Basal Lower Esophageal Sphincter Pressure Research Articles

Influence of Menthol Infusion on Esophageal Peristalsis in Patients With Ineffective Esophageal Motility.

Activation of the cold receptor, transient receptor potential melastatin 8 (TRPM8) by menthol inhibits esophageal secondary peristalsis in healthy adults. Ineffective esophageal motility (IEM) is common. This study is to evaluate the effects of acute infusion of menthol on esophageal peristalsis in patients with IEM. Twenty patients with IEM (males 11, mean age 36) were studied for esophageal peristalsis using high-resolution manometry. All participant had primary peristalsis performed with 10 water swallows and secondary peristalsis generated with 10 rapid air injections of 20 mL via mid-esophageal infusion port. Two different sessions by randomly performing acute administration of placebo or menthol (3 mM) were used for testing their effects on esophageal peristalsis. Menthol infusion had no effects on distal contractile integral (P = 0.471), distal latency (P = 0.58), or complete peristalsis (P = 0.251). Menthol infusion did not change basal lower esophageal sphincter pressure (P = 0.321), esophagogastric junction contractile integral (P = 0.758), or integrated relaxation pressure (P = 0.375) of primary peristalsis, but reduced upper esophageal sphincter pressure (P = 0.037). Infusion of menthol significantly reduced the frequency of secondary peristalsis for air injects of 20 mL (P = 0.002), but did not affect distal contractile integral of secondary peristalsis for air injections of 20 mL. This work has suggested that activation of TRPM8 by menthol can attenuate mechanosensitivity of secondary peristalsis in response to rapid air distension regardless of the presence of IEM.

Does preoperative symptom duration affect outcomes following per oral endoscopic myotomy (POEM)?

Per oral endoscopic myotomy (POEM) is a safe therapy for the treatment of achalasia. Long-term effects of untreated achalasia include worsening dysmotility and disruptions in esophageal anatomy, i.e., tortuosity and dilation. We hypothesize that long-standing achalasia prior to intervention will have worse outcomes following POEM than in patients with symptoms for shorter duration. We retrospectively analyzed achalasia patients who underwent POEM at our institution from 2011 to 2023, categorizing them into symptom duration cohorts (< 1year, 1-3years, 4-10years, > 10years). Inclusion criteria comprised patients with documented achalasia diagnosis who received POEM treatment at our facility. Exclusion criteria encompassed individuals lacking data pertaining to achalasia diagnosis, the time frame before intervention, or those missing pre and postoperative Eckardt scores. POEM failure was defined as symptom recurrence, necessity for repeat intervention, or high postoperative Eckardt score. We compared demographic, preoperative, and postoperative outcomes across these cohorts, and employed multivariable logistic regression to explore the link between symptom duration and POEM response. During the study period, in our increased cohort 234 patients met inclusion criteria. 75 patients had symptoms for < 1year, 78 patients had symptoms from 1 to 3years, 47 patients had symptoms from 4 to 10years, and 34 patients had symptoms > 10years. Patient demographics such as age, sex, BMI, Charleson-Deyo-Comorbidity-Index, and diabetes did not differ amongst cohorts. High-resolution manometry data, including achalasia type, Median IRP, LES residual pressure, and Basal LES pressure did not differ between groups. Preoperative Eckardt scores ranged from 4 to 5 across groups (p 0.24). Patients endorsed an average of three total preoperative symptoms across groups (p 0.13). Patients with symptoms greater than 4years had significantly more endoscopic interventions prior to POEM (37% vs, 68% p .001). There was no significant difference in post-procedure mean Eckardt scores between cohorts. All cohorts experienced the same number of post-POEM symptoms. Post-POEM manometric measurements remained consistent across cohorts. Similarly, there were no significant differences in terms of symptom recurrence, requirement for repeat interventions, or repeat POEM among the cohorts. Multivariable logistic regression analysis determined achalasia symptoms greater than a decade did not result in increased odds of having a higher postoperative Eckardt score, worse dysphagia, regurgitation, or weight loss. In this increased cohort, this data once again suggests that longer symptom duration is not associated with increased rates of POEM failure.

