Search

Per-oral endoscopic myotomy (POEM) is one of the main modalities of treatment of achalasia cardia today across subtypes and we are increasingly seeing patients persistent or recurrent symptoms after POEM. An accurate high-resolution esophageal manometry (HREM) is one of the most important tests that can help us guide the treatment in cases of failure of POEM. HREM can help us direct the therapy. The therapy can be lower esophageal sphincter-directed therapy or esophageal body-directed therapy that can be ascertained using HREM. With this review, we detail the factors associated with failure of POEM, tests that can be utilized for its evaluation, and case-based analysis using HREM in patients of post-POEM failure.

Background: Improvement in lower esophageal sphincter (LES) competency after laparoscopic Nissen fundoplication (LNF) is well established, yet esophageal body physiology data are limited. We aimed to describe the impact of LNF on whole esophagus physiology using standard and novel manometric characteristics., Methods: A cohort of patients with an intact fundoplication without herniation and no postoperative dysphagia were selected and underwent esophageal manometry at one-year after surgery. Pre- and post-operative manometry files were reanalyzed using standard and novel manometric characteristics and compared., Key Results: A total of 95 patients were included in this study. At 16.1 (8.7) months LNF increased LES overall and abdominal length and resting pressure (p < 0.0001). Outflow resistance (IRP) increased [5.8 (3-11) to 11.1 (9-15), p < 0.0001] with a 95th percentile of 20 mmHg in this cohort of dysphagia-free patients. Distal contractile integral (DCI) also increased [1177.0 (667-2139) to 1321.1 (783-2895), p = 0.002], yet contractile amplitude was unchanged (p = 0.158). There were direct correlations between pre- and post-operative DCI [R: 0.727 (0.62-0.81), p < 0.0001] and postoperative DCI and postoperative IRP [R: 0.347 (0.16-0.51), p = 0.0006]. Contractile front velocity [3.5 (3-4) to 3.2 (3-4), p = 0.0013] was slower, while distal latency [6.7 (6-8) to 7.4 (7-9), p < 0.0001], the interval from swallow onset to proximal smooth muscle initiation [4.0 (4-5) to 4.4 (4-5), p = 0.0002], and the interval from swallow onset to point when the peristaltic wave meets the LES [9.4 (8-10) to 10.3 (9-12), p < 0.0001] were longer. Esophageal length [21.9 (19-24) to 23.2 (21-25), p < 0.0001] and transition zone (TZ) length [2.2 (1-3) to 2.5 (1-4), p = 0.004] were longer. Bolus clearance was inversely correlated with TZ length (p = 0.0002) and time from swallow onset to proximal smooth muscle initiation (p < 0.0001). Bolus clearance and UES characteristics were unchanged (p > 0.05)., Conclusions & Inferences: Increased outflow resistance after LNF required an increased DCI. However, this increased contractile vigor was achieved through sustained, not stronger, peristaltic contractions. Increased esophageal length was associated with increased TZ and delayed initiation of smooth muscle contractions., (© 2024 The Authors. Neurogastroenterology & Motility published by John Wiley & Sons Ltd.)

Background: Despite the established efficacy of achalasia treatments on symptomatic outcomes, there are limited data evaluating the treatment effect on esophageal dilatation. This study aimed to assess the effect achalasia treatment on esophageal dilatation and the effect of esophageal width reduction ("recoil") on clinical outcomes., Methods: Patients with type I or type II achalasia that completed high-resolution manometry (HRM), functional lumen imaging probe (FLIP), and timed barium esophagram (TBE) pre and post treatment were included. Esophageal width was measured using TBE. Focused subgroup analysis was performed on patients with normal posttreatment EGJ opening on FLIP. Good clinical outcomes were defined as barium column height of <5 cm at 5 min and Eckardt Score ≤3., Key Results: Sixty-nine patients (41% type I and 59% type II) were included. Esophageal width decreased from pre to post treatment mean (SD) 4.2 (1.3) cm-2.8 (1.2) cm; p < 0.01. In the normal post treatment EGJ opening subgroup, esophageal width was less in patients with good TBE outcome compared to poor outcome mean (SD) 2.2 (0.7) cm versus 3.2 (1.4) cm (p < 0.01), but did not differ in good versus poor symptomatic outcome groups. Esophageal width recoil >25% posttreatment was associated with a greater rate of good TBE outcome (71% vs. 50%, p = 0.04) and good symptomatic outcome (88% vs. 50%; p = 0.04)., Conclusions and Inferences: Esophageal recoil was associated with good achalasia treatment outcome in patients without posttreatment EGJ obstruction. This suggests that mechanical properties of the esophageal wall, likely associated with tissue remodeling, play a role in clinical outcomes following achalasia treatment., (© 2024 The Authors. Neurogastroenterology & Motility published by John Wiley & Sons Ltd.)

