Esophageal Contraction Amplitude Research Articles

Automated calculation of the distal contractile integral in esophageal pressure topography with a region‐growing algorithm

The distal contractile integral (DCI) is an index of contractile vigor in high-resolution esophageal pressure topography (EPT) calculated as the product of amplitude, duration, and span of the distal esophageal contraction. The aim of this study was to develop an automated algorithm calculating DCI. The DCI was calculated conventionally using ManoView™ (Given Imaging, Los Angeles, CA, USA) software in EPT studies from 72 controls and 20 patients and compared to the calculation using a MATLAB™ (Version 7.9.0, R2009b; The MathWorks Inc., Natick, MA, USA) 'region-growing' algorithm. This algorithm first established the spatial limits of the distal contraction (the proximal pressure trough to either the distal pressure trough or to the superior margin of the lower esophageal sphincter at rest). Pixel-by-pixel horizontal line segments were then analyzed within this span starting at the pressure maximum and extending outward from that point. The limits of 'region-growing' were defined either by the spatial DCI limits or by encountering a pressure <20 mmHg. The DCI was then calculated as the total units of mmHg s cm greater than 20 mmHg within this domain. Excellent correlation existed between the two methods (r = 0.98, P < 0.001). The DCI values obtained with the conventional calculation were slightly but significantly greater than with the region-growing algorithm. Differences were attributed to the inclusion of vascular pressures in the conventional calculation or to differences in localization of the distal limit of the DCI. The proposed region-growing algorithm provides an automated method to calculate DCI that limits inclusion of vascular pressure artifacts and minimizes the need for user input in data analysis.

Postoperative Impedance–pH Testing is Unreliable After Nissen Fundoplication With or Without Giant Hiatal Hernia Repair

IntroductionCombined 24-h multichannel intralumenal impedance–pH monitoring (MII-pH) is gaining popularity as a diagnostic tool for gastroesophageal reflux. Since the surgical reduction of hiatal hernias and creation of a fundoplication anatomically restores the gastroesophageal reflux barrier, one would assume that it effectively stops all reflux regardless of composition. Our aim is to evaluate the results of routine MII-pH testing in successful Nissen fundoplication patients. Material and MethodsSixty-two patients with normal acid exposure, confirmed by 24-h pH testing, after Nissen fundoplication were evaluated with symptomatic questionnaire, esophageal manometry and MII-pH testing more than 6 months after surgery. Patients were grouped into normal and abnormal based on postoperative impedance results. Patients with Nissen alone were separately compared to patients with Nissen + giant hiatal hernia (GHH). ResultsTwenty-nine (47%) patients exhibited abnormal impedance after successful Nissen fundoplication. Abnormal impedance was associated with GHH repair, lower bolus pressures, and lower distal esophageal contraction amplitudes. ConclusionPostoperative testing with the standard MII-pH catheters using published normative values seems to be clinically irrelevant. Clinicians should analyze the results of routine MII-pH testing in the setting of a fundoplication critically as the current technology is associated with a high false positive rate.

The role of poor oesophageal clearance in patients with suspected laryngopharyngeal reflux

IntroductionLaryngopharyngeal reflux (LPR) disease is thought to occur in one-third of gastro-oesophageal reflux disease (GORD) patients. Currently, there is no gold standard investigation for patients with suspected LPR. The ResTech...

Predictors of objectively identified recurrent reflux after primary Nissen fundoplication