Manometric profile of patients presented with dysphagia – A hospital-based descriptive study

Objectives: The prevalence of dysphagia is 16–22%. Achalasia is characterised by impaired relaxation of the lower oesophageal sphincter (LES) and absent oesophageal peristalsis. Minimally invasive procedures, endoscopic pneumatic balloon dilatation (PD) and peroral endoscopic myotomy (POEM) are treatments of choice. We aimed to assess the manometric profile of patients presented with dysphagia and pre- and post-LES pressure and integrated relaxation pressure (IRP) of patients who underwent PD and POEM. Materials and Methods: One hundred and twenty-nine patients presented with dysphagia underwent high resolution oesophageal manometry (HREM). Manometric parameters: IRP, LES and pattern of motility were noted. According to Chicago classification 4.0, those who are diagnosed with achalasia underwent PD (17) and POEM (15). Statistical analysis was performed using the Statistical Package for the Social Sciences version 28. Pre- and post-procedure values (IRP and basal LES) were compared using the Wilcoxon signed-rank test. Results: Out of 129 patients with dysphagia, 57 had increased IRP and 75 had simultaneous motility. The mean LES pressure and IRP were found to be 28 ± 19.82 and 17 ± 14.04 mmHg, respectively. On analysis, of patients who underwent procedures PD (17) and POEM (15), a statistically significant decrease in IRP was observed in patients with post POEM compared to post PD status (P = 0.005 and 0.017, respectively). Reduced basal LES pressure was observed in patients with post-POEM status compared to post-PD status, which was not statistically significant. Conclusion: About 44% of patients presented with dysphagia were diagnosed with achalasia cardia. POEM procedure was found to be more effective compared to pneumatic dilatation.

Oestrogen and Gastroesophageal Reflux Disease Dynamics in Premenopausal and Postmenopausal Women: A Cross-sectional Study

Introduction: Gastroesophageal Reflux Disease (GERD) is a common clinical disorder characterised by the reflux of stomach contents into the oesophagus, primarily due to the temporary relaxation of the Lower Oesophageal Sphincter (LES). The aetiology of GERD is multifactorial. The prevalence of GERD in females has been found to sharply increase throughout the postmenopausal period compared to the reproductive phase. Aim: To study the relationship between serum oestrogen levels in premenopausal and postmenopausal women with GERD. Materials and Methods: In this cross-sectional study, 60 patients with GERD were divided into 30 premenopausal and 30 postmenopausal groups. The study subjects underwent high-resolution oesophageal manometry. The Cobas e 411 immunoassay analyser was utilised to measure serum oestrogen levels through electrochemiluminescence. The independent, unpaired Student's t-test was employed to analyse the collected data. Results: The statistical analysis revealed that the mean reduced LES pressure of 9.76±3.80 mmHg and the mean reduced Oesophagogastric Junction Contractile Integral (EGJ-Cl) of 14.503±10.64 mmHg were lower in women with postmenopausal GERD who exhibited lower oestrogen levels compared to those with premenopausal GERD. An increase in LES pressure was also associated with an increase in EGJ-CI, demonstrating a statistically significant positive linear correlation between LES pressure and EGJ-CI. The p-value &lt;0.05 was deemed highly statistically significant. Conclusion: Parameters such as basal LES pressure and EGJCl were observed to be reduced in postmenopausal women with GERD who had low oestrogen levels. This study suggests that oestrogen plays a crucial role in safeguarding the oesophageal epithelium against the reflux of gastric contents.

High-resolution 3-dimensional tomography may be a useful tool for understanding the anatomy of hiatal hernias and surgical planning of patients eligible for laparoscopic or robotic antireflux surgery.

3D computed tomography (CT) has been seldom used for the evaluation of hiatal hernias (HH) in surgical patients. This study aims to describe the 3D CT findings in candidates for laparoscopic or robotic antireflux surgery or HH repair and compare them with other tests. Thirty patients with HH and/or gastroesophageal reflux disease (GERD) who were candidates for surgical treatment and underwent high-resolution CT were recruited. The variables studied were distance from the esophagogastric junction (EGJ) to the hiatus; total gastric volume and herniated gastric volume, percentage of herniated volume in relation to the total gastric volume; diameters and area of the esophageal hiatus. HH was diagnosed with CT in 21 (70%) patients. There was no correlation between the distance EGJ-hiatus and the herniated gastric volume. There was a statistically significant correlation between the distance from the EGJ to the hiatus and the area of the esophageal hiatus of the diaphragm. There was correlation between tomographic and endoscopic findings for the presence and size of HH. HH was diagnosed with manometry in 9 (50%) patients. There was no correlation between tomographic and manometric findings for the diagnosis of HH and between hiatal area and lower esophageal sphincter basal pressure. There was no correlation between any parameter and DeMeester score. The anatomy of HH and the hiatus can be well defined by 3D CT. The EGJ-hiatus distance may be equally measured by 3D CT or upper digestive endoscopy. DeMeester score did not correlate with any anatomical parameter.

