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Introduction: Prospective randomized trials document long term relief of gastro-esophageal reflux (GERD) symptoms in 85% of patients following antireflux surgery. One of the key challenges, in the decision to pursue antireflux surgery, is assuring that the patients symptoms are actually caused by GERD. Mathematical calculations of the relationship of reflux events to the occurrence of symptoms have been proposed as a mechanism to support GERD as the underlying cause of both typical and atypical reflux symptoms. The symptom index (SI) and Symptom Association Probability (SAP) are the most commonly calculated measures in clinical use. The clinical utility of these measures is unclear and unexplored with respect to antireflux surgery.
Methods: The study population included 66 patients (mean age 52.6 years; 58% female) undergoing laparoscopic fundoplication from November 2006 to October 2011. All were pH-positive (DeMeester Score >14.72) with either cough, heartburn and/or regurgitation, in which SI (positive ≥50%) and SAP (positive ≥95%) were calculated pre-op. Symptom outcome after surgery was categorized as ‘improvement’, ‘no change’ and ‘worsening’ in their symptoms. All available data were logged into SPSS (version 18) for statistical analyses.
Results: At the time of pH testing heartburn was recorded in 51 (84%), regurgitation in 22 (33%) and cough in 21 (32%) patients. One or both symptom indices were positive in 85% (56/66) and both negative in 15% (10/66) of the patients. Cough was significantly less associated with positive SI and/or SAP when compared to heartburn and regurgitation (SI 19% vs. 72.5% and 81.8%; p<0.0001; SAP 33.3% vs. 78.4% and 68.2%; p=0.0007 and p=0.0337 respectively). Overall, 93% (62/66) of patients reported improvement in their symptoms which was independent of a positive or negative SI or SAP. Eighty percent of patients (8/10) with negative SI and SAP pre-op improved compared to 87% (54/62) with positive SI and/or SAP (p=0.6217). There was no significant difference in symptom improvement between atypical and typical symptoms; patients with heartburn improved in 98%, regurgitation in 95.5% and cough in 85.7% (p=0.072).
Conclusion: These data show that symptom improvement following antireflux surgery is independent of the commonly used 24hour pH symptom indices SI and SAP. Atypical symptoms such as cough are less likely associated with a positive symptom index, particularly when compared to typical symptoms such as heartburn and regurgitation.