Laparoscopic Nissen fundoplication is the most frequently performed operation for gastro-oesophageal reflux disease (GORD). Studies on predictors of subjective outcome of fundoplication have yielded inconsistent results. This study identified predictors of objective reflux control after Nissen fundoplication. This was a retrospective analysis of prospectively collected data from patients who underwent Nissen fundoplication for proton pump inhibitor-refractory GORD with pathological acid exposure in a single centre between 1997 and 2005. The predictive value of demographics, endoscopic hiatal hernia size, oesophagitis, lower oesophageal sphincter pressure, distal oesophageal contraction amplitude, percentage of peristaltic contractions and acid exposure was determined. Endpoints were recurrent pathological acid exposure on 24-h pH monitoring at 6 months and surgical reintervention for recurrent GORD up to 6 years. Of 177 patients, 22 had recurrent pathological acid exposure at 6 months for which 11 had surgery within 6 years. Only low percentage of peristaltic contractions (odds ratio (OR) 0·97, 95 per cent confidence interval 0·95 to 0·99; P = 0·004) and high supine acid exposure (OR 1·03, 1·00 to 1·07; P = 0·025) were independent predictors of recurrent pathological acid exposure. The absolute risk of recurrent exposure was 45·5 per cent in patients with both predictors. High supine acid exposure was also an independent predictor of surgical reintervention (OR 1·05, 1·01 to 1·08; P = 0·006). Nissen fundoplication should not necessarily be withheld from patients with poor oesophageal peristalsis or excessive supine acid exposure. As about half of patients with both variables experience recurrent pathological acid exposure after primary Nissen fundoplication, surgery should be restricted in this group.

Acid exposure and esophageal motility following laparoscopic fundoplication: A comparative randomized study.

Review: Gastro-esophageal reflux disease is one of the most widely spread diseases allover the world. The principle underlying its surgical management is the creation of a mechanical antireflux barrier between the esophagus and the stomach through the creation of either a total (360 degree), or partial anterior or posterior fundal wraps around the lower esophageal end. The ability of surgery to mechanically control the reflux has been documented. The pathogenesis of gastro-esophageal reflux disease is essentially a motility-related problem with varying contributory elements. The role of different techniques in correcting the underlying motility disorder has been little studied in the randomised literature. Aim: The aim of this study was to compare the ability of the laparoscopic partial posterior and the laparoscopic total fundoplication techniques in objectively controlling the reflux and correcting the underlying esophageal motility disorder in gastro-esophageal reflux patients on the mid-term. Patients and methods: In the period between June 1998 and July 2007, 40 patients considered for antireflux surgery in the department of surgery, Tanta University Hospital, were prospectively recruited and randomised to undergo either laparoscopic total (Nissen) or laparoscopic partial posterior (Toupet) fundoplication. In addition to the clinical follow-up, objective follow up through esophageal manometry, 24-h pH monitoring and upper gastrointestinal endoscopy were performed 24 months after operation and compared to the same data recorded preoperatively. Results: Both the total and the partial posterior fundoplication techniques showed excellent control of heartburn and regurgitation postoperatively. This correlated well with the postoperative endoscopic findings, where both techniques were equally effective in correcting hiatus hernias and healing reflux esophagitis. In the Nissen group, the lower esophageal resting pressure significantly increased postoperatively from a median of 23, to 33 mmHg (p 0.05). Length of the abdominal component was significantly increased postoperatively from a median of 3 to 4 cm and from a median of 2 to 4 cm in the Nissen and Toupet groups respectively (p 0.05). No significant changes were found in the esophageal body contraction amplitude on comparing the pre and postoperative values in both groups (p>0.05). The median total acid exposure time in the Nissen and Toupet groups was significantly reduced from a preoperative 13% to 1% and from 17 % to 0% respectively, with similar reduction in the number of pH proven reflux episodes from a median of 24 to 2 and from 30 to 2 respectively (p < 0.01). The small number of cases with Barrett’s metaplasia in our study made it difficult to draw hard conclusions on the difference between the two surgical techniques in this particular type of patients. Conclusion: The partial posterior and total fundoplication techniques are equally effective in restoring the lower esophageal pressure profile and in objectively controlling the reflux on the mid-term. No changes in the esophageal body contraction amplitude could be found with either technique. No objective advantages could be demonstrated for either technique to support a tailored approach.

