Esophageal Motility Research Articles

Hood-attached versus conventional triangular tip-jet knife in peroral endoscopic myotomy: a propensity score matching cohort study

Peroral endoscopic myotomy (POEM) is a safe and effective endoscopic treatment for achalasia and other esophageal motility disorders, and a versatile knife (TriangleTipKnife J [TTJ]; Olympus, Tokyo, Japan) is currently widely used in POEM. Recently, we reported a novel modification of TTJ, which was adjusted to a knife length of 2mm by attaching a disposable clip (QuickClip Pro; Olympus) sheath to the tip as a hood attachment. This study compares the safety and effectiveness of TTJ and TTJ with a hood attachment (TTJ-H) in POEM. This 1:1 propensity score-matched retrospective cohort study compared the procedure time, myotomy efficiency, number of coagulation forceps usage, adverse events, length of hospital stay after POEM, procedural success, and clinical success between the TTJ and TTJ-H groups. A total of 682 consecutive patients who underwent POEM between January 2021 and June 2023 were examined. We excluded 134 patients who had already undergone POEM or laparoscopic Heller myotomy as prior myotomy. Finally, 98 propensity score-matched pairs (n= 196) were identified. The mean procedure time was shortened from 93.5 minutes to 80.2 minutes (14% reduction, P= .012) when comparing the TTJ-H group versus the TTJ group. The mean myotomy efficiency was improved from 2.76 min/cm to 2.32 min/cm (16% improvement, P≤ .001), and usage of coagulation forceps for hemostasis was decreased from 3.87 to .55 (86% reduction, P≤ .001). This study showed that use of TTJ-H could reduce total procedure time, improve myotomy efficiency, and reduce costs compared with TTJ.

Anesthesia choice and its potential impact on endoluminal functional lumen imaging probe measurements in esophageal motility disorders

The widespread use of peroral endoscopic myotomy (POEM) has revolutionized the management of esophageal motility disorders (EMDs). The introduction of an endoluminal functional lumen imaging probe (EndoFLIP, Medtronic, Dublin, Ireland) can serve as a complementary diagnostic tool to assess the mechanical properties (ie, pressure, diameter, distensibility, topography) of the esophagus. During EndoFLIP measurements, different anesthesia techniques may induce variable degrees of neuromuscular blockade, potentially affecting esophageal motility and altering the results of EndoFLIP metrics. The aim of this study was to compare the impact of using total intravenous anesthesia (TIVA) versus general anesthesia with inhalational anesthetics (GAIA) on diagnostic EndoFLIP measurements. This retrospective study included all adult patients (≥18 years) undergoing EndoFlip during the POEM procedure at our institution between February 2017 and February 2022. Differences in pressure, diameter, and distensibility index were obtained by using propofol-based TIVA versus sevoflurane-based GAIA with a 30 mL and a 60 mL balloon. The differences were divided into terciles and compared between diagnoses by using univariate comparisons and logistic regression models. A total of 49 patients were included (39% type I achalasia, 43% type II or III achalasia, and 18% jackhammer esophagus [JE]). Compared with spastic disorders (types II and III achalasia and JE), type I had lower values of pressure differences at 60 mL in univariate (3.75 vs 15.20, P= .001) and multivariate (adjusted odds ratio, .89; 95% confidence interval, .82-.978) analyses. Compared with type I, types II and III achalasia had higher rates of pressure differences at 60 mL in the univariate (9.85 vs 3.75, P= .04) analysis and nearly reached significance in the multivariate analysis (1.09; 95% confidence interval, 1-1.20). Compared with type I achalasia, JE exhibited higher values in pressure differences at 60 mL (27.7 vs 3.75, P< .001). Esophageal pressure, as measured by EndoFLIP, was significantly reduced when patients were sedated with sevoflurane-based GAIA. The use of sevoflurane-based GAIA for diagnostic EndoFLIP may potentially lead to the misclassification of spastic disorders as type I achalasia. Propofol-based TIVA should therefore be considered over sevoflurane-based GAIA for sedation during the diagnostic test.

The Effect of STW5 (Iberogast) on Reflux Symptoms in Patients With Concurrent Dyspeptic Symptoms: A Double-blind Randomized Placebo-controlled Crossover Trial.

