Esophageal Motility Research Articles

Ineffective Esophageal Motility: Current Criteria and Management

Ineffective Esophageal Motility: Current Criteria and Management

MS O10 - BN Case Report: Aberrant Right Subclavian Artery As A Rare Differential For Dysphagia

Abstract Background Dysphagia lusoria (DL) is characterised by swallowing difficulty due to external oesophageal compression from congenital aortic arch malformations. It is clinically rare and affects less than 2.5% of the population. The most prevalent form of DL is the aberrant right subclavian artery (ARSA) where approximately 10% of patients experience dysphagia. Despite AL being congenital, dysphagia often manifests later in life, likely due to age-related atherosclerotic changes in the vasculature and decreased oesophageal flexibility. Method Presented is a case report of a female in her seventies where, despite repeat hiatal hernia repair and maximal medical management, her index symptoms of dyspepsia and retrosternal discomfort persisted when reviewed in specialist upper gastrointestinal clinic. She underwent extensive investigation; however, her symptoms were unremitting, manifesting in numerous emergency department presentations to exclude acute coronary syndrome. This case report details the anatomical differences via diagrams and documents the comprehensive investigation and multi-disciplinary approach to the management of dysphagia in ARSA. Results Prior to referral to our team, the patient had a laparoscopic hiatus hernia repair and Nissen fundoplication undertaken. Oesophageal manometry revealed weak oesophageal motility and 24-hour pH monitoring did not demonstrate pathological acid-reflux. Recurrence of hiatus hernia was observed on oral contrast swallow and gastroscopy. Subsequently, the patient underwent laparoscopic revision of hiatus hernia and conversion of Nissen to a Dor. Post-operatively her symptoms required complete fundoplication reversal. Following reversal, assessment demonstrated improved distal oesophageal emptying. Her CT emphasised an ARSA causing significant compression and deviation of the proximal oesophagus. The patient was referred onwards to vascular surgery. Conclusion Initial diagnostic workup for patients presenting with dysphagia in the upper gastrointestinal clinic seeks to encompass several common aetiologies including oesophageal motility disorders, malignant compression and benign strictures. Clinicians must consider less common causes of extrinsic compression, such as ARSA, particularly in patients with unrelenting and persistent symptoms despite appropriate implementation of both medical and surgical interventions. Treatment approaches for ARSA reflect symptom severity, with both conservative and surgical options considered.

BN O05 - Physiological Transit Assessment of the Oesophagus In Patients With Anti-Reflux Surgery

Abstract Background High-resolution manometry (HRM) is the gold-standard investigation for oesophageal motility in patients with dysphagia. The HRM findings may influence surgical decision for myotomy or anti-reflux surgery (ARS). However, HRM pitfall is the inability to measure oesophageal transit in parallel to the motility during physiology testing. Both transit and motility are complementary that offer insights in the pathophysiology and aetiology of the dysphagia symptoms. This research evaluates the multichannel intraoesophageal impedance transit (MIIT) concept [1] to assess the oesophageal transit in symptomatic patients who undertook the postoperative oesophageal physiology testing between January 2020 and June 2024. Method This cross-sectional retrospective study selected patients with intact Nissen fundoplication (NF) wrap on gastroscopy or with known LINX implant in-situ. HRM with Chicago Classification (version 4.0)[2] compared the ARS cases with augmented antireflux barrier [AARB] from the surgery to healthy treatment naïve controls. The multichannel impedance-pH studies assessed both reflux and the MIIT [1]. MIIT >0.76 minutes were considered positive and comparable to GOJ outflow obstruction [1]. This project was approved by the NHS institution and the local research ethics committee (REC 18/NW/0120)(IRAS 333800). Results 60 patients were found (NF 54, LINX implant 6)(females 30, mean age 51.3 years). 11 patients(18.3%) had pathological reflux despite ARS(DeMeester scores >14.72); 2 patients (18.2%) demonstrated hypotensive AARB. Conversely, 6 patients(10%) showed poor relaxation from the AARB and were compatible to outflow obstruction (5 patients [83.3%] showed conformation with MIIT >0.76 minutes). Patients with ineffective oesophagus (20%) and absent contractility(11.7%) showed MIIT >0.76 minutes in respectively two-thirds with ineffective oesophagus and in all patients with absent contractility. Normal HRM study was observed in 35 patients (58.3%) with 27 patients (77.1%) demonstrating MIIT >0.76 minutes. Conclusion MIIT was able to explain the post-surgical dysphagia in majority of patients from the equivalent transit to outflow obstruction (n=52 patients, 86.7%). Half of these cases had a normal HRM study and would have been perceived as having functional dysphagia. We would recommend performing MIIT adjunctive testing as part of postoperative oesophageal physiology assessment in symptomatic patients. Incidentally, we observed 16 patients (26.7%) having hypotensive AARB post ARS comparing to healthy treatment naïve controls with 2 patients (12.5%) having persistent pathological reflux who may still benefit from surgical revision.