Systematic Review With Meta-Analysis: Chronic Opioid Use Is Associated With Esophageal Dysmotility in Symptomatic Patients.

We aimed to conduct a systematic review and meta-analysis to assess the impact of chronic opioid exposure on esophageal motility in patients undergoing manometric evaluation. Multiple databases were searched through October 2022 for original studies comparing the manometric results of patients who have used chronic opioids (for >90 days) with those who do not. The primary outcomes were esophageal dysmotility disorders. Three high-resolution manometry parameters were conducted as secondary outcomes. A random-effects model was applied to calculate the odds ratio (OR) and means difference (MD) along with a 95% confidence interval (CI). Nine studies were included in this meta-analysis. Opioid use was associated with higher esophageal dysmotility disorders, including distal esophageal spasm (pooled OR 4.84, 95% CI 1.60-14.63, P = 0.005, I 2 = 96%), esophagogastric junction outflow obstruction (pooled OR 5.13, 95% CI 2.11-12.43, P = 0.0003, I 2 = 93%), and type III achalasia (pooled OR 4.15, 95% CI 2.15-8.03, P < 0.0001, I 2 = 64%). No significant differences were observed for hypercontractile esophagus, type I achalasia, or type II achalasia. The basal lower esophageal sphincter pressure (MD 3.02, 95% CI 1.55-4.50, P < 0.0001, I 2 = 90%), integrated relaxation pressure (MD 2.51, 95% CI 1.56-3.46, P < 0.00001, I 2 = 99%), and distal contractile integral (MD 640.29, 95% CI 469.56-811.03, P < 0.00001, I 2 = 91%) significantly differed between the opioid use and nonopioid use group. However, opioid use was associated with a lower risk of ineffective esophageal motility (pooled OR 0.68, 95% CI 0.49-0.95, P = 0.02, I 2 = 53%). Chronic opioid exposure is associated with an increased frequency esophageal dysmotility disorders. Our results revealed that opioid use is significantly associated with type III achalasia but not with type I and II achalasia. Therefore, opioid treatment should be taken into account as a potential underlying risk factor when diagnosing these major esophageal motor abnormalities.

Evaluating the efficacy and safety of acotiamide in patients with esophagogastric junction outflow obstruction: study protocol for an investigator-initiated, multi-center, randomized, double-blind, placebo-controlled phase II trial

BackgroundWe have determined that the impaired accommodation of the lower esophageal sphincter (LES) underlies the pathogenesis of esophagogastric junction outflow obstruction (EGJOO). We have also found that acotiamide may treat EGJOO by improving impaired LES accommodation. The effects of acotiamide in patients with EGJOO need to be further confirmed in a prospective study.MethodsThis trial is a multicenter, randomized, double-blind, placebo-controlled study to compare the efficacy and safety of acotiamide (300 mg/day or 600 mg/day) with those of a placebo in the treatment of patients with EGJOO. The primary endpoint will be the proportion of patients who report an improvement in symptom of food sticking in the chest after 4 weeks of treatment period 1. The secondary endpoints will be the proportion of patients with normalized integrated relaxation pressure (IRP), the value of change from baseline in the distal contractile integral, basal LES pressure, EGJOO–quality of life score, Gastrointestinal Symptom Rating Scale, and the correlation between IRP and each symptom score. During the 2-year trial period, 42 patients from five institutions will be enrolled.DiscussionThis trial will provide evidence to clarify the efficacy and safety of acotiamide as a treatment for patients with EGJOO. Acotiamide might help improve the quality of life of patients with EGJOO and is expected to prevent the progression of EGJOO to achalasia.Trial registrationThis study was approved by the Institutional Review Board (IRB) of Kyushu University Hospital as well as the local IRBs of the participating sites for clinical trials and registered in the Japan Registry of Clinical Trials (jRCT: 2071210072). The registration date is on October 11, 2021.

Orientation of Lower Esophageal Sphincter Pressure Using Three-Dimensional High-Resolution Manometry in Patients with Achalasia: A Pilot Study.

