Chicago Classification Criteria Research Articles

Do children with dysphagia and normal esophageal motility according to Chicago Classification always have "normal" esophageal motility?

Internationally adopted Chicago Classification (CC) criteria based on adult normative data have been used to diagnose children with esophageal motility disorders undergoing high-resolution esophageal manometry (HREM). The aim of this study was to compare HREM parameters of children without dysphagia and children with dysphagia and normal findings according to CC. HREM metrics of 41 children (13.2 (9-18) years; 20 female) without dysphagia and 41 children (13.7 (8-18) years; 30 female) with dysphagia and normal diagnosis according to CC were compared. Analyzed data included resting and integrated relaxation pressures (IRP) of upper (UES) and lower (LES) esophageal sphincters, esophageal peristaltic contractile integrals, transition zone (TZ) gaps, distal latency (DL), and manometric esophageal length to height ratio (MELH). 95%ile normative cutoffs were calculated from the cohort without dysphagia. Proximal contractile integral (PCI), UES and LES mean resting and IRP were not significantly different between the cohorts (p > 0.3). On the contrary, distal contractile integral (DCI), TZ gap and MELH were notably different with p = 0.0002, p = 0.027, and p = 0.033 respectively. According to 95%ile normative cutoffs of DCI, TZ gap and MELH, in cohort with dysphagia 27%, 15%, and 22% of patients respectively were not normal. First study ever to compare HREM parameters of children without dysphagia to children with dysphagia. Considerable proportion of children with dysphagia may be underdiagnosed according to the adult criteria. This emphasizes the need for universally accepted child-specific diagnostic protocols and norms.

S600 Defining the Natural History of Ineffective Esophageal Motility and Change in Diagnosis with Updated Chicago Classification Criteria

S600 Defining the Natural History of Ineffective Esophageal Motility and Change in Diagnosis with Updated Chicago Classification Criteria

Outcomes of peroral endoscopic myotomy in patients with spastic esophageal motility disorders that do not fulfill Chicago Classification criteria.

per-oral endoscopic myotomy (POEM) has become a mainstream treatment for achalasia and is a promising therapy in spastic disorders. this is a retrospective study of prospectively collected data (case series). We present the first results of the use of POEM in patients with atypical spastic esophageal motor disorders that do not satisfy current Chicago Classification criteria. Seven consecutive patients with troublesome and persistent symptoms (12-180 months) related to atypical spastic esophageal motor dysfunction were systematically assessed before and after POEM, the extent of which was tailored by manometric findings. In five of the patients, other endoscopic or surgical procedures had failed. high-resolution manometry (HRM) showed a spastic esophageal body contractile segment in varying positions and lengths along the esophageal body which did not meet Chicago Classification criteria. After POEM, dysphagia and/or chest pain had either resolved or was greatly reduced. HRM 3-6 months after myotomy showed that the regions of spastic contraction targeted by myotomy had been ablated. There were no major complications. The clinical responses were fully maintained up to the most recent assessments after POEM (range 7-44 months). in our seven patients, POEM was a highly effective treatment for patients with troublesome symptoms related to atypical spastic esophageal motility disorders.

Characteristics of Achalasia Subtypes: Result of a Study in a Tertiary Hospital.

Background:With the appearance of enhancing high-resolution manometry (HRM), realizing the difference of achalasia symptoms between classified groups by HRM is an outcome of interest in areas with remote access to this device.Methods:All patients newly diagnosed with achalasia from January 2019 to March 2020 were enrolled in the study. All the patients were diagnosed via HRM after undergoing endoscopy to rule out pseudo-achalasia, and grouped based on the Chicago classification criteria and answered a questionnaire assessing relevant symptoms.Results:We included 62 patients recently diagnosed with achalasia with a mean age of 53.66 in males (n=30), and 45.4 in females (n=32). Mean time of diagnosis was 24 months. Thirty-seven percent were in type I, 50% in type II, and 13% in type III. Dysphagia and weight loss were higher in type III, while all other relevant symptoms were higher in type II, none of which, however, was statistically significant. Weight loss was reversely associated with duration of symptoms (Spearman correlation= -0.3, P=0.01), and this reverse association was more prominent in females (Spearman correlation= -0.47, P=0.009), type III (Spearman correlation= -0.74, P=0.03), and in the first clinical stages (Spearman correlation= -0.55, P=0.04) in sub analysis.Conclusion:Type II is the most common type of achalasia in this study. Unlike HRM classification, clinical manifestations alone cannot be used to group patients into different types. However, significant weight loss of the newly diagnosed subjects can become an indicator of on-time diagnosis of the patients.

