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Manometric assessment of the gastroesophageal junction (GEJ) and esophageal body is the key to a better understanding of the mechanics of antireflux surgery (ARS) and maximizing its benefits while minimizing adverse outcomes. However, there is an attitude of uncertainty regarding the necessity of esophageal motility prior to ARS among some surgeons. This evidence-based review highlights the critical role of manometry in the preoperative workup for patients undergoing ARS. It also discusses how manometry can detect findings associated with favorable outcomes or the risk of postoperative dysphagia. Manometric data can be used for risk stratification and the prediction of outcomes, aiding the surgeon in matching an operation to the specific physiology of each individual patient.

Background/Aims Esophageal high-resolution manometry (HRM) enables the comprehensive evaluation of the esophageal motor function. However, protocols are not uniform and clinical practices vary widely among institutions. This study aims to understand the current HRM practice in Korea. Methods The survey was sent via email through the Korean Society of Neurogastroenterology and Motility. The questions covered descriptive information, preparation, techniques, analysis, and reporting of esophageal HRM. Results The survey was completed in 32 (74.4%) out of 43 centers, including 24 tertiary and 8 secondary referral centers. Of the 32 centers, 25 (78.1%) performed HRM in a sitting position, while 7 centers (21.9%) reported performing HRM in a supine position. All the centers utilized single wet swallows as a standard, but the volume, frequency, and interval between swallows varied widely. Sixteen centers (50.0%) applied adjunctive tests, including multiple rapid swallows (n = 16) and rapid drink challenges (n = 9). Parameters assessed and documented in the report were similar. In addition to the assessment of the esophagogastric junction and esophageal body, 27 centers (84.8%) and 18 centers (56.3%) included measurements for the upper esophageal sphincter and the pharynx, respectively, in the HRM protocol. Conclusions We found a variation in the available HRM practice among centers, even though they broadly agreed in the data analysis. Efforts are needed to develop a standardized protocol for HRM measurement. (J Neurogastroenterol Motil 2021;27:347-353)

Phenotypes of achalasia are based on esophageal body pressurization during swallow. The reasons that lead to pressurized waves are still unclear. This study aims to evaluate manometric parameters that may determine pressurized waves in patients with achalasia. A total of 100 achalasia high-resolution manometry tests were reviewed. We measured before each swallow: upper esophageal sphincter (UES) basal pressure, esophageal length, lower esophageal sphincter (LES) basal pressure, LES length, gastric and thoracic pressure, transdiaphragmatic pressure gradient and the LES retention pressure (LES basal pressure-TPG); during swallow: UES pressure, UES residual pressure, UES recovery time, LES relaxation pressure, gastric and thoracic pressure, transdiaphragmatic pressure gradient and after swallow: esophageal length, LES length, wave pressure, gastric and thoracic pressure and transdiaphragmatic gradient pressure. Univariate analysis showed in pressurized waves before swallow: higher thoracic, UES and LES basal pressure, longer LES length and decrease in LES retention pressure; during swallow: higher thoracic, gastric and UES pressure, higher UES and LES relaxation pressure and after swallow: higher thoracic and gastric pressure. Multivariate analysis in pressurized waves showed as significant before swallow: thoracic and UES basal pressure; during swallow: thoracic, gastric and UES pressure, UES residual pressure and UES recovery time and after swallow: thoracic pressure. Basal esophageal pressurization and the UES are independent variables that may be associated with pressurized waves.

To evaluate the impact of MSA on lower esophageal sphincter (LES) and esophageal body using high resolution impedance manometry.MSA is an effective treatment in patients with gastroesophageal reflux disease, but there is limited data on its impact on esophageal functional physiology.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.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), P0.001]. 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), P0.001]. Outflow resistance at the EGJ increased after MSA as demonstrated by elevation in intrabolus pressure (19.6 vs 13.5 mmHg, P0.001) and integrated relaxation pressure (13.5 vs 7.2, P0.001). 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), P0.001]. The percent peristalsis and incomplete bolus clearance remained unchanged (P = 0.47 and 0.08, respectively).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.

High resolution manometry (HRM), developed from conventional manometry, is the gold standard for assessment of esophageal motor function worldwide. The Chicago Classification, now in its fourth iteration, is the modern standard for HRM categorization of esophageal motility disorders. The HRM protocol has expanded from the original 10 supine swallow standard, to include upright swallows, and provocative maneuvers such as multiple rapid swallows, rapid drink challenge and standardized test meal. Impedance has been incorporated into HRM for visualization of bolus clearance. Futhermore, barium radiography and functional lumen imaging probe complement HRM when evidence of esophagogastric junction obstruction is inconclusive. The biggest impact of HRM is in the improved diagnosis and subtyping of achalasia spectrum disorders, with implications on management. Spastic disorders and absent contractility are better characterized. Within the reflux spectrum, HRM provides definition of morphology and tone of the esophagogastric junction, and assesses integrity of esophageal body peristalsis, which have pathophysiologic implications for reflux and its clearance. HRM provides characterization of behavioral disorders such as supragastric belching and rumination syndrome, which can mimic reflux disease. Thus, HRM has revolutionized the evaluation of esophageal motor function, and has expanded the utility of esophageal manometry in clinical practice.