This study was performed to evaluate the orientation of lower esophageal sphincter (LES) pressure in patients with untreated achalasia using three-dimensional high-resolution manometry (3D-HRM). The study involved 20 patients with untreated achalasia (10 men, 60 [47-74] years of age). The 3D-HRM assembly had 32 standard channels and 12 3D channels. During basal LES pressure measurements, the orientations of the LES high- and low-pressure zones were evaluated at end-expiration. The directional relationships between the orientation of the LES high- and low-pressure zones were also evaluated. The LES high-pressure zones were located on the greater curvature side in nine (45%) patients, from the greater curvature to posterior wall side in six (30%), and from the greater curvature to anterior wall side in five (25%). The LES high-pressure zones were located mainly on the greater curvature side, but there were some variations of the orientation among the patients. The LES low-pressure zones were most frequently located from the lesser curvature to the posterior wall side in 11 (55%) patients, from the lesser curvature to anterior wall side in 6 (30%), on the posterior wall side in 2 (10%), and on the anterior wall side in 1 (5%). Significant differences were found in the directional relationships between the orientation of the LES high- and low-pressure zones (P = 0.0053). This is the first report from Japan focusing on the LES pressure orientation using 3D-HRM. Such evaluation may be useful for clarifying the pathophysiology of achalasia.

Correlation between Lower Esophageal Sphincter Metrics on High-Resolution Manometry and the Clinical Presentation of Patients with Newly Diagnosed Achalasia

Achalasia is characterized by aperistalsis with poor relaxation of the lower esophageal sphincter (LES). We aimed to systematically assess whether LES metrics on high-resolution manometry (HRM) correlate with the symptomatic or endoscopic presentation of patients with achalasia. A retrospective study was performed at two tertiary medical centers. All cases of newly diagnosed, untreated achalasia were reviewed for demographics, symptoms, and endoscopic findings. These were correlated with HRM metrics, including LES basal pressure (LESP), integrated relaxation pressure (IRP), percent LES relaxation, and esophagogastric junction (EGJ) morphology. 108 achalasia patients were included; 56 (51.9%) were men, with a mean overall age of 55.6 ± 17.9 years old. Achalasia subtypes included 23.1% with Type I, 65.7% Type II, and 11.1% Type III. Mean LESP was 40.9 ± 13.7 mmHg, IRP 26.8 ± 11.5 mmHg, with 36% ± 20% LES relaxation. On univariate analyses, a higher IRP was associated with age < 50 (p = 0.028), female sex (p = 0.030), Arab ethnicity (p < 0.001), weight loss (p = 0.016), a tortuous esophagus (p = 0.036), and resistance at the EGJ (p = 0.033). However, on multivariate regression analyses, only ethnicity remained significantly associated with IRP. No unique variables were associated with either LESP or percent LES relaxation. Achalasia subtype and Eckardt score were not associated with any LES metrics. Non-Type 1 EGJ morphology was associated with a lower LESP. LES metrics on HRM do not appear to correlate with the clinical or endoscopic presentation of patients with untreated achalasia.

The Efficacy of Peroral Endoscopic Myotomy vs Pneumatic Dilation as Treatment for Patients With Achalasia Suffering From Persistent or Recurrent Symptoms After Laparoscopic Heller Myotomy: A Randomized Clinical Trial

For patients with achalasia experiencing persistent or recurrent symptoms after laparoscopic Heller myotomy (LHM), pneumatic dilation (PD) is the most frequently used treatment. Per-oral endoscopic myotomy (POEM) is increasingly being investigated as rescue therapy. This study aimed to determine the efficacy of POEM vs PD for patients with persistent or recurrent symptoms after LHM. This randomized multicenter controlled trial included patients after LHM with an Eckardt score >3 and substantial stasis (≥2 cm) on timed barium esophagogram and randomized to POEM or PD. The primary outcome was treatment success, defined as an Eckardt score of ≤3 and without unscheduled re-treatment. Secondary outcomes included the presence of reflux esophagitis, high-resolution manometry, and timed barium esophagogram findings. Follow-up duration was 1 year after initial treatment. Ninety patients were included. POEM had a higher success rate (28 of 45 patients [62.2%]) than PD (12 of 45 patients [26.7%]; absolute difference, 35.6%; 95% CI, 16.4%-54.7%; P= .001; odds ratio, 0.22; 95% CI, 0.09-0.54; relative risk for success, 2.33; 95% CI, 1.37-3.99). Reflux esophagitis was not significantly different between POEM (12 of 35 [34.3%]) and PD (6 of 40 [15%]). Basal lower esophageal sphincter pressure and integrated relaxation pressure (IRP-4) were significantly lower in the POEM group (P= .034; P= .002). Barium column height after 2 and 5 minutes was significantly less in patients treated with POEM (P= .005; P= .015). Among patients with achalasia experiencing persistent or recurrent symptoms after LHM, POEM resulted in a significantly higher success rate than PD, with a numerically higher incidence of grade A-B reflux esophagitis. NL4361 (NTR4501), https://trialsearch.who.int/Trial2.aspx?TrialID= NTR4501.

