Segment Of Esophagus Research Articles

Analysis of non-obstructive dysphagia with esophageal high-resolution manometry

Objective To analyze the distribution and esophageal motility characteristics of patients with non obstructive dysphagia (NOD).Methods From June 2010 to June 2012,ninety seven patients with a sense of obstruction when swallowing were selected and patients with esophageal organic stenosis was excluded through endoscopic examination and upper gastrointestinal radiography.While nine healthy volunteers were recruited as healthy control.High-resolution esophageal manometry was performed with high-resolution multi-channel Netherlands CTD Synectics gastrointestinal function monitoring system (Pcpolygraf polysomnography recording system) and MMS digestive power detection system.The observation parameter included upper esophageal sphincter pressure (UESP),upper esophageal sphincter relaxation rate (UESRR),the length of the lower esophageal sphincter (LESL),lower esophageal sphincter pressure (LESP),intergrated relaxation pressure (IRP),lower esophageal sphincter relaxation rate (LESRR),esophageal subordinate segments pressure and esophageal effective peristalsis ratio.The rank sum test was performed for comparison between groups.Results Among 97 patients with NOD,the percentage of achalasia,nonspecific esophageal motor disorder andgastroesophageal reflux disease (GERD) was 41.2％ (40/97),39.2％ (38/97)and 19.6％(19/97),respectively.Among patients with nonspecific esophageal motor disorder,the percentage of abnormal peristalsis,absent peristalsis,normal pressure and distal esophegesl spasm was 39.5％(15/38),36.8％(14/38),15.8％(6/38) and 7.9％(3/38),respectively.The differences in lESL,LESP,LESRR,esophageal subordinate segments pressure and esophageal effective peristalsis ratio among achalasia,GERD,nonspecific esophageal motor disorder and healthy control were statistically significant (F 6.143,57.490,50.559,10.155 and 22.046,all P＜0.05).LESP oF patients with achalasia was higher than that of healthy control,however LESRR,esophageal subordinate segments pressure and esophageal effective peristalsis ratio were all lower than those of healthy control and the differences were statistically significant (F 2.276,11.113,-8.036 and -14.663,all P＜0.05).LESL and LESP of achalasia were both higher than those of GERD group,LESRR,esophageal subordinate segments pressure and esophageal effective peristalsis ratio were all lower than those of GERD group and the differences were statistically significant (F=4.325,15.983,-19.235,-3.410 and-4.351,all P＜0.05).LESL and LESP of achalasia group both were higher than those of nonspecific esophageal motor disorder group,LESRR and esophageal effective peristalsis ratio were both lower than those of GERD group and the differences were statistically significant (F=2.376,7.668,2.873 and-3.873,all P＜0.05).LESRR of GERDgroup was higher than that of healthy control group,LESL,LESP,esophageal subordinate segments pressure and esophageal effective peristalsis ratio were all lower than those of healthy control group and the differences were statistically significant (F=5.931,-2.483,-14.618,-3.071 and-4.516,all P＜0.05).LESL and LESP of GERD group were both lower than those of nonspecific esophageal motor disorder group,LESRR was higher than that of nonspecific esophageal motor disorder group and the differences were statistically significant (F =--2.113,6.578 and 10.979,all P ＜ 0.05).LESP,LESRR,esophageal subordinate segments pressure and esophageal effective peristalsis ratio of nonspecific esophageal motor disorder group were all lower than those of healthy control group and the differences were statistically significant (F=-6.313,-3.580,-3.511 and-8.150,all P＜0.05).IRP of 40 patients with achalasia were all beyond the normal range.Conclusions NOD mainly included achalasia,nonspecific esophageal motor disorder and GERD.The reduction of effective esophageal peristalsis may be an important pathophysiological mechanism of NOD. Key words: Manometry; Deglutition disorders; Esophageal achalasia; Gastroesophageal reflux

Preliminary results of antiscarring therapy in the prevention of postendoscopic esophageal mucosectomy strictures