Objective: To evaluate the impact of MSA on lower esophageal sphincter (LES) and esophageal body using high resolution impedance manometry. Background: MSA is an effective treatment in patients with gastroesophageal reflux disease, but there is limited data on its impact on esophageal functional physiology. Methods: Patients who underwent MSA were approached 1-year after surgery for objective foregut testing consists of upper endoscopy, esophagram, high resolution impedance manometry, and esophageal pH-monitoring. Postoperative data were then compared to the preoperative measurements. Results: A total of 100 patients were included in this study. At a mean follow up of 14.9(10.1) months, 72% had normalization of esophageal acid exposure. MSA resulted in an increase in mean LES resting pressure [29.3(12.9) vs 25(12.3), P < 0.001]. This was also true for LES overall length [2.9(0.6) vs 2.6(0.6), P = 0.02] and intra-abdominal length [1.2(0.7) vs 0.8(0.8), P < 0.001]. Outflow resistance at the EGJ increased after MSA as demonstrated by elevation in intrabolus pressure (19.6 vs 13.5 mmHg, P < 0.001) and integrated relaxation pressure (13.5 vs 7.2, P < 0.001). MSA was also associated with an increase in distal esophageal body contraction amplitude [103.8(45.4) vs 94.1(39.1), P = 0.015] and distal contractile integral [2647.1(2064.4) vs 2099.7(1656.1), P < 0.001]. The percent peristalsis and incomplete bolus clearance remained unchanged (P = 0.47 and 0.08, respectively). Conclusions: MSA results in improvement in the LES manometric characteristics. Although the device results in an increased outflow resistance at the EGJ, the compensatory increase in the force of esophageal contraction will result in unaltered esophageal peristaltic progression and bolus clearance. [ABSTRACT FROM AUTHOR]

Per-oral endoscopic myotomy (POEM) is one of the main modalities of treatment of achalasia cardia today across subtypes and we are increasingly seeing patients persistent or recurrent symptoms after POEM. An accurate high-resolution esophageal manometry (HREM) is one of the most important tests that can help us guide the treatment in cases of failure of POEM. HREM can help us direct the therapy. The therapy can be lower esophageal sphincter-directed therapy or esophageal body-directed therapy that can be ascertained using HREM. With this review, we detail the factors associated with failure of POEM, tests that can be utilized for its evaluation, and case-based analysis using HREM in patients of post-POEM failure. [ABSTRACT FROM AUTHOR]

Introduction: Plotting the pressure-cross-sectional area (P-CSA) hysteresis loops within the esophagus during a contraction cycle can provide mechanistic insights into esophageal motor function. Pressure and cross-sectional area during secondary peristalsis can be obtained from the functional lumen imaging probe (FLIP). The pressure-cross-sectional area plots at a location within the esophageal body (but away from the sphincter) reveal a horizontal loop shape. The horizontal loop shape has phases that appear similar to those in cardiovascular analyses, whichinclude isometric and isotonic contractions followed by isometric and isotonic relaxations. The aim of this study is to explain the various phases of the pressurecross-sectional area hysteresis loops within the esophageal body.Materials and Methods: We simulate flow inside a FLIP device placed inside the esophagus lumen. We focus on three scenarios: long functional lumen imaging probe bag placed insidethe esophagus but not passing through the lower esophageal sphincter, long functional lumen imaging probe bag that crosses the lower esophageal sphincter, and a short functional lumen imaging probe bag placed in the esophagus body that does not pass through the lower esophageal sphincter.Results and Discussion: Horizontal P-CSA area loop pattern is robust and is reproduced in all three cases with only small differences. The results indicate that the horizontal loop pattern is primarily a product of mechanical conditions rather than any inherently different function of the muscle itself. Thus, the distinct phases of the loop can be explained solely based on mechanics.

