Esophageal Function Research Articles

To Dor or Not to Dor? Heller Myotomy, a Retrospective Study.

Achalasia is a neurodegenerative disorder affecting esophageal sphincter function. Treatment options include non-surgical and surgical approaches, such as Heller myotomy (HM). Combining Dor fundoplication with HM is controversial but may prevent gastroesophageal reflux disease (GERD). This retrospective cohort study aimed to assess whether HM with Dor fundoplication reduces GERD rates and increases dysphagia rates. Eighty patients who underwent HM between January 2018 and August 2023 were included. Sixty-four patients had Dor fundoplication and were matched 4:1 to 16 patients without fundoplication. Records were reviewed for GERD and achalasia symptoms at various postoperative time points. No significant differences in GERD or dysphagia symptoms were found between the two groups at any time point. Similarly, there were no significant differences in chest pain or dysphagia treatment. In conclusion, this study suggests that the addition of Dor fundoplication to HM does not significantly impact postoperative GERD or achalasia-related symptoms.

Additional Diagnostic Yield of the Rapid Drink Challenge in Chicago Classification Version 4.0 Compared With Version 3.0.

Chicago classification version 4.0 enhances the diagnosis of esophageal motility disorders using position change and provocative tests such as multiple rapid swallows and a rapid drink challenge. This study investigates the diagnostic role of the rapid drink challenge based on Chicago classification 4.0 using a functional luminal imaging probe to estimate the cutoff value. This study included 570 patients who underwent esophageal manometry with a rapid drink challenge between January 2019 and October 2022. The diagnostic flow was analyzed according to Chicago classification 4.0. Ninety-nine patients (38, achalasia; 11, esophagogastric junction outflow obstruction; 7, ineffective esophageal motility; 1, hypercontractile esophagus; and 42, normal esophageal function) failed the rapid drink challenge. Among the 453 participants, 50 and 86 were diagnosed with achalasia and esophagogastric junction outflow obstruction, respectively, using Chicago classification 4.0. In 249/453 (55.0%) patients initially diagnosed with esophagogastric junction outflow obstruction using Chicago classification 3.0, the diagnosis was changed to achalasia (n = 28), hypercontractile esophagus (n = 7), ineffective esophageal motility (n = 7), or normal esophageal function (n = 121) using Chicago classification 4.0. Rapid drink challenge-integrated relaxation pressure's diagnostic cutoff value was 19 mmHg. Nine patients had diagnoses changed after the rapid drink challenge, including 3 with panesophageal pressurization. Chicago classification 4.0 increased the diagnostic yield of the rapid drink challenge by 2.0% (9/453 patients). However, the rapid drink challenge had a failure rate of 17.9% (99/552 patients). Given the relatively low diagnostic yield and high failure rate of the rapid drink challenge, we recommend adopting an individualized approach to manometry.

Corticosteroid Effects on Upper Esophageal Sphincter Function in Anterior Cervical Discectomy and Fusion: A Study Using High-Resolution Impedance Manometry.

The aim of our study was to explore the effect of local corticosteroids on dysphagia in patients undergoing anterior cervical discectomy and fusion (ACDF). To address a gap in the limited research on this topic, we utilized high-resolution impedance manometry (HRIM) and the Eating Assessment Tool-10 (EAT-10) questionnaire to assess the effects on key swallowing muscles, including the upper esophageal sphincter (UES). We randomly assigned patients undergoing ACDF to either the corticosteroid group or the saline solution group. Patients received 10 mg of local triamcinolone or saline solution prevertebrally at the cervical spine level before wound closure. Swallowing function preoperatively and at 1 month postoperatively were compared between the groups with use of HRIM parameters (e.g., UES relaxation, UES opening extent, intrabolus pressure, and pharyngeal contraction) and EAT-10 scores. Patients were also followed for postoperative complications and mortality within 12 months after surgery. Thirty patients completed the study. The median age was 55 years in the corticosteroid group and 57 years in the saline group, and each group had 8 female patients. All participants were Taiwanese. We found no significant difference in median preoperative UES relaxation pressure between the corticosteroid and saline solution groups (33.8 and 31.3 mm Hg, respectively; p = 0.54). Postoperatively, the corticosteroid group had significantly lower median UES relaxation pressure than the saline solution group (24.5 versus 33.6 mm Hg; p = 0.01). Before and after surgery, all other HRIM parameters and EAT-10 scores were similar between the groups, with the corticosteroid group demonstrating median pre- and postoperative EAT-10 scores of 0 and 4, respectively, and the saline solution group demonstrating scores of 2 and 3, respectively. There were no adverse events. The findings suggest that local corticosteroids may reduce UES relaxation pressure at 1 month after ACDF, potentially enhancing UES opening. Further research is required to verify our findings. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Gastric fundoplication with endoscopic technique: A novel approach for gastroesophageal reflux disease treatment.