Esophageal dysmotility associated with systemic sclerosis: a high-resolution manometry study

Esophageal involvement occurs in about 80% of patients with systemic sclerosis, with a marked diminution of peristaltic pressures in the distal two-thirds of the esophagus. Our aims were to more fully characterize esophageal motility disorders in systemic sclerosis using high-resolution manometry (HRM) and to determine predictive factors of esophageal involvement. Fifty-one patients (46 females) with systemic sclerosis were included in this retrospective study. Esophageal motility was characterized with HRM. The demographic data, esophageal symptoms, presence of other organ involvement, and autoantibody profile (anti-Scl70 antibodies [Scl70], anticentromere antibodies [ACA]) were recorded for all patients. Esophageal body dysmotility was present in 33 patients (67.3%) and was associated with hypotensive esophagogastric junction in 27 patients (55.1%). The velocity of proximal contractions was higher in patients with esophageal body dysmotility compared to patients with normal peristalsis (median 10.8 cm/s vs. 5.5, P = 0.04). The amplitude of middle esophageal contraction but not of distal esophageal contraction was reduced in patients with hypoperistalsis. Diffuse esophageal skin involvement, presence of Scl70 and absence of ACA were associated with esophageal involvement. Esophageal symptoms encountered in 87.5% of patients were not predictive of esophageal dysmotility. This HRM series confirms the high prevalence of esophageal body dysmotility in systemic sclerosis. Diffuse skin involvement, positive Scl70 and negative ACA, but not esophageal symptoms, may predict esophageal body dysmotility.

Does esophageal dysfunction affect the course of treadmill stress test in patients with recurrent angina-like chest pain?

cardioesophageal reflex may increase severity of chest pain and signs of myocardial ischemia on electrocardiogram (ECG), both in patients with and without significant coronary artery stenosis. the aim of the study was to evaluate the relationships between esophageal pH and pressure and clinical and electrocardiographic signs of myocardial ischemia. in 129 consecutive patients with recurrent chest pain, 77 without significant coronary artery lesions in coronary angiography and 52 with myocardial ischemia, panendoscopy, pH-metry, manometry, and treadmill stress test were performed. The prevalence of esophageal disorders was similar in patients with and without significant coronary artery narrowing. Subjects with significant ST interval depression in the stress test had a higher rate of simultaneous esophageal contractions. There were no differences in the results of the treadmill test between patients with and without esophageal disorders. Forty percent of patients with significant coronary artery lesions, who had to stop the test because of chest pain, did not present significant ST interval depression on ECG; however, such depression was observed in 60% of patients with normal coronary angiography. Patients with exercise-provoked chest pain had more pronounced abnormalities in esophageal pH, together with the amplitude and coordination of esophageal contractions. Demographic and clinical factors associated with chest pain and changes in exercise ECG were not evaluated. esophageal disorders are an important cause of chest pain, potentially affecting the results of the treadmill stress test. However, further research is needed to determine the predictors of the cardioesophageal loop activity.

Effects of ursodeoxycholic acid in esophageal motility and the role of the mucosa. An experimental study

Esophageal motor abnormalities are frequently found in patients with gastroesophageal reflux disease. The role of bile in reflux-induced dysmotility is still elusive. Furthermore, it is questionable weather mucosal or muscular stimulation leads to motor dysfunction. The aims of this study were to analyze (i) the effect of bile in the amplitude of esophageal contractions; and (ii) the effect of mucosal versus muscular stimulation. Eighteen guinea pig esophagi were isolated, and its contractility assessed with force transducers. Three groups were studied. In group A (n= 6), the entire esophagus was incubated in 100 µmL ursodeoxycholic acid for 1 hour; in group B (n= 6) the mucosal layer was removed and the muscular layer incubated in 100 µmL ursodeoxycholic acid for 1 hour; and in group C (n= 6) (control group) the entire esophagus was incubated in saline solution. In all groups, five sequential contractions induced by 40 mm KCl spaced by 5 minutes were measured before and after incubation. Contractions amplitudes before incubation were 1.319 g, 0.306 g, and 1.795 g, for groups A, B, and C, respectively. There were no differences between groups A and C (P= 0.633), but there were differences between groups A and B (P= 0.039), and B and C (P= 0.048). After incubation amplitude of contraction were 0.709 g, 0.278 g, and 1.353 g for groups A, B, and C, respectively. Only group A showed difference when pre and post-stimulation amplitudes were compared (P= 0.030). Our results show that (i) bile exposure decreases esophageal contraction amplitude; and (ii) the esophageal mucosa seems to play an important role in esophageal motility.

