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BACKGROUND:
Gastroesophageal reflux (GER) has been defined as abnormal acid exposure in the distal esophagus as measured by 24 hr pH testing. However, there is a subset of patients who present with classic reflux symptoms but have a normal pH test. These patients present a treatment dilemma for the esophageal surgeon as anti-reflux surgery (ARS) based on symptoms alone has often been associated with unpredictable outcomes. Non-acid reflux has been suggested as a valid indication for ARS in certain subsets of patients as identified by multi-channel intraluminal impedance (MII) testing . However, there is a paucity of data regarding the incorporation of this modality in routine surgical decision making. The aim of this study is to evaluate the impact of MII-pH testing in a high volume ARS practice.
METHODS:
Routine pH-MII testing was incorporated in our esophageal testing laboratory in 2010. Prospectively collected data for all patients who underwent standard laparoscopic Nissen fundoplication from 2004-2010 was reviewed. Patients with partial fundoplication, gastroparesis, paraesophageal hernia, redo ARS or Collis gastroplasty were excluded. Patients were divided into 2 groups (pH-ONLY, pH-MII) based on the type of testing they had before surgery. Standardized symptom assessment scores (pre and postoperative), indication for operation and pH and pH-MII results were analyzed. Total number of referrals for ARS with normal preoperative pH testing was recorded for comparison.
RESULTS:
Three hundred five ARS patients were analyzed (250 pH-ONLY, 55 pH-MII). In the pH ONLY group, 17/250 (6.8%) underwent ARS despite a normal preoperative pH test compared to 13/55 (23.6%) in the pH-MII group (p=0.0004). The average number of referrals for ARS with normal preoperative pH testing was 50/yr and did not change with the introduction of pH-MII testing but annual rate of ARS in patients with a normal preoperative pH increased from 4/50 (8%) to 12/50 (24%) (p=0.03). Primary symptoms for patients with normal pH were similar for both groups. The most common surgical indications were similar between groups: esophagitis, large-volume regurgitation, and symptom correlation (pH-ONLY) or positive symptom index (pH-MII). The MII testing influenced the decision to operate in seventy-seven percent of patients in the pH-MII group (6/13 abnormal reflux events, 4 positive symptom index) and the remainder (3/13) had biopsy proven esophagitis. The symptom scores for heartburn, regurgitation, and chest pain were improved after surgery in both groups (p<0.05).
CONCLUSIONS:
Conventional pH testing has been the gold standard for selecting patients for ARS. In patients with normal 24-hour pH testing, the addition of impedance resulted in a 3-fold increase in patients identified as appropriate surgical candidates.