S473 High Prevalence of Esophageal Motility Disorders in Patients With Rheumatic Diseases

Introduction: While esophageal motor dysfunction is known to be associated with systemic sclerosis, the prevalence of esophageal dysmotility in other rheumatic conditions is not well known. The aim of this study was to examine the prevalence of esophageal motility disorders in rheumatic diseases. Methods: In this retrospective cohort study, adults with a diagnosis of a rheumatic disease [rheumatoid arthritis (RA), Sjogren’s syndrome, systemic sclerosis (SS), systemic lupus erythematous (SLE), mixed connective tissue disease (MCTD), idiopathic Raynaud’s phenomenon, and other], who underwent high-resolution esophageal manometry (HREM) were included. Demographics, clinical characteristics, rheumatic diseases and associated therapies, HREM findings, motility disorders per Chicago classification (CCv3.0) criteria and swallow characteristics, were extracted from the medical record. We analyzed the data using descriptive statistics to assess the prevalence and types of esophageal motor disorders amongst patients with known rheumatic conditions. Results: Of 118 patients, 80% were women, and 73% were white (Table). The most common esophageal symptoms were dysphagia (88%), heartburn (81%), and regurgitation (41%). Rheumatic diseases included RA (38%), Raynaud’s (30%), Sjogren’s (22%), SS (19%) and MCTD (11%). On HREM, 53% had an esophageal motility disorder per Chicago classification. Of note, 38% of the sample with a normal barium swallow had an esophageal dysmotility disorder on HREM. Esophageal hypocontractility (including ineffective esophageal motility, absent contractility, and fragmented peristalsis) was diagnosed in 29 patients (25%), achalasia and/or esophagogastric junction outflow obstruction were found in 25 (21%), and esophageal hypercontractility (including diffuse esophageal spasm and jackhammer esophagus) in 8 (7%). These esophageal disorders were found amongst rheumatic diseases including SLE, RA, Sjogren’s, SS, MCTD, psoriatic arthritis and Raynaud’s (Figure). Conclusion: Esophageal motor disorders were found in more than half of patients with rheumatic diseases who underwent HREM, even though many patients previously had a normal barium swallow. HREM should be considered in patients with rheumatic conditions who present with esophageal symptoms.Figure 1.: Disorders of Esophageal Motility by Rheumatologic DiseaseTable 1.: Patient Characteristics and Manometry Findings

Effects of Age on Esophageal Motility: A High-Resolution Manometry Study.

BackgroundStudies have found possible physiologic changes to esophageal motility with aging currently not taken into account in routine high-resolution manometry (HRM) interpretation. We aimed to quantify the relationship between these physiologic changes and aging to improve HRM interpretation.MethodsWe conducted a retrospective analysis of patients who underwent HRM at a tertiary hospital center between 2015 and 2019. Inclusion criteria were patients aged ≥18 years with normal HRM. Exclusion criteria were abnormal HRM, abnormal upper digestive endoscopy or imagery. Outcomes were median integrated relaxation pressure (IRP), lower esophageal sphincter (LES) pressure, distal contractal integral (DCI), distal latency (DL), and peristaltic break (PB) according to the v4.0 Chicago classification criteria. Effect of age was examined through univariate and multivariate linear regression analysis.ResultsWe identified 1,917 patients with HRM and included 722 patients with normal exams (median age 56 years (interquartile range (IQR) 46 - 66), 63.8% female). Indications for HRM included dysphagia (39.6%), gastroesophageal reflux disease (29.5%), and chest pain (11.5%). There was statistically significant relationship between age and IRP (r = 0.20, P < 0.0001) as well as DCI (r = 0.12, P = 0.001) and DL (r = -0.09, P = 0.02). No statistically significant relationship was found between age and LES pressure or PB.ConclusionWe found that IRP, DCI, and to a lesser extent, DL, are significantly correlated with the normal aging process in symptomatic patients. These findings should be taken into consideration when interpreting esophageal HRM.