Esophageal endoscopic submucosal dissection (ESD) is an effective minimally invasive therapy for early esophageal cancer and high-grade Barrett dysplasia. However, esophageal stricture formation after circumferential or large ESD has limited its wide adoption. Mitomycin C(MMC), halofuginone (Hal), and transforming growth factor β3 (TGF-β3) exhibits antiscarring effects that may prevent post-ESD stricture formation. Using endoscopic mucosectomy (EEM) technique, an 8- to 10-cm-long circumferential esophageal mucosal segment was excised in a porcine model. The site was either untreated (control, n=6) or received 40 evenly distributed injections of antiscarring agent immediately and at weeks 1 and 2. High and low doses were used: MMC 5mg (n=2), 0.5mg (n=2); Hal 5mg (n=2), 1.5mg (n=2), 0.5mg (n=2); TGF-β3 2μg (n=2), 0.5μg (n=2). The degree of stricture formation was determined by the percentage reduction of the esophageal lumen on weekly fluoroscopic examination. Animals were euthanized when strictures exceeded 80% or the animals were unable to maintain weight. The control group had a luminal diameter reduction of 78.2±10.9% by 2weeks and were euthanized by week 3. Compared at 2weeks, the Hal group showed a decrease in mean stricture formation (68.4% low dose, 57.7% high dose), while both TGF-β3 dosage groups showed no significant change (65.3% low dose, 76.2% high dose). MMC was most effective in stricture prevention (53.6% low dose, 35% high dose). Of concern, the esophageal wall treated with high-dose MMC appeared to be necrotic and eventually led to perforation. In contrast, low dose MMC, TGF-β3 and Hal treated areas appeared re-epithelialized and healthy. Preliminary data on MMC and Hal demonstrated promise in reducing esophageal stricture formationafter EEM. More animal data are needed to perform adequate statistical analysis in order to determine overall efficacy of antiscarring therapy.

Squamous Papilloma of the Esophagus Associated with Barrettʼs Esophagus

Purpose: Squamous papilloma of the esophagus is a rare lesion with a prevalence of less than 0.05%. The clinical relevance is uncertain and its possible relationship with other conditions is unclear. Reports have failed to show an association with the human papilloma virus or to show progression to squamous cell carcinoma. However, there have been cases that have shown a potential endoscopic relationship with esophagitis or a hiatal hernia. We report the first case of squamous papilloma of the esophagus in the setting of Barrett's epithelium. An 80-year-old woman with a long-standing history of esophageal reflux and Barrett's epithelium presented for surveillance upper endoscopy. An upper endoscopy performed 3 years earlier for gastroesophageal reflux revealed erosive esophagitis and a segment of gastric-appearing mucosa extending above the z-line that was suspicious for Barrett's epithelium. Biopsy confirmed Barrett's esophagus without evidence of dysplasia. She was started on a proton pump inhibitor resulting in improvement of her symptoms. Her repeat endoscopy again revealed a 3-cm segment of Barrett's esophagus in the distal esophagus. Surveillance biopsies confirmed Barrett's epithelium without evidence of dysplasia. In addition, a 5-mm, white, fleshy, sessile nodule was found adjacent to the Barrett's segment. On histology, the nodule was identified as a squamous papilloma. The etiology of the squamous papilloma of the esophagus is uncertain. Definitive associations with other conditions have not been established. Our case is particularly interesting because of a potential relationship between squamous papilloma and Barrett's epithelium. The initial upper endoscopy, during which Barrett's epithelium was diagnosed, did not reveal the squamous papilloma. In the 3-year interim between endoscopies, the squamous papilloma developed adjacent to the Barrett's epithelium. Further evaluation of this potential relationship is warranted as squamous papillomas are increasingly identified.

