1. Reflux

2. Common Symptoms Heartburn Globus Chest Pains

3. Complex Reflux Symptoms Mass Reflux Cough/Asthma/recurrent Chest Infections Sore Throat

4. Complex Symptoms Dysphagia Pain

5. Differential Diagnoses Cancer Dysmotility –Oesophageal –gastric

6. Treatment Conservative Medical –PPI –Barrier Surgical

7. Medical vs Surgical Only three Trials of Lap vs Medicine –Mahon 2005 –Anvari 2006 –Grant 2008 All Show improve QOL at 1 year

8. Indications for Surgery Lifestyle Breakthrough Symptom Control Complex Reflux Control

9. Why pH Manometry Prove reflux Avoid dysmotility Manage expectation

10. Patients All three patients described have –Dysphagia –Odynophagia –Reflux

11. Hypotensive dysmotility – typical of GORD

13. Vigorous Achalasia

16. Structural obstruction at the PIP

18. Complex Reflux Disease Mr Yuen Soon