Mean height, weight, and BMI of AMN-107 the patients were within normal limits. These findings are comparable to those found in the study by Lal et al. [3], where mean age was 37.38 years and 35.33 years for the groups treated by laparoscopic Nissen’s and laparoscopic Toupet’s fundoplication, respectively [3]. They had also found that gastroesophageal reflux disease had equal sex distribution (50% for males and females) [3]. Nagpal et al. [4] found that 57.14% of the patients were males and 42.86% were females [4]. 72% cases had daily intake of tea or coffee (more than 2 cups per day) and 68% cases had sedentary life style, whereas 50% cases had spicy and oily food and 46% had non-vegetarian diet. 32% cases had alcohol consumption and smoking/tobacco chewing, respectively.

This is in accordance with the study by Somi et al. [5], where drinking excess amount of tea was associated with symptoms of gastroesophageal reflux disease [5]. Heartburn (94%) and regurgitation (92%) were the most common symptoms at the time of diagnosis. Dysphagia (16%) was uncommon. Angina like chest pain and respiratory symptoms (cough and hoarseness) were not seen (Table 1). In the study done by Nagpal et al. [4], the most common symptom was heartburn, followed by regurgitation and constipation [4]. In a study of 107 patients done by Balsara et al. [6], the symptoms on presentation were heartburn in all (100%), regurgitation in 43 (50.59%), and volume reflux in 39 (45.88%) patients [6]. Table 1 Symptomatology at presentation. On endoscopy, hiatal hernia was present in 100% of the cases at diagnosis.

All the patients had type I (sliding) hiatal hernia. Esophagitis was present in 66% patients (mainly Grade A and Grade B) at diagnosis (Table 2). Table 2 Comparison of changes in endoscopy findings in operated cases. On esophageal manometry, there was a hypotensive lower esophageal sphincter with complete relaxation and presence of hiatal hernia in 100% of the cases. Esophageal body motility was normotensive in the majority of cases (88%) and was hypotensive in only 12% (Table 3). No studies have documented manometric findings in such detail. Table 3 Comparison of changes in manometry findings in operated cases. Barium studies were not done as they are outdated now. 24-hour pH studies could not be done as they are expensive and not available in our public setup.

After three months of conservative management (with lifestyle changes, tablet Pantoprazole 40mg twice a day, and tablet Levosulpiride 75mg twice a day), heartburn (54%) and regurgitation (50%) were the persistent symptoms. Overall, there were 30 patients who were still symptomatic (60% cases) after three months of conservative management. This is in accordance with the findings of Drug_discovery Sifrim and Zerbib [7], who noted that approximately a third of patients with suspected gastroesophageal reflux disease are resistant or partial responders to proton pump inhibitors [7].