Effect of bolus volume on proximal esophageal contractions of patients with Chagas' disease and patients with idiopathic achalasia

Chagas' disease and idiopathic achalasia patients have similar impairment of distal esophageal motility. In Chagas' disease, the contractions occurring in the distal esophageal body are similar after wet or dry swallows. Our aim in this investigation was to evaluate the effect of wet swallows and dry swallows on proximal esophageal contractions of patients with Chagas' disease and with idiopathic achalasia. We studied 49 patients with Chagas' disease, 25 patients with idiopathic achalasia, and 33 normal volunteers. We recorded by the manometric method with continuous water perfusion the pharyngeal contractions 1 cm above the upper esophageal sphincter and the proximal esophageal contractions 5 cm from the pharyngeal recording point. Each subject performed in duplicate swallows of 3-mL and 6-mL boluses of water and dry swallows. We measured the time between the onset of pharyngeal contractions and the onset of proximal esophageal contractions (pharyngeal-esophageal time [PET]), and the amplitude, duration, and area under the curve (AUC) of proximal esophageal contractions. Patients with Chagas' disease and with achalasia had longer PET, lower esophageal proximal contraction amplitude, and lower AUC than controls (P≤ 0.02). In Chagas' disease, wet swallows caused shorter PET, higher amplitude, and higher AUC than dry swallows (P≤ 0.03).There was no difference between swallows of 3- or 6-mL boluses. There was no difference between patients with Chagas' disease and with idiopathic achalasia. We conclude that patients with Chagas' disease and with idiopathic achalasia have a delay in the proximal esophageal response and lower amplitude of the proximal esophageal contractions.

Pyridostygmine, A Potential Therapy for Dysphagia Secondary to Ineffective Esophageal Motility

Purpose: Clinical Presentation: A 47-year-old white woman with GERD initially presented 7 years ago for possible anti-reflux surgery evaluation due to heartburn and severe dysphagia of solids and liquids. She was previously treated with multiple antireflux regimens and endoscopic dilations without improvement. Esophageal impedance manometry testing confirmed the diagnosis of severe ineffective esophageal motility (IEM). Over the next 4 years, acid control therapy was continually altered and a prolonged trial of bethanechol yielded little improvement. Repeat testing continued to reveal severe IEM, normal number of reflux episodes and esophageal acid exposure, and negative symptom association. She was then started on Mestinon 30 mg BID based on recent studies showing increased esophageal contraction amplitudes. Within the next 3 months the patient's dysphagia drastically improved as evidenced by a 15 lb weight gain. Although repeat esophageal impedance manometry continued to show severe IEM, distal contraction amplitudes improved and the patient's dose of Mestinon was increased to 60 mg BID. Most recently the patient still struggled with heartburn but her dysphagia has disappeared, and her biggest health concern currently is obesity having since gained >60 lb since initiation of Mestinon! Discussion: IEM was redefined by the presence of greater than or equal to 50% liquid swallows with contraction amplitude <30 mm Hg in one of the two distal sites in the lower esophagus. Although antireflux therapy has been the mainstay of IEM treatment, restoration of esophageal smooth muscle contractility by the muscarinic receptor agonist, bethanechol, improved esophageal contraction pressures as well as bolus transit. Recent comparison of oral pyridostygmine (Mestinon), buspirone, and bethanechol was undertaken after short-acting acetylcholinesterase inhibitors were shown to increase esophageal contraction amplitude and duration. After our patient failed to improve with antireflux therapy and a trial of bethanechol, addition of Mestinon was attempted. Although the addition of Mestinon did not change her diagnosis of severe IEM, it did increase distal contraction amplitudes and overall bolus transit of both solids and liquids, but more importantly completely cured the symptom of dysphagia as evidenced by the patient's drastic weight gain over the follow 3 years. Conclusion: The addition of pyridostygmine greatly improved the distal esophageal contraction amplitudes and bolus transit in this patient. Although the degree of improvement was not enough to change her diagnosis of severe IEM, the therapeutic benefit has proven to dramatically improve this woman's quality of life and cure her dysphagia.