Esophageal Circumferential En Bloc Endoscopic Submucosal Dissection

Endoscopic esophageal piecemeal mucosectomy for high-grade dysplasia on Barrett's esophagus leads to suboptimal histologic evaluation, as well as recurrence on remaining mucosa. Circumferential en bloc mucosal resection would significantly improve the management of dysplastic Barrett's esophagus. Our aim was to describe a new method of esophageal circumferential endoscopic en bloc submucosal dissection (CESD) in a swine model. After submucosal injection, circumferential incision was performed at each end of the esophageal segment to be removed. Mechanical submucosal dissection was performed from the proximal to the distal incision, using a mucosectomy cap over the endoscope. The removed mucosal ring was retrieved. Clinical, endoscopic, and histologic data were prospectively collected. Esophageal CESD was conducted on 5 pigs. A median mucosal length of 6.5 cm (range, 4 to 8 cm) was removed in the lower third of the esophagus. The mean duration of the procedure was 36 minutes (range, 17 to 80 min). No procedure-related complication, including perforation, was observed. All animals exhibited a mild esophageal stricture at day 7, and a severe symptomatic stricture at day 14. Necropsy confirmed endoscopic findings with cicatricial fibrotic strictures. On histologic examination, an inflammatory cell infiltrate, diffuse fibrosis reaching the muscular layer, and incomplete reepithelialization were observed. CESD enables expeditious resection and thorough examination of large segments of esophageal mucosa in safe procedural conditions, but esophageal strictures occur in the majority of the cases. Efficient methods for stricture prevention are needed for this technique to be developed in humans.

Effects of mosapride on esophageal motor activity and esophagogastric junction compliance in healthy volunteers

The effects of the prokinetic drug mosapride on esophageal motor activity vary at standard doses. In addition to esophageal motor activities, compliance of the esophagogastric junction (EGJ) is important for prevention of gastroesophageal reflux. However, the effects of mosapride on EGJ compliance have not been reported. Here, we investigated the effects of high-dose mosapride on esophageal motor activities and EGJ compliance. Nine healthy volunteers were enrolled in the study. Peristaltic esophageal contraction and lower esophageal sphincter pressures before and after administration of 40 mg mosapride were examined by high resolution esophageal manometry. Esophageal compliance was also investigated by intra-esophageal impedance planimetry (EndoFLIP(®)). High-dose mosapride augmented peristaltic contractions, especially in the distal esophageal segments (P < 0.05). The mean resting lower esophageal sphincter pressure was elevated from 25.0 mmHg before administration to 28.9 mmHg after (P < 0.05). In addition, mosapride significantly reduced EGJ compliance (P < 0.05). Mosapride at 40 mg augmented esophageal motor activities and reduced EGJ compliance in healthy volunteers.

Type-A long-gap esophageal atresia treated by thoracoscopic esophagoesophagostomy after sequential extrathoracic esophageal elongation (Kimura’s technique)

We report four cases of long-gap esophageal atresia (LGEA) treated with thoracoscopic esophagoesophagostomy (TEE) after sequential extrathoracic esophageal elongation (SEEE: Kimura's technique). All initially had gastrostomy, then SEEE. The proximal end of the esophagus was introduced into the apex of the thorax under direct vision during TEE. Mean birth weight was 1.9 kg. Mean gestational age was 35.0 weeks (range 30-39); mean age at initial esophagostomy was 43.2 days (range 15-110); SEEE was performed for a mean of 3 times (range 2-4) at mean intervals of 5.3 months (range 2-10), with the upper esophageal segment lengthened by a mean of 2.1 cm each time (range 1.1-3.5). Mean age and weight at TEE were 22.3 months and 9.8 kg, respectively. Gap was initially 4.5 vertebrae (range 4-5). Mean operating time was 9.6 h. TEE was successful in 3; 1 required thoracotomy, then re-anastomosis after 11 months of anastomosis leakage; 2 cases with post-TEE anastomosis leakage were treated conservatively. Postoperatively, all cases required fundoplication and esophageal dilatation (2, 3, 5, 8 times, respectively). At mean follow-up of 3.6 years, 2 eat normally and 2 eat minced food. TEE after SEEE appears to be a feasible option for treating LGEA.

Bench surgical training with lyophilized esophageal segments

To present lyophilized esophageal segments that can be used to learn surgical skills. Four esophagus were harvested from four non-esophagus related research dogs at the moment of euthanasia. Each esophagus was trimmed in 3 cm long segments. They were lyophilized and stored during 30 days. The day programmed for surgical skills practice, they were rehydrated. Sixteen segments have been used. After rehydrating, all the segments kept their normal anatomic shape and structural integrity. One incision was made on every esophageal segment and sutured with running stitches of 3-0 polyglactin 910. There were no complications, such as tissue tears, nor esophageal hardening. The lyophilized esophagus is a high fidelity, practical, reproducible, portable, low-cost bench model. It allows general surgery apprentices to learn how to handle an esophagus, as well as to perfect their surgical and suture abilities before applying them on real patient's esophagus.

