Bolus Transit Research Articles

The Impact of Vocal Tremor on Deglutition: A Pilot Study.

Vocal tremor (VT) poses treatment challenges due to uncertain pathophysiology. VT is typically classified into two phenotypes: isolated vocal tremor (iVT) and essential tremor-related voice tremor (ETvt). The impact of phenotypes on upper aerodigestive tract physiology during swallowing remains unclear. Qualitative and quantitative measures were employed to characterize tremor phenotypes and investigate the effects on swallowing physiology. Eleven ETvt participants (1 Male, 10 Female; x̄ age = 74) and 8 iVT participants (1 Male, 7 Female; x̄ age = 71) swallowed 20 mL boluses in cued and uncued conditions under standardized fluoroscopic visualization. Sustained/a/productions were captured to assess the rate and extent of fundamental frequency (F0) modulation. Penetration and Aspiration Scale (PAS) scores were obtained and swallowing biomechanics were captured using Swallowtail™ software. Participants also completed the Swallowing Quality of Life (SWAL-QOL) questionnaire. Hypopharyngeal transit was faster in both VT phenotypes compared with Swallowtail™ normative reference data. Total pharyngeal transit times, however, were only faster in patients with iVT, relative to reference data. No significant differences were observed on the SWAL-QOL or PAS between tremor phenotypes. SWAL-QOL scores revealed that these patients rarely reported dysphagia symptoms. Subtle differences in swallowing patterns were observed across VT phenotypes, possibly related to adaptive mechanisms resulting in quicker pharyngeal bolus transit. Most patients did not report swallowing issues or dysphagia symptoms. This study is foundational for larger studies on this challenging population. 4 Laryngoscope, 134:4599-4603, 2024.

A Comprehensive and Repeatable Contrast-Enhanced Ultrasound Quantification Approach for Clinical Evaluations of Tumor Blood Flow.

The aim of this study is to define a comprehensive and repeatable contrast-enhanced ultrasound (CEUS) imaging protocol and analysis method to quantitatively assess lesional blood flow. Easily repeatable CEUS evaluations are essential for longitudinal treatment monitoring. The quantification method described here aims to provide a structure for future clinical studies. This retrospective analysis study included liver CEUS studies in 80 patients, 40 of which contained lesions (primarily hepatocellular carcinoma, n = 28). Each patient was given at least 2 injections of a microbubble contrast agent, and 60-second continuous loops were acquired for each injection to enable evaluation of repeatability. For each bolus injection, 1.2 mL of contrast was delivered, whereas continuous, stationary scanning was performed. Automated respiratory gating and motion compensation algorithms dealt with breathing motion. Similar in size regions of interest were drawn around the lesion and liver parenchyma, and time-intensity curves (TICs) with linearized image data were generated. Four bolus transit parameters, rise time (RT), mean transit time (MTT), peak intensity (PI), and area under the curve (AUC), were extracted either directly from the actual TIC data or from a lognormal distribution curve fitted to the TIC. Interinjection repeatability for each parameter was evaluated with coefficient of variation. A 95% confidence interval was calculated for all fitted lognormal distribution curve coefficient of determination (R2) values, which serves as a data quality metric. One-sample t tests were performed between values obtained from injection pairs and between the fitted lognormal distribution curve and direct extraction from the TIC calculation methods to establish there were no significant differences between injections and measurement precision, respectively. Average interinjection coefficient of variation with both the fitted curve and direct calculation of RT and MTT was less than 21%, whereas PI and AUC were less than 40% for lesion and parenchyma regions of interest. The 95% confidence interval for the R2 value of all fitted lognormal curves was [0.95, 0.96]. The 1-sample t test for interinjection value difference showed no significant differences, indicating there was no relationship between the order of the repeated bolus injections and the resulting parameters. The 1-sample t test between the values from the fitted lognormal distribution curve and the direct extraction from the TIC calculation found no statistically significant differences (α = 0.05) for all perfusion-related parameters except lesion and parenchyma PI and lesion MTT. The scanning protocol and analysis method outlined and validated in this study provide easily repeatable quantitative evaluations of lesional blood flow with bolus transit parameters in CEUS data that were not available before. With vital features such as probe stabilization ideally performed with an articulated arm and an automated respiratory gating algorithm, we were able to achieve interinjection repeatability of blood flow parameters that are comparable or surpass levels currently established for clinical 2D CEUS scans. Similar values and interinjection repeatability were achieved between calculations from a fitted curve or directly from the data. This demonstrated not only the strength of the protocol to generate TICs with minimal noise, but also suggests that curve fitting might be avoided for a more standardized approach. Utilizing the imaging protocol and analysis method defined in this study, we aim for this methodology to potentially assist clinicians to assess true perfusion changes for treatment monitoring with CEUS in longitudinal studies.

