Objective definition and detection of transient lower esophageal sphincter relaxation revisited: is there room for improvement?

Background The advent of drugs that inhibit transient lower esophageal sphincter relaxation (TLESR) necessitates accurate identification and scoring. We assessed the intra- and inter-assessor variability of the existing objective criteria for TLESR, improving them where necessary. Methods Two 3-h postprandial esophageal manometric and pH recordings were performed in 20 healthy volunteers. Each recording was duplicated. The recordings were analyzed by five experienced observers for TLESRs based on their expert opinion. TLESRs were also analyzed for the presence of the original four criteria as well as inhibition of the crural diaphragm (ID), a prominent after-contraction (AC), acid reflux and an esophageal common cavity. Key Results The overall inter- and intra-observer agreements for TLESRs scored, according to observer's expert opinion, were 59% (range 56-67%) and 74% (60-89%), respectively. When TLESRs were restricted to those fulfilling the original criteria, these agreements fell to 46% (40-53%) and 60% (44-67%), respectively. Cleaning the recordings by removal of technically flawed sections improved agreements by 5%. Inclusion of additional criteria (ID and AC) resulted in inter- and intra-observer agreements of 62% (52-70%) and 69% (53-79%), respectively. A consensus analysis performed collectively by three observers and based on the new criteria (original ± ID and AC) resulted in 84% agreement between the paired recordings. Conclusions & Inferences The original criteria for the definition of TLESRs allows for substantial inter- and intra-observer variability, which can be reduced by incorporation of additional objective criteria. However, the highest level of intra-observer agreement can be achieved by consensus analysis.