Aberrant right subclavian artery in video-assisted thoracoscopic esophagectomy.

When performing video-assisted thoracoscopic esophagectomy, the area at the level above the aortic and in the space between the esophagus and the spine, is usually regarded as a safe area for dissection of upper segment of thoracic esophagus. However, an aberrant right subclavian artery may appear in this area and lead to disastrous complications. We reported a case of aberrant artery encountered during video-assisted thoracoscopic esophagectomy. In order to avoid iatrogenic damage to this artery, it was converted to thoracotomy.

Endoscopic eradication therapy for mucosal neoplasia in Barrettʼs esophagus

Endoscopic eradication therapy is frequently used to treat dysplasia and early cancers in Barrett's esophagus. This review addresses some of the recent developments in the field of endoscopic eradication therapy for Barrett's esophagus. Data on the effectiveness of Barrett's esophagus ablation programs have been published recently, with excellent results for dysplasia eradication. Studies describing long-term results have shed light on the durability of endoscopic ablation, with recurrence of Barrett's esophagus and neoplasia seen in some cases, particularly at the gastroesophageal junction. Risk factors for failed ablation include longer Barrett's esophagus segments and persistent gastroesophageal reflux. New developments include studies combining radiofrequency ablation (RFA) and endoscopic mucosal resection into a single endoscopic session, endoscopic submucosal dissection for Barrett's esophagus neoplasia, and a simplified RFA algorithm. New data on the cost-effectiveness of RFA have also been published, suggesting that RFA is cost-effective for both high-grade and low-grade dysplasia, but not for nondysplastic Barrett's esophagus. A systematic review has shown that lymph node metastases are rare (∼2%) with intramucosal adenocarcinoma, supporting the use of endoscopic eradication for that lesion. Research and clinical experience with the endoscopic therapies for Barrett's esophagus continue to grow. Proper patient selection and technique are critical for ensuring a good outcome. Endoscopic surveillance after any of the ablative therapies still appears to be necessary.

Mitomycin-C: ‘a ray of hope’ in refractory corrosive esophageal strictures

Increasingly frequent dilation may become a self-defeating cycle in refractory stricture as recurrent trauma enhance, scar formation, and ultimately recurrence and potential worsening of the stricture. In 12 patients of caustic induced esophageal stricture, who failed to respond despite rigorous dilatation regimen for more than one year, a trial of topical mitomycin-C application to improve dilatation results was undertaken, considering the recently reported efficacy and safety of this agent. Mitomycin-C was applied for 2-3 minutes at the strictured esophageal segment after dilation with wire-guided Savary-Gilliard dilator. Patient was kept nil by mouth for 2-3 hours. After 4-6 sessions of mitomycin-C treatment, resolution of symptoms and significant improvement in dysphagia score and periodic dilatation index was seen in all 12 patients. Mitomycin-C topical application may be a useful strategy in refractory corrosive esophageal strictures and salvage patients from surgery.

Giant cellular neurilemmoma, a rare mesenchymal tumor of the oesophagus: A case report

Introduction: Gastrointestinal schwannomas are classified as mesenchymal or neuroectodermal neoplasms. Most common site is stomach followed by rectum. Schwannoma of oesophagus is very rare. It can present with dysphagia and odynophagia. Case Report: A 30­year­old female was presented with progressive dysphagia, mild odynophagia, retrosternal heartburn and vomiting for last six months. On radiological investigations a rounded radio opaque shadow in right paratracheal region was seen. Endoscopy showed ulcerated mucosa that bled on touch. Lumen was narrowed. Endoscopic biopsy showed only mild dysplasia in squamous epithelial lining. Segmental oesophagectomy was done to remove the mass. On gross examination an already cut open segment of oesophagus of about 6 cm in length was received. An irregular, lobulated, firm, grey white growth, of 7x5x8.5 cm, having smooth external surface was observed towards serosal surface. Cut surface was homogenous white. Histology showed monomorphic spindle shaped cells arranged in fascicular and whorled pattern with nuclear palisading at places. Peri tumoral lymphoid aggregates were also seen. Conclusion: Oesophageal schwannomas are benign tumors having excellent prognosis following surgical resection. A case of oesophageal schwannoma is documented here.