The goal of this study was to conceptualize and compute measures of “mechanical work” done by the esophagus using data generated during functional lumen imaging probe (FLIP) panometry and compare work done during secondary peristalsis among patients and controls. Eighty-five individuals were evaluated with a 16-cm FLIP during sedated endoscopy, including asymptomatic controls (n = 14) and those with achalasia subtypes I, II, and III (n = 15, each); gastroesophageal reflux disease (GERD; n = 13); eosinophilic esophagitis (EoE; n = 9); and systemic sclerosis (SSc; n = 5). The FLIP catheter was positioned to have its distal segment straddling the esophagogastric junction (EGJ) during stepwise distension. Two metrics of work were assessed: “active work” (during bag volumes ≤ 40 mL where contractility generates substantial changes in lumen area) and “work capacity” (for bag volumes ≥ 60 mL when contractility cannot substantially alter the lumen area). Controls showed median [interquartile range (IQR)] of 7.3 (3.6–9.2) mJ of active work and 268.6 (225.2–332.3) mJ of work capacity. Patients with all achalasia subtypes, GERD, and SSc showed lower active work done than controls (P ≤ 0.003). Patients with achalasia subtypes I and II, GERD, and SSc had lower work capacity compared with controls (P < 0.001, 0.004, 0.04, and 0.001, respectively). Work capacity was similar between controls and patients with achalasia type III and EoE. Mechanical work of the esophagus differs between healthy controls and patient groups with achalasia, EoE, SSc, and GERD. Further studies are needed to fully explore the utility of this approach, but these work metrics would be valuable for device design (artificial esophagus), to measure the efficacy of peristalsis, to gauge the physiological state of the esophagus, and to comment on its pumping effectiveness. NEW & NOTEWORTHY Functional lumen imaging probe (FLIP) panometry assesses esophageal response to distension and provides a simultaneous assessment of pressure and dimension during contractility. This enables an objective assessment of “mechanical work” done by the esophagus. Eighty-five individuals were evaluated, and two work metrics were computed for each subject. Controls showed greater values of work compared with individuals with achalasia, gastroesophageal reflux disease (GERD), and systemic sclerosis (SSc). These values can quantify the mechanical behavior of the distal esophagus and assist in the estimation of muscular integrity.

BACKGROUND: Chronic opioid use can induce esophageal dysfunction with symptoms resembling achalasia and a manometric pattern of esophagogastric junction-outflow obstruction (EGJ-OO). However, the effect of opioids in acute setting on pharyngeal function and esophageal body contractility has not been investigated. METHODS: After positioning the high-resolution impedance manometry (HRiM) catheter, codeine (60 mg) or placebo (glucose syrup) was infused intragastrically. Forty-five minutes post-infusion, participants received liquid, semi-solid, and solid boluses to assess esophageal and pharyngeal function. HRiM analysis was performed adhering to the Chicago classification v3.0. (CC v3.0). Pressure flow analysis (PFA) for the esophageal body and the pharynx was performed using the SwallowGateway™ online platform. KEY RESULTS: Nineteen healthy volunteers (HV) [5 male; age 38.3] were included. After codeine administration, higher integrated relaxation pressure 4 s values resulted in significantly reduced deglutitive EGJ relaxation and distal latency was significantly shorter. Distal contractility was similar in both conditions. Bolus flow resistance at the EGJ and distention pressures increased significantly after codeine infusion. Based on CC v3.0, acute infusion of codeine induced EGJ-OO in six HV (p = 0.0003 vs. placebo). Codeine administration induced no significant alterations in any of the pharyngeal PFA metrics. CONCLUSIONS & INFERENCES: In HV, acute administration of codeine increased bolus resistance at the EGJ secondary to induced incomplete EGJ relaxation leading to major motility disorders in a subset of subjects including EGJ-OO. However, an acute single dose of codeine did not affect motility or bolus flow in pharynx and UES. ClinicalTrials.gov number, NCT03784105. ispartof: NEUROGASTROENTEROLOGY AND MOTILITY vol:33 issue:5 ispartof: location:England status: published

Because it offers real-time assessment, barium esophagram should be the modality of choice when studying esophageal peristalsis. However, no standard reporting method is available for BE results. Presently, peristaltic disorders are defined according to high-resolution manometry (HRM), but HRM findings do not correlate with clinical symptoms. The aim of this study was to stratify esophageal peristaltic function via standardized evaluation of BE, and to define the association between esophageal peristalsis and dysphagia and regurgitation. Methods After IRB approval, a prospectively maintained database was reviewed for patients who underwent both HRM and BE from 08/01/2016 to 12/31/2019. Patients with conditions associated with outflow impairment were excluded. BEs were re-examined in blinded fashion and assigned subjective scores (0, 1, or 2) for dilation grade (DG) and contractility grade (CG). Patients were categorized according to the sum of the DG and CG: Group A = 0, Group B = 1–2, and Group C = 3–4. Mean distal contractile integral (DCI), number of failed contractions on HRM, and number of patients with dysphagia/regurgitation in each group were analyzed and compared. Results In all, 124 patients were included. The mean DCI (mmHg*cm*s) was 2539.1 ± 1357.8 in Group A, 884.4 ± 916.9 in Group B, and 77.4 ± 192.3 in Group C (p Conclusion The combined DG and CG allowed us to identify the patients with a grade of peristaltic disfunction that was significantly more associated with dysphagia or regurgitation (Group C). However, in order to achieve a clearer definition of the different peristaltic disfunction levels according to their propensity to cause dysphagia or regurgitation, a more objective assessment of both DG and CG should be provided; therefore, further studies are required.