It has been suggested that STW5 (Iberogast) reduces heartburn symptoms in patients with functional dyspepsia, but underlying mechanisms of action are unclear. The aim of this study is to investigate whether STW5 affects esophageal sensitivity or esophageal motility, thereby reducing occurrence and perception of reflux events. We performed a double-blind, randomized, placebo-controlled, crossover trial in patients with functional dyspepsia (Rome IV) and reflux symptoms. After 4 weeks of treatment with either placebo or STW5, patients were studied with an esophageal acid perfusion test and ambulatory 24-hour pH-impedance monitoring. A total of 18 patients (7 men, median age 54, range [19-76]), were included in the study. Although we found no statistical difference in our primary outcome the total Reflux Disease Questionnaire score 2.33 (0.25-4.33) vs 2.67 (1.17-4.00), P = 0.347, "gastroesophageal reflux disease" and "regurgitation" subscale scores were lower after STW5 treatment compared to placebo (P = 0.049 and P = 0.007). There was no statistical difference in number of reflux events, acid exposure time and acid sensitivity scores between STW5 and placebo. In a subgroup analysis of patients with pH-metry confirmed gastroesophageal reflux disease, treatment with STW5 significantly reduced the total number of acidic reflux events (P = 0.028). Moreover, in patients with reflux esophagitis, the median lag time to acid perception increased after STW5 treatment (P = 0.042). We found some indications pointing towards a beneficial effect of STW5 on reflux symptoms in dyspeptic patients, with reduction of esophageal hypersensitivity as a potential underlying mechanism. Our findings will have to be confirmed in larger studies.

Сучасне розуміння етіопатогенезу гастроезофагеальної рефлюксної хвороби: висвітлення ключових аспектів та перспектив

Gastroesophageal reflux disease (GERD) is one of the most common diseases among gastroenterological pathologies. The relevance of GERD is due not only to medical aspects, but also to economic ones, since the vast majority of patients are young working-age people. The prevalence of GERD ranges from 20% to 30% of the adult population. GERD is associated with a significant decrease in quality of life and the development of Baretta’s esophagus and esophageal adenocarcinoma. GERD is a chronic disease with spontaneous repetitive spillage of gastric or duodenal-gastric contents into the esophagus, with typical complaints of heartburn and regurgitation. The pathogenesis is complex and includes the following aspects: decreased tone of the lower esophageal sphincter, diaphragmatic hernia, impaired protective function of the esophageal mucosa and esophageal motility, and increased intra-abdominal pressure. Obesity plays a significant pathogenetic role in the development of GERD. Weight loss is associated with symptom relief and a reduced risk of complications. Diagnosis of GERD is based primarily on typical clinical symptoms and empirical trial therapy with PPI. Treatment includes lifestyle changes, medications, and surgery. Еndoscopy and pH monitoring additionally contribute to the correct diagnosis. Further research on pathogenetic mechanisms is needed to implement effective strategies for diagnosis, treatment and prevention of complications.

Esophageal biomechanics assessed by impedance planimetry (EndoFLIPTM) in healthy subjects and in patients with eosinophilic esophagitis. Normality values.

active eosinophilic esophagitis is associated with esophageal caliber, distensibility and motility changes that may be reversed with treatment. to study esophageal diameter, distensibility and contractility in healthy subjects compared to patients with eosinophilic esophagitis, both before and after treatment. a quasi-experimental study, EndoFLIP™, was used to analyze the esophageal body and esophago-gastric junction (EGJ) in all three groups, and a program was designed to obtain esophageal diameter, distensibility and contractility values. ten healthy volunteers (24-61 years, six men) and nine patients with eosinophilic esophagitis (21-52 years, seven men) were included. The esophagogastric junction distensibility index was 5.07 mm2/Hg in the control subjects, 2.40 mm2/Hg in the subjects with eosinophilic esophagitis before treatment and 2.46 mm2/Hg after treatment. The distensibility plateau was 20.02 mm, 15.43 mm and 17.41 mm, respectively, and the diameter was 21.90 mm, 17.73 mm and 18.30 mm, showing significant differences (p < 0.05), except between control subjects and patients after treatment (p = 0.079). Repetitive antegrade contractions developed in 90 % of control subjects, 66.7 % of eosinophilic esophagitis patients before treatment and 88.9 % of the latter after treatment (p > 0.05). esophago-gastric junction distensibility index, distensibility plateau and diameter values were higher in controls than in patients, although six weeks of treatment seems a short period to observe significant changes in esophageal biomechanics. Repetitive antegrade contractions are the predominant pattern in healthy subjects and eosinophilic esophagitis. We provide normality values for esophageal biomechanics, measured by impedance planimetry in our setting.