Tu1764 The Effects and Mechanism of Esophageal Acid Exposure on Trachea Mucous Production

In prior studies we found that esophageal acid exposure caused a small decrease in airway diameter, an increase in tracheobronchial mucus secretion, and a decrease in mucociliary transport rate. However, the store of mucus is not large and can easily be depleted, therefore, we hypothesized that mucus production may be under physiological control. AIM: To determine whether a physiological stimulus can affect mucus production and to investigate the mechanism of this effect. METHODS: Sixteen cats were anesthetized using alphachloralose. The esophagus was ligated 3-4 cm from the UES and the esophagus proximal and distal to the ligation was cannulated. Either the proximal (N=8) or distal (N=8) esophagus was perfused using 0.1N HCl for 30 min followed by 30 min of PBS while the opposite esophageal segment was perfused with PBS for 60 min. The trachea was excised, fixed, sliced at 5μ, and stained with Periodic Acid Schiff (PAS)-Alcian Blue (AB) at pH 1.0. The areas of neutral (PAS-positive) and acidic (AB-positive) mucosubstances in the epithelial and submucosal mucous glands of the trachea adjacent to the proximal and distal cervical segments of esophagus perfused were quantified using Image J software. RESULTS: We found that the primary type of mucous of the epithelial and submucosal mucous cells was AB-positive and PAS-positive, respectively. Acid exposure of either esophageal segment caused a greater total and PAS-positive mucous content of the submucosal cells adjacent to the HCl-administered esophagus than adjacent to the PBS-administered esophagus (Table). CONCLUSIONS: The primary types of mucosubstances of the tracheal epithelial and submucosal cells are acidic and neutral respectively. Esophageal acid exposure increases mucus production of neutral mucosubstances of the tracheal submucosa probably through the previously identified local direct neural connection between the esophagus and trachea. We hypothesize that this pathway is part of the innate tracheal defense mechanism which prepares the trachea for acid exposure due to gastric reflux. Effects of HCl and PBS on Tracheal Mucous Content

Tu1765 Regurgitation Can Indicate Either True Esophago-Pharyngeal Reflux (EPR) Event or Upper Esophageal Sphincter (UES) and Sub-Sphincter Proximal Esophageal Acid Exposure

In prior studies we found that esophageal acid exposure caused a small decrease in airway diameter, an increase in tracheobronchial mucus secretion, and a decrease in mucociliary transport rate. However, the store of mucus is not large and can easily be depleted, therefore, we hypothesized that mucus production may be under physiological control. AIM: To determine whether a physiological stimulus can affect mucus production and to investigate the mechanism of this effect. METHODS: Sixteen cats were anesthetized using alphachloralose. The esophagus was ligated 3-4 cm from the UES and the esophagus proximal and distal to the ligation was cannulated. Either the proximal (N=8) or distal (N=8) esophagus was perfused using 0.1N HCl for 30 min followed by 30 min of PBS while the opposite esophageal segment was perfused with PBS for 60 min. The trachea was excised, fixed, sliced at 5μ, and stained with Periodic Acid Schiff (PAS)-Alcian Blue (AB) at pH 1.0. The areas of neutral (PAS-positive) and acidic (AB-positive) mucosubstances in the epithelial and submucosal mucous glands of the trachea adjacent to the proximal and distal cervical segments of esophagus perfused were quantified using Image J software. RESULTS: We found that the primary type of mucous of the epithelial and submucosal mucous cells was AB-positive and PAS-positive, respectively. Acid exposure of either esophageal segment caused a greater total and PAS-positive mucous content of the submucosal cells adjacent to the HCl-administered esophagus than adjacent to the PBS-administered esophagus (Table). CONCLUSIONS: The primary types of mucosubstances of the tracheal epithelial and submucosal cells are acidic and neutral respectively. Esophageal acid exposure increases mucus production of neutral mucosubstances of the tracheal submucosa probably through the previously identified local direct neural connection between the esophagus and trachea. We hypothesize that this pathway is part of the innate tracheal defense mechanism which prepares the trachea for acid exposure due to gastric reflux. Effects of HCl and PBS on Tracheal Mucous Content

529 Esophageal Contraction Wave Abnormalities on High Resolution Manometry (HRM) Not Meeting Chicago Classification Criteria: Are They Clinically Relevant?