Peristaltic disorders of the esophageal body have been categorized according to how they appear on high-resolution manometry. Abnormalities in peristalsis may lead to abnormal esophageal clearance and dysphagia. The aim of our retrospective analysis was to study bolus transit patterns on barium esophagogram in patients with various grades of esophageal body peristalsis as diagnosed by high-resolution manometry. Methods After Institutional Review Board approval, we queried an esophageal center database to identify patients with normal lower esophageal sphincter parameters. Patients with jackhammer esophagus, esophageal spasm, previous foregut surgery, hiatal hernia, and fragmented peristalsis were excluded. Remaining patients were divided into 11 groups based on their percentages of normal swallows out of 10 swallows (0%–100% swallows normal, DCI > 450 mmHg.s.cm). All previously obtained video esophagograms were re-evaluated in blinded fashion. Bolus transit time through the esophagus was measured in upright and prone positions, using live time stamps at the entry and exit of the bolus. ANOVA and χ2 were used. Results In total, 146 patients were included in the analysis. 73 (50%) were men. Mean age and body mass index were 58.4 ± 14.7 years and 22.8 ± 10.4 kg/m2, respectively. Bolus transit time in prone-position swallows increased in tandem with increases in number of abnormal swallows (11.3 ± 3.7, 22 ± 15.5, 29.5 ± 24.3, 42.7 ± 39.5, 42.4 ± 46.9, 64 ± 70.8, 59.4 ± 34.6, 58.8 ± 37.9, 110 ± 66.6, 83.2 ± 49.6 and 105.6 ± 72.5 seconds, p Conclusion Bolus transit time in prone-position swallows progressively increases as percentage of normal swallows decreases. Further work associated with symptoms to define a cutoff between normal and ineffective peristalsis would be useful.

Endoscopic ultrasonography (EUS) and high-resolution manometry (HRM) can be used in the evaluation of eosinophilic esophagitis (EoE) for frequent symptoms such as dysphagia. However, the role of these examinations is not clear. The aim of this study was to objectively evaluate the subjective symptoms of EoE patients with EUS and HRM. Patients who had endoscopic findings indicative of EoE and matched the number of eosinophil infiltrates used as diagnostic criteria were recruited between September 2018 and August 2019. Evaluable subjects underwent EUS and HRM and completed the Gastrointestinal Symptom Rating Scale (GSRS) questionnaire. The esophageal wall thickness (evaluated with EUS) and HRM parameters between patients with and without symptoms were retrospectively compared. Symptomatic patients were re-examined using EUS and HRM 6 months after treatment. A total of 35 patients (29 males, median age of 49 years) were divided into symptomatic (20 patients) and asymptomatic groups (15 patients). The esophageal wall was thicker, and the distal contractile integral (DCI) values were higher in the symptomatic group (P

Achalasia is a neurodegenerative condition resulting in abnormal lower esophageal sphincter relaxation and impaired upstream esophageal body peristalsis.1 The pathophysiology and natural history of achalasia remain unclear, and evaluation of the histopathogenesis of achalasia has traditionally been challenging because the esophageal wall muscularis propria is not typically accessible via routine endoscopic biopsies.

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.

Ineffective esophageal motility (IEM) describes esophageal body hypomotility detected during manometry. The concept of IEM was first established in 1997 using standard manometry, and the definition has changed over time due to the advent of high-resolution manometry (HRM). The latest Chicago Classification (version 3.0) defines IEM during HRM as frequent (≥50%) weak distal esophageal contractions (distal contractile integral (DCI) < 450 mmHg·cm·s).

Background/Aims Achalasia is a chronic, progressive motility disorder of the esophagus. The sigmoid-type achalasia is an advanced stage of achalasia characterized by severe dilatation and tortuous angulation of the esophageal body. Peroral endoscopic myotomy (POEM) has been reported to provide excellent clinical outcomes for achalasia, including the sigmoid type, but the restoration of esophageal morphology and function remain poorly described. The aim of our study is to investigate esophageal restoration after POEM for sigmoid-type achalasia. Methods From 98 patients with achalasia who underwent POEM in the Yonsei University Health System from 2013 to 2018, we recruited 13 patients with sigmoid-type achalasia (7 male; mean age 53.3 years) and assessed morphological and manometric changes in the esophagus. Results Clinical success (Eckardt score < 3) was achieved in all cases. After POEM, the average angle of esophageal tortuosity became more obtuse (91.5° vs 114.6°, P = 0.046), esophageal body diameter decreased (67.6 vs 49.8 mm, P = 0.002), and esophagogastric junction opening widened (6.4 vs 9.5 mm, P = 0.048). Patients whose esophageal tortuosity did not improve had longer durations of symptoms than patients with improvement (80.2 vs 636 months, P < 0.001). An absence of peristalsis was observed in all patients pre- and post-POEM. Conclusions POEM resulted in excellent clinical outcomes and morphologic improvement in sigmoid-type achalasia. These results suggest that the improvement of esophageal tortuosity through POEM reflects a reduced esophageal burden.