383. LOSS OF PERISTALTIC RESERVE DETERMINED BY MULTIPLE RAPID SWALLOWS CORRELATES WITH DYSPHAGIA AND POOR BOLUS TRANSIT IN INEFFECTIVE ESOPHAGEAL MOTILITY

Abstract Introduction Ineffective esophageal motility (IEM) is a common finding on high resolution esophageal manometry (HRM) and is often of unclear clinical significance as its impact on dysphagia and bolus transit is variable. Multiple rapid swallow (MRS) testing is a provocative maneuver performed during HRM that assesses peristaltic reserve, documented by the presence of contractile augmentation (defined by contractile vigor after MRS greater than that seen with single swallows). Lack of augmentation after MRS is associated with dysphagia after anti-reflux surgery. To date, no studies have evaluated the impact of peristaltic reserve on dysphagia and bolus transit in IEM patients. Methods Retrospective review of 159 patients with Chicago classification 4.0 IEM. 52 patients were excluded due to prior esophageal surgery, technically inadequate MRS, or concomitant esophagogastric junction outflow obstruction. Demographics and brief esophageal dysphagia questionnaire (BEDQ) results were obtained from a prospectively maintained database. MRS and bolus transit data were analyzed using a commercially available software. Impedance analysis documented complete versus incomplete bolus transit. Augmentation was defined as the ratio of post-MRS DCI to mean single swallow DCI > 1. Fisher's exact test for continuous data and linear model ANOVA were used to assess for statistical significance. Results 107 IEM patients were included, 46 of them had loss of peristaltic reserve (no augmentation on MRS). Compared to IEM patients with augmentation, those without augmentation had more severe dysphagia documented by higher mean BEDQ score (6.8 versus 4.8, p= 0.045), and increased rates of impaired bolus transit (73% versus 55%, p-= 0.013). Discussion IEM patients without augmentation on MRS have more severe dysphagia and more frequent incomplete bolus clearance. These findings support adding MRS response to the diagnosis of IEM or using it to describe a subset of patients with more severe disease.

Characterizing Biomarkers of Continuous Peristalsis and Bolus Transit During Oral Feeding in Infants at pH-Impedance Evaluation: Clinical and Research Implications

ObjectiveTo examine the biomarkers of pharyngoesophageal swallowing during oral feeding sessions in infants undergoing pH-impedance testing and determine if swallow frequencies are distinct between oral- and partially oral-fed infants. Study designOne oral feeding session was performed in 40 infants during pH-impedance studies and measurements included swallowing frequency, multiple swallow rate, air and liquid swallow rates, esophageal swallow clearance time (ESCT), and gastroesophageal reflux (GER) characteristics. Linear and mixed statistical models were applied to examine the swallowing markers and outcomes. ResultsInfants (30.2 ± 4.4 weeks birth gestation) were evaluated at 41.2 ± 0.4 weeks postmenstrual age (PMA). Overall, 10,675 swallows were analyzed during the oral feeding sessions (19.3 ± 5.4 min per infant) and GER events were noted (2.5 ± 0.3 per study). Twenty-four-hour acid reflux index (ARI) was 9.5 ± 2.0%. Differences were noted in oral- and partially oral-fed infants for: volume consumption (p<0.01), consumption rate (p<0.01), and length of hospital stay in days (p<0.01). Infants with ARI >7% had greater frequency of swallows (p=0.01). The oral-fed group had greater ARI (12.7 ± 3.3%, p=0.05). ConclusionsOropharyngeal swallowing regulatory characteristics decrease over the feeding duration and were different between ARI >7% vs ≤7%. Although GER is less in infants who are partially oral-fed, the neonates with increased acid exposure achieved greater oral intakes and shorter hospitalizations, despite the presence of comorbidities. Pharyngoesophageal stimulation as during consistent feeding or GER events can activate peristaltic responses and rhythms, which may be contributory to the findings.