BN SO47 - Can Peroral Endoscopic Myotomy (POEM) be the new gold standard for Achalasia? – as it is safe and effective

Abstract Background Laparoscopic Heller’s cardiomyotomy is the gold standard for treatment of achalasia. POEM has emerged as a revolutionary minimal invasive procedure in the management of achalasia and related oesophageal motility disorders. POEM effectively utilises an endoscopic approach by creating a submucosal tunnel to perform a myotomy at the lower oesophageal sphincter (LES) , achieving symptomatic relief. Being firstly introduced in 2008, POEM offers an excellent alternative option to surgical intervention and conservative approaches. The aim of this study is to evaluate the clinical efficacy and safety of POEM since its introduction in our unit. Method POEM procedures performed in adult patients are recruited prospectively from May 2020 to January 2024 and data are collected using electronic trust records. Eckardt score (a commonly used scoring system to characterise severity of achalasia) is recorded before and after the procedure. A total of 46 patients are identified however three patients are excluded in this study due to unavailable clinical information. This study presents a cohort of patients with median age of 60 and an equal gender distribution. Results Out of 43 patients, 69.8% were treatment naïve and 30.2% had previous treatments. Mean Eckardt score pre-procedure was 8.2. The average length of hospital stay was 1.7 days and immediate post treatment complications were 6.9% (2.3% mucosotomy, 2.3% oesophageal leak, 2.3% infection). No mortality was recorded within 30 days post-procedure. A 93% clinical success rate (Eckardt score ≤3) was achieved in the initial follow-up period (three to six months) with a mean Eckardt score of 1.1. 41.9% of patients experienced reflux symptoms which require proton pump inhibitor use within four weeks post-procedure. 18.4% of patients had recurrent achalasia symptoms over their follow-up period. Conclusion The clinical success rate (Eckardt score ≤3) and recurrence rate post POEM in this study are comparable with the international cohort quoted in literature. Post POEM reflux rate is prevalent, which is a well-known complication. The substantial improvement in clinical outcomes, evidenced by the Eckardt score reduction and the low incidence of post-operative complications, underscores the procedure’s efficacy and safety. Overall, POEM represents a significant advancement in the treatment of oesophageal motility disorders, especially achalasia. This study presents POEM as a safer and less invasive treatment alternative compared to Heller’s cardiomyotomy.

BN SO30 - One hundred consecutive Laparoscopic Heller's Cardiomyotomy & Fundoplication – a personal series

Abstract Background Oesophageal Achalasia (OA) is an uncommon primary oesophageal motility disorder, characterised by the loss of inhibitory neurons in the oesophageal myenteric plexus. The primary goal of treating OA is to alleviate dysphagia caused by the functional obstruction of the distal oesophagus due to the inability of the lower oesophageal sphincter (LOS) to relax appropriately after swallowing. Heller's cardiomyotomy (HCM) remains a standard treatment for OA. The aim of this study was to assess the symptomatic improvement and post-operative outcomes following HCM with fundoplication at our centre. Method All patients underwent HCM through laparoscopic blunt muscle separation technique, between January 2005 and March 2024, by a single surgeon. Retrospective review of electronic and compiled paper patient records were analysed to assess patient demographics, preoperative symptoms, operative details, length of stay (LOS), complications, post-operative symptoms, gastroscopy and pneumatic dilation (PD) as well as revisional surgery. Primary outcomes assessed were binary changes in key symptoms of weight loss, dysphagia, retrosternal pain and regurgitation. Comparison of pre and post-operative outcomes were performed using paired t-test. A p-value of <0.05 was considered statistically significant. Results 100 procedures involving 99 patients (average age 50 years, 43% female), 1 conversion to open and 1 revision at 3 years. ASA grades were 1 (27%), 2 (58%), and 3 (15%). Median LOS was one day, median follow-up 99 months. Post-operatively; weight loss persisted in 11% of patients from 48%, dysphagia reduced from 98% to 42%, retrosternal chest pain from 39% to 20% and regurgitation from 57% to 24% (all p<0.05). 2 patients required (PD) ≤30 days (CD≥3). 36 patients underwent PD at median of 13 months, 20 needed repeat PD. None of the patients developed cancer. Conclusion As demonstrated in this large series of 100 consecutive patients, HCM remains one of the best treatment modalities for OA. Key symptoms of OA significantly reduced following HCM. Our technique avoided the use of energy devices, ensured a short hospital stay and durable symptom improvement, lends support to its continued application in managing this condition.

