Utility of pH monitoring in surgical decision-making and outcome prediction in revisional antireflux surgery for anatomical failure.

Background: 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.

Methods: 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.

Results: 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].

Conclusions: 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.