Effect of bolus property on swallowing dynamics in patients with dysphagia.

Modification of foods or liquids is commonly administered as part of dysphagia treatment. However, no consensus exists on the parameters for defining texture-modified food for patients with dysphagia. The aim of this study was to evaluate the effect of food/liquid material on swallowing physiology in patients with dysphagia and to discuss the optimal food choice for direct swallowing therapy. A total of 140 patients underwent a videofluoroscopic swallowing study using three test foods/liquids: 3 mL of mildly thick liquid (Thick liquid), jelly made of agar and polysaccharide (Jelly) and jelly made of pectin (Reset gel). Outcome measures of videofluoroscopic images, bolus transit time and hyoid movements were compared. The frequency of chewing movements was highest for Jelly, followed by Reset gel and Thick liquid. While the probability of oral residue was the highest for Reset gel, pharyngeal residue after swallowing was high for Thick liquid as compared to Jelly and Reset gel. Oral transit time and pharyngeal transit time for Thick liquid were significantly smaller than that for Jelly and Reset gel. Pharyngeal delay time was significantly smaller for Thick liquid than that for Jelly and Reset gel. There was no difference in hyoid elevation time and hyoid movement time among the conditions. Mildly thick liquid material may be optimal for patients with primarily oral motor function impairment and jelly, such as Reset gel, may be more suitable for patients with primarily pharyngeal motor function impairment or oral and pharyngeal coordinative motor function decline.

Pulmonary blood volume measured by 82Rb-PET in patients with chronic obstructive pulmonary disease: a retrospective cohort study.

In patients with chronic obstructive pulmonary disease (COPD), pulmonary vascular dysfunction and destruction are observable before the onset of detectable emphysema, but it is unknown whether this is associated with central hypovolemia. We investigated if patients with COPD have reduced pulmonary blood volume (PBV) evaluated by 82Rb-positron emission tomography (PET) at rest and during adenosine-induced hyperemia. This single-center retrospective cohort study assessed 6,301 82Rb-PET myocardial perfusion imaging (MPI) examinations performed over a 6-yr period. We compared 77 patients with COPD with 44 healthy kidney donors (controls). Cardiac output ([Formula: see text]) and mean 82Rb bolus transit time (MBTT) were used to calculate PBV. [Formula: see text] was similar at rest (COPD: 3,649 ± 120 mL vs. control: 3,891 ± 160 mL, P = 0.368) but lower in patients with COPD compared with controls during adenosine infusion (COPD: 5,432 ± 124 mL vs. control: 6,185 ± 161 mL, P < 0.050). MBTT was shorter in patients with COPD compared with controls at rest (COPD: 8.7 ± 0.28 s vs. control: 11.4 ± 0.37 s, P < 0.001) and during adenosine infusion (COPD: 9.2 ± 0.28 s vs. control: 10.2 ± 0.37 s, P < 0.014). PBV was lower in patients with COPD, even after adjustment for body surface area, sex, and age at rest [COPD: 530 (29) mL vs. 708 (38) mL, P < 0.001] and during adenosine infusion [COPD: 826 (29) mL vs. 1,044 (38) mL, P < 0.001]. In conclusion, patients with COPD show evidence of central hypovolemia, but it remains to be determined whether this has any diagnostic or prognostic impact.NEW & NOTEWORTHY The present study demonstrated that patients with chronic obstructive pulmonary disease (COPD) exhibit central hypovolemia compared with healthy controls. Pulmonary blood volume may thus be a relevant physiological and/or clinical outcome measure in future COPD studies.

Noninvasive Bolus Transit Detection in Cervical Esophagus Utilizing Ultrasound Characteristics.

This pilot study aims to identify characteristic A-mode ultrasound features relevant to noninvasive detection of esophageal bolus transit in the proximal esophagus. Ultrasound signals at a lateral neck site were obtained via a single-element ultrasonic transducer with synchronous videofluoroscopic swallowing studies images of swallows of differing viscosities in 21 adult dysphagia outpatients. Characteristic ultrasound features were extracted to differentiate a bolus-filled from a collapsed esophagus. From 21 subjects, 412 swallows exhibited 4 reproducible waveform patterns associated with bolus transit as displayed in a heatmap: (1)Strong Reflectors; (2)Echo Shifts; (3)Distal Acoustic Enhancement; and (4)Speckling: One or more of these features were observed in the swallow series for all 21 subjects. Distinct acoustic waveform features acquired by single-element ultrasonic transducers can identify bolus transit through the cervical esophagus.