Robotic Heller-Dor for Idiopathic Achalasia: the Pisa experience.

Achalasia is a rare motility disorder of the esophagus. According to the Chicago Classification criteria, there are three clinical types of Achalasia and the treatment is patient-tailored. Laparoscopic Heller-Dor is the gold-standard treatment for the most frequent types of Achalasia. However, robotic surgery is able to combine the clinical advantages of minimally invasive surgery with a powerful dexterity on complex anatomic structures. The aim of this study is to report the institutional experience developed in a referral center of esophageal surgery in the treatment of Achalasia by Robotic Heller-Dor. We retrospectively analyzed data of patients that consecutively underwent Robotic Heller-Dor at our institution between January 2012 and January 2020 using the Da Vinci® Surgical System. Sixty-nine patients underwent Robotic Heller-Dor. Among the patients, 35 (51%) were classified as type I, 29 (42%) as type II, and 5 (7%) as type III. The Da Vinci® SI HD Surgical System and the Da Vinci® XI HD Surgical System were used in 56 (81%) and 13 (19%) patients, respectively. No mucosal perforation was observed and post-operative mortality was absent. The mean follow-up was 23.3months (6-84). Ten patients (14.5%) reported post-operative complaints. In our opinion, Robotic Heller-Dor is an effective tool in the treatment of Achalasia. Robotic Heller-Dor may be a suitable procedure for learning and teaching robotic surgery in the perspective of pursing more complex esophago-gastric surgical procedures.

High resolution manometry in esophageal disorders

Esophageal manometry is one of the main axes in diagnostic armamentarium that deals with esophageal motility disorders, next to endoscopic and radiological methods. Traditional, conventional manometry, has greatly been replaced by a modern technique, high resolution manometry which enables not only better spatiotemporal signal resolution and compatibility, but also shortens the time of the procedure which is extremely important for patients undergoing it. Two catheters are being used, solid state and water perfused. Both record pressures within the esophageal lumen and both esophageal sphincters. Contemporary technology has also enabled incorporation of impedance sensors into the catheter. Impedance is based on resistance changes to liquid or food boluses.These changes help in bolus transit evaluation, reducing the need for ionization procedures. Each examined bolus (liquid or solid) is evaluated according to Chicago classification criteria and parameters that are within these criteria. According to the third version of the Classification, functional esophageal disorders are divided into EGJ outflow obstruction disorders, major peristaltic and minor peristaltic disorders. Introduction of this methodology, but also the continuous update of Chicago classification, help in timely diagnosis and further treatment of all the more frequently diagnosed functional esophageal disorders.

A233 AGING AND ESOPHAGEAL MOTILITY: A HIGH-RESOLUTION MANOMETRY STUDY

Abstract Background Studies have found possible physiologic changes to esophageal motility with aging that are not currently taken into account in routine high-definition esophageal manometry (HDEM) interpretation. Aims We aimed to quantify the relationship between these physiologic changes and aging to improve HDEM interpretation. Methods We conducted a retrospective analysis of medical records for all patients who underwent HDEM at a tertiary hospital center between January 2015 and December 2019. Inclusion criteria were patients ≥18 years with normal HDEM. Exclusion criteria were abnormal HDEM; abnormal upper digestive endoscopy or imagery. Outcomes were median integrated relaxation pressure (IRP); mean lower esophageal sphincter (LES) pressure; mean distal contractal integral (DCI); mean distal latency (DL); mean peristaltic break (PB) according to the v3.0 Chicago classification criteria. Data was extracted from electronic patient medical records into a database for analysis. Effect of age on outcomes was examined through univariate and multivariate linear regression analysis. Results We identified 1917 patients with HDEM and included 790 patients with normal exams [mean age 55.8 yrs (IQR 46 – 66), 64% female]. Indications for HDEM included dysphagia (41.3%); gastroesophageal reflux disease (29.2%); chest pain (11.0%); other (13.3%). There was a statistically significant relationship between age and IRP [Coef=0.08 (95%CI 0.05 – 0.1), p&amp;lt;0.001, R^2=0.04] as well as DCI [Coef=10.9 (95%CI 4.1 – 17.8), p=0.002, R^2=0.01] and DL [Coef=-0.01 (95%CI -0.02 – -0.002), p=0.01, R^2=0.008]. No statistically significant relationship was found between age and LES pressure [Coef=0.03 (95%CI -0.01 – 0.08), p=0.16] or PB [Coef=0.007 (95%CI -0.002 – 0.016), p=0.14]. Multivariate analysis showed statistically significant relationships between IRP and age (p&amp;lt;0.001), BMI (p=0.001), NSAID use (p=0.034), and female sex (p=0.048). Conclusions We found that IRP, DCI, and DL are significantly correlated with the normal aging process. Modifications could therefore be considered for normal diagnostic cutoffs for both age extremes to prevent over or under-diagnosis of motility disorders. Funding Agencies None