Achalasia phenotypes and prediction of peroral endoscopic myotomy outcomes using machine learning.

High-resolution manometry (HRM) and esophagography are used for achalasia diagnosis; however, achalasia phenotypes combining esophageal motility and morphology are unknown. Moreover, predicting treatment outcomes of peroral endoscopic myotomy (POEM) in treatment-naïve patients remains an unmet need. In this multicenter cohort study, we included 1824 treatment-naïve patients diagnosed with achalasia. In total, 1778 patients underwent POEM. Clustering by machine learning was conducted to identify achalasia phenotypes using patients' demographic data, including age, sex, disease duration, body mass index, and HRM/esophagography findings. Machine learning models were developed to predict persistent symptoms (Eckardt score ≥3) and reflux esophagitis (RE) (Los Angeles grades A-D) after POEM. Machine learning identified three achalasia phenotypes: phenotype 1, type I achalasia with a dilated esophagus (n = 676; 37.0%); phenotype 2, type II achalasia with a dilated esophagus (n = 203; 11.1%); and phenotype 3, late-onset type I-III achalasia with a nondilated esophagus (n = 619, 33.9%). Types I and II achalasia in phenotypes 1 and 2 exhibited different clinical characteristics from those in phenotype 3, implying different pathophysiologies within the same HRM diagnosis. A predictive model for persistent symptoms exhibited an area under the curve of 0.70. Pre-POEM Eckardt score ≥6 was the greatest contributing factor for persistent symptoms. The area under the curve for post-POEM RE was 0.61. Achalasia phenotypes combining esophageal motility and morphology indicated multiple disease pathophysiologies. Machine learning helped develop an optimal risk stratification model for persistent symptoms with novel insights into treatment resistance factors.

STRICTURE AND MEGAESOPHAGEAL IN LOCAL CATS

The esophagus is part of the digestive system which is between the oropharynx and the stomach of the animal. The condition characterized by reduced or absent esophageal motility is called megaesophagus. Megaesophagus causes accumulation of ingesta, dilatation of the esophageal lumen, and regurgitation of feed (which is often mistaken for vomiting by cat owners). The aim of this study was to treat a female cat, 9 months old, weighing 3.2 kg was diagnosed with stricture and megaesophagus. The cat was brought in with vomiting several times after eating since seven days after the ovariohysterectomy surgery. Clinical examination showed that the cat experienced regurgitation and increased respiratory rate. Supporting examinations such as a complete hematological examination were carried out with the result leukocytosis. Radiographic examination in the form of x-rays show that there is stricture and dilatation in the esophageal area. Cats are handled by feeding them with an upright position for about 20-30 minutes. Treatment is by administering the antibiotic cefotaxime sodium (Cefotaxim sodium®, PT. Dankos Farma, Jakarta, Indonesia) intravenously at a dose of 20 mg/kg IV two times a day, administering the anti-inflammatory drug Dexamethasone at a dose of 0.125 mg/kg by injection, administering antiemetic drugs Ondansetron 0.2 mg/kgBW intravenously and Ranitidine HCl at a dose of 2 mg/kgBW intravenously. The cat's condition did not show any improvement during the treatment which was carried out after 7 days, therefore it was decided that euthanasia would be the best choice.

OGBN O06 Enhancing Surgical Decision-Making with High-Resolution Manometry and Distal Contractile Integral in Preoperative Assessment for Magnetic Sphincter Augmentation (LINX)