Chewing Well Modulates Pharyngeal Bolus Transit During Swallowing in Healthy Participants.

Mastication is controlled by central pattern generator in the brainstem and can be modulated by volition. The aim of this study was to investigate the effect of chewing well on swallowing. Twenty-six healthy participants were instructed to eat 8, 12, and/or 16g of steamed rice with barium sulphate under the following two conditions: chewing freely task (CF; chewing naturally in their usual manner) and chewing well task (CW; chewing the food with a request to "chew well"). We evaluated bolus transport and swallowing movement using videofluoroscopy and electromyography of the masseter, suprahyoid and thyrohyoid muscles. The chewing time and pharyngeal transit time (PTT) at the first swallow showed high reproducibility in both CF and CW. PTT for CW was significantly shorter and longer than CF in 12 and 16g, respectively. In 12g, CW increased the pharyngeal bolus velocity and decreased thyrohyoid EMG activity during swallowing compared with CF. In 16g, the difference between CW and CF in the estimated swallowed bolus volume was positively correlated with that in upper esophageal sphincter transit duration. We speculate that CW modulates PTT during swallowing depending on the mouthful volume.

The Effects of Short- and Long-Term Ingestion of Plastic Toxin Bisphenol A on Gastrointestinal Transit Time in Rats.

Introduction Exposure to bisphenol A (BPA), a toxic chemical released from plastic, affects various body functions, including reproduction, metabolism, and development. The most common route of exposure to BPA is oral, and the gastrointestinal(GI) tract is, therefore, the first body system to be exposed to BPA. BPA has been well-documented to impair gut contractility in rats, in vitro. It may therefore be hypothesized that BPA may adversely affect GI motility and hence slow down the movement of food, resulting in the increased transit of food bolus in the GI tract. There are no reports so far on the effects of BPA on GI transit time. Objectives The present study was undertaken to examine the impact of exposure to BPA by a single oral dose (termed as short-term ingestion of BPA) and chronic (28-day) oral dose (termed as long-term ingestion of BPA) on the transit time of food bolus in the gut of adult male albino rats. Methods and materials The study was conducted in the Department of Physiology,Institute of MedicalSciences,Banaras Hindu University, Varanasi,Uttar Pradesh, India. In one set of experiments, each animal was fed a food pellet, once (short-term ingestion) containing BPA (2 µg/kg and 50 µg/kg in different groups), and in another set of experiments, each animal was fed a food pellet containing BPA (50 µg/kg/day) for 28 consecutive days (long-term ingestion). Control rats in both sets were fed food pellets without BPA. Subsequently, the gastric transit index (GTI), ileocecal transit index (ICTI), and colonic transit time (CTT) were determined by the standard charcoal marker method. Results One-time ingestion of a food pellet containing BPA caused a significant (p < 0.05) drop in the GTI and ICTI and an increase in the CTT with both doses of BPA (2 and 50 µg/kg). Similarly, after chronic (28-day), oral BPA exposure, a significant decrease in the GTI and ICTT and an increase in CTT were observed. Conclusion Both short-term (one-time) and long-term (28-day) oral exposure to BPA-containing food harmed GI transit. Slow GI transit may lead to metabolic disorders and GI motility disorders, such as constipation.

Interpretation of Impedance Data on High-resolution Impedance Manometry Studies-A Worldwide Survey.