Introduction: The subjective perception of solid bolus hold up during swallowing is a common reason for referral for manometric investigation, yet standardmeasures of esophageal function relate poorly to patient perception and a large proportion of patients with dysphagia demonstrate no apparent abnormality on routine diagnostic testing for esophageal dysfunction. The utility of combined esophageal pressure-impedance recording has been recently enhanced by automated impedance manometry pressure-flow analysis (AIM analysis) and newmetrics have been conceived that better describe the interactions between bolus transport and pressure generation. In this study we undertook to assess whether these new esophageal pressure-flow metrics were altered when subjects perceived solid bolus hold up. Methods: Esophageal high-resolution pressure-impedance recordings of 5ml/10ml liquid/viscous swallows and 2cm/4cm solid swallows from 20 control subjects (29-73 years) were analysed. Two solid state pressure(P)/impedance(Z) catheter configurations were used; 32 1cm P/16 2cm Z (Sandhill Scientific) and 36 1cm P/18 2cm Z (Given Imaging). Bolus flow resistance, the relationship between bolus compression and bolus flow timing, was assessed using the pressure flow index (PFI) (Myers et al Neurogastro. Mot. 2012; Nguyen et al Neurogastro. Mot. 2012). Heightened perception of bolus hold up was assessed on a swallow by swallow basis using a 6 point scale (1 = no perception, 2 = awareness of bolus transit, 3-6 = bolus hold up). Results: On a swallow by swallow analysis, heightened perception of solid boluses (swallows with scores 3+) was associated with a higher PFI (distal esophagus Odds Ratio for score 3+ 1.001 [1.000 1.002], p = 0.021). A significant correlation was observed between the maximum subject reported perception score and the average PFI for solids (distal esophagus Pearson's r = 0.690, p,0.001). Grouping of subjects in relation to bolus perception revealed that the PFI was elevated for solids and viscous boluses, but not liquids, in subjects reporting bolus hold up (Figure). Esophageal peak pressures and iso-contour defect size were not significantly related to bolus perception. Conclusion: We report novel findings in relation to mechanical factors during bolus transport that may enhance bolus perception. This study shows that heightened perception of a swallowed bolus relates to subtle differences in flow resistance, which suggests higher levels of muscle tension during the transition phase from a bolus-containing to a lumen-occluded esophageal segment.

Tu1788 Comparison of Post-Operative Physiology Parameters Between Asymptomatic and Symptomatic Patients After Anti-Reflux Surgery

Background: A TLESR is a major mechanism of acid reflux in healthy subjects and patients with reflux esophagitis and we have noticed that the amplitude of primary peristalsis and EGJ pressure, following a TLESR, is accompanied by a forceful contraction, when compared with before a TLESR. The aim of this study is to investigate whether or not primary peristalsis and EGJ pressure, when accompanied by a forceful contraction and following a TLESR, is a characteristic finding of a TLESR. Methods: 10 healthy subjects underwent esophageal high-resolution manometry with a 21-lumen perfused assembly, which monitored pressure in the pharynx, the upper esophageal sphincter, the esophageal body, LES and the proximal stomach. The EGJ was evaluated using ten side holes, spaced at 1-cm intervals. Recordings were then taken, in the sitting position, for 1 hour after a meal (692 kcal, 33 % fat). A TLESR is defined as previously described. Data were analyzed, using Trace! Software (Dr. G.S Hebbard, The Royal Melbourne Hospital, Australia). The contractile integral (CI) of the distal esophageal segment (D-CI: volume of the domain above 20 mmHg), excluding the EGJ segment, was measured both before and after a TLESR, and the CI of the EGJ (EGJCI) (volume of the domain above 0 mmHg), was measured for 8 seconds after primary peristalsis reached the EGJ, both before and after a TLESR. Results: 56 TLESRs were measured during the study. The D-CI (1603 mmHg s cm (1177-2120), median (interquartile range)) following a TLESR was significantly greater than before a TLESR (484 (323-1079)) and more than a 50% increase of D-CI in 35 (62.5%) of the 56 TLESRs was observed. The EGJCI (790 (465-1009)) following a TLESR was significantly greater than before a TLESR (238 (186-308)) and more than a 50% increase in the EGJ-CI in 48 (85.7%) of the 56 TLESRs was observed. Conclusions: The D-CI and the EGJ-CI following a TLESR, were significantly greater than before a TLESR and this tendency was evident in the EGJ-CI, although it can, at times, be difficult to evaluate a TLESR. If the focus is on a forceful contraction of primary peristalsis or on the EGJ, it may be easier to detect and evaluate a TLESR.

