Sarici Inanc S, Eriksson Sven E, Chaudhry Naveed, Zheng Ping, Nguyen Johnathan, Ayazi Shahin
Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA.
Chevalier Jackson Esophageal Research Center, Western Pennsylvania Hospital, Pittsburgh, PA, USA.
Surg Endosc. 2025 Aug;39(8):4780-4790. doi: 10.1007/s00464-025-11857-4. Epub 2025 Jun 12.
Antireflux surgery (ARS) is effective for controlling GERD, but 10-20% of patients experience anatomical failure, and 3-7% eventually require revisional surgery. While pH monitoring is routinely used preoperatively, its role in guiding revisional ARS remains unclear. This study aimed to evaluate the role of pH monitoring in predicting the need for and outcomes of revisional ARS.
We reviewed 278 patients (68% female, mean age 55) with anatomical failure after fundoplication who underwent 48-h pH monitoring from 2015 to 2023. Patients were stratified by DeMeester score at failure: normal vs. abnormal (≥ 14.7). Primary outcome was need for revisional ARS. Secondary outcome was favorable outcome at 1-year post-revision, defined as freedom from PPIs and patient satisfaction. Multivariable logistic regression evaluated the impact of pH monitoring on need for and outcome of revisional ARS.
Abnormal DeMeester scores were found in 132 patients (47.5%), who had higher rates of simultaneously herniated and disrupted fundoplication (48.5 vs. 24.0%, p < 0.001), longer median (IQR) time to failure [54.9 (20.9-121.0) vs. 27.9 (14.8-77.8) months, p = 0.004], and higher GERD-HRQL heartburn scores (p < 0.05). These patients were more likely to undergo revisional ARS (68.9 vs. 47.3%, p < 0.001), confirmed on multivariable analysis [OR 2.36 (1.28-4.37), p = 0.006]. At 14 (3) months post-revision, patients with abnormal DeMeester scores had higher rates of patient satisfaction (82.9 vs. 65.5%, p = 0.026) and freedom from PPIs (77.6 vs. 60.3%, p = 0.037) with lower GERD-HRQL total scores [7.0 (2.0-21.5) vs. 14.0 (6.0-32.0), p = 0.003]. Abnormal DeMeester score was the strongest predictor of favorable outcomes after revisional ARS [OR 3.98 (1.75-9.04), p = 0.001].
Abnormal DeMeester score at time of failure predicts need for revisional ARS and is the strongest predictor of favorable outcome after revisional ARS, underscoring its role in surgical decision-making after failure.
抗反流手术（ARS）对控制胃食管反流病（GERD）有效，但10%-20%的患者会出现解剖学失败，3%-7%的患者最终需要再次手术。虽然pH监测在术前常规使用，但其在指导ARS再次手术中的作用仍不明确。本研究旨在评估pH监测在预测ARS再次手术需求及结果中的作用。
我们回顾了2015年至2023年间278例（68%为女性，平均年龄55岁）胃底折叠术后出现解剖学失败并接受48小时pH监测的患者。患者根据失败时的DeMeester评分分层：正常与异常（≥14.7）。主要结局是ARS再次手术的需求。次要结局是再次手术后1年的良好结局，定义为无需使用质子泵抑制剂（PPI）且患者满意。多变量逻辑回归评估pH监测对ARS再次手术需求及结果的影响。
132例患者（47.5%）DeMeester评分异常，这些患者同时发生胃底折叠术疝出和破裂的比例更高（48.5%对24.0%，p<0.001），失败的中位（IQR）时间更长[54.9（20.9-121.0）个月对27.9（14.8-77.8）个月，p=0.004]，GERD-HRQL烧心评分更高（p<0.05）。这些患者更有可能接受ARS再次手术（68.9%对47.3%，p<0.001），多变量分析证实[比值比（OR）2.36（1.28-4.37），p=0.006]。再次手术后14（3）个月，DeMeester评分异常的患者患者满意度更高（82.9%对65.5%，p=0.026），无需使用PPI的比例更高（77.6%对60.3%，p=0.037），GERD-HRQL总分更低[7.0（2.0-21.5）对14.0（6.0-32.0），p=0.003]。DeMeester评分异常是ARS再次手术后良好结局的最强预测因素[OR 3.98（1.75-9.04），p=0.001]。
失败时DeMeester评分异常可预测ARS再次手术的需求，且是ARS再次手术后良好结局的最强预测因素，强调了其在失败后手术决策中的作用。
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