Esophageal manometry is the gold standard for esophageal motility evaluation. High-resolution esophageal manometry with impedance (HRIM) allows concurrent assessment of bolus transit and manometry. Inconsistencies between concomitant impedance and manometry data pose a clinical dilemma and has not yet been addressed. We aim to assess interpretation trends of HRIM data among gastroenterologists worldwide. A cross-sectional study using an anonymous survey was conducted among gastroenterologists worldwide. Statistical analysis was performed to compare responses between providers. We received responses from 107 gastroenterologists (26 countries). Most were adult providers (69, 64.5%), and most (77, 72.0%) had > 5 years of experience. Impedance was found to be helpful by 83 (77.6%) participants, but over 30% reported inconsistencies between impedance and manometry data. With incomplete bolus clearance and normal manometry 41 (38.7%) recommended observation, 41 (38.7%) recommended 24-hours pH-impedance, and 16 (15.1%) recommended prokinetics. With abnormal manometry and complete bolus clearance, 60 (57.1%) recommended observation while 18 (17.1%) recommended 24-hours pH impedance and 15 (14.3%) recommended prokinetics. A significant difference was found between providers from different continents in treating cases with discrepancy between impedance and manometry findings (P < 0.001). No significant differences were seen in responses between adult versus pediatric providers and between providers with different years of experience. There is no consensus on interpreting HRIM data. Providers' approaches to studies with inconsistencies between manometry and impedance data vary. There is an unmet need for guidelines on interpreting impedance data in HRIM studies.

Higher obesity class is associated with more severe esophageal symptoms and reflux burden but not altered motor function or contractile reserve.

Patients with obesity often report esophageal symptoms, with abnormal reflux and esophageal motility suggested as potential mechanisms. However, prior studies showed varying results, often limited by study design/size and esophageal function/symptom measures utilized. We aimed to examine the relationship between obesity and objective esophageal function testing and patient-reported outcomes, utilizing prospective symptom, manometric and reflux monitoring data with impedance. Adults referred for high-resolution impedance-manometry (HRiM) and multichannel intraluminal impedance-pH monitoring (MII-pH) to evaluate esophageal symptoms were enrolled. Validated symptom and health-related quality of life (HR-QOL) instruments were prospectively collected: GERDQ, reflux symptoms index (RSI), dominant symptom intensity (DSI, multiplied 5-point Likert scales for symptom frequency/severity), global symptom severity (GSS, 100-point visual analog scale), and Short Form-12 (SF-12) for HR-QOL. Esophageal function testing measures were compared across body mass index (BMI) categories and correlated with patient-reported outcomes. Seven hundred and fifty four patients were included (Normal:281/Overweight:253/Class I obesity:137/Class II/III obesity:83). Reflux burden measures on MII-pH (acid exposure time, total reflux episodes, bolus exposure time), conclusive pathologic reflux (Lyon), and hiatal hernia were increased in higher obesity classes compared to normal BMI. Class II/III obesity was associated with more normal/hypercontractile swallows, less ineffective swallows, and better bolus transit on HRiM. BMI correlated positively with GERDQ/RSI/DSI/GSS, and negatively with physical component score (SF-12). Esophageal symptom severity and HR-QOL correlated strongly with MII-pH findings, but not HRiM measures. Obesity is associated with increased esophageal symptom burden and worse physical HR-QOL, which correlate with higher acid/bolus reflux burden but not altered esophageal motility/transit/contractile reserve.

Assessing mechanical function of peristalsis with functional lumen imaging probe panometry: Contraction power and displaced volume.

The distal contractile integral (DCI) quantifies the contractile vigor of primary peristalsis on high-resolution manometry (HRM), whereas no such metric exists for secondary peristalsis on functional lumen imaging probe (FLIP) panometry. This study aimed to evaluate novel FLIP metrics of contraction power and displaced volume in asymptomatic controls and a patient cohort. Thirty-five asymptomatic controls and adult patients (with normal esophagogastric junction outflow/opening and without spasm) who completed HRM and FLIP panometry were included. The patient group also completed timed barium esophagram (TBE). Contraction power (estimate of esophageal work over time) and displaced volume (estimate of contraction-associated fluid flow) were computed from FLIP. HRM was analyzed per Chicago Classification v4.0. In controls, median (5th-95th percentile) contraction power was 27 mW (10-44) and displaced volume was 43 mL (17-66). 95 patients were included: 72% with normal motility on HRM, 17% with ineffective esophageal motility (IEM), and 12% with absent contractility. Among patients, DCI was significantly correlated with both contraction power (rho = 0.499) and displaced volume (rho = 0.342); p values < 0.001. Both contraction power and displaced volume were greater in patients with normal motility versus IEM or absent contractility, complete versus incomplete bolus transit, and normal versus abnormal retention on TBE; p values < 0.02. FLIP panometry metrics of contraction power and displaced volume appeared to effectively quantify peristaltic vigor. These novel metrics may enhance evaluation of esophageal motility with FLIP panometry and provide a reliable surrogate to DCI on HRM.