Abstract Background Preoperative assessment for magnetic sphincter augmentation (MSA) (LINX) involves evaluating the Mean Distal Amplitude (MDA) on conventional manometry to assess the patient suitability and risk of post-operative dysphagia. In the last decade high-resolution manometry (HRM) has superseded conventional manometry owing to obtaining more clinical information on the oesophageal motility, including the Distal Contractile Integral (DCI) that incorporates contractile amplitude, duration and contractility propagation length within the oesophageal body. The purpose of this study is to translate the MDA to modern DCI as preoperative marker to MSA. Methods This retrospective study includes patients referred to oesophageal laboratory at Guy’s Hospital between March and May 2023. Patients underwent HRM with ten 5ml water swallows that provided manometric information to compute mean DCI and MDA (MDA waveforms at 11cm, 7cm and 3cm above the GOJ were used). Statistical analysis investigated the relationship between MDA and mean DCI using Pearson correlation, Student t-test, ROC curve analysis and relevant metrics assess the cut-off threshold accuracy and reliability in classifying normal MDA. Results 270 patients were included in the study (female:male=190:80 males, mean age 52.1 years). There was strong direct correlation between MDA and mean DCI (r=0.71, p&amp;lt;0.0001) (Figure 1). Patients with normal MDA had a significantly higher mean DCI compared with weak MDA at 11cm (601mmHgscm vs 167.15mmHgscm, p&amp;lt;0.0001) 7cm (286.4mmHgscm vs 741mmHgscm, p&amp;lt;0.001), 3cm (592mmHgscm vs 192.6mmHgscm, p&amp;lt;0.0001) and overall MDA (714.2mmHgscm vs 259mmHgscm, p&amp;lt;0.001) (Figure 2). ROC curve analysis revealed the mean DCI thresholds for normal MDA to be 615mmHgscm at 11cm, 419mmHgscm at 7cm, 318mmHgscm at 3cm and 453mmHgscm for the overall MDA (Table 1). Conclusions The findings of this study show HRM and the clinical measurement DCI may be a suitable preoperative assessment for MSA. This translation of MDA to modernisation in manometry may assist surgeons adopt DCI which is regarded as more robust assessment that offers more detailed clinical information of the oesophageal motility health and disorder.

OGBN P36 Surgical Consideration in Patients with Ineffective Oesophagus: Implications for Low Risk of Dysphagia and Suitability for Antireflux Operation

Abstract Background Ineffective oesophageal motility (IOM) is a minor motility disorder that is commonly found in patients. The IOM diagnosis is based on heterogenous combination of failed peristalsis, weak peristalsis activity and peristaltic defects that are observed during the stimulation to 5mL standard water swallows. IOM is implicated to post-surgical dysphagia and therefore influences the surgical decision making. This paper will address this topic. Methods A retrospective review was conducted on patients who underwent oesophageal high-resolution manometry (HRM) between March and May 2023. The diagnosis of IOM was based on the international Chicago Classification guideline (version 4.0). Patients' oesophageal motility profiles were assessed for peristaltic reservation (PR) and oesophageal contractile mean wave amplitude (MWA). PR &amp;gt;100% in IOM patients indicates low risk of dysphagia after laparoscopic Nissen fundoplication (LNF). Similarly, normal MWA indicate a low risk of dysphagia in considering patients for Magnetic Sphincter Augmentation (MSA). Results 120/270 patients (44.4%) were diagnosed with IOM (female:male=86:34, median age 52 years old). Mean PR in IOM patients was 217.8% [95%CI:181.2%-254.4%] with 60.8% demonstrating PR &amp;gt;100%. Average MWA found in IOM patients was 40.8mmHg (95%CI:38.5mmHg-43.1mmHg) with 38.3% demonstrating normal MWA. 13.3% (16/120) of patients did not invoke peristalsis on MWS, but 6 of the 16 patients showed normal MWA. 24.2% (29/120) patients demonstrated PR &amp;gt;100% and normal MWA. 14.2% (17/120) of patients showed adequate PR and weak MWA and pose risk of postsurgical dysphagia. 75% (90/120) of patients with IOM were suitable for at least one antireflux operation. Conclusions Approximately half of the oesophageal physiology patients have IOM and three-quarters of these patients are suitable for at least one form surgical intervention with low risk postsurgical dysphagia. Only 14.2% of patients with IOM pose a risk of post-surgical dysphagia. The overall findings suggests that surgical intervention may be a viable option for patients with IOM that could potentially improve their quality of life and prevent reflux oesophagitis/pre-cancerous Barrett’s oesophagus. This study was limited by not investigating the relationship between IOM pathophysiology and the reflux oesophagitis severity grade.