S0452 Impact of EndoFLIP in an Esophageal Clinical Practice

INTRODUCTION: High resolution manometry (HRM) with Chicago Classification (CC) interpretation is the gold standard for defining esophageal motility disorders. However, HRM may reveal abnormalities that do not meet CC criteria, or may be normal in patients with esophageal symptoms. Also, EGJ outflow obstruction (EGJOO) comprises a heterogeneous group of disorders that may require disparate treatments. We have utilized EndoFLIP for suspected dysmotility, and have reviewed our experience to explore the impact of EndoFLIP on management. METHODS: We reviewed medical records for patients in our Center for Esophageal Disease with EndoFLIP performed November 2018-March 2020. We recorded EGJ diameter (D) and distensibility index (DI) at the 60 mL volume, and topography contraction patterns [repetitive antegrade (RACs), repetitive retrograde, disorganized diminished, hypercontractile, and sustained esophageal contractions (SECs), or absent contractility] at the 40 and 60 mL volumes. We also recorded CC diagnosis, symptoms [Eckardt score and Brief Esophageal Dysphagia Questionnaire (BEDQ)], working diagnosis, and EndoFLIP-guided change of therapy (botulinum injection, pneumatic dilation, or myotomy). RESULTS: We performed EndoFLIP on 249 patients with esophageal symptoms who had HRM and no prior foregut surgery. Table 1 shows D, DI, symptom scores, and EndoFLIP impact on diagnosis and therapy. Endoflip confirmed the diagnosis in all patients with achalasia by HRM and did not alter management. Among 97 patients with EGJOO, 50/97 (52%) of EGJOO patients had low DI (mean 1.3) with abnormal patterns on FLIP in all cases and were considered to have a primary EGJOO dysmotility disorder. These cases were also less likely to have any RACs compared to those with normal DI (12% v 32%, P < 0.05). In 2 (18%) of 11 patients with absent contractility and IRP <15 mmHg, a low DI on Endoflip suggested a diagnosis of achalasia. Among 49 patients with ineffective esophageal motility (IEM), 12 (24%) had low DI (mean 1.4) and 6 (12%) had SECs. In 37 patients with a normal HRM, 9 (24%) had SECs. CONCLUTION: We found EndoFLIP especially useful in evaluation of patients with EGJOO, IEM and absent contractility in whom it supported dysmotility on the achalasia spectrum in 52%, 24%, and 18% of patients respectively. Overall, we found Endoflip guided escalation of therapy in 9% of patients. The clinical implications of the FLIP topography in these cases requires further investigation.Table 1.: Endoflip characteristics and Clinical Impact by HRM associated Diagnosis

A128 JACKHAMMER ESOPHAGUS – A META-ANALYSIS OF PATIENT DEMOGRAPHICS, DISEASE PRESENTATION, MANOMETRY DATA AND TREATMENT OUTCOMES