BN SO18 - Considering Physiology Surveillance in Patients with Oesophageal Atresia

Abstract Background Oesophageal atresia (OA) is a congenital malformation found between one in every 2,400 to 4,500 new-borns per year world-wide [1] who require immediate oesophageal surgery and lifelong endoscopic surveillance for complications of gastroesophageal reflux, oesophagitis, Barrett's oesophagus, anastomotic strictures, oesophageal dysmotility and dysphagia [2, 3]. This study investigates whether ad-hoc oesophageal physiology surveillance would be clinically beneficial for patients with post OA surgical history. Method Retrospective study was conducted on patients with surgical history for OA and undergone oesophageal physiology studies between 2010 and 2023. 11 patients were found (6 females) who had oesophageal physiology at mean age of 29 years (95% CI 26.7 to 35.3 years) or correspondingly post-surgery for OA. Standard high-resolution manometry assessment was re-interpreted with reference Chicago Classification(version 4.0)[4]. This followed by stimulation with multiple water swallowing and solid bolus swallows as adjunctive testing [5, 6, 7]. This project was approved by the NHS institution and the local research ethics committee (REC 18/NW/0120)(IRAS 333800). Results Major dysmotility was observed in 7 patients (63.6%)(achalasia 3, absent contractility(AC) 4) and minor dysmotility was apparent in 4 patients (ineffective oesophageal motility [IOM]). Development of major dysmotility was at a later onset post-surgery to minor dysmotility (30.4 years vs 26.5 years, p=0.214). As was achalasia to AC (32.3 years vs 29.0 years, p=0.379). Adjunctive testing augmented oesophageal smooth muscle contractility in all patients with IOM and invoked remaining neuromuscular functioning in 2 patients with AC. The achalasia diagnosis in the 3 patients remained unchanged during the adjunctive testing. Conclusion Oesophageal physiology surveillance in patients with post OA surgery would enable identifying the staging of the motility disorder and which may direct further surgical management. This study revealed patients were still suitable for partial fundoplication post OA surgery (54.5%) and surgical myotomy for achalasia (27.3%). The prevalence of achalasia (27.3%) and absent contractility (36.4%) in post OA surgery observed this study are significantly higher compared to the non-OA treatment-naïve patients found in the general population living with achalasia and absent contractility disorders.

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.

Lymphocytic Esophagitis—A Novel Clinicopathologic Variant of Chronic Esophagitis: A Review Paper

Background/Objectives: Lymphocytic esophagitis is a rare inflammatory disease of the esophagus, first described in 2006. Since that time, interest in this disease entity has steadily increased, yet specific data on the etiology of the disease are still lacking. Lymphocytic esophagitis co-occurs with esophageal motility disorders, Crohn’s disease, hypersensitivity (allergy, asthma), the use of certain medications, or immune disorders. Risk factors include smoking and alcohol abuse. The disease is more prevalent in women, developing predominantly within the sixth decade of life. The most important symptom is dysphagia, with odynophagia, epigastric, and chest pain or heartburn being less common. No particular endoscopic presentation is pathognomonic for lymphocytic esophagitis, the findings not infrequently resembling those of eosinophilic esophagitis. Conclusions: There is great need for an international consensus defining strict histopathological criteria for the diagnosis of lymphocytic esophagitis as well as relevant diagnostic and therapeutic management. This review paper presents the current state of knowledge on lymphocytic esophagitis.