528 The Mechanics of Esophageal Bolus Transport Are Altered in Subjects Reporting Perception of Solid Bolus Hold up

Introduction: The subjective perception of solid bolus hold up during swallowing is a common reason for referral for manometric investigation, yet standardmeasures of esophageal function relate poorly to patient perception and a large proportion of patients with dysphagia demonstrate no apparent abnormality on routine diagnostic testing for esophageal dysfunction. The utility of combined esophageal pressure-impedance recording has been recently enhanced by automated impedance manometry pressure-flow analysis (AIM analysis) and newmetrics have been conceived that better describe the interactions between bolus transport and pressure generation. In this study we undertook to assess whether these new esophageal pressure-flow metrics were altered when subjects perceived solid bolus hold up. Methods: Esophageal high-resolution pressure-impedance recordings of 5ml/10ml liquid/viscous swallows and 2cm/4cm solid swallows from 20 control subjects (29-73 years) were analysed. Two solid state pressure(P)/impedance(Z) catheter configurations were used; 32 1cm P/16 2cm Z (Sandhill Scientific) and 36 1cm P/18 2cm Z (Given Imaging). Bolus flow resistance, the relationship between bolus compression and bolus flow timing, was assessed using the pressure flow index (PFI) (Myers et al Neurogastro. Mot. 2012; Nguyen et al Neurogastro. Mot. 2012). Heightened perception of bolus hold up was assessed on a swallow by swallow basis using a 6 point scale (1 = no perception, 2 = awareness of bolus transit, 3-6 = bolus hold up). Results: On a swallow by swallow analysis, heightened perception of solid boluses (swallows with scores 3+) was associated with a higher PFI (distal esophagus Odds Ratio for score 3+ 1.001 [1.000 1.002], p = 0.021). A significant correlation was observed between the maximum subject reported perception score and the average PFI for solids (distal esophagus Pearson's r = 0.690, p,0.001). Grouping of subjects in relation to bolus perception revealed that the PFI was elevated for solids and viscous boluses, but not liquids, in subjects reporting bolus hold up (Figure). Esophageal peak pressures and iso-contour defect size were not significantly related to bolus perception. Conclusion: We report novel findings in relation to mechanical factors during bolus transport that may enhance bolus perception. This study shows that heightened perception of a swallowed bolus relates to subtle differences in flow resistance, which suggests higher levels of muscle tension during the transition phase from a bolus-containing to a lumen-occluded esophageal segment.

Tu1787 Primary Peristalsis and Esophagigastric Junction (EGJ) Pressure, Following a Transient Lower Esophageal Sphincter Relaxation (TLESR), Are Accompanied by a Forceful Contraction

