title: Gastroesophageal reflux symptoms do not correlate with objective pH testing after peroral endoscopic myotomy.
abstract: BACKGROUND
  Peroral endoscopic myotomy (POEM) is an emerging treatment for esophageal achalasia. Postoperative reflux has been found in a significant number of patients, but it is unknown whether subjective reports of reflux correlate with objective pH testing. The purpose of this study was to compare the objective rate of reflux with standardized reflux symptom scales after POEM. Our hypothesis was that subjective symptoms would not correlate with objective measurement of reflux.
  
  
  METHODS
  Data on all patients undergoing POEM were collected prospectively between August 2012 and June 2014 and included demographics, objective testing (48-h pH probe, manometry, endoscopy), as well as gastroesophageal reflux disease health-related quality of life (GERD-HRQL), GERD symptom scale (GERSS), and antacid use.
  
  
  RESULTS
  Forty-three patients underwent POEM during the study period. The mean age was 53.5 ± 17.4 years with a BMI of 29.6 ± 8.4 kg/m(2), and 27 (63%) were male. Forty-two patients (98%) completed at least 6 months of follow-up, and 26 (60%) underwent repeat pH measurement. Dysphagia scores improved from 4 (0-5) at baseline to 0 (0-3) (p < 0.001). On follow-up pH testing, 11 (42%) were normal and 15 (58%) had elevated DeMeester scores. Postoperative GERSS or GERD-HRQL scores did not correlate with DeMeester scores on Spearman's rank-order tests (r = 0.02, p = 0.93 and r = 0.04, p = 0.50, respectively). Postoperative PPI use was not significantly associated with normal or abnormal pH testing: 5 of 7 (71%) patients who were taking PPIs postoperatively had abnormal DeMeester scores compared to 9 of 18 (50%) of patients who were not taking PPIs (p = 0.332).
  
  
  CONCLUSIONS
  Peroral endoscopic myotomy provides excellent dysphagia relief for patients with achalasia, but is associated with a high rate of reflux on pH testing postoperatively. Subjective symptoms are not a reliable indicator of postoperative reflux. Routine pH testing should be considered in all patients following POEM.
authors.affiliation: Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, N729 Doan Hall, 410 W 10th Ave, Columbus, OH, 43210, USA. Edward.Jones@UCDenver.edu.
authors.forename: Edward L
authors.initials: EL
authors.lastname: Jones
authors.affiliation: Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, N729 Doan Hall, 410 W 10th Ave, Columbus, OH, 43210, USA.
authors.forename: Michael P
authors.initials: MP
authors.lastname: Meara
authors.affiliation: Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, N729 Doan Hall, 410 W 10th Ave, Columbus, OH, 43210, USA.
authors.forename: Jennifer S
authors.initials: JS
authors.lastname: Schwartz
authors.affiliation: Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, N729 Doan Hall, 410 W 10th Ave, Columbus, OH, 43210, USA.
authors.forename: Jeffrey W
authors.initials: JW
authors.lastname: Hazey
authors.affiliation: Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, N729 Doan Hall, 410 W 10th Ave, Columbus, OH, 43210, USA.
authors.forename: Kyle A
authors.initials: KA
authors.lastname: Perry
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003680:Deglutition Disorders / Q000601:surgery; D004931:Esophageal Achalasia / Q000601:surgery*; D050782:Esophageal pH Monitoring; D004945:Esophagoscopy / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D005764:Gastroesophageal Reflux / Q000209:etiology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D057605:Natural Orifice Endoscopic Surgery; D011446:Prospective Studies; D011788:Quality of Life; D055815:Young Adult
keywords: Achalasia; POEM; Proton pump inhibitor; Reflux; Subjective; pH