Esophageal Motility in Children With Suspected Gastroesophageal Reflux Disease

Motility abnormalities in adults with gastroesophageal reflux disease (GERD) include nontransmitted contractions, reduced distal esophageal contraction amplitude, and simultaneous contractions. Information on esophageal body motility in children with GERD is scarce. Our aim was to study esophageal motility patterns in children with GERD, taking into account the presence of anatomical abnormalities and neurological impairment, the effect of age on esophageal motility in GERD, and the relation between esophageal manometry and GERD severity parameters (acid exposure and presence of esophagitis). Consecutive children referred for severe GER(D) symptoms underwent a barium swallow, upper endoscopy, pH monitoring, and stationary water-perfused esophageal manometry. Mean lower esophageal sphincter (LES) pressure and velocity of propagation in the proximal and distal esophagus decreased with age in this group of children with GERD (all P < 0.01). Severely disturbed esophageal motility was found in children with previous esophageal atresia. Patients with psychomotor retardation had significantly lower occurrence of peristaltic waves (94% +/- 21% vs 79% +/- 38%; P = 0.001), distal propagation velocity (0.8 +/- 0.4 vs 0.6 +/- 0.5 cm/s; P = 0.05), and distal contraction duration (3.1 +/- 0.8 vs 3.4 +/- 1 seconds; P = 0.05). None of the manometric characteristics differed between patients with normal or abnormal esophageal pH monitoring or with or without erosive esophagitis. LES pressure and esophageal velocity decreased with increasing age. Esophageal manometry is severely impaired in children with esophageal atresia and psychomotor retardation. No specific esophageal motor abnormalities related to the presence of endoscopic esophagitis or abnormal pH monitoring were found.

987 Is Bile Reflux-Induced Esophageal Dysmotility Mediated by Mucosal Stimulation? An Experimental Study

Background and Aims: Esophageal motor abnormalities are frequently found in patients with gastroesophageal reflux disease. The role of bile in reflux-induced dysmotility is still elusive. Furthermore, it is questionable weather mucosal or muscular stimulation leads to motor modification. The aims of this study were: (a) analyze the effect of bile infusion in the amplitude of esophageal contractions and (b) analyze the effect of mucosal vs muscular stimulation. Methods: 18 guinea-pig esophagi were isolated and its contractility assessed with force transducers. Three groups were studied. In group A (n= 6) the entire esophagus was used and incubated in 100 mML ursodexocicolic acid for 2 hours. In group B (n=6) the mucosal layer was removed and themuscular layer incubated in 100mML ursodexocicolic acid for 1 hours. In group C (n=6) (control group) the entire esophagus was used and incubated in saline solution. In all groups, five sequential contractions spaced by 1 minute were measured before and after incubation. Contractions were recorded after KCl 40 mM stimulation. Results: Contractions before incubation did differed among groups (p= 0,006) and averaged 1,319(A),0,306(B) and 1,795(C). After incubation amplitude of contraction was 0,709 , 0,278 and 1,353 for groups A, B and C respectively. Before incubation there is no diferrences between groups A and C (p=0,633) there is difference between groups A and B (p=0,039) and B and C (p=0,048). After incubation there is no differences between groups A and B (p=0,134) there is difference between groups A and C (p=0,022) and B and C (p=0,000).When we compare average within groups (before and after) there is difference only in group A (p=0,030). Conclusion: Our results show that bile exposure may induce ineffective esophageal motility and the mucosa seems to take an important role in esophageal motility.