Gastric fundoplication with endoscopic technique (GFET) is an innovative approach to managing gastroesophageal reflux disease (GERD). This minimally invasive procedure utilizes the GEN-2 Apollo endosuture device and Olympus H2T180 gastroscope to perform partial fundoplication by strategically placing Prolene 2-0 sutures at the 11, 7, 5, 1, and 3 o'clock positions around the gastroesophageal junction. To evaluate whether GFET enhances the lower esophageal sphincter function by creating comprehensive plication to improve the barrier against reflux. This single-center prospective study included patients undergoing GFET. Before beginning GFET, pH metrics and subsequent manometric measurements were obtained. An analysis of variance was performed to determine statistically significant differences between quality of life (QOL) and DeMeester scores at the time of the procedure and 6 and 12 months postoperatively. Pearson's χ 2 test was performed to identify statistically significant differences between categorical variables at the time of the procedure and 6 and 12 months postoperatively. Eighteen participants were enrolled (11 males and 7 females; mean age, 35 years). More than 70% had an initial Hill grade of IIb. One adverse event was recorded after the procedure. One patient underwent valve reinforcement at 12 months. The mean QOL score was markedly higher at the time of the procedure (39.9 ± 4.0) compared to those at 6 and 12 months postoperatively (P < 0.001). Scores at 12 months were slightly higher than those at 6 months. The highest mean QOL score was observed at the time of the procedure, followed by those at 6 and 12 months postoperatively (P < 0.001). A similar trend was noted for the mean DeMeester scores (P < 0.001). GFET is a minimally invasive alternative to traditional surgical interventions and endoscopic techniques for managing GERD. Further research is warranted to validate its long-term efficacy and effectiveness over existing treatments.

Experience in Using 99mTc-Technephyt Esophageal Transit Scintigraphy for Assessing Pneumatic Dilation Outcome in Patients with Achalasia Cardia

Objective: to show the possibility of using 99mTc-technephyt esophageal transit scintigraphy (ETS) to assess the effect of cardiodilation in patients with achalasia cardia.Material and methods. We examined 7 patients (6 males and 1 female) aged 44–73 years (mean age 57.8 years) diagnosed with achalasia cardia, who were treated in Department of Thoracic Surgery No. 2 at Republican Clinical Hospital from June 2022 to January 2023. The disease duration before admission to the hospital ranged from 2 to 17 years (mean 9.2 years).Results. The analysis of ETS results showed a decreased radiopharmaceutical residual activity percentage in cardia for all patients after treatment compared with the initial data. It indicated a positive effect of cardiodilation and coincided with X-ray examination data. The obtained results demonstrate the possibility of ETS using and its practical significance to assess the effect of therapeutic measures, in particular cardiodilation, in patients with achalasia cardia.Conclusion. Performed according to the described protocol, ETS is a physiological and safe method for both the diagnosis of achalasia and the subsequent assessing therapeutic effect, including cardiodilation, myotomy, conservative treatment, and long-term dynamic monitoring. It is a physiological and safe procedure, which can be recommended in cases of difficulties in evaluating the esophageal function by X-ray, endoscopic and manometric methods or when their use is impossibile.

S649 Design of the Phase 4 REMODEL Study Assessing the Effect of Dupilumab on Esophageal Function and Remodeling in Adult Patients With Active Eosinophilic Esophagitis

S649 Design of the Phase 4 REMODEL Study Assessing the Effect of Dupilumab on Esophageal Function and Remodeling in Adult Patients With Active Eosinophilic Esophagitis

Esophageal Function Testing Patterns in the Evaluation and Management of Lung Transplantation: Results of a National Survey.