Background: The esophagogastric junction (EGJ) is classified into 3 anatomical subtypes according to lower esophageal sphincter-crural diaphragm (LES-CD) separation. We aimed to assess their relationship to esophageal motility, reflux characteristics, and symptom perception., Methods: We analyzed data from 1740 consecutive patients with typical reflux symptoms, who underwent high resolution manometry and a 24-h pH-impedance study during a 13-year period. A diagnosis of gastroesophageal reflux disease (GERD) was made if acid exposure time (AET) was >6%. EGJ types were classified as 1, 2, or 3, if LES-CD separation was up to 1 cm, 1-3 cm, or ≥3 cm, respectively., Results: EGJ type distribution was 72.2%, 22.1% and 5.7%, for types 1, 2 and 3, respectively. GERD was diagnosed in 31.2% and was more common among patients with EGJ type 2/3 vs. 1 (P<0.001). Length of LES-CD separation significantly correlated with AET and number of reflux episodes. Patients with type 2 or 3 EGJ more often showed ineffective or absent peristalsis compared with type 1 (P=0.008 and P<0.001 respectively). In the multivariate analysis, EGJ type 2/3 correlated with AET (P=0.001) and reflux episodes (P=0.041) but not with positive symptomatic markers or with ineffective/absent peristalsis., Conclusions: Our study confirms that EGJ anatomical morphology is a strong risk factor for GERD and correlates with both AET and the number of reflux events, though the length of separation is more important than the type. The multivariate analysis revealed that EGJ type 2 or 3 was not correlated with symptom perception or esophageal hypomotility., Competing Interests: Conflict of Interest: None, (Copyright: © Hellenic Society of Gastroenterology.)

Introduction: Plotting the pressure-cross-sectional area (P-CSA) hysteresis loops within the esophagus during a contraction cycle can provide mechanistic insights into esophageal motor function. Pressure and cross-sectional area during secondary peristalsis can be obtained from the functional lumen imaging probe (FLIP). The pressure-cross-sectional area plots at a location within the esophageal body (but away from the sphincter) reveal a horizontal loop shape. The horizontal loop shape has phases that appear similar to those in cardiovascular analyses, whichinclude isometric and isotonic contractions followed by isometric and isotonic relaxations. The aim of this study is to explain the various phases of the pressurecross-sectional area hysteresis loops within the esophageal body. Materials and Methods: We simulate flow inside a FLIP device placed inside the esophagus lumen. We focus on three scenarios: long functional lumen imaging probe bag placed insidethe esophagus but not passing through the lower esophageal sphincter, long functional lumen imaging probe bag that crosses the lower esophageal sphincter, and a short functional lumen imaging probe bag placed in the esophagus body that does not pass through the lower esophageal sphincter. Results and Discussion: Horizontal P-CSA area loop pattern is robust and is reproduced in all three cases with only small differences. The results indicate that the horizontal loop pattern is primarily a product of mechanical conditions rather than any inherently different function of the muscle itself. Thus, the distinct phases of the loop can be explained solely based on mechanics., Competing Interests: PK and JP hold shared intellectual property rights and ownership surrounding FLIP panometry systems, methods, and apparatus with Medtronic Inc. DC: Medtronic (Speaking, Consulting) PK: Ironwood (Consulting), Reckitt (Consulting), Johnson \& Johnson (Consulting) JP: Crospon, Inc. (stock options), Given Imaging (Consultant, Grant, Speaking), Sandhill Scientific (Consulting, Speaking), Takeda (Speaking), Astra Zeneca (Speaking), Medtronic (Speaking, Consulting), Torax (Speaking, Consulting), Ironwood (Consulting), Impleo (Grant). The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Elisha, Halder, Carlson, Kahrilas, Pandolfino and Patankar.)