OGBN P46 Megaoesophagus in a patient with achalasia treated with laparoscopic Heller cardiomyotomy

Abstract Background Achalasia is an oesophageal motility disorder that is a rare but important differential diagnosis in patients with dysphagia. Surgical treatment with laparoscopic Heller myotomy (LHM) and fundoplication is the gold standard; other options include peroral endoscopic myotomy (POEM), dilatation in cases that are unsuitable for surgery, and esophagectomy as a last resort. Methods We describe a case reported at our institution and the relevant workup, findings and management. Results A 41-year-old woman presented with persistent cough and shortness of breath on exertion. Chest x-ray showed right basal consolidation and a dense structure along the right mediastinum. CT revealed megaoesophagus with an oesophageal diameter of 7cm. Detailed history revealed long-standing history of progressive dysphagia and acid reflux and more recent history of weight loss, retrosternal pain and shortness of breath when eating solid foods. Workup included gastroscopy, oesophageal manometry and Chagas disease testing due to potential exposure to T. cruzi. A diagnosis of idiopathic achalasia was made, and she underwent laparoscopic Heller’s cardiomyotomy and Dor fundoplication. Conclusions Achalasia is an important differential in patients presenting with symptoms of dysphagia. This case reveals an atypical presentation of the disorder, suggesting a need to consider it in a wider range of presentations. Successful treatment of achalasia depends on timely diagnosis prior to oesophageal failure when it is still possible to intervene effectively.

OGBN P30 Post-operative and symptomatic outcomes following Laparoscopic Hellers Cardiomyotomy- single centre experience

Abstract Background Esophageal achalasia represents a uncommon primary oesophageal motility disorder secondary to loss of inhibitory neurons in the oesophageal myenteric plexus level. The main goal of treating oesophageal achalasia is to relieve dysphagia secondary to the functional obstruction of the distal oesophagus by the inability of the Lower Oesophageal Sphincter (LOS) to relax appropriately after deglutition. The Eckardt score (ES) was developed to objectively assess the symptom severity and continues to be widely used. Aim of this study was to assess the post-operative outcomes and symptomatic improvement using ES in consecutive patients undergoing laparoscopic Hellers cardiomyotomy for achalasia in our unit. Methods Data of consecutive patients who underwent LHCM between January 2016 and December 2021 was collected. Patient demographics, surgical details, perioperative course, ES, and manometric data including Integrated Relaxation Pressure (IRP), were retrieved from a prospectively maintained database. Primary outcomes assessed were peri-operative morbidity assessed using Clavien-Dindo grade. Secondary outcomes assessed were improvement in symptoms using ES (pre- and post-operative). ES of ≤3 was considered as symptomatic improvement. Data was analysed using Microsoft Excel. Comparison of pre-operative and post-operative means was performed using paired t test. Fishers exact test was used for categorical variables. A p-value &amp;lt;0.05 was considered statistically significant. Results 41 patients underwent LHCM. Twenty-one were males. Median age was 56 years (20-77). 95.12% patients had dysphagia for a median duration of 24 months (2-180). Type II achalasia was most common in 87.80%. Median IRP was 22.3 mm Hg (11-78). Oesophageal dilation was performed in 2 while, 10 patients received botulin injection pre-operatively. Median hospital stay was 1 day (1-12). 92.68% had no post operative complications. None of the patients had significant complications (Clavien-Dindo &amp;gt;grade 2). At a median follow-up of 60 months, there was significant improvement in ES 8±1.97 to 1.82±1.16, p&amp;lt;0.001 and dysphagia score (p&amp;lt;0.001). Conclusions LHCM with fundoplication leads to significant symptomatic improvement with excellent short and medium term outcomes with low morbidity and complication rates. A detailed pre-operative discussion with patients is essential to provide tailored treatment as per individual patient symptoms.

Single-center experience of transitioning from video-assisted laparoscopic to robotic Heller myotomy with Dor fundoplication for esophageal motility disorders