We surveyed esophageal motility laboratories affiliated with adult pulmonary transplant centers to determine esophageal function testing (EFT) practices. Gastroesophageal reflux and esophageal dysmotility are associated with worse lung transplant outcomes, yet no consensus guidelines for EFT exist in this population. A deidentified online survey was sent to gastrointestinal motility laboratory directors of 49 academic and community-affiliated medical centers that perform lung transplants. Practice characteristics, including annual lung transplant volume and institutional EFT practices pre-lung transplantation and post-lung transplantation were queried. Respondents were categorized by transplant volume into small and large programs based on median annual volume. Among 35 respondents (71% response rate), the median annual transplant volume was 37, and there were 18 large programs. Institutional EFT protocols were used pretransplant by 24 programs (68.6%) and post-transplant by 12 programs (34.2%). Among small and large programs, 52.9% and 72.2% always obtained high-resolution manometry before transplant, respectively. Endoscopy before transplant was performed more often in small programs (n=17, 100%) compared with large programs (n=15,83.3%). Pretransplant endoscopy ( P =0.04), barium esophagram ( P <0.01), and high-resolution manometry ( P =0.04) were more common than post-transplant. In contrast, post-transplant reflux monitoring off-therapy was more common than pretransplant ( P =0.01). In general, pulmonologists direct referrals for EFT and gastroenterology consultation (n=28, 80.0%), with symptoms primarily prompting testing. In the absence of established guidelines, substantial variability exists in pretransplant and post-transplant EFT, directed by pulmonologists. Standardized EFT protocols and gastroenterologist-directed management of esophageal dysfunction has potential to improve lung transplant outcomes.

The Relationship between Upper Esophageal Sphincter Manometry Function and Esophageal Motility Disorders.

High-resolution manometry (HRM) provides measures of esophageal function which are used to classify esophageal motility disorders based on the Chicago Classification system. Upper esophageal sphincter (UES) measures are obtained from HRM, but are not included in the classification system, rendering the relationship between UES measures and esophageal motility disorders unclear. Furthermore, changes in the acceptable amount of esophageal dysfunction between versions of this classification system has created controversy. The objective of this study was to determine the relationship between UES measures and esophageal function. Cross-sectional study. Referral centre. HRM studies from the Calgary Gut Motility Center were reviewed for UES mean basal pressure, mean residual pressure, relaxation time-to-nadir, relaxation duration, and recovery time. Patients were grouped by number of failed swallows according to different iterations of the Chicago Classification: 0 to 4 (Group 1), 5 to 7 (Group 2), and 8 to 10 (Group 3). 2114 patients (65.1% female, median age 56 y) were included. There were significant increases in UES mean basal pressure (P < .001), mean residual pressure (P < .001), relaxation duration (P < .001), and recovery time (P < .001) between groups. Positive correlations existed between number of failed swallows and UES mean basal pressure (r = 0.143; P < .001), mean residual pressure (r = 0.201; P < .001), relaxation duration (r = 0.145; P < .001), and recovery time (r = 0.168; P < .001). Differences in UES measures exist among patients with failed swallows, with a positive correlation between UES dysfunction and increasing dysmotility. Our findings illustrate that UES measures are closely related to esophageal function, and that even minor esophageal dysfunction is related to UES dysfunction.

Personalized diagnosis of patients with gastroesophageal reflux disease using 24-hour pH-impedance testing and high-resolution esophageal manometry