PURPOSE OF REVIEW: To present the latest developments in esophageal motility testing and summarize the current paradigm of esophageal motility disorders. RECENT FINDINGS: While high-resolution esophageal pressure topography interpreted according to the Chicago Classification represents the gold standard to evaluate esophageal motility, recent studies highlight the additional value of novel manometric applications. Novel applications include provocative measures to assess for obstructive physiology at the esophagogastric junction (EGJ), esophageal peristaltic reserve, and rumination and supragastric belching disorders. Furthermore high-resolution impedance manometry provides assessment of bolus flow in relation to pressure changes. Distinct from manometry, the endolumenal functional lumen imaging probe examines esophageal motor response to distension to provide complementary and alternative data with regards to EGJ function and esophageal body motor function. Barium esophagram with timed swallow and barium tablet continues to be an important esophageal motility test. Furthermore, current use of multichannel intraluminal impedance pH monitoring extends beyond reflux monitoring to measure reflux clearance and esophageal epithelial integrity. SUMMARY: The diagnostic armamentarium for esophageal motility disorders has expanded tremendously to include a multitude of sophisticated tools. Advancements in diagnostic technology and understanding of esophageal physiology have shifted the field to more precisely characterize esophageal motility and guide phenotype driven management.

As surgeons address foregut disease in their patients with different procedures, a review of relevant anatomy and physiology of the esophagus and LES will complement discussion with their patients and decision-making. As will be apparent in this chapter, the esophagus is more than a conduit that directs liquids and food to other organs, deters reflux, and serves as a passageway for radiographic contrast or endoscopes to define more distant foregut disease/disorders. Instead, the esophagus is a very complex organ whose function is directed by CNS and intrinsic esophageal control that is implemented by skeletal and smooth muscle.

High-resolution manometry is the gold standard test for evaluation of esophageal motility, which includes both the efficacy of esophageal body contractility and esophagogastric junction relaxation in response to swallowing. It is the best study for the work-up of patients with dysphagia and noncardiac chest pain, in whom a mechanical obstruction has been ruled out via upper endoscopy. As such, manometric parameters form the basis for diagnosis of major and minor esophageal motility disorders, including achalasia. This chapter will describe in detail the technical aspects of performing and analyzing a high-resolution manometry study. The current Chicago Classification of esophageal motility disorders serves as a basis for interpretation of these studies and classification of patients into diagnostic categories. Based on manometric findings, the resulting major and minor motility disorders and their treatments are discussed. Lastly, the use of manometry in the preoperative evaluation of patients with gastroesophageal reflux disease is explored, as well as the use of manometry for selective “tailoring” of fundoplication for patients undergoing antireflux surgery.

Esophageal high-resolution manometry (HRM) is currently the gold standard for the evaluation of esophageal motility. The Chicago Classification categorizes the esophageal motility disorders based on the HRM findings. Achalasia and esophagogastric junction outflow obstruction are characterized by a median integrated relaxation pressure that is higher than in healthy subjects. Major motility disorders are aperistalsis, distal esophageal spasm, and hypercontractile esophagus. Minor motility disorders include ineffective esophageal motility and fragmented peristalsis.

Background Distensibility evaluation of the esophageal body using the functional lumen imaging probe (FLIP) offers an objective measure to characterize patients with eosinophilic esophagitis (EoE), though this analysis may be limited by unrecognized catheter movement and esophageal contractility. The aims of this study were to report novel FLIP analytic methods of esophageal distensibility measurement in EoE and to assess the effect of contractility. Methods Nine healthy controls (six female; ages 20–49) and 20 EoE patients (four female; ages 19–64; grouped by degree of distension-mediated contractility identified on FLIP) were evaluated with a 16-cm FLIP device during step-wise balloon distension during upper endoscopy. A distensibility plateau (DP) was generated using multiple methods to identify the narrowest esophageal body diameter: (i) wavelet decomposition (WD), (ii) maximal diameter (MD), and (iii) FLIP Analytics software. Key Results Distensibility was reduced in EoE patients compared with controls using the WD (p = 0.002) and MD (p = 0.001) methods; a trend was detected using the FLIP Analytics method (p = 0.055). Significant intra-subject differences were detected between methods among both patients and controls (p-values

