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RETHINKING ESOPHAGEAL ACID EXPOSURE THRESHOLDS FOR THE DIAGNOSIS OF GERD IN THE LYON 2.0 ERA: A RETROSPECTIVE MATCHED COHORT STUDY
Giovanni Capovilla
*, Renato Salvador, Giulia Nezi, Matteo Santangelo, Alessia Scarton, Francesca Forattini, Arianna Vittori, Lucia Moletta, Elisa Sefora Pierobon, Gianpietro Zanchettin, Edoardo V. Savarino, Michele Valmasoni
Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy
BackgoundModern diagnosis of GERD is largely based on abnormal acid exposure time (AET) at pH testing during the 24 hours recording. However, the DeMeester score (DeM) is still widely adopted in clinical practice, particularly in the pre-operative surgical setting. We sought to compare the performance of the DeM and AET in identifying reflux phenotypes and segregating patients (pts) with a favorable symptom response after anti-reflux surgery
MethodsWe retrospectively reviewed records of pts who underwent anti-reflux surgery at our Department from 2005 to 2022 because of GERD symptoms. Preoperatively, upper endoscopy, manometry and 24h-pH-metry were performed. Patients were segregated according to the total AET as follows: a) the "AET 1-4 DeM+ group" included pts with a pathological DeM and an AET of 1% to 4%; b) the "AET 4-6 DeM+ group" included DeM+ pts with an AET > 4% and
< 6%. Pts with an AET > 6% were selected as a control-group. Clinical characteristics, operative data and outcomes were compared. A subsequent analysis was conducted using a clustering-matched controlled group. Matched variables were age, sex, BMI and main indication for anti-reflux surgery. Exclusion criteria were preoperative DeM < 14.7, large hiatal hernias (> 5 cm), anatomical failure of the wrap (slippage, migration or disruption), pathological postoperative AET, and previous foregut surgery. Failure of the surgical treatment was defined as a postoperative GERDQ score > 8 at the last follow up.
ResultsThe results are summarized in the table. Overall, 255 pts met the inclusion criteria: 20 in the AET 1-4 DeM+ group, 67 in the AET 4-6 DeM+ group and 168 in the control group. Pts in the unmatched controlled group were significantly older (p=0.009). No significant differences in the preoperative clinical and endoscopic characteristics were detected. The preoperative GERDQ score was similar in all groups. The preoperative acid exposure was significantly higher in both the matched and the unmatched control groups. No difference in the type of surgery performed was detected. Postoperatively, acid exposure was normal in all groups. The outcome of anti-reflux surgery in the AET 1-4 DeM+ group and the AET 4-6 DeM+ was comparable to the surgical outcome of pts with an AET > 6% (p=ns).
ConclusionIn this study the DeM score outperformed AET in segregating pts with a favorable outcome after anti-reflux surgery. Pts classified as borderline or with inconclusive evidence for GERD using the AET, were correctly identified as good candidates for anti-reflux surgery using the DeM. This study prompts further evaluation regarding the 24h-pHmetry parameters that should be used when selecting pts for GERD treatment. Furthermore, it underlines the need for further evaluation of the currently adopted thresholds of reflux monitoring metrics for the definition of GERD.
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