Abstract Background Jackhammer esophagus (JE) is a newly described esophageal motility disorder characterized by the presence of distal esophageal hypercontractility. However, there is limited data on JE and this entity remains misunderstood. Aims To systematically review the published clinical data on JE and present pooled data on patient demographics, disease presentation, manometry parameters and treatment outcomes from the available literature. Methods We performed a systematic review of clinical series on JE (based on the latest Chicago Classification criteria (v3.0)) through MEDLINE, EMBASE and Web of Science. Patient data from included studies were then extracted and random-effects meta-analyses were performed to calculate and compare pooled data. Results Thirty-seven studies met inclusion criteria reporting on at least one pooled variable. The pooled prevalence of JE was 1.97% [95% CI: 1.39%-2.78%] amongst patients referred for high resolution manometry (HRM) based on eleven studies reporting this data (Figure 1). The mean age at diagnosis was 60.8 years [95% CI: 57.1–64.4] and 65% [95% CI: 58%-72%] of patients were female. JE was significantly more prevalent in post-lung transplant patients and morbidly obese patients undergoing HRM (23.99% [95% CI: 9.00%-38.97%] and 5.18% [95% CI: 1.76%-14.3%] respectively). Dysphagia was the most common presentation of JE (64% [95% CI: 52%-77%]) followed by gastroesophageal reflux disease (GERD) (46% [95% CI: 26%-67%]), regurgitation (39% [95% CI: 10%-67%] and heartburn (34% [95% CI: 22%-45%]). The pooled mean distal contractile integer (DCI) of all ten standard HRM swallows was 9,535 mmHg●s●cm [95% CI: 6,978–12,093] and the pooled mean integrated relaxation pressure (IRP) was 13.9 mmHg [95% CI: 8.2–19.7]. Endoscopic treatment as a whole was more successful than medical treatment in achieving clinical symptom improvement (79% [95% CI: 74%-85%] vs. 63% [95% CI: 47%-79%]; p=0.012). The pooled clinical success rate of peroral endoscopic myotomy (POEM) specifically was 82% [95% CI: 75%-90%]. Conclusions JE is a new motility disorder most commonly presenting with dysphagia. High clinical suspicion is important because the diagnosis can only be made through HRM and treatment outcomes are generally satisfactory. Funding Agencies None

Novel Pressure‐Impedance Parameters for Evaluating Esophageal Function in Pediatric Achalasia

In achalasia, absent peristalsis and reduced esophagogastric junction (EGJ) relaxation and compliance underlie dysphagia symptoms. Novel high-resolution impedance manometry variables, that is, bolus presence time (BPT) and trans-EGJ-bolus flow time (BFT) have been developed to estimate the duration of EGJ opening and trans-EGJ bolus flow. The aim of this study was to evaluate esophageal motor function and bolus flow in children diagnosed with achalasia using these variables. High-resolution impedance manometry recordings from 20 children who fulfilled the Chicago Classification (V3) criteria for achalasia were compared with recordings of 15 children with normal esophageal high-resolution manometry findings and no other evidence suggestive of achalasia. Matlab-based analysis software was used to calculate BPT and BFT. Both BPT and BFT were significantly reduced in achalasia patients compared with children with normal esophageal motility (BPT 3.3 s vs 5.1 s P < 0.01; BFT 1.4 s vs 4.3 s P < 0.001). BFT was significantly lower than BPT (achalasia difference 1.9 s ± 1.3 s, P = 0.001 and normal difference 0.9 ± 0.3 s, P = 0.001). Overall, there was a significant correlation between BPT and BFT (r = 0.825, P < 0.001). We observed a 2-way differentiation of achalasia patients; those in whom the BPT and BFT were proportional, but significantly lower than in patients with normal peristalsis, and those in whom BFT was disproportionately lower than BPT. Calculation of BPT and BFT may help determine whether esophageal bolus transport to the EGJ and/or esophageal emptying through the EGJ are aberrant. For achalasia, this may detect flow resistance at the EGJ, potentially improving both diagnosis and objective assessment of therapeutic effects.

High resolution manometry and new classification of esophageal motility disorders.