Assessment of Esophageal Motility Disorders in Patients With Refractory Gastroesophageal Reflux Disease

There is insufficient data about esophageal body dysmotility in patients with refractory gastroesophageal reflux disease (RGERD) and inadequate response to proton pump inhibitors (PPIs) treatment. This study aimed to assess esophageal motility disorder and reflux parameters among these patients by high-resolution manometry (HRM) and intraluminal impedance and pH (MII‐pH) monitoring after stopping PPI therapy. A retrospective study was conducted among 100 RGERD patients admitted to Taleghani Hospital (Tehran, Iran) for one year. More than half of them were males (55%). Their mean age was 47.10±6.92, and 50% of patients had ineffective esophageal motility (IEM). Middle, distal, and proximal esophageal pressure (MEP, DEP, and PEP), lower esophageal sphincter (LES) basal pressure (LESP), integrated relaxation pressure (IRP), distal contractile integral (DCI), large breaks, upper esophageal sphincter basal pressure (UESP), and LES length (LESL) in IEM patients were significantly lower than the patients with normal esophageal motility (P&lt;0.001). Furthermore, there were more patients in the IEM group with long-term and abnormal weakly acid reflux compared with the non-IEM group (P&lt;0.05). It seems that the evaluation of reflux parameters and esophageal motility could lead to additional insights into the pathophysiological mechanisms of RGERD. Nevertheless, further studies are suggested to evaluate the effects of esophageal motility disorders among RGERD patients.

Long-term outcomes of peroral endoscopic myotomy for Chicago classification type I vs type III achalasia in treatment-naive patients.

The efficacy of peroral endoscopic myotomy (POEM) for achalasia has potential associations with Chicago classification by high-resolution manometry (HRM). Type II achalasia demonstrates the best response to POEM of all subtypes, while there remain controversies between type I and type III. Moreover, previous treatment history might cause discrepancy in direct comparison. We aimed to compare the clinical outcome of POEM for type I vs type III in treatment-naive patients. In total, 82 patients with type I or type III achalasia (45 type I, 37 type III) from February 2015 to December 2018 were enrolled and POEM was carried out as the initial treatment. Clinical success, change of Eckardt scores and HRM parameters were analyzed and compared between type I and type III group. About, 43 (95.6%) patients and 34 (91.9%) patients in type I and type III group acquired the clinical success (P = 0.821). Eckardt score and HRM results after POEM treatment decreased significantly in either group (P<0.01). Compared to type III group, higher reduction rates of Eckardt score (type I vs type III, 78.6 vs 66.9%, P = 0.034) and basal LES pressure (type I vs type III, 58.9 vs 40.4%, P = 0.040) were observed in type I group. Type I achalasia patients showed better response to POEM with more favorable clinical remission in Eckardt score and HRM outcomes than type III.

Association between endoscopic pressure study integrated system (EPSIS) and high-resolution manometry.

Background and study aims The endoscopic pressure study integrated system (EPSIS), a novel diagnostic tool for gastroesophageal reflux disease (GERD), allows evaluation of the anti-reflux barrier using endoscopy by monitoring the intragastric pressure (IGP) during insufflation. In this study, we evaluated the association between EPSIS results and lower esophageal sphincter (LES) function measured by high-resolution manometry (HRM) to elucidate whether EPSIS can evaluate the LES function. Patients and methods A retrospective, single-center study of patients with GERD symptoms who underwent endoscopy, pH-impedance monitoring, EPSIS, and HRM was conducted. The primary outcome was basal LES pressure and the secondary outcomes were end-respiratory LES pressure and integrated relaxation pressure (IRP). As EPSIS parameters, the following were measured: 1) pressure difference (mmHg), the difference between maximum and basal IGP; and 2) pressure gradient (mmHg/s), calculated by dividing pressure difference by the insufflating time. Pressure difference < 4.7 mmHg or pressure gradient < 0.07 mmHg/s was defined as an EPSIS GERD pattern. Results Forty-seven patients (median age: 53 years, 37 female) were analyzed. Pressure difference and pressure gradient significantly correlated with basal LES pressure (ρ = 0.29; P = 0.04 and ρ = 0.29; P = 0.04). Patients with EPSIS GERD pattern showed significantly lower basal LES pressure [13.2 (4.8–26.6) vs 25.3 (10.4–66.7) mmHg, P = 0.002], lower end-respiratory LES pressure [8.5 (1.1–15.9) vs 15.5 (1.9–43.9) mmHg, P = 0.019] and lower IRP [5.9 (1.0–12.0) vs 9.8 (1.3–17.8) mmHg, P = 0.020]. Conclusions This study showed a close association between EPSIS results and LES pressures measured by HRM. This indicates that EPSIS can evaluate the LES function during endoscopy and endorse the role of EPSIS as a diagnostic tool for GERD.