Gender variation in oesophageal motor function: Analysis of 129 healthy individuals

Background Oesophageal manometry is the standard for diagnosis of oesophageal motor disorders. Minimal data exist assessing the effect of gender on normal oesophageal manometry values. Aim Evaluate the impact of gender on normal oesophageal manometry values. Methods Healthy volunteers were recruited from the Jacksonville metropolitan area. Exclusion criteria were symptoms suggestive of oesophageal disease, medication use or concurrent illness that could affect oesophageal manometry. All underwent oesophageal manometry using a solid-state system with wet swallows. Results Sixty-three males and 66 females were enrolled. All completed oesophageal manometry without difficulty. Resting lower oesophageal sphincter pressure, distal oesophageal contraction duration and distal oesophageal body contraction amplitude values were significantly higher in females while distal oesophageal body contraction velocity was significantly lower in females ( p < 0.05). No differences were seen in other oesophageal manometry parameters. Conclusion Significant gender differences exist in normal oesophageal manometry. Gender-specific reference values for oesophageal manometry are needed for accurate diagnosis of oesophageal motility disorders.

Gender differences in proximal esophageal contractions

There are reports showing that gender has an influence on swallowing and on the contractions of the distal esophageal body. In this investigation we studied the effect of gender on proximal esophageal contraction. We studied 20 men (22-68 years old, median 39 years) and 44 women (18-61 years old, median 41 years) without symptoms and without gastrointestinal or respiratory diseases. We measured the time interval between the onset of pharyngeal contraction 1 cm proximal to the upper esophageal sphincter and the onset of the proximal esophageal contraction 5 cm from the pharyngeal recording. We also measured the amplitude, duration and area under the curve of the proximal esophageal contractions. The recording was performed by the manometric method with continuous perfusion. The contractions were recorded in duplicate after swallows of a 5 mL bolus of water. There were no differences between men and women in the interval between the onset of pharyngeal and of esophageal contractions or in the amplitude of esophageal contractions. The duration of contractions was longer in women (2.35 +/- 0.60 s) than in men (2.07 +/- 0.62 s) but the difference did not reach statistical significance (P = 0.087). The area under the curve of the esophageal contraction was higher in women (130.2 +/- 55.2 mm Hg x s) than in men (97.4 +/- 49.4 mm Hg x s, P = 0.026). We conclude that there is a difference between men and women in the proximal esophageal contractions in response to wet swallows, although this difference is of no clinical relevance.

Patients with physiological acid exposure and positive symptom association scores: a distinct group within the GORD spectrum

Studies comparing pH-metrically well-characterized gastro-oesophageal reflux disease (GORD) patients with physiological reflux to GORD patients with pathological reflux, with regard to clinical and epidemiological data, are lacking. We included 273 GORD patients with pathological 24-h pH-monitoring (pH+), defined as pH<4 > or = 6% of time. A symptom index (SI) > or = 50% was considered positive, as well as a symptom association probability (SAP) > or = 95%. We included 84 GORD patients with physiological acid exposure (pH-) and a positive SI and/or SAP. Manometry and endoscopy reports were reviewed. Subjects completed questionnaires about demographics and medical history, functional dyspepsia and irritable bowel syndrome, the Nepean Dyspepsia Index symptom score and the RAND-36 quality of life scale. pH- patients were younger (45 vs 50 years, P = 0.003), more often female (60%vs 39%, P = 0.001), smoked more (31%vs 19%, P = 0.021) and reported proton pump inhibition failure more often (47%vs 32%, P = 0.027). A hypotensive lower oesophageal sphincter was less common in pH- patients (18%vs 34%, P = 0.008) and distal oesophageal contraction amplitude was higher (11 vs 9.5 kPa, P = 0.045). pH- patients had hiatal hernia and oesophagitis less often (48%vs 73%, P < 0.0005; 36%vs 54%, P = 0.012 respectively). pH- patients less often reported no other symptoms besides GORD (20%vs 34%, P = 0.015). pH- patients scored worse at the Nepean (reflux 19 vs 12 out of 39, P < 0.0005; dyspepsia 54 vs 38 out of 156, P < 0.0005). In the subgroup of patients who have physiological oesophageal acid exposure the enhancement of the perceived symptom burden appears to be the most important mechanism in GORD pathogenesis.