Quantification of Hepatocellular Carcinoma Vascular Dynamics With Contrast-Enhanced Ultrasound for LI-RADS Implementation.

The aim of this study is to describe a comprehensive contrast-enhanced ultrasound (CEUS) imaging protocol and analysis method to implement CEUS LI-RADS (Liver Imaging Reporting and Data System) in a quantifiable manner. The methods that are validated with a prospective single-center study aim to simplify CEUS LI-RADS evaluation, remove observer bias, and potentially improve the sensitivity of CEUS LI-RADS. This prospective single-center study enrolled patients with hepatocellular carcinoma (April 2021-June 2022; N = 31; mean age ± SD, 67 ± 6 years; 24 men/7 women). For each patient, at least 2 CEUS loops spanning over 5 minutes were collected for different lesion scan planes using an articulated arm to hold the transducer. Automatic respiratory gating and motion compensation algorithms removed errors due to breathing motion. The long axis of the lesion was measured in the contrast and fundamental images to capture nodule size. Parametric processing of time-intensity curve analysis on linearized data provided quantifiable information of the wash-in and washout dynamics via rise time ( RT ) and degree of washout ( DW ) parameters extracted from the time-intensity curve, respectively. A Welch t test was performed between lesion and parenchyma RT for each lesion to confirm statistically significant differences. P values for bootstrapped 95% confidence intervals of the relative degree of washout ( rDW ), ratio of DW between the lesion and surrounding parenchyma, were computed to quantify lesion washout. Coefficient of variation (COV) of RT , DW , and rDW was calculated for each patient between injections for both the lesion and surrounding parenchyma to gauge reproducibility of these metrics. Spearman rank correlation tests were performed among size, RT , DW , and rDW values to evaluate statistical dependence between the variables. The mean ± SD lesion diameter was 23 ± 8 mm. The RT for all lesions, capturing arterial phase hyperenhancement, was shorter than that of surrounding liver parenchyma ( P < 0.05). All lesions also demonstrated significant ( P < 0.05) but variable levels of washout at both 2-minute and 5-minute time points, quantified in rDW . The COV of RT for the lesion and surrounding parenchyma were both 11%, and the COV of DW and rDW at 2 and 5 minutes ranged from 22% to 31%. Statistically significant relationships between lesion and parenchyma RT and between lesion RT and lesion DW at the 2- and 5-minute time points were found ( P < 0.05). The imaging protocol and analysis method presented provide robust, quantitative metrics that describe the dynamic vascular patterns of LI-RADS 5 lesions classified as hepatocellular carcinomas. The RT of the bolus transit quantifies the arterial phase hyperenhancement, and the DW and rDW parameters quantify the washout from linearized CEUS intensity data. This unique methodology is able to implement the CEUS-LIRADS scheme in a quantifiable manner for the first time and remove its existing issues of currently being qualitative and suffering from subjective evaluations.

Reduction of Uncertainty in Bolus Transit Time Measurement in Quantitative Fluorescence Angiography

Abstract During cerebral revascularization surgeries, blood flow values help surgeons to monitor the quality of the procedure, e.g., to avoid cerebral hyperperfusion syndrome due to excessively enhanced perfusion. The state-of-the-art technique is the ultrasonic flow probe that has to be placed around the blood vessel. This causes contact between probe and vessel, which, in the worst case, leads to rupture. The recently developed intraoperative indocyanine green (ICG) Quantitative Fluorescence Angiography (QFA) is an alternative technique that overcomes this risk. However, it has been shown by the developer that the calculated flow has deviations. After determining the bolus transit time as the most sensitive parameter in flow calculation, we propose a new two-step uncertainty reduction method for flow calculation. The first step is to generate more data in each measurement that results in functions of the parameters. Noise can then be reduced in a second step. Two methods for this step are compared. The first method fits the model for each parameter function separately and calculates flow from models, while the second one fits multiple parameter functions together. The latter method is proven to perform best by in silico tests. Besides, this method reduces the deviation of flow comparing to original QFA as expected. Our approach can be generally used in all QFA applications using two-point theory. Further development is possible if number of dimensions of the achieved parameter data are broadened that results in even more data for processing in the second step.