To determine the phenotypic variants of patients with symptoms of gastroesophageal reflux disease (GERD), non-erosive reflux disease (NERD), hypersensitive esophagus (HSE), functional heartburn (FH) using 24-hour pH-impedance testing and high-resolution esophageal manometry (HSEM). Fifty-five treatment-native symptomatic patients with newly diagnosed GERD and 48 control group subjects (CG) were examined. The mean age of the subjects was 45.0 years (95% confidence interval [CI] 41.0-48.9). Patients were grouped based on typical symptoms (heartburn, belching, regurgitation, odynophagy, dysphagia), medical history, endoscopy results, and 24-hour pH-impedance testing. Patients with typical symptoms of GERD and Grade B, C, D erosive esophagitis (EE) according to the Los Angeles Classification (LA) based on endoscopy were excluded from the further study. All patients without changes in the esophageal mucosa on endoscopy or with LA grade A EE (presumably NERD) underwent 24-hour pH-impedance testing and HSEM without proton pump inhibitors. Acid exposure, acid reflux count, symptom association with reflux (with symptom index and symptom association with reflux), mean nocturnal impedance, and post-reflux swallow-induced peristaltic wave index were assessed. The structure (presence or absence of a hiatal hernia) and function (presence or absence of the lower esophageal sphincter hypotonia) of the esophagogastric junction, as well as the motor function of the thoracic esophagus, were assessed using HSEM. The results of the HSEM were interpreted according to the Chicago Classification, 3rd edition (2015). The number of acid refluxes in patients with NERD was 71.0 (95% CI 58.4-83.7), in subjects with HSE - 38.5 (95% CI 28.3-49.0), with FH - 13.0 (95% CI 6.5-18.2), in CG - 16.5 (95% CI 9.0-21.0). The average nocturnal basal impedance was 1300 ohms (95% CI 1000-1986) in patients with NERD, 1725 ohms (95% CI 1338-2261) in patients with HSE, 2760 ohms (95% CI 2453-3499) in FH, 2515 ohms (95% CI 2283-2700) in CG. The index of post-reflux swallow-induced peristaltic wave in patients with NERD was 61% (95% CI 57-71), with HSE - 85% (95% CI 82-88), with FH - 71% (95% CI 64-78), in CG - 66% (95% CI 63-69). Hiatal hernia and/or hypotonia of the LES were more common in patients with NERD (23%) than in CG (13.3%). Ineffective motility was detected in 34% of patients with NERD, in 23% of subject with FH and in 66.7% of patients with HSE. The results support the hypothesis that patients with GERD symptoms represent a heterogeneous population. 24-hour pH-impedance testing and HSEM helps to differentiate endoscopically negative patients with GERD symptoms and patients with Grade A EE by LA to NERD, HSE and FH.

546. ESOPHAGEAL FUNCTION TESTS BEFORE AND AFTER LAPAROSCOPIC SLEEVE GASTRECTOMY FOR SEVERE OBESITY

Abstract Background Gastroesophageal reflux disease is common in patients with severe obesity. However, changes in esophageal motility and gastroesophageal reflux in patients undergoing sleeve gastrectomy have not been well-studied. In this study, we evaluated the effects of sleeve gastrectomy on esophageal function. Methods All patients undergoing laparoscopic sleeve gastrectomy (LSG) at our institution are entered into a prospectively maintained database. We queried this database to identify patients who underwent pre- and post-LSG esophageal function tests (ie, high-resolution manometry [HRM] and 24-hour pH monitoring). Post-operative was esophageal function tests done at 12 months after surgery. Results A total of 44 patients underwent LSG between Jul. 2018 and Dec. 2022, of which 11 patients underwent both pre and post-LSG esophageal function tests. The study cohort had a mean age of 65.4 years with 5 males. BMI was significantly decreased after LSG (40.0 vs. 27.4 kg/m2，p=0.004). Manometric hiatal hernia was increased post-LSG (0% vs. 45.5% [n=5/11]), though this difference did not reach statistical significance (p=0.063). Esophagogastric junction contractile integral (EGJ-CI), thoraco-abdominal pressure gradient, and distal contractile integral (DCI) were similar between the two groups (p=0.155, p=0.154, and p=0.131, respectively). Post-LSG 24-hour pH monitoring showed higher acid exposure time (0.4% vs. 11.2%, p=0.005) and DeMeester score (3.5 vs. 33.2, p=0.003). Conclusions Gastroesophageal reflux was significantly exacerbated post-LSG, although esophageal motility and EGJ pressures were preserved after LSG. This may indicate that the change in EGJ morphology and disruption of the angle of His have an important role in mechanism of LSG-related GERD.