The aims of this study were to 1) examine pharyngoesophageal and cardiorespiratory responses to provoking pharyngeal stimuli, and 2) to determine potential contributory factors impacting heart rate (HR) changes to provide insight into cardiorespiratory events occurring in preterm infants. Forty-eight neonates (19 females and 29 males, born at 27.7 ± 0.5 wk; mean ± SE) pending discharge on full oral feeds were studied at 38.7 ± 0.2 wk postmenstrual age using concurrent pharyngoesophageal manometry, electrocardiography, respiratory inductance plethysmography, and nasal airflow thermistor. Pharyngoesophageal and cardiorespiratory responses (prevalence, latency, and duration) were quantified upon abrupt pharyngeal water stimuli (0.1, 0.3, and 0.5 ml in triplicate). Mixed linear models and generalized estimating equations were used for comparisons between HR changes. Contributory factors included stimulus characteristics and subject characteristics. Of 338 pharyngeal stimuli administered, HR increased in 23 (7%), decreased in 108 (32%), and remained stable in 207 (61%) neonates. HR decrease resulted in repetitive swallowing, increased respiratory-rhythm disturbance, and decreased esophageal propagation rates (all, P < 0.05). HR responses were related to stimulus volume, stimulus flow rate, and extreme prematurity (all, P < 0.05). In preterm infants, HR remains stable in a majority of pharyngeal provocations. HR decrease, due to pharyngeal stimulation, is related to aberrant pharyngoesophageal motility and respiratory dysregulation and is magnified by prematurity. We infer that the observed aberrant responses across digestive, respiratory, and cardiovascular systems are related to maladaptive maturation of the parasympathetic nervous system. These aberrant responses may provide diagnostic clues for risk stratification of infants with troublesome cardiorespiratory events and swallowing difficulty.NEW & NOTEWORTHY Cardiorespiratory rhythms concurrent with pharyngeal, upper esophageal sphincter, and esophageal body responses were examined upon pharyngeal provocation in preterm-born infants who were studied at full-term maturation. Decreased heart rate (HR) was associated with extreme preterm birth and stimulus flow/volume. With HR decrease responses, aerodigestive reflex abnormalities were present, characterized by prolonged respiratory rhythm disturbance, repetitive multiple swallowing, and poor esophageal propagation. Promoting esophageal peristalsis may be a potential therapeutic target.

Background and study aims Detecting esophageal achalasia remains a challenge. We describe the diagnostic utility of corona appearance, a novel endoscopic finding specific to esophageal achalasia. Patients and methods Corona appearance and seven conventional endoscopic findings were compared for sensitivity and consistency (κ-value) among 53 untreated esophageal achalasia patients who underwent endoscopy at our hospital. The following criteria had to be met during lower esophageal sphincter examination using the attached ST Hood short-type for positive corona appearance: A) congestion inside the hood, B) ischemic change around the hood, and C) palisade vessels outside the hood. Results Corona appearance had the highest sensitivity (91%; κ-value, 0.71). Other findings in descending order of sensitivity included 1) functional stenosis of the esophagogastric junction (EGJ; 86%; κ-value, 0.58), 2) mucosal thickening and whitish change (71%; κ-value, 0.27), 3) abnormal contraction of the esophageal body (59%; κ-value, 0.32), 4) dilation of the esophageal lumen (58%; κ-value, 0.53), 5) liquid remnant (57%; κ-value, 0.51), 6) Wrapping around EGJ (49%; κ-value, 0.14), and 7) food remnant (30%; κ-value, 0.88). Even in 22 patients with poor (grade 1) intraluminal expansion, corona appearance had highest sensitivity (88%) compared to other endoscopic findings (κ-value, 0.63). Conclusions Among endoscopic findings using a ST Hood short-type to diagnose esophageal achalasia, corona appearance had the highest sensitivity and its consistency (κ-value) among endoscopists was substantial compared to other endoscopic findings. Similar results were obtained for esophageal achalasia cases with poor expansion. Endoscopic diagnosis of esophageal achalasia with hood attached is useful.

BACKGROUND Esophageal stasis is a hallmark of achalasia. Timed barium esophagogram (TBE) is used to measure stasis but exposes patients to ionizing radiation. It is suggested that esophageal stasis can be objectified on high-resolution manometry (HRM) as well using a rapid drinking challenge test (RDC). We aimed to assess esophageal stasis in achalasia by a RDC during HRM and compare this to TBE. METHODS Thirty healthy subjects (15 male, age 40 [IQR 34-49]) and 90 achalasia patients (53 male, age 47 [36-59], 30 untreated/30 treated symptomatic/30 treated asymptomatic) were prospectively included to undergo HRM with RDC and TBE. RDC was performed by drinking 200 mL of water. Response to RDC was measured by basal and relaxation pressure in the esophagogastric junction (EGJ) and esophageal pressurization during the last 5 seconds. KEY RESULTS EGJ basal and relaxation pressure during RDC were higher in achalasia compared to healthy subjects (overall P

Secondary achalasia may result from diseases that either infiltrate or compress the lower esophageal sphincter to create an increased high-pressure zone and subsequent esophageal body changes. With bariatric surgery, a potential high-pressure zone is created by a sleeve, band, or bypass just distal to the esophagus. We report four patients who years after a bariatric procedure developed dysphagia followed by esophageal body radiographic and/or manometric features of achalasia. In addition, each of these patients responded symptomatically to endoscopic or surgical therapy either which lowered this high-pressure zone. Furthermore, review of prior cases in the literature suggests this has occurred before. Physicians should be aware of this association but further study is needed on its true prevalence.