To present application of Chicago classification criteria of esophageal motility disorders defined in high resolution manometry in clinical practice. High-resolution manometry is the most exact hi-tech diagnostic method for esophageal motor function disorders according to Chicago classification v3.0. Uniqueness of the method consists in capacity to define integrated quantitative and qualitative metrics of esophageal contractile function and to establish their specific disorders e.g.: change of intrabolus pressure at disorders of esophagogastric junction (EGj) outflow, hypercontractile esophagus, fragmented contractions and weak or failed peristalsis, distal esophageal spasm. Assessment of the type of achalasia subtypes has significant impact on the patients' treatment choice. According to anatomical location of the lower esophageal sphincter and crural diaphragm several morphological types of gastro-esophageal junction are defined that determine severity of gastroesophageal reflux disease. Multiple rapid swallow responses during esophageal high-resolution manometry reflect esophageal body peristaltic reserve and is a predictor of postoperative complications. Differential diagnosis of belching type became possible at combined application of high-resolution manometry and impedance measurement. High-resolution manometry is a fundamental diagnostic test of esophageal motor function disorders. Clinical application of this method significantly expands diagnostic potential and allows to carry out personalized treatment that increases treatment quality.

Normal Values of High-Resolution Manometry in Supine and Upright Positions in a Thai Population.

Although cut-off values used in high-resolution manometry (HRM) to diagnose esophageal motility disorders are based on representative samples of the US population and assume a supine position, differences in population and body positioning can reportedly affect results. To establish normal HRM values for Thai people in both supine and upright positions. Forty-one healthy subjects were recruited, each of whom underwent solid-state HRM with ten 5-mL swallows of water in both the supine and upright positions. Measuring parameters according to the Chicago classification criteria (CC v3.0) were included, for which the mean, median and 5th and 95th percentiles (PCTLs) were calculated. The results corresponded with the CC v3.0 criteria, except for the mean, and 5th PCTL of the distal contractile integral (DCI), which were lower for this population. In the upright position, the mean and median values for DCI, intrabolus pressure and integrated relaxation pressure were significantly decreased, whereas the length of the transitional zone was significantly increased. The limitations of this study include: (1) the relatively low number of participants, (2) the limited recruitment of participants only at Ramathibodi Hospital and (3) the limited recruitment of only young and middle-aged participants. We established normal values for the HRM parameters in a representative sample of the Thai population. Our supine results still prove that the use of the CC v3.0 is preferable. HRM testing in patients measured in the upright position should be analyzed based on the normative values obtained from upright swallow studies.

Esophageal motility disorders: new perspectives from high-resolution manometry and histopathology.

High-resolution manometry (HRM) and peroral endoscopic myotomy (POEM) have contributed significantly to the field of esophageal motility disorders in recent years. The development of HRM has categorized various esophageal motility disorders with a focus on a diverse range of manometric anomalies. Additionally, the Chicago classification criteria is widely used for manometric diagnosis. Moreover, POEM was introduced as a minimally invasive radical therapy for achalasia and shows promise for other spastic esophageal motility disorders as well. POEM has also enabled a transluminal endoscopic approach for determining the histology of the esophageal muscle layer, which is expected to assist in elucidating the etiology of disorders associated with esophageal motility. The purpose of this review is to update the diagnosis, pathology, and treatment of esophageal motility disorders, with a focus on the recent advances in this field.

Is integrated relaxation pressure a promising predictor ofeffectiveness of peroral endoscopic myotomy for achalasia?

Peroral endoscopic myotomy (POEM), first introduced in 2010, appears to be an effective therapy with few complications. This study aimed to find an optimal predictor of POEM outcome in achalasia. We retrospectively assessed 89 patients diagnosed with achalasia who underwent POEM in General Hospital of Tianjin Medical University, from September 2012 to March 2015. Associations of Eckardt score with symptom duration, lower esophageal resting pressure, 4-second integrated relaxation pressure (4s-IRP), and maximum esophageal diameter were assessed before POEM. The most relevant data were progressively grouped to compare symptom improvement after POEM in 85 patients at 1 year follow-up. The most significant correlation was found between 4s-IRP and Eckardt score (p < 0.01). The 85 achalasia patients (1-year follow-up after POEM) were divided into 3 groups according to 4s-IRP values; patients with mean 4s-IRP of 25 - 34 mmHg exhibited significantly greater improvement of clinical symptoms compared with the remaining 2 groups (p < 0.05). No significant postoperative difference was noted between types I and II in all patients according to Chicago classification criteria. The 40 patients with 4s-IRP of 25 - 34 mmHg were further divided into 2 subgroups; the 28 patients with type II achalasia responded better to POEM than the 12 with type I disease (p < 0.05). 4s-IRP, together with achalasia subtypes, may predict treatment outcome after POEM. Patients with type II achalasia and 4s-IRP of 25 - 34 mmHg may experience more satisfactory remission after POEM.

