we present two cases of children with difficult-to-treat asthmatic symptoms, which were eventually found to be related to GERD. The two children were treated with anti-reflux procedures and both became symptom free. Literature was also reviewed to shed a light into this complex disease.