Esophageal body and esophagogastric junction (EGJ) motor abnormalities are well characterized by the Chicago Classification version 3.0, which identifies disorders under the broad categories of EGJ outflow obstruction, major motor disorders not encountered in health, and minor motor disorders that can be associated with bolus transit abnormalities. However, abnormalities of the esophageal body peristaltic wave (contraction wave abnormalities), breaks in peristaltic integrity, and morphologic and motor EGJ abnormalities can be encountered when esophageal motor function is designated normal under the Chicago Classification. Other nonspecific motor abnormalities can be encountered in supragastric belching and rumination. This chapter elaborates these nonspecific disorders of esophageal and EGJ motor function, and describes potential relationships to symptoms.

We describe a new video-assisted technique for the management of a giant midesophageal diverticulum using a single 5-cm port. It maintained the same principles of the traditional open technique as diverticulectomy, myotomy, and fundoplication. The better visualization of the main esophageal body, diverticulum, and esophagogastric junction and the better alignment of the stapler cartridge to the longitudinal axis of the esophagus are all technical factors supporting our procedure. Heavily calcified mediastinal lymph nodes and diffuse pleural adhesions are the main contraindications. However, future experiences are needed before this technique can be recommended as acceptable treatment. (C) 2017 by The Society of Thoracic Surgeons.

Current parameters of the Chicago classification include assessment of the esophageal body (contraction vigour and peristalsis), lower esophageal sphincter relaxation pressure, and intra-bolus pressure pattern. Esophageal disorders include achalasia, esophagogastric junction outflow obstruction, major disorders of peristalsis, and minor disorders of peristalsis. Sub-classification of achalasia in types I, II, and III seems to be useful to predict outcomes and choose the optimal treatment approach. The real clinical significance of other new parameters and disorders is still under investigation.

Impedance planimetry measures tissue wall distensibility as a function of pressure and cross-sectional area. Recent interest in this technique’s relevance to the gastrointestinal tract has been accelerated by the availability of the functional lumen imaging probe, a catheter-based system that dynamically quantitates these biomechanical properties. Herein, we review the device’s particular utility in the setting of esophageal pathology, including processes affecting the esophageal body as well as the upper and lower esophageal sphincters. An expanding suite of disease-specific indications for impedance planimetry includes achalasia, gastroesophageal reflux disease, and eosinophilic esophagitis. The technique has also demonstrated a role in the intraoperative guidance of therapy and in the definition of hitherto unrecognized patterns of esophageal dysmotility. Device-specific technology remains in active evolution, which, in conjunction with progressively larger datasets, sets the stage for broader clinical applicability in the near future.

Esophageal dysmotility is a medical term that refers to an interruption in the bolus propagation through the esophagus. This chapter provides a description of the esophageal anatomy and physiology, the causes (if known) of esophageal dysmotility, and the current pharmacologic treatments.

Symptoms in patients with achalasia are produced by outflow obstruction at the level of the lower esophageal sphincter (LES). As a consequence of neural destruction, the LES does not undergo normal swallow-induced relaxation. In addition, the esophageal body loses normal peristaltic function and esophageal emptying is on the basis of gravity. All therapies for achalasia are palliative in that normal LES or esophageal body function cannot be restored. The efficacy of any therapy for achalasia is directly related to its ability to reduce the outflow obstruction at the LES. The three main treatment options are pneumatic dilatation, laparoscopic myotomy with partial fundoplication, and per-oral endoscopic myotomy (POEM). Details of the procedures and outcomes will be discussed.

The function of the esophagus is transporting nutrients from the oropharyngeal cavity to the stomach. This is achieved by coordinated contractions and relaxation of the tubular esophagus and the upper and lower esophageal sphincter. Multichannel intraluminal impedance monitoring offers quantification of esophageal bolus transit and/or retention without the use of ionizing radiation. Combined with conventional or high-resolution manometry, impedance measurements complement the quantification of esophageal body contraction and sphincter relaxation, offering a more comprehensive evaluation of esophageal function. Further studies evaluating the utility of quantifying bolus transit will help clarify the role and position of impedance measurements.

Relationships of timed barium esophagram (TBE) findings to achalasia types defined by high-resolution manometry (HRM) have not been elucidated. Therefore, we correlated preoperative TBE and HRM measurements in achalasia types and related these to patient symptoms and prior treatments. From 2006 to 2013, 248 achalasia patients underwent TBE and HRM before Heller myotomy. TBE height and width were recorded at 1 and 5 minutes; HRM measured lower esophageal sphincter mean basal pressure, integrated relaxation pressure (IRP), and mean esophageal body contraction amplitude. Achalasia was classified into types I (25%), II (65%), and III (9.7%). TBE height at 5 minutes was higher for I (median 8 cm; interquartile range 6-12) and II (8 cm; 8-11) than for III (1 cm; 0-7). TBE width at 5 minutes was widest (3 cm; 2-4), narrower in II (2 cm; 2-3), and narrowest in I (1 cm; 0-2), P < 0.001. Volume remaining at 1 and 5 minutes was lower in III (1 m(2) ; 0-16) than I (42 m(2) ; 17-106) and II (39 m(2) ; 15-60), highlighting poorer emptying of I and II. Increasing TBE width correlated with deteriorating morphology and function from III to II to I. Symptoms poorly correlated with TBE and HRM. Prior treatment was associated with less regurgitation, faster emptying, and lower IRP. Although TBE and HRM are correlated in many respects, the wide range of their measurements observed in this study reveals a spectrum of morphology and dysfunction in achalasia that is best characterized by the combination of these studies.