Impact of thoracic surgery on esophageal motor function-Evaluation by high resolution manometry.

Alteration of esophageal function is a potential risk factor for postoperative complications in thoracic surgery. This prospective study investigates esophageal motility and function during and after thoracic procedures via high resolution manometry (HRM) and impedance technology with spatiotemporal representation of pressure data. Twelve consecutive patients eligible for elective thoracic surgery underwent preoperative and postoperative (48 hours and 7 days) esophageal HRM. Swallowing acts were carried out with 5 mL of water, 10 mL of water and 1 cm3 bread in physiological posture to evaluate distal contraction integral (DCI). Length and location of contractile integrity breaks were measured by investigators blinded to the form of surgical intervention. The impact of surgical procedures on esophageal motility was quantified according to current Chicago Classification (CC) criteria. Pre-, intra- and postoperative 24-hour multi-channel impedance pH-metry (MII-pH) was performed to further analyze gastroesophageal reflux patterns. All patients were investigated 48 hours prior to and 7 days after thoracic procedures, with a total of n=675 swallowing acts being included in our study. Increased motility patterns of the tubular esophagus occurred temporally 48 hours postoperatively. DCI 48 hours after surgery increased significantly (5 mL, P=0.049; solid, P=0.014) and returned to baseline values after seven days (5 mL, P=0.039; solid, P=0.039). Break length was significantly reduced 48 hours postoperatively, especially in the proximal esophageal segment (transition zone). Follow-up measurements after another week were comparable to preoperative baseline findings. The perioperative MII-pH measurement showed numerous artifacts caused by intubation and ventilation during surgery also with increasing short and frequent acidic reflux episodes. Thoracic procedures cause a transient modulation of esophageal peristalsis with postoperative increased contractility of the tubular esophagus, presumably without affecting intraesophageal reflex arcs. Although limited by the number of patients, we can conclude on our data that postoperative esophageal hypomotility is unlikely to promote secondary pulmonary complications.

Ineffective esophageal motility: clinical, manometric, and outcome characteristics in patients with and without abnormal esophageal acid exposure.

The etiology and clinical impact of ineffective esophageal motility (IEM) remain poorly understood. Unless gastroesophageal acid reflux (GERD) is identified, symptomatic patients with IEM are challenging to treat. We sought to determine whether any clinical or functional characteristics could distinguish those patients with IEM and either normal or abnormal esophageal acid exposure.In this retrospective cohort study, we identified 46 consecutive patients presenting with heartburn, and other GER symptoms who underwent clinical, endoscopic, and functional evaluation that included high-resolution manometry (HRM) and ambulatory pH monitoring. IEM was defined using the Chicago Classification criteria (v.3) as ≥50% ineffective swallows (DCI ≤ 450 mmHg.s.cm). Esophageal acid exposure by ambulatory pH monitoring was considered abnormal when total time with esophageal pH < 4 exceeded 4.2%.Of the 46 IEM patients identified, 19 (mean age: 42 years, 37% female), had normal esophageal acid exposure and 27 patients, mean age 54 years, 33% female, evidence of pathologic acid reflux. There was a 12 years age difference between the groups, with those with normal acid exposure being significantly younger (P < 0.01); the mean body mass index (BMI) was 22.6 ± 0.6 in the normal group and 25.4 ± 0.7 in the abnormal group (P < 0.001); otherwise the groups were endoscopically and histologically similar. Symptoms were not discriminatory and heartburn and regurgitation were the most prevalent in both groups. HRM did not discriminate symptomatic patients with IEM and either normal or abnormal esophageal acid exposure. Proton pump inhibition (PPI) therapy was significantly more effective (74% vs. 10%) in patients with pathologic acid reflux (P < 0.001). As pH exposure becomes abnormal in the context of IEM, there is dominance for supine reflux.IEM appears to be an early, primary event, eventually associated with pathologic acid exposure, particularly supine. Higher BMI is also associated with abnormal esophageal acid exposure in such patients. GER symptoms are not discriminatory in patients with IEM with and without underlying pathologic acid reflux. Clinical response to PPI in such patients depends on the presence of esophageal pathologic acid exposure. Those with IEM and normal acid exposure remain symptomatic and mostly resistant to therapy.