The authors presents a clinical case: 1 year and four month old aged patient with an accidental ingestion of sharp foreign body complicated with mediastinitis, the clinical symptoms being masked by association of an upper respiratory tract infection.

Background/Aims: The effect of peroral endoscopic myotomy (POEM) on esophageal body movement in achalasia is poorly understood. This study aims to evaluate morphological changes in esophageal body movement after POEM in type III achalasia by analyzing intraluminal ultrasound (US) images in comparison to type I and II achalasia. Methods: Intraluminal US images and impedance values of the distal esophagus from 47 achalasia patients who underwent POEM or pneumatic dilatation (PD) (30 patients in the POEM group and 17 patients in the PD group) with pre- and post-procedural high-resolution impedance manometry and intraluminal US examinations were analyzed. The muscle thickness (MT), muscle cross-sectional area, lumen cross-sectional area (LCSA), contractility and distensibility indices, swallow-to-distension interval, and distension duration during each bolus transport were analyzed. Results: The MT increased and LCSA decreased significantly (P < 0.001), but the contractility index was not improved after POEM or PD in type I achalasia. Baseline MT increased and LCSA decreased significantly after POEM and PD in type II achalasia (P < 0.001). In contrast, MT and the swallow-to-distension interval decreased and the distension LCSA/duration and contractility index increased after POEM in type III achalasia (P < 0.001). In contrast to type I and II achalasia, in type III achalasia, these effects were unique to the POEM group. Conclusions: POEM decreased the esophageal LCSA by decreasing intrabolus pressure without improving contractility in type I and II achalasia. In contrast, POEM increased esophageal body distension and contractility and improved the inhibitory process during bolus transport in type III achalasia. [ABSTRACT FROM AUTHOR]

Goal: The goal of this study was to compare the clinical presentations of esophagogastric junction outflow obstruction (EGJOO) with coexisting abnormal esophageal body motility (EBM) to isolated EGJOO., Background: The clinical significance and management of EGJOO remain debated, as patients may have varied to no symptoms. The effect of coexisting abnormal EBM in EGJOO is unclear. We hypothesized that a concomitant EBM disorder is associated with clinical symptoms of EGJOO., Study: This was a retrospective cohort study of consecutive adults diagnosed with EGJOO on high-resolution impedance-manometry (HRIM) at 2 academic centers in March 2018 to September 2018. Patients with prior treatment for achalasia, foregut surgery, or evidence of obstruction were excluded. Subjects were divided into EGJOO with abnormal EBM per Chicago classification v3.0 and isolated EGJOO. Statistical analyses were performed using Fisher-exact or Student t test (univariate) and logistic or linear regression (multivariate)., Results: Eighty-two patients (72% women, age 61.1±10.7 y) were included. Thirty-one (37.8%) had abnormal EBM, including 16 (19.5%) ineffective esophageal motility and 15 (18.2%) hypercontractile esophagus. Esophageal symptoms (heartburn, regurgitation, chest pain, dysphagia) were more prevalent among those with abnormal EBM (90.3% vs. 64.7%, P=0.01). On logistic regression adjusting for age, gender, body mass index, and opioid use, abnormal EBM remained predictive of esophageal symptoms (adjusted odds ratio [aOR] 7.51, P=0.007). On separate models constructed, HE was associated with chest pain (aOR 7.45, P=0.01) and regurgitation (aOR 4.06, P=0.046), while ineffective esophageal motility was predictive of heartburn (aOR 5.84, P=0.009) and decreased complete bolus transit (β-coefficient -0.177, P=0.04)., Conclusion: Coexisting abnormal EBM is associated with esophageal symptoms and bolus transit in patients with EGJOO., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Postreflux swallow-induced peristaltic wave (PSPW) on pH-impedance monitoring and contraction vigor on high-resolution manometry (HRM) both assess esophageal peristaltic response. We aimed to evaluate relationships between PSPW and esophageal peristalsis on HRM in the context of reflux disease in this multicenter cohort study., Methods: pH-impedance and HRM studies performed on patients with persisting reflux symptoms were reviewed from 6 centers (5 in Europe and 1 in US). Total, upright and supine acid exposure time (AET) were evaluated from pH-impedance studies; PSPW index (PSPWI) and mean nocturnal baseline impedance (MNBI) were calculated using standard methodology. Esophageal body contraction vigor was analyzed using distal contractile integral (DCI), and DCI ratio > 1 between single swallows and multiple rapid swallows (MRS) defined presence of contraction reserve. Student's t test, ANOVA, and linear regression were utilized to investigate relationships between PSPW, contraction vigor, and contraction reserve., Key Results: Of 296 patients (52.8 ± 0.8 yr, 63% F), median PSPWI was 0.475. Only 24.0% had intact DCI; the remainder had varying degrees of hypomotility. As hypomotility increased, PSPWI and MNBI decreased significantly, while total AET and reflux episodes had an inverse response (P ≤ .002 for each). MRS data were available in 167 (56.4%), 72.5% had contraction reserve. MRS cohorts with normal PSPWI had significantly lower reflux burden compared to low PSPWI, regardless of presence or absence of contraction reserve (P ≤ .001)., Conclusions and Inferences: PSPWI correlates with esophageal hypomotility and reflux burden, and complements clinical reflux evaluation. Intact PSPW is more relevant to esophageal reflux clearance than contraction reserve., (© 2020 John Wiley & Sons Ltd.)