Background: A TLESR is a major mechanism of acid reflux in healthy subjects and patients with reflux esophagitis and we have noticed that the amplitude of primary peristalsis and EGJ pressure, following a TLESR, is accompanied by a forceful contraction, when compared with before a TLESR. The aim of this study is to investigate whether or not primary peristalsis and EGJ pressure, when accompanied by a forceful contraction and following a TLESR, is a characteristic finding of a TLESR. Methods: 10 healthy subjects underwent esophageal high-resolution manometry with a 21-lumen perfused assembly, which monitored pressure in the pharynx, the upper esophageal sphincter, the esophageal body, LES and the proximal stomach. The EGJ was evaluated using ten side holes, spaced at 1-cm intervals. Recordings were then taken, in the sitting position, for 1 hour after a meal (692 kcal, 33 % fat). A TLESR is defined as previously described. Data were analyzed, using Trace! Software (Dr. G.S Hebbard, The Royal Melbourne Hospital, Australia). The contractile integral (CI) of the distal esophageal segment (D-CI: volume of the domain above 20 mmHg), excluding the EGJ segment, was measured both before and after a TLESR, and the CI of the EGJ (EGJCI) (volume of the domain above 0 mmHg), was measured for 8 seconds after primary peristalsis reached the EGJ, both before and after a TLESR. Results: 56 TLESRs were measured during the study. The D-CI (1603 mmHg s cm (1177-2120), median (interquartile range)) following a TLESR was significantly greater than before a TLESR (484 (323-1079)) and more than a 50% increase of D-CI in 35 (62.5%) of the 56 TLESRs was observed. The EGJCI (790 (465-1009)) following a TLESR was significantly greater than before a TLESR (238 (186-308)) and more than a 50% increase in the EGJ-CI in 48 (85.7%) of the 56 TLESRs was observed. Conclusions: The D-CI and the EGJ-CI following a TLESR, were significantly greater than before a TLESR and this tendency was evident in the EGJ-CI, although it can, at times, be difficult to evaluate a TLESR. If the focus is on a forceful contraction of primary peristalsis or on the EGJ, it may be easier to detect and evaluate a TLESR.

One case of synovial sarcoma extending from hypopharynx to thoracic segment of esophagus

One case of synovial sarcoma extending from hypopharynx to thoracic segment of esophagus

Dynamic Magnetic Resonance Imaging of the Pharynx during Deglutition

We utilized dynamic magnetic resonance imaging to visualize the pharynx and upper esophageal segment in normal, healthy subjects. A 3-T scanner with a 4-channel head coil and a dual-channel neck coil was used to obtain high-speed magnetic resonance images of subjects who were swallowing liquids and pudding. Ninety sequential images were acquired with a temporal resolution of 113 ms. Imaging was performed in axial planes at the levels of the oropharynx and the pharyngoesophageal segment. The images were then analyzed for variables related to alterations in the area of the pharynx and pharyngoesophageal segment during swallowing, as well as temporal measures related to these structures. All subjects tolerated the study protocol without complaint. Changes in the area of the pharyngeal wall lumen and temporal measurements were consistent within and between subjects. The inter-rater and intra-rater reliabilities for the measurement tool were excellent. Dynamic magnetic resonance imaging of the swallow sequence is both feasible and reliable and may eventually complement currently used diagnostic methods, as it adds substantive information.

Hiatal hernia and the risk of Barrett's esophagus

Barrett's esophagus has been associated with the presence of hiatal hernia; however, to date no meta-analysis of the relationship has been performed. We aimed to conduct a systematic review and meta-analysis, providing a quantitative estimate of the increased risk of Barrett's esophagus associated with hiatal hernia. A search was conducted through four electronic databases (Medline, PubMed, Embase, and Current Contents Connect) to 4 April 2012, for observational studies of Barrett's esophagus patients. We calculated pooled odds ratios and 95% confidence intervals using a random effects model for the association of hiatal hernia with any length Barrett's esophagus, as well as with short segment Barrett's esophagus and long segment Barrett's esophagus. 33 studies comprising 4390 Barrett's esophagus patients were eligible for the meta-analysis. Hiatal hernia was associated with an increased risk of Barrett's esophagus of any length (odds ratio 3.94; 95% confidence interval 3.02-5.13). Heterogeneity was present (I2 = 82.03%, P < 0.001), and the Egger test for publication bias was significant (P = 0.0005). The short segment Barrett's esophagus subgroup analysis likewise showed an increased risk (odds ratio 2.87; 95% confidence interval 1.75-4.70). The strongest association was between hiatal hernia and long segment Barrett's esophagus (odds ratio 12.67; 95% confidence interval 8.33-19.25). The increased risk was present even after adjusting for reflux and body mass index. The presence of hiatal hernia was associated with an increased risk of Barrett's esophagus, even after adjusting for clinically significant confounders. The strongest association was found between hiatal hernia and long segment Barrett's esophagus.