Objective: Surgical treatment is controversial in patients who have reflux symptoms but normal 24 hour pH monitoring and endoscopic evaluation. The objective of this study was to determine the clinical outcome of patients who are referred for antireflux surgery and have normal ambulatory 24 hr pH test results.
Methods: 490 patients were referred to our esophageal motility lab for esophageal studies between March 1998 and September 1999, and 174 had complete 24 hour ambulatory pH evaluations. 24 hr pH monitoring was performed with single (167) or double (7) transducer probes. Symptom diaries were kept and symptoms recorded on the portable data collection units. Results were analyzed by proprietary software (Medtronics). Nineteen of the 174 (12%) had normal results, and constitute the patient cohort for this retrospective study. Clinical follow-up data were obtained from a clinical outcomes database or by telephone interview. A standardized symptom assessment tool was administered as part of follow-up in all patients.
Results: 19 patients had normal 24 hr pH studies and GERD symptoms. Mean follow up was 16.3 months (range 4-26). Nine patients (47%) had subsequent surgery: three for gastric problems, one Heller myotomy for achalasia, and five antireflux surgeries. Six patients were maintained on medical therapy. Four (21%) patients had symptom resolution without intervention. Of four patients having non-antireflux surgery, three were improved and one was worse. Of five patients having antireflux surgery, two (40%) were improved, two have continued foregut complains and one was worse.
Conclusion: Normal 24 hr pH studies are found on a minority of patients referred for antireflux surgery. Many of these patients are found to have pathology other than gastroesophageal reflux disease as an explanation for their symptoms. Patients who do go on to have antireflux surgery have poor clinical outcomes compared to patients who have abnormal pH test results.