The incidence of achalasia is increasing over the recent decade due to the improvement of both the diagnosis methods and management strategies. Clinical investigation focused on symptom and severity evaluation is the fundamental step in the diagnosis algorithm. Upper endoscopy is a necessary examination for achalasia to rule out the malignancy and to determine a differential diagnosis. Barium esophagram shows the typical “bird beak” sign, and the time barium esophagram could provide a quantitative evaluation of esophageal luminal dilation and bolus retention. High resolution manometry (HRM) is the “gold standard” for achalasia, the updated Chicago classification defines the different subtypes of achalasia which are related to the treatment outcomes. The endoscopic functional luminal imaging probe (EndoFLIP) is a new technique which is able to measure the esophagogastric junction (EGJ) distensibility in achalasia patients and also a promising way to detect the contractility of the esophageal body among these patients.

BACKGROUND The results of the esophageal body motility differences between liquid and solid swallows from high-resolution manometry (HRM) studies are not consistent. The information of the frequency of ineffective liquid and solid bolus swallows in healthy individuals during HRM procedure is limited. The normative values of the HRM parameters of both liquid and solid swallows for Chinese population are lacking. METHODS The esophageal HRM data of 101 healthy volunteers from multicenters in China were analyzed. The values of the HRM parameters were summarized and compared between liquid and solid swallows. The frequencies of ineffective liquid and solid swallows were summarized. RESULTS Esophagus contracted stronger and slower in solid bolus swallows than water swallows with HREM. Ineffective water swallow (DCI

This study was designed to clarify whether laparoscopic antireflux surgery (LARS) improves the esophageal body motility (EBM) in patients with reflux esophagitis. Thirty-five patients with gastroesophageal reflux disease (GERD) scheduled to undergo LARS were divided into a mild esophagitis group (ME; n = 18, Grade O:A:B = 7:10:1) and a severe esophagitis group (SE; n = 17, Grade C:D = 13:4), according to the Los Angeles classification of reflux esophagitis. The types of fundoplication (Nissen/Toupet) were 6/12 in the ME group and 4/13 in the SE group. Esophageal pH monitoring and manometry were performed before and 1 year after surgery. The fraction time of a pH below 4 significantly decreased after surgery in both groups. The LES pressures did not change significantly after surgery in the ME group, but significantly increased in the SE group. The peristaltic amplitudes 18 and 13 cm above the LES did not change significantly after surgery in either group. The peristaltic amplitudes 8 and 3 cm above the LES did not change significantly after surgery in the ME group, but significantly increased after surgery in the SE group. The preoperative EBM was not improved by LARS in patients with GERD and mild mucosal breaks in the esophagus, but the preoperative middle to distal EBM was improved by LARS in patients with GERD and severe mucosal breaks.

Background This study aimed to evaluate the spatial variation in esophageal distensibility in normal subjects using a novel multichannel functional luminal imaging probe (FLIP). Methods Ten healthy subjects (four men, age 21–49 years) were evaluated during endoscopy with a high-resolution impedance planimetry probe (FLIP) positioned through the esophagogastric junction (EGJ) and distal 10 cm of the esophageal body. Stepwise bag distensions using 5-mL increments from 0 to 60 mL were conducted, and simultaneous measurements of cross-sectional area (CSA) and the associated intrabag pressure from each subject were analyzed using a customized MATLAB™ program. The distensibility along the esophagus was determined and compared between the EGJ and interval locations at 2–5 cm and 6–10 cm above the EGJ. Key Results The pressure–CSA relationship was nearly linear among sites at lower pressures (0 to 7.5 mmHg) and reached a distension plateau at pressures ranging from 8 to 24 mmHg. The location of greatest distensibility was 4 cm above the EGJ. Although the CSAs of individual recording loci were not significantly different, there was a significant difference between the mean CSAs when comparing the region 2 to 5 cm proximal to EGJ with that 6 to 10 cm proximal to the EGJ. Conclusions & Inferences There were significant regional differences in distensibility along the distal esophagus with lower values in the proximal part compared with more distal part. The greatest distensibility was noted to occur at about 4 cm above the EGJ in close proximity to the location of the contractile deceleration point and phrenic ampulla.

Background/Aims Little data exists about esophageal body dysmotility and reflux patterns in refractory gastroesophageal reflux disease (RGERD) patients off therapy. We aimed to evaluate effects of esophageal body dysmotility on reflux parameters in RGERD patients by combining impedance-pH monitoring and high-resolution manometry (HRM). Methods We retrospectively reviewed the impedance-pH data and HRM metrics in patients with refractory gastroesophageal reflux symptoms. Impedance-pH monitoring and manometric data were compared between 2 groups: ineffective esophageal motility (IEM) and normal motility. Results Forty-eight patients (30 males, mean age 54.5 years) were included (16 erosive esophagitis, 24 non-erosive reflux disease, and 8 functional heartburn), amongst which 24 subjects showed IEM, and others had normal motility. Number of patients who had a large break in the IEM group was significantly higher than that of normal motility patients. IEM group had more patients with weakly acid reflux and long term acid reflux than the normal group (P = 0.008, P = 0.004, respectively). There was no statistical difference in baseine impedance levels from z4 to z6 between the 2 groups (2911 ± 1160 Ω vs 3604 ± 1232 Ω, 2766 ± 1254 Ω vs 3752 ± 1439 Ω, 2349 ± 1131 Ω vs 3038 ± 1254 Ω, all P > 0.05). Acid exposure time, numbers of long term acid reflux and weakly acid reflux showed strong negative correlation with esophageal body motility and/or lower esophageal sphincter function. Conclusions IEM was associated more with acid exposure, abnormal weakly acid reflux, and long term acid reflux in RGERD patients. These data suggested the role of esophageal body dysmotility in the pathophysiological mechanisms of RGERD patients.