Effect of peroral endoscopic myotomy on growth and esophageal motility for pediatric esophageal achalasia

Peroral endoscopic myotomy (POEM), a novel minimally invasive treatment for esophageal achalasia, has been shown to be effective and safe for both adult and pediatric patients. However, studies on its application in children in Taiwan and its impact on growth and esophageal motility are lacking. We conducted a retrospective study on consecutive pediatric patients who were diagnosed with esophageal achalasia at National Taiwan University Hospital and underwent POEM during 2015-2022. Disease characteristics and treatment outcomes were analyzed. Ten patients (age 16.9±3.1 years), nine newly diagnosed and one previously treated with pneumatic dilatation, underwent POEM for achalasia (type I/II/III: 3/7/0). Average symptom duration before diagnosis was 19.4±19.9 months, mean POEM procedure time was 83.6±30.7min, and clinical success (Eckardt score ≤3) was achieved in all patients. Eight patients experienced mild adverse events during POEM, but none required further endoscopic or surgical intervention. Over a mean follow-up period of 3.7±1.6 years, mean Eckardt score decreased significantly from 5.7±2.4 to 1.1±0.7 (p=0.0001). The BMI z-score also increased significantly after POEM (p=0.023). Five patients received follow-up high-resolution impedance manometry (HRIM), and all had improved lower esophageal sphincter resting pressures (p=0.011), body contractility, and bolus transit (p=0.019). POEM is an effective and safe treatment for pediatric achalasia in Taiwan. Early diagnosis and treatment with POEM may help to restore esophageal function and nutrition status in children.

Patterns of Esophageal Motility and Bolus Transit in Children With Repaired Esophageal Atresia

Background: Esophageal dysmotility is common after esophageal atresia (EA) repair. Esophageal manometry (HRM) is the gold standard to investigate motility. We aim to characterize esophageal dysmotility and bolus transit for liquid and solids in children with repaired EA. Method: Retrospective analysis of HRM from children with repaired EA. Five liquid and 5 solid swallows per child were assessed for the standard manometric measurement and peristalsis pattern. Impedance tracings were used to assess bolus transit. Results: Ninety measurements were assessed from 9 patients, 44% Females. Mean age was 10.5 (±4.6) years. All children had dysphagia and anastomotic strictures were excluded. None of the children had intact peristalsis, 44.4% of the liquid swallows were failed, 33.3% fragmented and 22.2% ineffective. 44.4% of the solid swallows were failed, 44.4% fragmented and 11.1% ineffective. 33.3% had incomplete bolus transit in the whole esophagus, 44.4% in the upper and 11% in the lower esophagus. Mean peristalsis break for liquid was 7 cm (±2.1) and for solid was 5.9 cm (±3.2) P .025. Conclusion: Impaired esophageal motility is universal post EA repair. Failed and ineffective peristalsis predominate with incomplete bolus transit and large peristalsis breaks after liquid and solid swallows. HRM can provide clinical guidance, diagnostic and prognostic information post EA repair.

Treatment Approaches for Swallowing Disorders in Children.

A swallowing disorder or dysphagia is defined as a disorder in the sequence of swallowing, during the oral or pharyngeal phase, which compromises the safety and/or efficiency of transit of the food bolus to the esophagus. The evaluation of neurodevelopment, nutrition, and preventive medicine actions are as important as the clinical evaluation of dysphagia, so they must be included and systematized in all pediatric evaluations; This evaluation can be divided into different parts: bedside swallowing evaluation, instrumental swallowing evaluation, and additional studies. The management of swallowing disorders requires a multidisciplinary team approach, depending on the child's age, cognitive and physical abilities, and the specific swallowing and feeding disorder, ensuring adequate and safe nutrition and improving the patient's quality of life.