Analysis of Esophageal Motility and Reflux Characteristics in Patients with Gastroesophageal Reflux Disease With or Without Extraesophageal Symptoms.

The pathogenesis of extraesophageal symptoms of gastroesophageal reflux disease is complex, and esophageal motility and reflux may be involved in it. In this study, we aimed to compare esophageal motility and reflux characteristics in gastroesopha- geal reflux disease patients with and without extraesophageal symptoms by high-resolution manometry and multichannel intraluminal impedance-pH monitoring. We retrospectively studied gastroesophageal reflux disease patients between January 2014 and December 2018. All patients had undergone high-resolution manometry and multichannel intraluminal impedance-pH monitoring. The results were compared and analyzed. A total of 59 patients were included in this study. Patients were divided into 3 groups according to their main complaint: only typical symptoms (group A, n = 11), both typical and extraesophageal symptoms (group B, n = 33), and only extraesophageal symp- toms (group C, n = 15). Compared with group A, the lower esophageal sphincter basal pressure, integrated residual pressure, and lower esophageal sphincter length were lower, and the proximal reflux percentages of a weak acid and non-acid reflux were higher in group B and group C (P < .017). The positive rate of esophageal motility disorders was lower in group A than in other groups (P < .05). The propor- tion of patients with multiple rapid swallows/single swallow-distal contractile integral ratio greater than 1-was higher in group A than in other groups (P < .05). Decreased lower esophageal sphincter pressure and lower esophageal sphincter length, increased proximal esophageal reflux of weak acid and non-acid reflux, esophageal motility disorders, and decreased peristaltic reserve are involved in the pathogenesis of extraesophageal symptoms of gastroesophageal reflux disease.

How a modified Nissen procedure works: a mechanistic study using intraoperative esophageal high-resolution manometry.

We aimed at demonstrating how a modified Nissen procedure works by analyzing intraoperatively the variations of the low esophageal sphincter pressure values using high resolution manometry. This study included 15 patients with documented gastroesophageal reflux disease who underwent a laparoscopic modified Nissen procedure. Data regarding the changes in the pressure values were recorded at each step of the procedures using high resolution manometry and after the progressive insufflation of air in the stomach. Categorical data were compared between the preoperative and postoperative periods using Fisher's test, and continuous data were compared using Mann-Whitney U non-parametric test. Preoperative versus postoperative variations in continuous data were assessed using Wilcoxon's non-parametric test for paired data. Intraoperative manometric data showed a rise of basal LES pressure until the creation of the wrap. An evident increase of pressure values was recorded after gastric air insufflation, as consequence of the increase of intragastric pressure. No intraoperative and postoperative complications were observed. All patients experienced a significant reduction in terms of intensity and frequency of gastroesophageal reflux symptoms and no patients complained of dysphagia. Intraoperative high resolution manometry was feasible in all patients and demonstrated that the modified Nissen procedure works by increasing the LES pressure in response to gastric distension, without impeding the progression of the bolus into the stomach.

Effects of menthol on esophageal motility in humans: Studies using high-resolution manometry.