Laparoscopic fundoplication improves esophageal motility in patients with GERD - A high-volume single-center controlled study in the era of high-resolution manometry and 24-hour pH-impedance

BackgroundMost 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. MethodsWe analyzed prospectively collected data on patients who underwent laparoscopic Nissen (LN) or Toupet (LT) fundoplication for GERD at our Department between 2010-2022. Demographic and clinical characteristics were recorded. Patients were evaluated with the GerdQ questionnaire, barium swallow, endoscopy, high-resolution manometry (HRM) and 24-hour pH-Impedance (pH-MII) before and after surgery. The HRM were reviewed by 2 experts, following the criteria of the Chicago Classification v4.0. LF failure was objectively defined in case of abnormal postoperative pH-MII according to Lyon 2.0 criteria with/without an abnormal GerdQ. ResultsDuring the study period 124 (M:F=89:35) GERD patients were recruited. Fifty-eight patients underwent LN and 66 underwent LT. All procedures were completed laparoscopically, and the 90-day postoperative mortality was nil. At the postoperative pH-MII, we recorded a good outcome in 103 patients and a failure in 21 patients. There was a significant association between a successful LF and the normalization of esophageal motility (p<0.05). ConclusionOur data confirmed that LF is an effective treatment in patients with GERD independently from with an esophageal motility status. Moreover, our results indicate that LF could determine a normalization of motility abnormalities in patients with GERD.

ENDOSCOPIC SEDATION TYPE DURING FLIP PANOMETRY DOES NOT SIGNIFICANTLY IMPACT FLIP MOTILITY CLASSIFICATION RELATIVE TO MANOMETRY

Functional lumen imaging probe (FLIP) Panometry evaluates esophageal motility at the time of sedated endoscopy and often parallels high-resolution manometry (HRM) performed in awake patients. This study aimed to assess the impact of endoscopic sedation on FLIP evaluation of esophageal motility. Adult patients who completed FLIP Panometry during sedated endoscopy and had a conclusive Chicago Classification v4.0 diagnosis on HRM were included in this retrospective study. HRM diagnoses relative to FLIP Panometry motility classifications were compared by sedation type used during FLIP, i.e. conscious sedation (CS) with midazolam and fentanyl or monitored anesthesia care (MAC) with propofol. 454 patients (mean (SD) age 53 (17) years, 62% female) completed FLIP Panometry under CS (n=174, 38%) or MAC (n=280, 62%; 177/280 MAC included fentanyl). On comparison of CS vs MAC, HRM diagnoses within FLIP Panometry motility classifications did not differ (P=0.306 across all 5 FLIP Panometry classifications; P values 0.202-0.856 within specific FLIP classifications). The proportion of HRM diagnoses within each FLIP Panometry classification also did not differ between FLIP completed with CS vs MAC with fentanyl (P=0.098) or MAC without fentanyl (P=0.0261) CONCLUSIONS: Whether CS or MAC was used as sedation during FLIP did not have a clinically significant impact on the relationship between diagnosis on FLIP Panometry and HRM. This supports the validity of diagnosing esophageal motility disorders using FLIP Panometry during sedated endoscopy.

Esophageal achalasia presenting as recurrent pneumonia in children: A case series.

Esophageal achalasia (EA) is a rare primary esophageal motility disorder that is considered a rare etiology of dysphagia among infants and children. The proposed primary pathophysiology is related to the loss of ganglion cells in the distal esophageal sphincters, particularly in the Auerbachian muscle layer, which then leads to the dysmotility and failure of lower esophageal sphincter relaxation. Dysphagia, vomiting, poor weight gain, cough, and recurrent aspiration pneumonia are the most common presenting complaints. Herein, we report 3 cases of EA who presented with chronic cough and recurrent aspiration pneumonia. This study reviewed 3 pediatric patients with typical symptoms of EA. All the patients were admitted and referred to the pediatric pulmonology service for evaluation of recurrent pneumonia and suspected aspiration syndrome. All patients underwent a barium esophagogram as a part of the aerodigestive workup of recurrent vomiting, dysphagia, and aspiration pneumonia. Additionally, all the patients underwent workup for other associated congenital anomalies, which included echocardiography, brain magnetic resonance imaging, and an abdominal ultrasound. All patients had EA and presented with recurrent pneumonia. All patients had isolated EA, and none had any evidence of Allgrove syndrome. Pneumatic balloon dilatation was performed for all patients at the same time as the upper gastrointestinal endoscopy. Later, all the patients underwent a laparoscopic Heller myotomy and had no postoperative complications, and their symptoms resolved. EA is a rare condition in children, yet it can be a serious and life-threatening condition if left untreated. Our cases emphasize the significance of considering achalasia in children who experience esophageal dysphagia and recurrent pneumonia. Several pediatric cases have been reported in which respiratory involvement was the primary manifestation of achalasia. These cases highlight the importance of considering gastrointestinal disorders, particularly EA, in the differential diagnosis of children who experience recurrent pneumonia. Early diagnosis and treatment with laparoscopic Heller myotomy can lead to good outcomes for children with achalasia.