M1575 The Clinical Significance of Elevated Esophageal Contraction Amplitudes: A High Resolution Manometric Study of “Nutcracker” Esophagus

M1575 The Clinical Significance of Elevated Esophageal Contraction Amplitudes: A High Resolution Manometric Study of “Nutcracker” Esophagus

The Effect of Oral Buspirone, Pyridostigmine, and Bethanechol on Esophageal Function Evaluated With Combined Multichannel Esophageal Impedance-manometry in Healthy Volunteers

There is limited information on medications with promotility effects on the esophagus. Studies in healthy volunteers have shown the potential role of the direct cholinergic agonist bethanechol and the serotonin receptor agonist buspirone in improving esophageal motility. It has been also shown that an acetylcholinesterase inhibitor, the short-acting drug edrophonium administered intravenously caused a greater increase in the esophageal contraction amplitude and duration than bethanechol. Edrophonium cannot be used as a promotility therapy owing to short duration of action and lack of oral administration. The use of another acetylcholinesterase inhibitor pyridostygmine with longer duration of action has not been studied. The aim of the study was to evaluate the effect of oral pyridostygmine (60 mg), buspirone (20 mg), and bethanechol (25 mg) on esophageal function assessed by combined multichannel intraluminal impedance-esophageal manometry. Ten healthy volunteers were enrolled in a double blind randomized 3-period crossover study. Multichannel intraluminal impedance-esophageal manometry recorded esophageal pressures and bolus transit data during 6 liquid and 6 viscous swallows at baseline and 20, 40, and 60 minutes after the randomized oral administration of each drug. Blinded analysis found significant increases in mean distal esophageal amplitude for liquid swallows from baseline to 60 minutes postdosing after pyridostygmine (87.6 vs. 118.0 mm Hg, P<0.001), buspirone (85.1 vs. 101.9 mm Hg, P<0.05), and bethanechol (87.6 vs. 118.8 mm Hg, P<0.01). Only pyridostygmine showed a significant decrease in mean distal onset velocity for liquid swallows at 60 minutes postdosing (3.4 vs. 2.3 cm/s, P<0.01) and increase in total bolus transit time at 60 minutes postdosing (7.9 vs. 9.3 s, P<0.05). All 3 agents significantly increased mean lower esophageal sphincter residual pressure for liquid swallows at 20, 40, and 60 minutes postdosing. Increased lower esophageal sphincter resting pressure was not significant. Similar results were found with viscous swallows. Oral pyridostygmine, buspirone, and bethanechol enhance esophageal motility with pyridostygmine appearing to have the greatest effect. A potential effect on improving esophageal function and symptoms in patients requires further study.

Stepwise radiofrequency ablation of Barrett’s esophagus preserves esophageal inner diameter, compliance, and motility

Stepwise endoscopic circumferential and focal radiofrequency ablation is safe and effective for the eradication of Barrett's esophagus. In contrast to other techniques, radiofrequency ablation appears to avoid significant esophageal scarring or stenosis. Our aim was to evaluate whether radiofrequency ablation has an adverse effect on esophageal function in patients treated for Barrett's esophagus containing intramucosal cancer and/or high-grade dysplasia. Twelve patients with Barrett's esophagus containing intramucosal cancer or high-grade dysplasia were included in the study. After endoscopic resection of visible abnormalities, stepwise circumferential and focal ablation were performed every 2 months up to a maximum of five sessions. Measurement of the inner diameter was performed at 1-cm intervals in the distal esophagus. Manometry was performed using a water-perfused sleeve catheter. Compliance was evaluated using the functional lumen imaging probe (FLIP), measuring eight cross-sectional areas within a saline-filled bag with two pressure side holes, one proximal to and one inside the bag. Esophageal sizing, manometry, and compliance were recorded in patients at baseline and at least 2 months after the final ablation session. In addition, FLIP and manometry measurements were performed in 10 healthy volunteers. All patients achieved complete eradication of dysplasia and Barrett's esophagus, without severe complications or ablation-related stenoses. The esophageal diameter was unchanged by the ablation. Lower esophageal sphincter pressure and length and esophageal contraction amplitude before and after ablation were not significantly different. Baseline compliance was significantly different between healthy volunteers and Barrett's esophagus patients. Compliance was not, however, significantly changed by ablation. Stepwise circumferential and focal ablation of Barrett's esophagus is an effective and safe treatment modality for early Barrett's neoplasia that appears to preserve the functional characteristics of the esophagus.