The cold receptor, transient receptor potential melastatin 8 (TRPM8), has been reported to be expressed in esophageal vagal afferents. Esophageal infusion of menthol modulates esophageal perception in reflux patients via TRPM8, but the effects of menthol on esophageal motility are not well investigated. This study aimed to test the hypothesis whether the infusion of menthol into the esophagus could affect esophageal peristaltic characteristics. Eighteen healthy adults (men 13, mean age 27) underwent high-resolution manometry (HRM) using a catheter with the injection port located in mid-esophagus. Primary peristalsis was performed with ten wet swallows, while secondary peristalsis was generated by 10 rapid air injections. Two different sessions were randomly performed including acute administration of menthol (3mM) and the placebo. Menthol significantly decreased upper esophageal (UES) pressure of primary peristalsis than the placebo (p=0.019). There was no difference in distal contractile integral (p=0.33), distal latency (p=0.86), basal lower esophageal sphincter pressure (p=0.19), or 4-second integrated relaxation pressure (p=0.75) between menthol and placebo. Menthol significantly decreased the frequency of secondary peristalsis subsequent to the administration of menthol during rapid injections with 20mL air (p=0.04). Intraluminal infusion of menthol reduces UES basal pressure and inhibits peristaltic frequency of secondary peristalsis. The data suggest that the triggering of secondary peristalsis is probably modulated by TRPM8-sensitive mechanoreceptors; however, the activation of TRPM8 from menthol does not alter esophageal motility following deglutition or distension-induced secondary peristalsis.

Esophagogastric junction contractile integral abnormalities in patients with proton pump inhibitor-refractory symptoms.

Esophagogastric junction contractile integral (EGJ-CI) is a novel indicator to evaluate quantitatively the esophagogastric junction (EGJ) barrier function. We aimed to assess the role of EGJ-CI in patients with refractory gastroesophageal reflux disease (GERD) symptoms and the correlation between EGJ-CI and impedance-pH monitoring characteristics. In total 82 patients with proton pump inhibitors (PPIs)-refractory gastroesophageal reflux symptoms (heartburn or regurgitation) were enrolled. These patients were further divided into two groups based on their EGJ-CI value (39 mmHg·cm). The mean nocturnal baseline impedance (MNBI) was measured to explore its association with EGJ-CI. The median EGJ-CI in patients with PPI-refractory symptoms was 30.8 mmHg·cm. EGJ-CI was inversely correlated with acid exposure time and reflux episodes; while it was positively correlated with MNBI, distal contractile integral, lower esophageal sphincter basal pressure and integrated relaxation pressure. Patients were further divided into the high (n=27) and low (n=55) EGJ-CI groups using a cut-off value of 39.0 mmHg·cm. Patients with a low EGJ-CI had a lower MNBI level than those with a high EGJ-CI (2703 Ω vs 3545 Ω, P = 0.034). In patients with PPIs-refractory symptoms, EGJ-CI is associated with acid exposure and conventional high-resolution manometry parameters. EGJ-CI may play an important role in the diagnosis and treatment of patients with refractory GERD.

Esophageal Physiologic Testing of Obese Subjects as a Part of Bariatric Surgery Planning

Background: Choice of bariatric procedure may be impacted by esophageal motor disorders and reflux disease, which are not routinely evaluated in obese subjects. Methods: Clinical characteristics on validated questionnaires and esophageal physiologic test findings were collected in 110 consecutive obese subjects (median age 48.5 years, 82% F, median BMI 46.9 kg/m2) evaluated for bariatric surgery. High resolution manometry (HRM) metrics included intragastric pressure (IGP), basal lower esophageal sphincter pressures (LESP), end-expiratory LESP, EGJ contractile integral (EGJ-CI), integrated relaxation pressure (IRP), distal contractile integral (DCI), and Chicago classification (CC) v4.0 diagnoses; acid exposure time (AET, normal if &lt;4%) was obtained from ambulatory reflux monitoring. Comparative analyses determined differences between obese subjects and 15 institutional normal controls (median age 24.7 years, 53% F, median BMI 24.7 kg/m2) and if symptoms predicted abnormal tests. Results: Basal LESP and EGJ-CI were higher in obese subjects ( P = .03) compared to controls, while end-expiratory LESP was similar ( P = .97). IGP was also higher in obese subjects ( P &lt; .0001), which modestly correlated with BMI. The most common CC 4.0 diagnosis was ineffective esophageal motility (IEM, 11.8%). EGJ outflow obstruction was seen in 9.1% and achalasia in 0.9%. Hiatus hernia (type 2 or 3 EGJ morphology) was found in 28%. Of 34 patients completing ambulatory reflux monitoring, 15 (44%) had elevated AET, without symptom or motor predictors. Conclusions: Achalasia, esophageal outflow obstruction, and reflux were encountered in higher than expected proportions without specific symptoms in pre-bariatric surgery patients. Thus, esophageal physiologic testing may be of value prior to bariatric surgery.

Manometric changes of the esophagus in morbidly obese patients.