Background/aims: The effect of peroral endoscopic myotomy (POEM) on esophageal body movement in achalasia is poorly understood. This study aims to evaluate morphological changes in esophageal body movement after POEM in type III achalasia by analyzing intraluminal ultrasound (US) images in comparison to type I and II achalasia., Methods: Intraluminal US images and impedance values of the distal esophagus from 47 achalasia patients who underwent POEM or pneumatic dilatation (PD) (30 patients in the POEM group and 17 patients in the PD group) with pre- and post-procedural high-resolution impedance manometry and intraluminal US examinations were analyzed. The muscle thickness (MT), muscle cross-sectional area, lumen cross-sectional area (LCSA), contractility and distensibility indices, swallow-to-distension interval, and distension duration during each bolus transport were analyzed., Results: The MT increased and LCSA decreased significantly ( P < 0.001), but the contractility index was not improved after POEM or PD in type I achalasia. Baseline MT increased and LCSA decreased significantly after POEM and PD in type II achalasia ( P < 0.001). In contrast, MT and the swallow-to-distension interval decreased and the distension LCSA/duration and contractility index increased after POEM in type III achalasia ( P < 0.001). In contrast to type I and II achalasia, in type III achalasia, these effects were unique to the POEM group., Conclusions: POEM decreased the esophageal LCSA by decreasing intrabolus pressure without improving contractility in type I and II achalasia. In contrast, POEM increased esophageal body distension and contractility and improved the inhibitory process during bolus transport in type III achalasia.

Electric stimulation (ES) could induce contraction of intestinal smooth muscle. The aim of this study was to analyze the effects of ES on esophageal motility and the underlying mechanism in vivo. Twenty-eight rabbits were equipped with a pair of subserosa electrodes (connected to an electrical stimulator) in the lower segment of the esophagus. The ES signal consisted of bipolar rectangular pulse trains, lasting for 3 s, with different amplitudes (1 mA, 3 mA, 5 mA and 10 mA), and frequencies (10 Hz, 20 Hz and 50 Hz). The amplitude of the contraction was recognized by high-resolution manometry. The effect of ES was tested under anesthesia and following administration of atropine, phentolamine or L-NAME. ES induced esophageal contraction at the stimulated site. A statistically significant increase in esophageal pressure was observed when the stimulation amplitude was above 3 mA. The increase in esophageal pressure was associated with the amplitude of stimulus as well as the frequency. During stimulation, atropine, phentolamine and L-NAME had no effect on the increase of esophageal pressure induced by ES. These findings implied that ES induced esophageal contraction were not mediated via the NANC, adrenergic or cholinergic pathway. The amplitude of esophageal contraction was current and frequency dependent. [ABSTRACT FROM AUTHOR]