325. SURGERY FOR EPIPHRENIC ESOPHAGEAL DIVERTICULUM, SHORT AND LONG TERM RESULTS

Abstract Background and Objectives We present our experience with laparoscopic surgery for epiphrenic oesophageal diverticulum. We wanted to assess our surgical results focusing on the patients’ quality of life. Short- and long-term results of surgical therapy were analysed. Methods 14 patients were examined with a symptomatic causing epiphrenic diverticulum. Patients underwent complex gastroenterological examinations before and after surgery (swallowing x-ray, oesophagogastroscopy, oesophageal manometry/pH monitoring). Surgery: laparoscopic transhiatal epiphrenic diverticulectomy with Heller cardiomyotomy and Dor anterior partial fundoplication were performed in 9 patients; laparoscopic diverticulectomy in 2 patients, laparoscopic Heller-Dor operation without diverticulectomy was 1 case (small (&amp;lt; 3cm) diverticulum) and laparoscopic diverticulectomy + Heller myotomy + Nissen fundoplication in 2 cases. Changes in quality of life with regard to symptoms related to oesophageal function were evaluated in our long-term studies (averaging 60 months, 10–138 months) by Eckardt-Zaninotto score. Results We had no intraoperative complication except one. In one case, a staple line leak developed (1/14 (7%), which was resolved with conservative therapy. Functional check-ups confirmed adequate oesophageal function in majority of the patients. The total symptom score for the patients was 6.3 points before surgery, and it decreased to 1.6 (P .001) after surgery, an average of 74% subjective improvement. During the follow-up period, proton pump inhibitor therapy was started in 4 patients to treat gastroesophageal reflux. In 3 cases, drug therapy was successful; in one case, Nissen antireflux surgery was performed. Conclusion Laparoscopic transhiatal diverticulectomy and Heller–Dor surgery are effective interventions with low morbidity. Patient quality of life significantly improves in the long term, but gastroesophageal reflux disease may occur. Key Words Epiphrenic oesophageal diverticulum, Laparoscopic transhiatal surgery, Long-term results

495. LAPAROSCOPIC FUNDOPLICATION IMPROVES ESOPHAGEAL MOTILITY IN PATIENTS WITH GERD A HIGH VOLUME SINGLE CENTER CONTROLLED STUDY IN HIGH-RESOLUTION MANOMETRY ERA

Abstract Background Pathophysiology of GERD is complex and esophageal motility disorders are frequently contributing to the disease. Most of the existing literature demonstrates that Laparoscopic Fundoplication (LF) is safe in the setting of ineffective or weak peristalsis, however the effect of the wrap on esophageal motility is still debated. This study aimed to assess how a functioning and effective fundoplication could impact the esophageal motility in patients with GERD. Methods We analyzed prospectively collected data on patients who underwent laparoscopic Nissen (LN) or Toupet (LT) fundoplication for GERD between 2010-2022. We selected patients who have been treated with LF according to the GERD international guidelines. The exclusion criteria were: patients with a giant hiatal hernia and patients with a proof of a too-tight LF. Patients were evaluated with the GerdQ questionnaire, barium-swallow, endoscopy and HRM and 24-hour pH-Impedance before and after surgery. The HRM were reviewed by 2 experts (Chicago Classification v4.0). LF failure was recorded in case of an abnormal postoperative pH-MII using the Lyon 2.0 criteria. Results We recruited 124 patients (M:F=89:35). Fifty-eight LN and 66 LT were recorded. A good outcome at the 24-hour pH-Impedance was registered in 103 patients (GLF) and a failure in 21 patients (FLF). As shown in Figure 1, in GLF patients, 29 had a preoperative motility disorder (24 IEM and 5 DES), and postoperatively 22 (76%) of these patients had a normalization of the esophageal motility. Ten FLF patients had a preoperative motility disorder (9 IEM and one DES); 4 (40%) of them showed normal motility after LF. There was a significant association between GLF and normalization of esophageal motility (p&amp;lt;0.05). Conclusion This study demonstrates that LF is an effective and functioning treatment in patients with GERD associated with an esophageal motility disorder. Moreover, our results indicate that LF could determine a normalization of the disordered esophageal motor function in patients with GERD.

