Department of Surgery, University of Chicago Pritzker School of Medicine, 5841 S. Maryland Ave., MC 5095, Chicago, IL 60637, USA.
J Gastrointest Surg. 2013 Jan;17(1):14-20; discussion p. 20. doi: 10.1007/s11605-012-2057-5. Epub 2012 Oct 23.
Many surgeons feel comfortable performing antireflux surgery (ARS) on the basis of symptomatic evaluation, endoscopy, and barium esophagography. While esophageal manometry is often obtained to assess esophageal peristalsis, pH monitoring is rarely considered necessary to confirm the diagnosis of gastroesophageal reflux disease (GERD).
The aim of this study was to analyze the sensitivity and specificity of symptoms, endoscopy, barium esophagography, and manometry as compared to pH monitoring in the preoperative evaluation of patients for ARS.
One hundred and thirty-eight patients were referred for ARS with a diagnosis of GERD based on symptoms, endoscopy, and/or barium esophagography. Barium esophagography, esophageal manometry, and ambulatory 24-h pH monitoring were performed preoperatively in every patient.
Four patients were found to have achalasia and were excluded from the analysis. Based on the presence or absence of gastroesophageal reflux on pH monitoring, the remaining 134 patients were divided into two groups: GERD+ (n = 78, 58 %) and GERD- (n = 56, 42 %). The groups were compared with respect to the incidence of symptoms, presence of reflux and hiatal hernia on esophagogram, endoscopic findings, and esophageal motility. There was no difference in the incidence of symptoms between the two groups. Within the GERD+ group, 37 patients (47 %) had reflux at the esophagogram and 41 (53 %) had no reflux. Among the GERD- patients, 17 (30 %) had reflux and 39 (70 %) had no reflux. A hiatal hernia was present in 40 and 32 % of patients, respectively. Esophagitis was found at endoscopy in 16 % of GERD+ patients and in 20 % of GERD- patients. Esophageal manometry showed no difference in the pressure of the lower esophageal sphincter or quality of peristalsis between the two groups.
The results of this study showed that (a) symptoms were unreliable in diagnosing GERD, (b) the presence of reflux or hiatal hernia on esophagogram did not correlate with reflux on pH monitoring, (c) esophagitis on endoscopy had low sensitivity and specificity, and (d) manometry was mostly useful for positioning the pH probe and rule out achalasia. Ambulatory 24-h pH monitoring should be routinely performed in the preoperative work-up of patients suspected of having GERD in order to avoid unnecessary ARS.
许多外科医生在基于症状评估、内镜检查和钡餐食管造影的基础上，对反流性疾病（GERD）进行抗反流手术（ARS）时感到舒适。尽管食管测压通常用于评估食管蠕动功能，但很少考虑 pH 监测来确诊 GERD。
本研究旨在分析症状、内镜、钡餐食管造影和测压与 pH 监测在 ARS 术前评估患者中的敏感性和特异性。
138 例患者因 GERD 症状、内镜和/或钡餐食管造影而被转诊行 ARS。每位患者均行术前钡餐食管造影、食管测压和 24 小时 pH 监测。
4 例患者被诊断为贲门失弛缓症，被排除在分析之外。基于 pH 监测有无胃食管反流，将其余 134 例患者分为 GERD+（n=78，58%）和 GERD-（n=56，42%）两组。比较两组的症状发生率、食管造影上的反流和食管裂孔疝、内镜发现和食管动力。两组症状发生率无差异。在 GERD+组中，37 例（47%）患者在食管造影上有反流，41 例（53%）无反流。在 GERD-患者中，17 例（30%）有反流，39 例（70%）无反流。食管裂孔疝分别存在于 40%和 32%的患者中。食管内镜检查发现食管炎分别占 16%和 20%的 GERD+和 GERD-患者。食管测压显示两组下食管括约肌压力和蠕动质量无差异。
本研究结果表明：（a）症状诊断 GERD 不可靠，（b）食管造影上的反流或食管裂孔疝与 pH 监测上的反流无相关性，（c）内镜下食管炎敏感性和特异性均较低，（d）测压主要用于定位 pH 探头并排除贲门失弛缓症。疑似 GERD 的患者术前应常规行 24 小时 pH 监测，以避免不必要的 ARS。
