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The Role of Syptom Index (SI) and Symptom Associated Probability (SAP) in the Surgical Treatment of Atypical GERD Symptoms
Andreas M. Schneider*, Brian E. Louie, Ralph W. Aye, Alexander S. Farivar
Thoracic Surgery, Swedish Medical Center, Seattle, WA
Introduction: Gastroesophageal reflux disease (GERD) is a common disease that causes a variety of symptoms that can significantly impair quality of life. Patients presenting with typical symptoms such as heartburn or regurgitation are well known to have an excellent response to surgery; whereas patients with atypical symptoms such as hoarseness, chronic cough, chest pain, aspiration and recurrent pneumonia have a less predictable surgical outcome and can pose a significant diagnostic and therapeutic challenge. PH monitoring and symptom indices such as Symptom Index (SI) and Symptom Associated Probability (SAP) are established parameters that help determine symptom correlation but have been studied primarily in patients with typical symptoms. We aimed to investigate the correlation of SI and SAP to postoperative outcomes and rate of symptom resolution to better predict the surgical response in patients with atypical symptoms.
Methods: Retrospective, single center study presenting with atypical symptoms who underwent surgical fundoplication from 2009 - 2013. Three clusters of frequent symptoms were analyzed. 1) ENT - sore throat, hoarseness, throat clearing. 2) Chest pain other than heartburn, paraesophageal hernia's were excluded. 3) Respiratory - cough, asthma, aspiration, recurrent pulmonary infections. A positive surgical outcome was defined as a postoperative symptom improvement of more than 50% from baseline. SI and SAP were determined for each symptom and the corresponding sensitivity and specificity as well as positive predictive values (PPV) and negative predictive values (NPV) were calculated.
Results: A total of 133 patient were identified: 115 with primary atypical symptoms, 72 with secondary atypical symptoms. The ENT group included sore throat (13), hoarseness (9), throat clearing (3) and 7 had other symptoms, of these 71% had an improvement of symptoms. Thirty patients presented with chest pain, of these 80% had significant improvement of their symptoms. Respiratory symptoms occurred in 72 patients and included cough (39), aspiration (15), recurrent infections (9), asthma (7) and SOB (2) and 79.2% had significant improvement of their symptoms. Table 1. shows the results of SI and SAP for each symptom complex.
Conclusion: Patients with atypical symptoms continue to pose a significant diagnostic and prognostic challenge. Fundoplication results is symptom resolution in the majority of patients. The role of SI and SAP in predicting surgical outcomes remains unclear. Despite a wide variation in sensitivity and specificity, patients with a positive test may have a good likelihood of improving after fundoplication. Further prospective studies are needed to help improve predictability of surgical outcomes for patients with atypical symptoms.
Results
| SI - ENT | SAP - ENT | SI - Chest Pain | SAP - Chest Pain | SI - Respiratory | SAP - Respiratory | | Sensitivity: | 18.2% | 13.6% | 54.2% | 28.6% | 39.7% | 46% | | Specificity: | 88.9% | 88.9% | 60% | 50% | 28.6% | 50% | | PPV: | 80% | 75% | 86.7% | 66.7% | 69.7% | 79.3% | | NPV: | 30.8% | 29.6% | 21.4 | 16.7% | 10.3% | 18.2% |
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