Background: The effectiveness of partial posterior wrap (Toupet procedure) in patients with defective esophageal body motility is controversial. Aim of the study: To evaluate the effect of Toupet procedure upon the outcome of laparoscopic (LF) and open (OF) fundoplications in gastroesophageal reflux disease (GERD) patients with defective esophageal body motility. Patients and Methods: This study included 32 patients with severe GERD who underwent Toupet procedure; 18 (56.25%) OF ′and 14 (43.75%) LF. Outcome measures included assessment of relief of the symptoms, results of repeated endoscopy, barium study, manometry and pH metry; both early (within six months) and late (two years at least). Results: Relief of heartburn was achieved in 26 patients (81.3%). These include 14 (77.7%) and 12 (85.7%) patients who underwent OF and LF respectively. Occasional dysphagia developed in six patients (18.7%) early, and three (9.4%) late; all were managed conservatively. Endoscopic esophagitis healed in 26 patients (81.3%); 14 (77.7%) OF and 12 (85.7%) LF. Mean LES and body pressures improved (10.5 to 17.7 and 29.0 to 41.0 mmHg respectively). Persistent acid reflux was detected in six patients (18.7%); two (22.3%) OF and two (14.3%) LF. Conclusion: Toupet fundoplication is an effective procedure for reflux control except in patients with severe GERD

BACKGROUND: Wet swallows cause a greater esophageal contraction amplitude and duration than dry swallows. In Chagas' disease there is a reduction in amplitude of esophageal contraction but we do not know if the difference between wet and dry swallows is seen in the disease. AIM: To compare the esophageal contractions after wet and dry swallows in patients with Chagas' disease. METHODS: We measured the area under the curve (amplitude x duration) of the esophageal contractions in 30 patients with a diagnosis of esophageal involvement by Chagas' disease and 44 controls. We used the manometric method with continuous perfusion. The contractions were measured at 2, 7, 12 and 17 cm below the upper esophageal sphincter, after five swallows of a 5 mL bolus of water alternated with five dry swallows. RESULTS: In the control group wet swallows caused a higher area under the curve than dry swallows. There was no difference between wet and dry swallows in Chagas' disease patients, and there was no difference in wet and dry swallows in Chagas' disease patients compared with dry swallows of controls. At 12 and 17 cm from the upper esophageal sphincter the area under the curve after wet and dry swallows in Chagas' disease patients younger than 60 years (n = 15) was higher than in Chagas' disease patients older than 60 years (n = 15). CONCLUSION: We conclude that in normal subjects there is adaptation to the presence of a liquid bolus inside the esophageal body, which does not happen in patients with Chagas' disease.RACIONAL: Deglutições de água causam maior amplitude e duração das contrações esofágicas do que deglutições "secas". Na doença de Chagas as contrações esofágicas são de baixa amplitude e de menor duração, porém não se sabe se há diferença entre deglutições líquidas e secas. OBJETIVO: Comparar as contrações esofágicas após deglutições líquidas e "secas" em pacientes com doença de Chagas. MÉTODOS: Estudou-se a área sob a curva (amplitude x duração) das contrações esofágicas em 30 pacientes com diagnóstico de esofagopatia chagásica, com diâmetro do esôfago no exame radiológico inferior a 4 cm, e 44 controles. Utilizou-se o método manométrico com perfusão contínua. As contrações foram medidas a 2, 7, 12 e 17 cm distais ao esfíncter superior do esôfago, após cinco deglutições de 5 mL de água alternadas com cinco deglutições "secas". RESULTADOS: No grupo controle deglutições de água provocaram maior área sob a curva do que deglutições "secas". Na doença de Chagas não houve diferença entre deglutições de água e "secas", bem como não houve diferença entre deglutições de água e "secas" nos pacientes com doença de Chagas e deglutições "secas" nos controles. A 12 e 17 cm do esfíncter superior do esôfago a área sob a curva após deglutições de água e "seca", em pacientes com doença de Chagas, foi maior em pacientes com idades abaixo de 60 anos (n = 15) do que pacientes com idades acima de 60 anos (n = 15). CONCLUSÃO: Concluiu-se que em pessoas normais há adaptação à presença do bolo líquido dentro do esôfago, o que não acontece em pacientes com doença de Chagas.