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.

Laparoscopic transhiatal surgery based on high-resolution manometric evaluation of epiphrenic esophageal diverticulum.

Epiphrenic esophageal diverticulum is rare and often associated with abnormalities of esophageal motility. Here, we report a case of a patient diagnosed with high-resolution manometry as having epiphrenic esophageal diverticulum with esophagogastric junction outflow obstruction, which were successfully treated with laparoscopic transhiatal surgery. A 59-year-old woman presented to our hospital for treatment of a symptomatic epiphrenic esophageal diverticulum. An esophagogram revealed a left epiphrenic diverticulum measuring 50mm. High-resolution manometry showed a high integrated relaxation pressure of 35.6mmHg (> 26mmHg) and preserved esophageal peristalsis. A chest computed tomography scan showed no external compression of the distal esophagus. Therefore, we diagnosed an epiphrenic esophageal diverticulum with esophagogastric junction outflow obstruction according to the Chicago Classification v3.0. Laparoscopic transhiatal diverticulectomy, planned and selective myotomy, and Dor fundoplication were performed. We performed myotomy just on the esophageal side and did not perform gastric myotomy. The postoperative course was uneventful, and the postoperative esophagogram showed smooth passage of contrast without leakage or stenosis. High-resolution manometry showed a normal integrated relaxation pressure (11.6mmHg) at three months after surgery. Because an epiphrenic esophageal diverticulum is frequently associated with esophageal motility disorder, not only morphologic but also functional and appropriate treatment must be considered.

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

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

Peroral endoscopic myotomy as a new approach in the treatment of patients with achalasia cardia

Background. Achalasia cardia is a disease characterized by an esophageal motility disorder in which the lower esophageal sphincter fails to fully relax in response to swallo-wing and esophageal motility progressively decreases. The aim of the work is to improve the outcomes of endoscopic treatment for esophageal achalasia by modifying peroral endoscopic myotomy (POEM) in stage II–III achalasia cardia. Materials and methods. In 2019–2023, 35 (100.0 %) patients with stage II–III achalasia cardia were examined and underwent POEM at the multidisciplinary surgical department in the Educational and Scientific Medical Center “University Clinic” of the Zaporizhzhia State Medical and Pharmaceutical University. The diagnosis was made based on the following data: complaints, clinical course, esophagram, endoscopic diagnosis, and computed tomography. The average age of the patients was 50.0 ± 15.7 years. Analyzing the frequency of this disease according to the WHO age classification, there were 16 (45.7 %) young, 8 (22.9 %) middle-aged, 10 (28.6 %) elderly, and 1 (2.8 %) senile patient. The group was equal in terms of gender: 16 men (45.7 %) and 19 women (54.3 %), p = 0.9654. Inclusion criteria: age over 18 years, stage II–III achalasia cardia, informed consent of a patient. Exclusion criteria: achalasia cardia stage I, as we believe that at this stage only conservative treatment and balloon dilatation are indicated; achalasia cardia stage IV for which only Heller myotomy with Dor fundoplication are indicated. Results. All patients of the study group were operated by the method of POEM under total intravenous ane-sthesia with artificial lung ventilation. Esophageal myotomy was performed along the posterior wall, considering the risk of recurrence and preservation of the anterior wall for repeated peroral myotomy or laparoscopic Heller myotomy. The length of the myotomy was determined depending on the stage of achalasia. So, for stage II, the beginning of the endoscopic tunnel formation and myotomy was determined from the first persistent esophageal spasm, which most often corresponded to a distance of 25.0 ± 2.0 cm from the incisors and, accordingly, myotomy of the esophagus, lower esophageal sphincter, and gastric myotomy averaged 15.0 ± 3.0 cm. We noted that in all operated patients six months after the operation, a propulsive activity appeared during contrast X-ray of the esophagus, and its volume decreased from 5.6 ± 0.4 cm at stage II to 2.3–4.1 cm (p = 0.0324) and from 7.4 ± 0.2 cm at stage III to 3.6 ± 0.8 cm (p = 0.0267), which indicates a decreased pressure in the lower esophageal sphincter after surgery. Based on the evaluation of the results of multichannel esophageal gastric pH monitoring, reflux was confirmed in 1 (6.7 %) patient with achalasia stage II and in 1 (5.0 %) case with achalasia stage III. Conclusions. Peroral endoscopic myotomy is an effective minimally invasive method of treating patients with achalasia cardia stage II–III. According to the Eckardt symptom score, reliable results were achieved already one month after surgery: 7.6 ± 1.1 points before surgery and 2.1 ± 0.4 points when evaluated one month after surgical treatment (p &lt; 0.0001, U = 475.0). Given the effectiveness and minimal trauma, the low risk of postoperative complications, a significant reduction in hospital stay and rapid postoperative rehabilitation, POEM can be an alternative to laparoscopic Heller myotomy.

