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Importance of Esophageal Manometry and pH Monitoring in the Evaluation of Patients With "Refractory GERD". a Multicenter Study.
Ciro Andolfi*1, Luigi Bonavina2, Robert T. Kavitt3, Vani J. Konda3, Emanuele Asti2, Marco G. Patti1
1Department of Surgery, University of Chicago, Chicago, IL; 2General Surgery, University of Milan Medical School, Milan, Italy; 3Gastroenterology, University of Chicago, Chicago, IL
Background: Patients who have heartburn are treated with acid reducing medications on the assumption that gastroesophageal reflux disease (GERD) is causing the symptom. In the absence of a response to therapy, they are often assumed to have “refractory GERD”, and they are referred for laparoscopic antireflux surgery (LARS), often without further diagnostic evaluation. We hypothesized that in some of these patients the heartburn is not secondary to reflux, but rather to stasis of food in the presence of achalasia, and that esophageal manometry and pH monitoring are essential to establish the proper diagnosis before surgery is considered.
Objective: To determine the prevalence of patients affected by achalasia previously treated for GERD and referred for LARS.
Design: Retrospective review of prospectively maintained databases.
Setting: Esophageal teams (radiologists, gastroenterologists and surgeons) in two quaternary care centers.
Patients and Methods: Five hundred and twenty-four patients referred to our centers, whose final diagnosis was achalasia. Symptomatic evaluation (Eckardt score, ES), barium swallow, endoscopy, manometry and pH monitoring were performed in all patients.
Main outcome measures: Number of patients treated for GERD and referred for LARS.
Results: One hundred and fifty-two patients (29%) had been treated with acid suppressing medications for an average of 29.3 months and were referred for LARS. One patient had already been treated with a Nissen fundoplication. All patients were diagnosed with achalasia, with a mean ES of 6.3, and underwent Heller myotomy and partial fundoplication. At a median follow-up of 40 months, the mean ES was 0.5.
Conclusions: The results of this study showed that: (a) in one third of achalasia patients, heartburn was the main complain; and (b) patients with refractory GERD need to be carefully evaluated before referral to surgery. These data confirm the importance of esophageal manometry and pH monitoring in any patient considered for LARS.
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