497. ENDOFLIP AND BOTULIN TOXIN INJECTION: THERAPEUTIC MANAGEMENT IN ESOPHAGEAL AND GASTRIC MOTILITY DISORDERS

Abstract Introduction Esophageal motility disorders present diagnostic and therapeutic challenges, with dysphagia being a common symptom prompting evaluation. The Endolumenal Functional Lumen Imaging Probe (EndoFLIP) has recently gained recognition as a valuable tool for assessing esophageal function. This study aims to evaluate the utility of EndoFLIP in guiding therapeutic interventions, specifically focusing on botulinum toxin injections, among patients presenting with diverse esophageal disorders. Moreover, the study acknowledges the potential of EndoFLIP as a diagnostic adjunct during diagnostic upper gastrointestinal endoscopy in cases where therapeutic alternatives are limited or as therapeutic trial. Methods A retrospective analysis was conducted on 21 patients who underwent EndoFLIP assessment and subsequently received botulinum toxin injection at the same procedure. These patients were identified from records at a tertiary center, covering the period from January 2022 to February 2023. EndoFLIP procedures were analyzed, focusing on patient symptoms and indication for the procedure. Data regarding clinical symptoms, EndoFLIP findings, and therapeutic interventions were extracted and analyzed to assess the role of EndoFLIP in guiding treatment decisions for esophageal disorders. The used cutoffs for esophagogastric junction (EGJ) distensibility index were &amp;lt; 2 mm2/mmHg and &amp;lt; 10 mm2/mmHg for pyloric distensibility. Results All patients referred for esophageal motility evaluation with EndoFLIP presented with dysphagia as the primary symptom. Two patients presented with postprandial bloating, leading to further evaluation with impedance planimetry to assess pyloric distensibility, suspected to be due to diabetic gastroparesis. Following EndoFLIP assessment, a conclusive diagnosis was achieved in all patients: 10 patients were diagnosed with esophagogastric junction outflow obstruction, 1 patient with absent contractility, 7 patients with achalasia, and 1 patient with hypercontractile esophagus. Patients who underwent planimetry to evaluate pyloric distensibility both exhibited reduced distensibility index. Following treatment, 10 patients showed clinical improvement and 11 await clinical reassessment. Conclusions Regarding the evaluation of the EGJ distensibility index in patients with achalasia without indication for invasive treatment, the EndoFLIP emerges as a diagnostic tool that allows for immediate guidance if intervention is recommended. Likewise, patients with refractory gastroparesis and pylorospasm identified through EndoFLIP may benefit from toxin injection for future myotomy decision. In conclusion, EndoFLIP serves as a valuable tool in diagnosing and guiding therapeutic interventions in patients with esophageal and gastric motility disorders. Further research is warranted to validate the role of EndoFLIP in optimizing treatment outcomes for esophageal disorders.

Proton pump inhibitors modulate esophageal epithelial barrier function and crosstalk with eosinophils.

Eosinophilic esophagitis (EoE) is a chronic allergic disease characterized by esophageal dysfunction, type-2 inflammation, and esophageal eosinophilic infiltrate. While proton pump inhibitor (PPI) therapy is commonly used for EoE management, the underlying mechanism of action remains unclear. Air-liquid interface culture of esophageal epithelial cells was employed to investigate the impact of the PPI omeprazole on barrier integrity in IL-13-treated cultures. Epithelial chemokine secretion was assessed following stimulation with IL-13 and omeprazole, and the migration of eosinophils from healthy human donors was evaluated using 3 μm pore-sized transwells. A co-culture system of epithelial cells and eosinophils was employed to study chemokine secretion and eosinophil adhesion and activation markers. Omeprazole treatment in the IL-13-treated air-liquid interface (ALI) model resulted in 186 differentially expressed genes and restored barrier integrity compared to ALI treated with IL-13 alone. Omeprazole treatment reduced STAT6 phosphorylation, downregulated calpain 14, and upregulated desmoglein-1 in the IL-13-treated air-liquid interface samples. IL-13-induced upregulation of Eotaxin-3, CXCL10, and periostin, but this was downregulated by omeprazole. Further, the expression of CD11b, CD18, and CD69 was lower on eosinophils from omeprazole-treated epithelial-eosinophil co-cultures, which also had lower levels of eotaxin-3, CXCL10, CCL2, and CCL4. Omeprazole reduced the effects of IL-13 in both the epithelial air-liquid interface model and eosinophil-epithelial co-cultures, reducing barrier dysfunction, chemokine expression, and upregulation of eosinophil adhesion markers.

Efficacy and safety of peroral endoscopic myotomy for pediatric achalasia: A nationwide study.