Medications to Modify Aspiration Risk: Those That Add to Risk and Those That May Reduce Risk.

Aspiration pneumonia results from the abnormal entry of fluids into the respiratory tract. We present a review of drugs known to affect the risk of aspiration. Drugs that increase the risk of aspiration pneumonia can be broadly divided into those that affect protective reflexes (like cough and swallowing) due to direct or indirect mechanisms, and drugs that facilitate gastric dysbiosis or affect esophageal and intestinal motility. Chief among the first group are benzodiazepines and antipsychotics, while proton pump inhibitors are the most well-studied in the latter group. Pill esophagitis may also exacerbate swallowing dysfunction. On the other hand, some research has also focused on pharmaceutical modulation of the risk of aspiration pneumonia. Angiotensin-converting enzyme inhibitors have been demonstrated to be associated with a decrease in the hazard of aspiration pneumonia in high-risk patients of Chinese or Japanese origin. Drugs like amantadine, nicergoline, or folic acid have shown some promising results in stroke patients, although the available evidence is thus far not enough to allow for any meaningful conclusions. Importantly, antimicrobial prophylaxis has been proven to be ineffective. Focusing on modifiable risk factors for aspiration pneumonia is relevant since this may help to reduce the incidence of this often severe problem. Among these, several commonly used drug classes have been shown to increase the risk of aspiration pneumonia. These drugs should be withheld in the high-risk population whenever possible, alongside general measures, such as the semirecumbent position during sleep and feeding.

Clinical characteristics of patients with eosinophilic esophagitis and eosinophilic esophageal myositis based on esophageal motility.

Eosinophilic esophagitis (EoE) presents with various esophageal motility disorders, and some cases of hypercontractile esophagus (HE) are associated with eosinophilic esophageal myositis (EoEM). This study aimed to compare the clinical characteristics of patients with EoE and EoEM according to their esophageal motility. The 28 patients with EoE and 2 patients with EoEM were divided into three groups based on esophageal motility: normal motility group, hypomotility group, and spastic contraction group. The clinical characteristics of the three groups were retrospectively compared. Among the 28 patients with EoE, there were 15 with normal esophageal motility, 9 with hypomotility (2 with absent contractility, 7 with ineffective esophageal motility), and 4 with spastic contractions (1 with type III achalasia, 1 with HE, 2 with unclassifiable multipeak contractions). The two patients with EoEM had HE. Most patients in the normal and hypomotility groups had typical endoscopic findings of EoE, whereas these typical findings were less common in the spastic contraction group (P < 0.001). Four of the five patients with esophageal stricture were in the hypomotility group (P = 0.036). The therapy method significantly differed between the three groups: the normal group had more patients that responded to a proton pump inhibitor or potassium-competitive acid blocker, the hypomotility group had more patients that responded to steroids, and the spastic contraction group contained two patients treated with per-oral endoscopic myotomy (P = 0.021). The endoscopic findings and therapy methods differ between patients with EoE and EoEM based on the esophageal motility.

Four-Dimensional Impedance Manometry in Esophageal Motility Disorders.