Frequency of Jackhammer Esophagus as the Extreme Phenotypes of Esophageal Hypercontractility Based on the New Chicago Classification.

Jackhammer Esophagus is defined as intact esophageal peristaltic contractions with extremely elevated amplitudes. We conducted a retrospective study to identify the frequency of esophageal hypercontractility and the clinical characteristics of Jackhammer Esophagus. Charts for the patients referred for manometric study at a tertiary-care motility center were reviewed. Data were collected utilizing the new Chicago classification criteria for Jackhammer Esophagus. Concomitant clinical variables were also explored. Eight patients were identified with Jackhammer Esophagus from a total of 205 (127 female/77 male) patients referred for high-resolution esophageal manometry. Jackhammer patients had an average distal contractile integral (DCI) of 9061 mmHg/ sec/ cm and median maximal DCI of 16,433 mmHg/ sec/ cm. The greatest DCI from 15 swallows was 28,875 mmHg/ sec/ cm. Hypercontractility was associated with multipeaked contractions in every Jackhammer patient. The mean lower esophageal sphincter (LES) pressure was 41 mm Hg with 4 patients having a hypertensive pressure of >40 mm Hg. Three of the 8 (37.5%) Jackhammer group had incomplete LES relaxation by integrated relaxation pressure criteria (>15 mm Hg residual pressure). Dysphagia (8/8) was the dominant indication for the manometric study, whereas the clinical background setting was gastroesophageal reflux disease (4/8) and hiatal hernia (1/8). Treatments included smooth muscle relaxation, antireflux regimens, and pneumatic dilation of the LES. Jackhammer Esophagus, an extreme manometric phenotype, was identified in 4.0% of patients referred to a University Motility Center. The patients with these esophageal hypercontractility states present mainly with dysphagia. A subgroup of Jackhammer did have accompanying incomplete LES relaxation and responded to targeted therapy with pneumatic dilatation.

Impaired bolus clearance in asymptomatic older adults during high-resolution impedance manometry.

Dysphagia becomes more common in old age. We performed high-resolution impedance manometry (HRIM) in asymptomatic healthy adults (including an older cohort >80years) to assess HRIM findings in relation to bolus clearance. Esophageal HRIM was performed in a sitting posture in 45 healthy volunteers (n=30 young control, mean age 37±11years and n=15 older subjects aged 85±4years) using a 3.2-mm solid-state catheter (Solar GI system; MMS, Enschede, The Netherlands) with 25 pressure (1-cm spacing) and 12 impedance segments (2-cm intervals). Five swallows each of 5- and 10-mL liquid and viscous bolus were performed and analyzed using esophageal pressure topography metrics and Chicago classification criteria as well as pressure-flow parameters. Bolus transit was determined using standard impedance criteria. A p-value <0.05 was considered significant. Impaired bolus clearance occurred more frequently in asymptomatic older subjects compared with young controls (YC) during liquid (40 vs 18%, χ2 =4.935; p<0.05) and viscous (60 vs 17%; χ2 =39.08; p<0.001) swallowing. Longer peristaltic breaks (p<0.05) and more rapid peristalsis (L: p<0.004, V: p=0.003) occurred in the older cohort, with reduced impedance-based clearance for both bolus consistencies (L: p<0.05, V: p<0.001). Decreased peristaltic vigor (distal contractile integral <450mmHg/s/cm) was associated with reduced liquid clearance in both age groups (p<0.001) and of viscous swallows in the older group (p<0.001). Impedance ratio, a marker of bolus retention, was increased in older subjects during liquid (p=0.002) and viscous (p<0.001) swallowing. Impaired liquid and viscous bolus clearance, esophageal pressure topography, and pressure-flow changes were seen in asymptomatic older subjects.