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WHICH IS THE BEST REFLUX MONITORING TEST CRITERION TO SELECT PATIENTS FOR SURGERY?
Marco Sozzi^*1, Stefano Siboni¹, Roberta De Maron¹, Pierfrancesco Visaggi², Nicola De Bortoli², Salvatore Tolone³, Elisa Marabotto⁴, Daniele Bernardi¹, Edoardo V. Savarino⁵, Emanuele L. Asti¹, C. Prakash Gyawali^6
1General and Emergency Surgery, IRCCS Policlinico San Danato, San Donato Milanese, Lombardia, Italy; ²Universita degli Studi di Pisa, Pisa, Toscana, Italy; ³Universita degli Studi di Napoli Federico II, Napoli, Campania, Italy; ⁴Universita degli Studi di Genova, Genova, Liguria, Italy; ⁵Universita degli Studi di Padova, Padova, Veneto, Italy; ⁶Washington University in St Louis, St Louis, MO

BACKGROUND
According to Lyon consensus 2.0, the main pH parameter for definitive diagnosis of gastroesophageal reflux disease (GERD) is an acid exposure time (AET) >6%. However, this parameter is not universally accepted, as it does not take into account supine reflux, which is heavily associated with erosive GERD, and it lacks of sensitivity, despite an excellent specificity. Many surgeons value more the traditional DeMeester score (DMS), particularly to select patients for anti-reflux surgery (ARS), although it presents some limitations, including complex calculation, need for documentation of meal times and absence of grey area. Recently, a novel pH score (Phoenix Score, PhxS) calculated using supine and upright reflux and offering a grey area for borderline patients, has been proposed in a cohort of patients studied with 48-hours wireless pH study. The aim of this study is to explore the relationship between AET, DMS and PhxS in a cohort of patients who underwent 24-hours pH-impedance monitoring (MII-pH) and to evaluate their performance in predicting clinical outcomes after ARS.
METHODS
Clinical data of consecutive adult patients with persistent GERD symptoms who underwent MII-pH at four Italian tertiary centers were collected. Follow-up data for patients who underwent surgery were also recorded. Successful outcome was defined as 50% reduction in global symptoms using the global esophageal symptom scale (GSS). AET was pathologic if >6%, non-pathologic if <4% and borderline in between. DMS was considered pathologic if >14.72, while PhxS if >8.45, non-pathologic if <7.06 and borderline in between. The relationship between positive, borderline and negative criteria was evaluated, as well as their linear correlation. Clinical improvement after surgery was assessed for the three criteria. The ability of the AET, DMS and PhxS in predicting outcomes after ARS was assessed through receiver operating characteristics (ROC) analysis.
RESULTS
Among 668 patients (49.3% males, age 51 years, BMI 24.8), 44.9% had pathologic GERD according to Lyon 2.0, 53.1% according to DMS and 50.8 according to PhxS. Pearson's correlation showed a strong relationship between AET and DMS (0.945, p <0.001), AET and PhxS (0.971, p <0.001) and DMS and PhxS (0.960, p <0.001). When the AET was pathologic, DMS was positive in 98.9% and PhxS in 99.3%. When PhxS was pathologic, 97.9% had a positive DMS. Good outcome was found in 90% of the patients with positive AET, 91.3% with positive DMS and 91.5% with positive PhxS (Figure 1). ROC analysis showed an area under the curve of 0.732 for AET, 0.753 for DMS and 0.763 for PhxS (Figure 2).
CONCLUSIONS
The novel PhxS correlates strongly with the standard reflux monitoring criteria (AET and DMS) in MII-pH. It shows a comparable ability to predict good clinical outcomes after ARS and might be therefore used to select patients for surgery.


Patients improvement after surgery according to different reflux monitoring criteria

ROC analysis for different reflux monitoring criteria

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