Achalasia, a rare esophageal motility disorder characterized by the inability of the lower esophageal sphincter to relax and loss of esophageal peristalsis, significantly impacts pediatric patient quality of life through symptoms like dysphagia, chest pain, and weight loss. This nationwide retrospective cohort study evaluates the efficacy and safety of peroral endoscopic myotomy (POEM) for pediatric achalasia in Mongolia, contributing to the limited global data on this minimally invasive treatment in children. Conducted between February 2020 and March 2022 at 2 tertiary centers, the study included symptomatic achalasia patients, treatment-naive or those with unsatisfactory outcomes from previous esophageal dilations. The POEM procedure was assessed for its impact on esophageal structure and function, symptom severity via the Eckardt score, and procedure-related safety, with outcomes measured at baseline, 3 days, and 12 months post-procedure. The study demonstrated notable post-procedure improvements across all measured outcomes: abnormal contraction length and esophageal width significantly reduced, underscoring the procedure's effectiveness. More precisely, the integrated relaxation pressure showed a significant improvement from a mean of 26.8 mm Hg (standard deviation [SD], 5.4 mm Hg) pre-procedure to 10.8 mm Hg (SD, 1.1 mm Hg) 12 months (P < .001). Similarly, Eckardt scores, which assess symptom severity, improved significantly from a pre-procedure mean of 7.0 (SD, 1.0) to a substantially lower score post-procedure (P < .001), reflecting enhanced patient quality of life and symptom alleviation. This study underscores POEM's role as an effective, minimally invasive option for pediatric achalasia management within the Mongolian population, offering significant symptomatic relief and improved esophageal function.

The impact of gastroesophageal reflux disease on upper esophageal sphincter function: Insights from PH impedance and high-resolution manometry.

Lower esophageal sphincter (LES) pathophysiology has been established in gastroesophageal reflux disease (GERD); however, less is understood regarding the role the upper esophageal sphincter (UES) plays in preventing laryngopharynphageal reflux. Sustained UES basal pressure prevents reflux into the pharynx while allowing relaxation during ingestion. We investigate whether GERD influences UES function via HRM and pH Impedance testing. A retrospective analysis of 318 patients who underwent high-resolution manometry with trans-nasally placed manometric catheter and 24-h multichannel intraluminal impedance pH monitoring. One hundred and forty-seven patients met Lyon consensus criteria for GERD based on acid exposure time >6%. The most common chief concern was heartburn or reflux, present in 59% of these patients. Upper esophageal sphincter basal and residual pressures were not significantly different between patients with GERD when compared to those without GERD, including a subanalysis of patients with extraesophageal symptoms. The LES basal and residual pressures, DCI and MNBI are statistically lower in patients with pathologic GERD. HRM and pH Impedance testing demonstrates no difference in UES basal and residual pressures based on pH diagnosis of GERD. We redemonstrate the association with hypotonic LES, diminished DCI and MNBI with GERD.

Metabolic dysfunction mediated by HIF-1α contributes to epithelial differentiation defects in eosinophilic esophagitis

Investigating the contributory role that epithelial cell metabolism plays in allergic inflammation is a key factor to understanding what influences dysfunction and the pathogenesis of the allergic disease eosinophilic esophagitis (EoE). We previously highlighted the absence of hypoxia signaling through HIF-1α in EoE contributes to esophageal epithelial dysfunction. However, metabolic regulation by HIF-1α has not been explored in esophageal allergy. Herein, we sought to define the role of HIF-1α-mediated metabolic dysfunction in esophageal epithelial differentiation processes and barrier function in EoE. In RNA-sequencing derived from EoE patient biopsies, we observed the expression pattern of key genes involved in mitochondrial metabolism/oxidative phosphorylation (OXPHOS) and glycolysis. Bioenergetics analysis using Seahorse was performed on EPC2-hTERT cells to decipher the metabolic processes involved in epithelial differentiation processes. In addition, air-liquid interface cultures were employed to delineate metabolic dependency mechanisms required for epithelial differentiation. Transcriptomic analysis identified an increase in genes associated with OXPHOS in patients with EoE. Epithelial origin of this signature was confirmed by complex V immunofluorescence of patient biopsies. Bioenergetic analysis in vitro revealed that differentiated epithelium was less reliant on OXPHOS compared with undifferentiated epithelium. Increased OXPHOS potential and reduced glycolytic capacity was mirrored in HIF1A-knockdown EPC2-hTERT cells which portray a significant absence of terminal markers of epithelial differentiation, including involucrin. Pharmacological glucose transport inhibition phenocopied this, while rescue of the HIF-1α-deficient phenotype using the pan-prolyl hydroxylase inhibitor DMOG resulted in restored expression of epithelial differentiation markers. An OXPHOS-dominated metabolic pattern in EoE patients, brought about largely by the absence of HIF-1α-mediated glycolysis, is linked with the deficit in esophageal epithelial differentiation.

Posterior Tracheopexy for Tracheomalacia: A Study of Clinical and Radiological Consequences on Esophagus.