The aim of this study was to compare esophageal motor characteristics between diabetics and healthy individuals.Esophageal manometry was performed in 34 type 2 diabetics and 32 healthy individuals. Waves were evaluated in the 3 thirds of the esophagus (P1=upper, P2=middle, and P3=distal).In diabetics vs. controls, wave distribution was as follows: peristaltic waves, 83.5 ± 22.2% vs. 96.3 ± 4.4%, p0.002; simultaneous waves, 3.26 ± 5.8% vs. 0.53 ± 1.3%, p0.01; no transmitted waves, 10.62 ± 20.7% vs. 2.75 ± 3.0%, p0.002; and retrograde waves, 2.68 ± 4.0% vs. 0.31 ± 1.1%, p0.03. Wave amplitude was similar between groups. Average upstroke (mmHg/s) in diabetics vs. non-diabetics was P2, 33.8 ± 13.9 vs. 40.2 ± 17.7, p0.03; and P3, 29.8 ± 15.3 vs. 41.3 ± 14.0, p0.002.(1) Simultaneous waves, no transmitted waves, and retrograde esophageal waves were significantly more frequent in diabetics. (2) Average upstroke was significantly lower within the middle and distal esophagus of diabetic individuals. (3) Wave amplitude was similar in both groups.

Achalasia is a rare esophageal motor disorder in children. The manometric hallmarks are esophageal body aperistalsis, lack of lower esophageal sphincter (LES) relaxation, and high LES pressure. However, LES relaxation and function may be heterogeneous, making the diagnosis difficult at times. The aim of the study was to describe LES function in children with achalasia.The present study is a retrospective review of manometric tracings of pediatric patients with achalasia and controls. LES response after each swallow was evaluated. LES parameters were defined as homogeneous (normal or abnormal) if the same response was observed in75% of swallows. Otherwise, the LES parameters were considered heterogeneous.Twenty-nine patients with achalasia and 16 control patients were included. All of the controls had normal LES pressure and relaxation in all of the wet swallows. In the achalasia group, some LES relaxation was present in 74% of swallows and 25% of swallows had normal relaxation. Depending on the parameter, a heterogeneous LES (resting pressure, relaxation, residual pressure, and duration of relaxation) was observed in 27.6% to 34.5% of patients with achalasia versus 0% of the controls (P 0.001). The rest of the patients with achalasia had homogeneous abnormal responses versus homogeneous normal responses in 100% of control patients (P 0.001).The LES function in pediatric patients with achalasia is heterogeneous. The classic description of a nonrelaxing high-pressure LES in patients with achalasia is rarely found in children. Partial relaxations are common, and normal relaxations may be present.

The following contains commentaries on distensibility testing using the functional lumen imaging probe (FLIP); the use of the distention test of the esophageal body in the clinic diagnosis of noncardiac chest pain; the functional lumen imaging in gastroesophageal reflux disease-impaired esophagogastric junction; a multimodal pain model for the esophagus; the rationale for distensibility testing; and further developments in standardized distension protocols.

Manometric location of the lower esophageal sphincter (LES) has been mandatory before esophageal pH monitoring, despite costs and discomfort related with esophageal manometry. The aims of the study were: (i) to map the pH of the gastroesophageal junction (GEJ) to determine a pH turning point (PTP) and its relation with LES; and (ii) to test the feasibility of this technique to orientate esophageal pH monitoring. We studied 310 adult patients who underwent esophageal manometry and pH monitoring off acid-suppressive therapy. GEJ pH mapping was carried out by step-pulling the pH sensor from 5 cm below to 5 cm above LES, and a PTP was determined when pH changed from below to above 4, in centimeters from the nostril. Thirty-six patients referred only for pH monitoring were studied with pH sensor placed at 5 cm above the PTP. Out of 310 patients, a PTP was found in 293 (94.5%): inside LES in 86.3%, into the stomach in 8.2% and in the esophageal body in 5.5% of patients. The median distance between PTP and place where pH sensor monitored reflux was 8 cm. Among 36 patients who performed pH monitoring without LES manometry, there was no gastric monitoring during reflux testing. In adult patients investigated off acid suppressive therapy, GEJ pH mapping with reflux monitoring 5 cm above the PTP can be an alternative technique to perform esophageal pH monitoring when LES manometry is not available. Additional studies are needed before the widespread use of GEJ pH mapping in the clinical practice.