BackgroundVideo-assisted laparoscopic Heller myotomy (LHM) has become the standard treatment option for achalasia. While robotic surgery offering some specific advantages such as better three-dimensional (3D) stereoscopic vision, hand-eye consistency, and flexibility and stability with the endowrist is expected to be shorter in learning curve than that of LHM for surgeons who are proficient in LHM. The aim of this study was to describe a single surgeon’s experience related to the transition from video-assisted laparoscopic to robotic Heller myotomy with Dor fundoplication.MethodsWe conducted a retrospective observational study based on the recorded data of the first 66 Heller myotomy performed with laparoscopic Heller myotomy with Dor fundoplication (LHMD, 26 cases) and with the robotic Heller myotomy with Dor fundoplication (RHMD, 40 cases) by the same surgeon in Department of Thoracic Surgery of The First Affiliated Hospital of Nanchang University in China. The operation time and intraoperative blood loss were analyzed using the cumulative sum (CUSUM) method. Corresponding statistical tests were used to compare outcomes of both serials of cases.ResultsThe median operation time was shorter in the RHMD group compared to the LHMD group (130 [IQR 123–141] minutes vs. 163 [IQR 153–169]) minutes, p < 0.001). In the RHMD group, one patient (2.5%) experienced mucosal perforation, whereas, in the LHMD group, the incidence of this complication was significantly higher at 19.2% (5 patients) (p = 0.031). Based on cumulative sum analyses, operation time decreased starting with case 20 in the LHMD group and with case 18 in the RHMD group. Intraoperative blood loss tended to decline starting with case 19 in the LHMD group and with case 16 in the RHMD group.ConclusionsBoth RHMD and LHMD are effective surgical procedures for symptom relief of achalasia patients. RHMD demonstrates superior outcomes in terms of operation time and mucosal perforation during surgery compared to LHMD. Proficiency with RHMD can be achieved after approximately 16–18 cases, while that of LHMD can be obtained after around 19–20 cases.

Association between time from esophageal food impaction to endoscopy and adverse events

Guidelines recommend emergent or urgent EGD for esophageal food impaction (EFI), but data on how time to EGD impacts the risk of adverse events remain limited. We determined whether EFI-to-EGD time was associated with adverse events. In this retrospective cohort study of patients with endoscopically confirmed EFI, adverse events were classified as esophageal (mucosal tear, bleeding, perforation) or extraesophageal (aspiration, respiratory compromise, hypotension, arrhythmia). Esophageal perforation and extraesophageal adverse events requiring intensive care unit admission were classified as serious adverse events. Baseline characteristics, event details, and procedural details were compared between patients with and without adverse events. Multivariable logistic regression was performed to assess for an association between EFI-to-EGD time and adverse events. Of 188 patients with EFI, 22 (12%) had any adverse event and 2 (1%) had a serious adverse event. Patients with adverse events were older and more likely to have an esophageal motility disorder, to tolerate secretions at presentation, and to have a higher American Society of Anesthesiologists score. EFI-to-EGD time was similar in those with and without adverse events. On multivariable analysis, EFI-to-EGD time was not associated with adverse events (odds ratio, 1.00 [95% confidence interval, .97-1.04] for 1-hour increments; odds ratio, 1.03 [95% confidence interval, .86-1.24] for 6-hour increments). Results were similar after stratifying by eosinophilic esophagitis status and after adjusting for possible confounders. Because the time from EFI to EGD is not associated with adverse events, emergent EGD for EFI may be unnecessary, and other considerations may determine EGD timing.

Chicago Classification Version 4.0 Improves Stratification of Ineffective Esophageal Motility Patients into Clinically Meaningful Subtypes: A Two-Center International Study.

The 4th iteration of the Chicago Classification (CC v4.0) for esophageal motility disorders offers more restrictive criteria for the diagnosis of Ineffective Esophageal Motility (IEM) compared to version 3.0 (CC v3.0). In light of the updated criteria for IEM, we aimed to characterize and compare the patients who retained their IEM diagnosis to those who were reclassified as normal motility, and to evaluate the clinical impact of the newly introduced CC v4.0. We performed a retrospective case-control study. We included all individuals who underwent a high-resolution manometry (HRM) between 2020 and 2021 at two centers. Consecutive studies reported as IEM according to the CC v3.0 were reanalyzed according to the CC v4.0. We compared demographics, clinical, manometry, and pH-monitoring parameters. Out of 452 manometry studies, 154 (34%) met criteria for IEM as per the CC v3.0 (CC v3.0 IEM group). Of those, 39 (25%) studies were reclassified as normal studies according to the CC v4.0 (CC v4.0 normal group), while the remaining 115 studies (25% of the overall cohort) retained an IEM diagnosis (CC v4.0 IEM group). The CC v4.0 normal group had more recovered contractions during solid swallows (p = 0.01), less ineffective swallows (p = 0.04), and lower acid exposure time (p = 0.02) compared to the CC4.0 IEM group. Under CC v4.0 criteria, fewer patients are diagnosed with IEM. Those diagnosed with IEM had worse esophageal function and higher acid burden. Though further studies are needed to confirm these findings, our results indicate that CC v4.0 criteria restrict the IEM diagnosis to a more clinically meaningful population.

