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Publications

Journal Article Multicenter Study Ppublish

PubMed: 42458701 DOI: 10.1111/nmo.70398

Inter-Observer Variability of Gerd-Related Metrics on High-Resolution Manometry and Calculation of the Milan Score.

Neurogastroenterol Motil 38(7):e70398

Authors: Marco Sozzi, Stefano Siboni, Andres R Latorre-Rodriguez, Sumeet K Mittal, Elisa Marabotto, Andrea Pasta, Francesco Calabrese, Erika Andreatta, Giovanni Aldinio, Marina Coletta, Roberto Penagini, Yeong Yeh Lee, Samir Ayad Mina Ehab, Vincent Tee, Robert H Lee, Luis G Alcala-Gonzalez, Benjamin Rogers, Mikayla S Hennen, Jordan Haworth, Amit Patel, Pooja Patel, Takahiro Masuda, Enrique Coss-Adame, Renato Salvador, Luca Provenzano, Loredana Nicoletti, Stefania Piccirelli, Edoardo Pezzuto, Salvatore Tolone, Emanuele Asti, Edoardo V Savarino, C Prakash Gyawali

Affiliations

  • Department of General and Emergency Surgery, IRCCS Policlinico San Donato, San Donato Milanese (Milano), Italy.
  • Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
  • Department of Internal Medicine, University of Genoa, Genoa, Italy.
  • IRCCS AOM Azienda Ospedaliera Metropolitana of Genoa, Genoa, Italy.
  • Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy.
  • School of Medical Sciences and GI Function and Motility Unit, Universiti Sains Malaysia, Kota Bharu, Malaysia.
  • Division of Gastroentero-Hepatology, Department of Internal Medicine, Faculty of Medicine-Dr. Soetomo Teaching Hospital, Universitas Airlangga, Surabaya, Indonesia.
  • H.H. Chao Comprehensive Digestive Disease Center at UCI School of Medicine, Orange, California, USA.
  • Digestive System Research Unit, Department of Digestive Diseases, Vall d'Hebron University Hospital, Barcelona, Spain.
  • Motility Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, Louisville, Kentucky, USA.
  • Functional Gut Clinic, Manchester, UK.
  • Division of Gastroenterology, Durham Veterans Affairs Medical Center and Duke University, Durham, North Carolina, USA.
  • Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan.
  • Departamento de Gastroenterologia y Laboratorio de Motilidad Gastrointestinal, Instituto Nacional de Ciencias Medicas y Nutricion "Salvador Zubiran", Mexico City, Mexico.
  • Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, School of Medicine, Padova, Italy.
  • Department of Gastroenterology and Digestive Endoscopy, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy.
  • Medicine & Surgery, Università degli Studi della Campania, School of Medicine, Naples, Italy.
  • Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA.

Abstract

BACKGROUND

High-resolution manometry (HRM) is increasingly used to assess risk of gastroesophageal reflux disease (GERD). The Milan Score (MS) integrates four HRM variables-EGJ morphology, EGJ contractile integral (EGJ-CI), ineffective esophageal motility (IEM), and straight leg raise (SLR) response-to predict pathological esophageal acid exposure. The inter-observer reproducibility of the MS and its components has never been formally assessed.

METHODS

A total of 50 consecutive HRM plots from patients undergoing evaluation for suspected GERD at a tertiary referral center were distributed to a multicenter pool of esophageal experts for blind review. Participants assessed EGJ type, EGJ-CI, IEM, and SLR response; the MS and corresponding GERD risk were automatically calculated. Inter-observer variability was evaluated using Fleiss' κ for categorical variables and Kendall's coefficient for continuous variables. MS accuracy was assessed by comparing calculated scores against MII-pH results.

RESULTS

Twenty-three esophageal experts from 16 international institutions reviewed all 50 plots. Agreement was fair for EGJ morphology (κ = 0.321), moderate for SLR (W = 0.531), and good for IEM (κ = 0.638), EGJ-CI (W = 0.675) and the final MS (W = 0.641). Median plot-level concordance between MS and pH-impedance study was 71.74% [IQR 51.08%]; median reader accuracy for Milan Score was 64% [IQR 12%], ranging from 54% to 80%.

CONCLUSIONS

Inter-observer variability of the Milan Score is good across a diverse international cohort of esophageal experts, supporting its reproducibility as a clinical tool. However, agreement for individual parameters was heterogeneous, and the assessment of EGJ morphology and the SLR maneuver achieved only fair-to-moderate agreement, highlighting the need for improved standardization.

MeSH

Gastroesophageal Reflux