Gastroesophageal reflux disease. Are we acting in the best interest of our patients?

Oesophageal adenocarcinoma is strictly related to gastroesophageal reflux and cylindrical metaplasia of the epithelium of the distal esophagus (Barrett's esophagus) due to chronic inflammation. Worldwide incidence of oesophageal adenocarcinoma is rising despite the availability of precise international guidelines for the treatment of gastroesophageal reflux disease and the increasing use of proton-pump inhibitors (PPIs). While PPIs can control GERD symptoms in a significant amount of cases, still a large number of patients progress to Barrett's esophagus and adenocarcinoma. Recent investigations have demonstrated that in one-third of the patients their reflux symptoms are due to non-acid reflux, obviously not affected by PPIs. Robust evidences are available to demonstrate the role of non-acid reflux in the development of Barrett's esophagus and adenocarcinoma. Therefore, PPIs are not effective in preventing the worst complications of GERD. It is mandatory to develop new and more effective guidelines on the treatment of GERD; that would take into account the fact that GERD should be considered a "surgical" disease, as it is due, at least in its late stages, to an anatomical defect of the lower oesophageal sphincter. Medical treatment should be considered in early stage GERD, when reflux is due to transient relaxations of the lower oesophageal sphincter, whereas surgery should be considered in late stages, in the presence of a demonstrated mechanical failure of the sphincter.