Pulmonary blood volume assessment from a standard cardiac rubidium-82 imaging protocol: impact of adenosine-induced hyperemia

BackgroundThis study aimed to assess the feasibility of estimating the pulmonary blood volume noninvasively using standard Rubidium-82 myocardial perfusion imaging (MPI) and characterize the changes during adenosine-induced hyperemia.MethodsThis study comprised 33 healthy volunteers (15 female, median age = 23 years), of which 25 underwent serial rest/adenosine stress Rubidium-82 MPI sessions. Mean bolus transit times (MBTT) were obtained by calculating the time delay from the Rubidium-82 bolus arrival in the pulmonary trunk to the arrival in the left myocardial atrium. Using the MBTT, in combination with stroke volume (SV) and heart rate (HR), we estimated pulmonary blood volume (PBV = (SV × HR) × MBTT). We report the empirically measured MBTT, HR, SV, and PBV, all stratified by sex [male (M) vs female (F)] as mean (SD). In addition, we report grouped repeatability measures using the within-subject repeatability coefficient.ResultsMean bolus transit times was shortened during adenosine stressing with sex-specific differences [(seconds); Rest: Female (F) = 12.4 (1.5), Male (M) = 14.8 (2.8); stress: F = 8.8 (1.7), M = 11.2 (3.0), all P ≤ 0.01]. HR and SV increased during stress MPI, with a concomitant increase in the PBV [mL]; Rest: F = 544 (98), M = 926 (105); Stress: F = 914 (182), M = 1458 (338), all P < 0.001. The following test–retest repeatability measures were observed for MBTT (Rest = 17.2%, Stress = 17.9%), HR (Rest = 9.1%, Stress = 7.5%), SV (Rest = 8.9%, Stress = 5.6%), and for PBV measures (Rest = 20.7%, Stress = 19.5%)ConclusionPulmonary blood volume can be extracted by cardiac rubidium-82 MPI with excellent test–retest reliability, both at rest and during adenosine-induced hyperemia.

Elucidation of gastric motor function caused by gastroesophageal reflux in Rumination syndrome

Rumination syndrome (RS) is a disease of the gastrointestinal (GI) tract characterised by repeated regurgitation of recently digested food back into the mouth. It can be difficult to distinguish from gastro-oesophageal reflux disease (GERD) and it is likely that many RS patients are treated for GERD due to being misdiagnosed. Assistant Professor Kenichiro Nakagawa is leading a team of experts based in the Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan, investigating the causes of gastroesophageal reflux. The researchers have already found that RS and GERD are very different in terms of pathology. They are using high-resolution impedance manometry (HRIM) as a diagnostic tool to comprehensively assess the motor function and bolus transit of food through the oesophagus. They are also utilising oesophageal multichannel intraluminal impedance-pH (MII-pH) monitoring to assess the pH of targeted oesophageal and gastric regions of the GI tract. In doing so, the team can pinpoint gastroesophageal reflux patterns, in turn highlighting the differences in gastroesophageal reflux patterns between RS and GERD patients and healthy control subjects. Using oesophagogastric scintigraphy, the researchers can compare the ratio of regurgitated food during gastroesophageal reflux in their three test groups, analysing where the food residue in RS and GERD patients and healthy control subjects localises in the proximal stomach.

The importance of shear and extensional rheology and tribology as the design tools for developing food thickeners for dysphagia management

Food texture manipulation and modification is a practical strategy to reduce the risk of aspiration for dysphagia management. Addition of thickening agent to thicken liquid can increase the bolus transit time, thus, potentially leading to safer swallowing. The important bolus characteristics for safe swallowing include viscosity, hardness, cohesiveness, and adhesiveness, which can be related to the rheological and tribological properties of bolus. Therefore, this work highlights the importance of shear and extensional rheology and tribology as the design tools for developing dysphagia food thickeners. A range of commercially available thickening powders (xanthan gum-, guar gum-, and modified starch-based) was studied to create baseline rheological and tribological data. In general, it was observed that the increase in thickener concentration led to increases in shear viscosity, viscoelastic properties, and extensional viscosity, but the impact on tribological behavior was varied depending on the type of thickener and lubrication regime. It was also revealed that, at the same liquid consistency based on IDDSI classification, xanthan gum-based thickener showed the highest low shear viscosity, extensional viscosity, and lubricating capacity than the other thickeners. More specifically, modified starch-based thickener showed the poorest extensional property and could be the least effective thickener for promoting safer swallowing. The proposed design tools may be used beneficially to tailor novel thickeners for dysphagia management based on the obtained baseline data. Nonetheless, in-depth knowledge on the relationship between these properties and in-vivo measurements of swallowing is still required and is key to achieve the most effective therapeutic strategy in the dysphagia treatment.