title: Importance of Esophageal Manometry and pH Monitoring in the Evaluation of Patients with Refractory Gastroesophageal Reflux Disease: A Multicenter Study.
abstract: BACKGROUND
  Patients who have heartburn are treated with acid-reducing medications on the assumption that gastroesophageal reflux disease (GERD) is causing the symptom. In the absence of a response to therapy, patients are often assumed to have refractory GERD, and they are referred for laparoscopic antireflux surgery (LARS), often without further diagnostic evaluation.
  
  
  OBJECTIVE
  We hypothesized that (1) in some patients with refractory GERD, the heartburn is not secondary to reflux, but rather to stasis and fermentation of food in the presence of achalasia and (2) esophageal manometry and pH monitoring are essential to establish proper diagnosis.
  
  
  METHODS
  Five hundred twenty-four patients, whose final diagnosis was achalasia, were referred to two quaternary care centers. Symptomatic evaluation, barium swallow, endoscopy, manometry, and pH monitoring were performed in all patients.
  
  
  RESULTS
  One hundred fifty-two patients (29%) had been treated with acid-reducing medications for an average of 29.3 months, and were referred for LARS because of lack of response to medical therapy. One patient had already been treated with a Nissen fundoplication. All patients were diagnosed with achalasia and underwent Heller myotomy and partial fundoplication.
  
  
  CONCLUSIONS
  The results of this study showed that (1) one-third of achalasia patients complained of heartburn and (2) patients with heartburn not responding to medical treatment must be carefully evaluated before referral to surgery. These data confirm the importance of esophageal manometry and pH monitoring in any patient considered for LARS.
authors.affiliation: 1 Department of Surgery, Pritzker School of Medicine, University of Chicago , Chicago, Illinois.
authors.forename: Ciro
authors.initials: C
authors.lastname: Andolfi
authors.affiliation: 2 Department of Surgery, School of Medicine, University of Milan , Milan, Italy .
authors.forename: Luigi
authors.initials: L
authors.lastname: Bonavina
authors.affiliation: 3 Department of Gastroenterology, Pritzker School of Medicine, University of Chicago , Chicago, Illinois.
authors.forename: Robert T
authors.initials: RT
authors.lastname: Kavitt
authors.affiliation: 3 Department of Gastroenterology, Pritzker School of Medicine, University of Chicago , Chicago, Illinois.
authors.forename: Vani J A
authors.initials: VJ
authors.lastname: Konda
authors.affiliation: 2 Department of Surgery, School of Medicine, University of Milan , Milan, Italy .
authors.forename: Emanuele
authors.initials: E
authors.lastname: Asti
authors.affiliation: 1 Department of Surgery, Pritzker School of Medicine, University of Chicago , Chicago, Illinois.
authors.forename: Marco G
authors.initials: MG
authors.lastname: Patti
mesh_terms: D000328:Adult; D000368:Aged; D004931:Esophageal Achalasia / Q000175:diagnosis* / Q000601:surgery; D050782:Esophageal pH Monitoring; D005260:Female; D018662:Fundoplication / Q000379:methods; D005764:Gastroesophageal Reflux / Q000175:diagnosis* / Q000601:surgery; D006801:Humans; D007087:Illinois; D007558:Italy; D010535:Laparoscopy / Q000379:methods; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D012008:Recurrence; D012720:Severity of Illness Index; D016896:Treatment Outcome