Manometric fndings in patients with isolated distalgastroesophageal reflux

To analyze manometric abnormalities in patients with isolated distal reflux and compare these findings in patients with erosive and non-erosive disease. Five hundred and fifty patients who presented to the outpatient clinic of Turkiye Yuksek Ihtisas Hospital with gastroesophageal reflux disease-like symptoms were enrolled. Each individual was evaluated with esophageal manometry, 24-h ambulatory pH monitoring, and upper gastrointestinal endoscopy. Manometric findings for the patients with isolated distal reflux were compared to findings in controls who were free of reflux disorders or hypersensitive esophagus. Findings for isolated distal reflux patients with and without erosive reflux disease were also compared. Of the 550 subjects enrolled, 97 (17.6%, mean age 48 years) had isolated distal reflux and 100 had no abnormalities on ambulatory pH monitoring (control group, mean age 45 years). There were no significant differences between the isolated distal reflux group and control group with respect to age, body mass index, and esophageal body contraction amplitude (EBCA). Mean lower esophageal sphincter pressure was significantly higher in the control group (12.7 +/- 10.3 mmHg vs 9.6 +/- 7.4 mmHg, P = 0.01). Fifty-five (56.7%) of the 97 patients with isolated distal reflux had erosive reflux disease. There were no statistical differences between the erosive reflux disease and non-erosive reflux disease subgroups with respect to mean EBCA, lower esophageal sphincter pressure, or DeMeester score. However, 13% of patients with gastroesophageal reflux disease had distal wave amplitudes < or = 30 mmHg, whereas none of the patients with non-erosive reflux disease had distal wave amplitudes in this low category. Patients with erosive and non-erosive disease present with similar manometric abnormalities. The only striking difference is the observation of very low EBCA exclusively in patients with erosive disease.

Predictors of symptomatic and objective outcomes after surgical reintervention for failed antireflux surgery

Recurrent gastro-oesophageal reflux disease (GORD) and troublesome dysphagia after primary antireflux surgery are treated successfully by reoperation in 70 per cent of patients. Identifying predictors of outcome could allow selection of patients likely to benefit from further surgery. The aim was to identify such predictors in patients reoperated on for recurrent GORD or troublesome dysphagia. Between 1994 and 2005, 83 patients (mean(s.d.) age 47.2(14.4) years; 47 men) with recurrent GORD and 47 (aged 50.7(13.4) years; 18 men) with troublesome dysphagia had further surgery. The predictive values of demographic, anatomical and manometric variables, and 24-h pH monitoring were analysed with respect to symptomatic and objective outcomes in each group. None of the factors included in a multivariable analysis predicted outcome after surgery for recurrent GORD. Independent predictors of symptomatic outcome after reoperation for dysphagia were amplitude of distal oesophageal contractions (odds ratio (OR) 1.613 (95 per cent confidence interval (c.i.) 1.087 to 2.393); P = 0.017), intrathoracic wrap migration (OR 0.077 (0.003 to 1.755); P = 0.108) and an abdominal approach (OR 0.012 (0.001 to 0.337); P = 0.009). Low-amplitude distal oesophageal contractions, intrathoracic wrap migration and an abdominal approach were significant predictors of an unsuccessful symptomatic outcome after reoperation for troublesome dysphagia.