Four-dimensional high-resolution impedance manometry (4D HRM) uses impedance to estimate esophageal luminal cross-sectional area and track nadir impedance to measure intrabolus pressure (IBP). We aimed to determine whether 4D HRM metrics could define abnormal esophagogastric junction (EGJ) opening between Chicago Classification version 4.0 motility disorders and compare 4D HRM with functional lumen imaging probe (FLIP) metrics. Symptomatic adult patients who completed high-resolution impedance manometry and FLIP were included and compared with an asymptomatic control group. 4D HRM analysis used custom-built software to measure IBP, maximum EGJ diameter, and distensibility index on supine test swallows. 4D HRM metrics were compared with FLIP EGJ metrics. Ninety patients (31 normal motility, 16 ineffective esophageal manometry, 9 absent contractility, 8 conclusive EGJ outflow obstruction [EGJOO], 12 type I achalasia, 14 type II achalasia, 12 type III achalasia, and 34 asymptomatic controls) were included. Phase 2 and 3 IBP was higher in type II and III achalasia compared with controls and normal motility groups ( P < 0.03). Maximum EGJ diameter and EGJ-distensibility index in the conclusive EGJOO and achalasia groups were significantly lower than in controls and normal motility groups ( P < 0.03). 4D HRM identified 37 of 44 (84%) subjects with normal EGJ opening and 29 of 39 (74%) subjects with reduced EGJ opening on FLIP. 4D HRM metrics correlated with expected clinical observations across a spectrum of esophageal motility disorders and defined EGJ obstruction. 4D HRM metrics may have value in defining EGJ obstruction in equivocal cases related to EGJOO or absent peristalsis.

Delayed diagnosis and treatment of achalasia: a case report

BackgroundAchalasia is characterized as an esophageal motility disorder with incomplete relaxation of the lower esophageal sphincter. Achalasia can be associated with abnormal peristalsis and symptoms of dysphagia, acid reflux, and chest pain. The exact pathophysiology of achalasia remains unclear, but it is hypothesized to be due to degeneration of the myenteric plexus.Case presentationIn this case, a 46-year-old Hispanic man presented to the emergency room with a 12-year history of progressive discomfort with swallowing solids and liquids. Due to many years of incomplete follow-up care and lack of understanding of the course of his disease, this patient’s symptoms escalated to complete intolerance of oral intake and significant weight loss. He was diagnosed with achalasia during his hospital stay and treated successfully with laparoscopic Heller myotomy.ConclusionsThis case discussion illustrates the importance of follow-up care and patient education so that diagnosis and treatment of achalasia are not delayed.

Effects of capsaicin on esophageal peristalsis in humans using high resolution manometry.

Capsaicin-containing red pepper sauce suspension augments esophageal contraction amplitude on conventional manometry. This study used high-resolution manometry (HRM) to investigate if capsaicin infusion modulates segmental esophageal smooth muscle peristalsis in healthy adults. Sixteen healthy volunteers (mean age 37 years, 14 male) underwent HRM for the evaluation of primary peristalsis and secondary peristalsis using slow and rapid air distensions. Both primary and secondary peristalsis were assessed following infusions of capsaicin-containing red pepper sauce and saline. Capsaicin infusion significantly increased heartburn symptoms compared to saline infusion (p < 0.001), and significantly decreased threshold volumes of secondary peristalsis during rapid air distensions (p = 0.02). The frequency of secondary peristalsis during rapid air distensions was significantly increased by capsaicin infusion (p = 0.03). Neither capsaicin infusion (p = 0.06) nor saline infusion (p = 0.27) altered threshold volume during slow air distensions. Capsaicin infusion significantly increased distal contractile integral (DCI) of primary peristalsis (p = 0.04), particularly in the proximal smooth muscle segment (p = 0.048). It enhanced secondary peristalsis during rapid air distensions (p = 0.003) but not during slow air distension (p = 0.23). Saline infusion significantly increased DCI of secondary peristalsis during rapid air distension (p = 0.01). Augmentation of distension-induced secondary peristalsis can be modulated by activation of capsaicin-sensitive afferents similar to mechanosensitive afferents. Capsaicin-induced augmentation of primary peristalsis isolates to the cholinergic-mediated proximal smooth muscle segment, which warrants study in ineffective esophageal motility to determine therapeutic potential.