Contraction reserve in high resolution manometry is correlated with lower esophageal acid exposure time in patients with normal esophageal motility: A retrospective observational study.

In high resolution manometry (HRM), distal contractile integral post multiple rapid swallow augmentation is considered as contraction reserve. The relationship between contraction reserve and esophageal acid reflux remains unclear. The aim of this study was to explore the correlation between contraction reserve and esophageal acid exposure in ineffective esophageal motility (IEM) and normal HRM. Patients who underwent HRM and ambulatory reflux monitoring were retrospectively screened. Those with diagnosis of normal HRM or IEM were included in the analysis. The proportion of patients with abnormal acid exposure time (AET) was compared between patients with and without contraction reserve. Multivariate regression analysis was performed to determine the predictors of abnormal AET and contraction reserve. A total of 338 patients, including 264 normal HRM and 74 IEM, were included in the analysis. In patients with normal HRM, proportion of abnormal total AET (AET > 6.0%) was significantly lower in patients with supine contraction reserve than patients without contraction reserve (13.85% vs. 24.63%, p = 0.027). Multivariate regression analysis showed that supine contraction reserve could independently predict abnormal total AET (OR = 0.468, 95% CI: 0.249-0.948, p = 0.034), while upright contraction reserve trended strongly (OR = 0.558, 95% CI: 0.290-1.071, p = 0.079). Subgroup analysis showed that upright contraction reserve was an independent predictor of abnormal total AET in patients with 50-70% infective swallows (OR = 0.205, 95% CI: 0.051-0.821, p = 0.025), whereas supine contraction reserve did not have predictive value (p = 0.359). Supine contraction reserve correlates with esophageal acid reflux in patients with normal HRM, while only upright contraction reserve correlates with esophageal acid reflux in patients with infective swallows of 50-70%.

Clinical and functional characteristics, possible causes, and impact of chronic cough in patients with cerebellar ataxia, neuropathy, and bilateral vestibular areflexia syndrome (CANVAS)

Cerebellar ataxia with neuropathy and bilateral vestibular areflexia syndrome (CANVAS) is an hereditary autosomal recessive disease. Recent studies propose including chronic cough (CC) as a symptom of CANVAS. For 10 patients with CANVAS as genetically confirmed by biallelic expansion of the AAGG repeat motif (AAGGGexp) in intron 2 of replication factor C subunit 1 (RFC1), our aim was, as a multidisciplinary team, to describe clinical and functional characteristics and possible causes of CC following European Respiratory Society (ERS) recommendations, and to evaluate CC impact on quality of life (QoL) using self-administered questionnaires (Cough Severity Diary, Leicester Cough Questionnaire, Discrete Emotions Questionnaire, and EQ-5D-5L). In all 10 patients, the CC was a dry cough that developed several years prior to the neurological symptoms (mean 14.2 years); 7 patients had symptoms compatible with gastroesophageal reflux (GER), 5 with pathological GER diagnosed by 24-h esophageal pH testing, and 6 patients had impaired esophageal motility diagnosed by high-resolution esophageal manometry, most frequently ineffective peristalsis. Although further studies are required for confirmation, we conclude that CC may be a characteristic prodrome of CANVAS and may be related to GER and esophageal disorders. Furthermore, CC affects patients’ QoL, especially in the psychosocial sphere.

&lt;i&gt;Achalasia cardia&lt;/i&gt;: An uncommon cause of aspiration syndrome in infancy

Achalasia is a primary oesophageal motility disorder characterized by the absence of Oesophageal peristalsis and impaired lower oesophageal sphincter (LES) relaxation in response to swallowing leading to functional obstruction at the gastroesophageal CC –BY 4.0 junction. It is unusual in childhood and extremely rare in infants. We report a case of Achalasia cardia in a twomonth bold infant treated with anterior oesophago-cardio- gastromyo to my ( Modified Heller’s procedure).

Optimizing the Management Algorithm for Esophageal Dysphagia After Index Endoscopy: Cost-Effectiveness and Cost-Minimization Analysis.