This prospective study aimed to determine the manometric pattern and the prevalence of esophageal dysmotility in 79 morbidly obese patients selected for laparoscopic sleeve gastrectomy. After clinical evaluation and upper gastrointestinal endoscopy, high-resolution esophageal manometry was performed. The esophageal peristalsis, lower esophageal sphincter (LES) basal pressure, and LES relaxation were evaluated. Demographic data showed a predominance of females (55.70%) and both females and males were in the 5th decade of life. In addition, approximately 3/4 of the patients (78.48%) were from the urban zone. The mean body mass index of the patients was 46.40±6.0069 kg/m2, with a maximum of 61 kg/m2. The LES basal pressure was normal in 59.49% of the patients, with a mean value of 31.40±18.43 mmHg. LES basal hypertonia was observed in 26.58%, and LES hypotonia in 13.93% of patients; 46.84% (37 patients) had abnormal manometric findings: 24.05% (19 patients) had EGJ outflow obstruction, 12.66% (10 patients) ineffective esophageal motility, 3.8% (3 patients) distal esophageal spasm, 3.8% (3 patients) Jackhammer esophagus, 2 cases were suggestive for type 2 achalasia but in asymptomatic patients. Ineffective esophageal motility was not associated with diabetes mellitus type 2 or erosive esophagitis according to our data. Hiatal hernia (HH) was manometrically diagnosed in 23 patients (29.11%). Preoperative high-resolution esophageal manometry in obese patients demonstrated a high prevalence of motility disorders, but in asymptomatic patients, thus in the future, we require more studies and larger cohorts to better appreciate the clinical impact.

S0351 Characterizing Reflux on High Resolution Esophageal Manometry With Impedance

INTRODUCTION: In some patients, reflux at esophagogastric junction (EGJ) can be seen on the impedance portion of the high-resolution esophageal manometry with impedance (HREMI) studies. How this might correlate with reflux seen on conventional esophageal reflux monitoring studies is unknown. We aimed to: 1) Determine prevalence of reflux seen on HREMI, and 2) Correlate reflux during HREMI studies with reflux on esophageal reflux monitoring studies. METHODS: Patients undergoing HREMI from 7/2019 to 2/2020 were studied. Results of ambulatory reflux monitoring were obtained if undergone. Patients rated the severity of symptoms. RESULTS: Of 354 patients (mean age 56.0 ± 1.0, 68% females) undergoing HREMI, 99 (28%) had reflux at EGJ on HREMI on 3.9 ± 0.3 swallows. Patients with reflux on HREMI had lower Distal Contractile Integral/DCI (1414 ± 137 vs 2049 ± 159), lower esophageal sphincter (LES) basal pressure (19.2 ± 1.3 vs. 32.4 ± 1.1), integrated relaxation pressure/IRP (7.2 ± 0.7 vs 13.8 ± 0.6), less likely to have EGJ outflow disorders (8.1% vs 29.4%) and major disorders of peristalsis (7.1% vs 21.2%), and more likely to have hiatal hernia/HH (71.7% vs 31.4%) than patients without reflux on HREMI (all P < 0.01, Table 1). Patients with reflux on HREMI had lower severities of regurgitation, dysphagia, and vomiting than patients without reflux (all P ≤ 0.01), likely due to lower prevalence of major esophageal motility disorders. Of the 273 patients with ambulatory pH monitoring (multichannel intraluminal impedance-pH = 257, Bravo = 16), 135 (49.5%) had GERD (Table 2). Patients with reflux on HREMI were more likely to have GERD on ambulatory pH monitoring (60.5%) than patients without reflux on HREMI (44.8%, P = 0.02). Patients with reflux on HREMI had a higher number of reflux events detected on MII-pH than patients without reflux on HREMI (56.0 ± 4.7 vs 42.6 ± 2.5, P = 0.01). Reflux on ≥1 swallow on HREMI had a specificity of 76.8% and sensitivity of 36.3% for GERD (Table 3). Reflux on ≥4 swallows on HREMI improved specificity to 90.6%, with sensitivity of 14.8% for GERD. CONCLUSION: Amongst patients undergoing HREMI, 28% had reflux at EGJ on HREMI. These patients had lower DCI, LES basal pressure, IRP and more frequent HH on HREMI than patients without reflux on HREMI. Patients with reflux on HREMI were more likely to meet criteria for GERD on ambulatory pH monitoring. Reflux on HREMI had good specificity but low sensitivity for GERD. Reflux seen on HREMI may be supportive evidence for GERD.Table 1Table 2Table 3