Posterior tracheopexy (PT) directly addresses the posterior trachealis membrane intrusion in severe tracheomalacia. During PT, the esophagus is mobilized and membranous trachea is sutured to the prevertebral fascia. Although dysphagia has been reported as a possible complication of PT, in the literature there are no data investigating postoperative esophageal anatomy and digestive symptoms. Our aim was to study clinical and radiological consequences of PT on esophagus. Patients with symptomatic tracheobronchomalacia scheduled for PT between May 2019 and November 2022 underwent pre- and postoperative esophagogram. For each patient, we analyzed radiological images and measured esophageal deviation providing new radiological parameters. All 12 patients underwent thoracoscopic PT (n = 3) or robot-assisted thoracoscopic PT (n = 9). For all patients, the postoperative esophagogram showed a right dislocation of the thoracic esophagus (median postoperative deviation = 27.5 mm). We report an esophageal perforation at postoperative day 7 in a patient affected by esophageal atresia, who underwent several surgical procedures before. A stent was placed and esophagus healed. Another patient with severe right dislocation referred transient dysphagia to solids, which resolved gradually in the first postoperative year. All the other patients did not present any esophageal symptoms. For the first time, we demonstrate the right dislocation of the esophagus after PT and we propose an objective method to measure it. In most patients, PT is a procedure not affecting esophageal function, but dysphagia can occur if dislocation is important. Esophagus mobilization during PT should be cautious, especially in patients who underwent previous thoracic procedures.

Manometric Abnormalities in Patients With and Without Chronic Cough

PurposeThis study examines the relationship between chronic cough and vagal hypersensitivity by measuring baseline esophageal motility, with interest in the upper esophageal sphincter (UES). Materials and methodsPatients undergoing workup for dysphagia were assigned to a chronic cough or control group based on self-reported symptoms. Differences in demographics, medical comorbidities, and high resolution esophageal manometry findings were obtained retrospectively. Results62.5% of our cohort had chronic cough (30/48). There were no significant differences between the two groups with respect to sex, age, and race/ethnicity. Laryngopharyngeal reflux (LPR) was the only statistically significant predictor of CC (OR 74.04, p = 0.010). Cough patients had upper esophageal sphincter relaxation duration (734 ms) significantly longer than the non-cough patients (582 ms; p = 0.03), though both groups had similar upper esophageal mean basal pressure, mean residual pressure, relaxation time-to-nadir, and recovery time. No significant difference was found in the median intrabolus pressure and UES motility mean peak pressure between groups. ConclusionSubtle differences in high-resolution manometry between patients with and without cough suggest, in line with previous studies, baseline alterations of upper esophageal function may manifest in patients with chronic cough through an undetermined mechanism that may include underlying vagal hypersensitivity. These findings encourage further manometric study examining the relationship between UES dysfunction and chronic cough.

Investigating immune profile by CyTOF in patients with eosinophilic esophagitis after treatment with orodispersible budesonide.

Eosinophilic esophagitis (EoE) is a chronic Th2-mediated inflammatory disease of the esophagus driven by dietary or inhalant allergens which if left untreated, leads to fibrosis and poor esophageal function. Although the inflammation in the esophagus is dominated by eosinophils, there are also elevated levels of T and B cells. Blood samples from ten patients with EoE before and after treatment with orodispersible budesonide and 10 healthy controls were compared using cytometry by time-of-flight. An antibody panel was designed that covers the major immunological cell populations with a particular focus on eosinophils. The data was analyzed with multivariate methods and cluster analysis. Correlation analysis was done between immune markers and endoscopic, histological, and symptomatologic assessments. Our analysis revealed that patients with EoE had lower levels of effector memory T cells after treatment with orodispersible budesonide to the same level as healthy subjects. In addition, more suppressive eosinophils were present in the circulation of EoE patients before treatment and more immature eosinophils were present after treatment. Furthermore, levels of galectin-10+ eosinophils correlated with histological findings in esophageal tissue from EoE patients. In all patients, the peak eosinophils were decreased after treatment with orodispersible budesonide. Intriguingly, 90% of the patients had remission in the histological assessment and 50% improved in the endoscopic assessment. This study reports a detailed immune profile in patients with EoE before and after treatment with orodispersible budesonide and it is a step toward finding blood-based immune parameters that could be useful to monitor response to treatment.