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Background: Many surgeons feel comfortable performing ARS on the basis of symptomatic evaluation, endoscopy and esophageal manometry, while a pH monitoring is seldom obtained.
Aims: To analyze the sensitivity and specificity of symptoms, barium esophagogram, endoscopy and manometry as compared to pH monitoring in the preoperative evaluation of patients for ARS.
Patients and Methods: 134 patients referred for ARS with a diagnosis of GERD based on symptoms, endoscopy, barium esophagogram and manometry. Ambulatory 24 hour pH monitoring was performed preoperatively in all of them.
Results: Based on the presence or absence of GERD on pH monitoring, patients were divided into two groups: GERD+ (n = 78) and GERD- (n = 56). The groups were compared with respect to the incidence of symptoms, presence of reflux and hiatal hernia on esophagogram, endoscopic findings, and esophageal motility.
There was no difference in the incidence of symptoms between the two groups (p=NS). Within the GERD+ group, 37 patients (47%) had reflux at the esophagogram and 41 (53 %) had no reflux. Among the GERD- patients, 17 (30%) had reflux and 39 (70%) had no reflux. Therefore, the sensitivity of esophagogram was 47% and the specificity was 70%. A hiatal hernia was present in 40% and 32% of patients respectively. Esophagitis was found at endoscopy in 16% of GERD+ patients and in 20% of GERD- patients, accounting for a sensitivity of 16% and a specificity of 80%. Esophageal manometry showed no difference in the pressure of the lower esophageal sphincter or the quality of peristalsis. Ambulatory 24-hour pH monitoring clearly separated the 2 groups (Table).
Conclusions: The results of this study showed that: (a) symptoms were unreliable in diagnosing GERD; (b) the presence of reflux or hernia on esophagogram did not correlate with reflux on pH monitoring; (c) endoscopy had low sensitivity and specificity; and (d) manometry was mostly useful for positioning the pH probe and rule out achalasia. We conclude that ambulatory pH monitoring should be routinely performed in the preoperative work-up of patients suspected of having GERD in order to avoid useless ARS.

N =134	GERD+ (78 pts)	GERD - (56 pts)	p
Reflux score	48 ± 37	6 ± 4	<0.0001§
Heartburn	(57) 73%	(35) 62%	0.193*
Regurgitation	(48) 61%	(26) 46%	0.083*
Dysphagia	(39) 50%	(31) 55%	0.540*
Reflux on BE	(37) 47%	(17) 30%	0.047*
Hiatal Hernia on BE	(31) 40%	(18) 32%	0.368*
Esophagitis	(6) 16%	(5) 20%	0.477*
LES pressure (mmHg)	18 ± 10	25 ± 26	0.37§
Normal peristalsis	(53) 68%	(45) 80%	0.110*

§Wilcoxon-Mann Whitney test; *Chi-square test; BE = barium esophagram; LES = lower esophageal sphincter; reflux score normal <14.7 Continuous variables are expressed as mean ± standard deviation.