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Donata Vaiciunaite*1, Sven Eriksson1, Inanc Sarici1, Ping Zheng1, Ali H. Zaidi1,2, Blair Jobe1, Shahin Ayazi1,2
1Esophageal Institute, Allegheny Health Network, Pittsburgh, PA; 2Department of Surgery, Drexel University, Philadelphia, PA

Abnormal DeMeester score on esophageal pH-monitoring is a well-established predictor of favorable outcome for antireflux surgery (ARS). Esophageal pH monitoring also facilitates analysis of the temporal association between symptoms and reflux episodes. This association can be expressed with several symptom-reflux association indices, symptom association probability (SAP) being the most reliable. SAP is often used as an adjunct to DeMeester score during risk stratification prior to ARS. However, the utility of SAP in predicting ARS outcome has not been well established. The aim of this study was to determine the impact of SAP as an adjunct to DeMeester score in predicting outcomes after fundoplication for GERD.

Records of patients who underwent primary (full or partial) fundoplication at our institution from 2015 to 2021 were reviewed. Patients with a preoperative DeMeester score > 14.7 on Bravo pH monitoring and a documented SAP for up to 3 symptoms were included. The SAP was considered positive if the calculated value was >95%, indicating the likelihood of a chance association between the reflux event and the symptom was <5%.
Patients completed the gastroesophageal reflux disease health-related quality of life (GERD-HRQL) questionnaire pre- and postoperatively. Favorable outcome was defined as freedom from proton pump inhibitor (PPI) and patient satisfaction at 1 year postoperatively. The presence and number of positive SAP, as well as positive SAP for individual symptoms and combined typical and atypical symptoms were evaluated for an association with surgical outcomes.

The final study population consisted of 360 patients (72.2% female) with a median (IQR) age of 60.0 (52-67). At a median (IQR) follow-up of 24.1 (13-46) months, 88.2% patients achieved favorable outcome, freedom from PPI was 88.9%, satisfaction was 86.7%, and 74.1% had at least 50% improvement in their GERD-HRQL score.
SAP was positive in 264 (73.3%) patients, of which 127 (48.1%) had one SAP positive symptom, 107 (40.5%) had two SAP positive symptoms, and 30 (11.4%) had all three SAP positive symptoms. There was no association between having at least one positive SAP symptom and favorable outcome (p=0.500), freedom from PPI (p=0.448), satisfaction (0.567), or 50% improvement in GERD-HRQL (p=0.375). There was no difference in favorable outcome between patients with one, two or all SAP positive symptoms (0.721). No association with favorable outcome was found among patients with positive SAP for typical symptoms (p=0.872) and atypical symptoms (p=0.819) or any of the individual symptoms.

Symptom association probability did not add any value to a positive DeMeester score for risk stratification prior to antireflux surgery. These findings suggest that SAP should not be used in surgical decision-making in patients with objective evidence of reflux.

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