Guidelines advise esophageal motility testing for dysphagia when structural disorders are ruled out, but cost concerns impede adoption. We evaluated cost-effective positioning of esophageal motility testing in the algorithm to evaluate esophageal dysphagia. We developed a decision analytic model comparing 3 strategies: (i) esophageal manometry, (ii) screening impedance planimetry followed by esophageal manometry if needed, or (iii) nonalgorithmic usual care. Diagnostic test accuracy was adapted to expected rates of esophageal motility disorders in general gastroenterology populations. We modeled routine testing for all patients with nonstructural/mechanical dysphagia compared with selective testing with strong suspicion for achalasia. Cost outcomes were defined on national commercial and Medicare datasets stratified on age and sex. Health outcomes were modeled on populations with achalasia. The time horizon was 1 year. Motility testing was preferred over nonalgorithmic usual care due to cost savings rather than health gains. To commercial insurers, routine esophageal manometry for nonstructural/mechanical dysphagia would be cost-saving below a reimbursed cost of $2,415. Screening impedance planimetry would be cost saving below a reimbursed cost of $1,130. The limit for reimbursed costs would be lower for patients older than 65 years to achieve cost savings mainly due to insurance. Sex did not significantly influence cost-effectiveness. Patients and insurers preferred routine screening impedance planimetry before manometry when the index of suspicion for achalasia was below 6%. Aligning with practice guidelines, routine esophageal motility testing seems cost saving to patients and insurers compared with nonalgorithmic usual care to evaluate nonstructural/mechanical dysphagia. Choice of testing should be guided by index of suspicion.

Composite score of physiomechanical esophageal function using functional lumen imaging probe panometry in eosinophilic esophagitis

Background and AimsThe evaluation provided by functional lumen imaging probe (FLIP) Panometry includes esophageal distensibility/compliance (mechanics) of the esophageal body and esophagogastric junction (EGJ) and esophageal motility (secondary peristalsis). We aimed to develop a composite score using these parameters to characterize physiomechanical function in patients with eosinophilic esophagitis (EoE). Methods215 adult patients with EoE that completed FLIP Panometry during sedated endoscopy with esophageal biopsies were included. FLIP metrics of esophageal body Compliance, Contractile response, Distensibility plateau, and maximum EGJ Diameter (C2D2) were scored as 0 for normal, vs 1 or 2 for increasing degree of abnormality. Scores were summed to calculate the composite “C2D2” score. ResultsThe C2D2 score had a significant positive correlation with mucosal eosinophil count (rho=0.241) and total endoscopic (EREFS) score (rho=0.467). Among patients off treatment at baseline evaluation (n=46), future proton pump inhibitor (PPI)-responders (i.e. achieved mucosal eosinophil count <15 per hpf after PPI treatment) had lower C2D2 scores than PPI-non-responders (median (IQR) 2 (1-3) vs 4 (2-6); P=0.003). A regression model (that controlled for age, sex, and baseline eosinophil count) showed a C2D2 score ≤3 had an odds ratio (95% confidence interval) of 14.5 (2.6-85) to predict future PPI-response. However, total EREFS scores (P=0.142) and baseline eosinophil count (P=0.480) did not differ between PPI-responders and PPI-non-responders. ConclusionsThis composite score of FLIP Panometry metrics, the C2D2 score, may facilitate characterizing physiomechanical function in EoE and serve as an objective outcome measure.

Surgery for multiple gastric gastrointestinal stromal tumors and large esophageal diverticulum related to germline mutation of the KIT gene: a case report

BackgroundFamilial gastrointestinal stromal tumors (GISTs) are mesenchymal tumors of the digestive tract caused by germline gain-of-function mutations in the KIT gene or platelet-derived growth factor receptor alpha gene (PDGFRA). These mutations cause not only multiple GISTs but also diffuse hyperplasia of interstitial cells of Cajal (ICCs), which is related to esophageal motility disorder.Case presentationA 53-year-old man was referred to our hospital because of anemia and dysphagia. Fifteen years earlier, he had undergone a laparoscopic partial gastrectomy for multiple gastric GISTs with a germline mutation in exon 17 of the KIT gene. An upper gastrointestinal endoscopy revealed that the patient had multiple gastric GISTs and a large esophageal diverticulum directly above the esophagogastric junction. The largest gastric tumor was 7 cm, with a delle that might cause bleeding. Because the patient presented with dysphagia, we performed video-assisted thoracic esophagectomy and laparoscopic-assisted proximal gastrectomy simultaneously. The patient had survived without metastasis for 4 years after surgery and dysphagia had improved.ConclusionsThis is the first report of successful laparoscopic–thoracoscopic surgery for a patient with familial gastric GISTs accompanied with a large esophageal diverticulum.