Incomplete Lower Esophageal Sphincter Relaxation Research Articles

Management of Functional Esophagogastric Junction Outflow Obstruction: A Systematic Review.

Awareness of functional esophagogastric junction outflow obstruction (fEGJOO) has increased, but because there is no consensus on its management, we performed a systematic review of the literature to explore treatment strategies and outcomes. EGJOO is a heterogenous disorder defined by high-resolution manometry parameters of elevated integrated relaxation pressure with preserved esophageal peristalsis. The etiology may be mechanical obstruction or idiopathic, the latter being fEGJOO. The PubMed/MEDLINE, Embase, and the Cochrane library electronic databases were searched through June 2018 for all studies of adult patients describing a treatment strategy for fEGJOO or incomplete lower esophageal sphincter relaxation. The search strategy yielded 1792 studies and 8 (0.4%) met inclusion criteria. All but one included studies were retrospective (n=184 patients). There were 5 interventions described, with botulinum toxin (Botox) injection (n=69) and expectant management (n=82) the most frequently reported, with success rates of 58% and 54%, respectively. There was substantial heterogeneity among patients and treatments were not directly compared, though reported symptom resolution was similar among all strategies with a mean follow-up time of 15 months. There are a variety of management strategies available for fEGJOO and some patients may not require any intervention. However, among 4 potential approaches aimed at disrupting lower esophageal sphincter hypertonicity, the largest existing evidence base supports either a therapeutic challenge of Botox injection or watchful waiting. Ultimately, these data indicate the need for further study with controlled trials to identify a definitive approach.

Findings of videofluoroscopic swallow study in the old age esophageal dysphagia (presbyesophagus)

Dysphagia has been reported in about 13.8% of the general population aged over 65 years and in 28.2% of people over 85 years. Among the dysphagia, esophageal dysphagia occurs more commonly in the aged. Presbyesophagus is proposed to explain age-related decrease in esophageal peristaltic pressure, abnormal esophageal contractions, incomplete lower esophageal sphincter relaxation and dilation of the esophagus in the aged. A 82-year-old female presented with swallowing difficulty for 3 years. Her symptoms were sensation of food stuck in the chest region and vomiting after swallowing in all consistencies of foods. The vomiting was spontaneous reflux type without nausea, especially in thin liquid. It started 2 years after her son's suicide. Initially, she had poor oral intake due to loss of appetite, and it had progressed to vomiting. In physical and neurologic examinations, brain MRI and esophagogastroduodenoscopy was unremarkable. Video fluoroscopic swallowing study (VFSS) showed intermittent esophageal dilation after passage of bolus of food and regurgitation from esophagus immediately after swallowing ( Fig. 1 ). Chest CT was unremarkable. Esophageal manometry measuring pressure and movement showed impaired esophageal peristalsis and ineffective bolus esophagus passage with relatively increased low esophageal sphincter pressure of 43.8 mmHg through rapid pull-through measurement. Esophagography revealed that lower esophageal sphincter was not properly relaxed, leading to gastroesophageal reflux ( Fig. 2 ). Finally, she was diagnosed with presbyesophagus. Life style and diet modification education and medications were prescribed. Presbyesophagus is not unusual phenomenon in elderly patients, and more prevalent with aging. Approximately 10% of over 67 years old with dysphagia symptoms have presbyesophagus. For non-invasive visualization of dynamic esophageal functions, VFSS or esophagography can be of diagnostic values. Of the two, VFSS has additional benefits in that it can also evaluate the swallowing function with diverse consistencies of foods and oropharyngeal swallowing dysfunction including aspiration, which is common in elderly patients.

Management of Functional Esophagogastric Junction Outflow Obstruction: A Systematic Review

Introduction: Esophagogastric Junction Outflow Obstruction (EGJOO) is an increasingly recognized disorder of incomplete lower esophageal sphincter (LES) relaxation with intact peristalsis and was first incorporated into the Chicago Classification (CC) for high resolution manometry in 2012. EGJOO may be idiopathic or related to a mechanical obstruction, the former being functional EGJOO. Although awareness of this diagnosis has increased, there is no consensus on its appropriate management. Methods: We performed a systematic review of the literature to examine the optimal treatment strategy for functional EGJOO. The Pubmed/MEDLINE, Embase and the Cochrane library electronic databases were searched through February 2017 for all studies including adult patients describing a treatment strategy for EGJOO or incomplete LES relaxation. The search strategy yielded 1,568 studies and 7 (0.4%) met inclusion criteria (Figure 1).Figure: PRISMA flow diagram of article search and identification.Results: All included studies were retrospective and comprised a total of 143 patients. Of these, one study was completed prior to the CC but satisfied criteria for EGJOO and was therefore included in the analysis. There were a total of 5 interventions described, with botulinum toxin (Botox) injection (N=61) and expectant management (N=57) the most frequently reported (Table 1). Treatments were not directly compared in any study and there was variability in how treatment success was defined. Reported successful resolution of symptoms was similar among all interventions, although the most robust evidence for therapeutic response was to both Botox injection (56%) and expectant management (54%). The mean follow-up time for the included studies was 21 months.Table: Table. Management Strategies and Treatment Response for Esophagogastric Junction Outflow ObstructionConclusion: Functional EGJOO is a heterogeneous disorder but may represent early or atypical achalasia. Overall, there are limited data on the optimal management strategy for EGJOO with some studies suggesting no treatment is needed. However, we identified 4 potential approaches aimed at disrupting LES hypertonicity. As a review of retrospective studies, these findings are limited by reporting and publication bias. Given that over half of patients with EGJOO resolve with expectant management alone, a reasonable approach may be to perform Botox injection as a diagnostic challenge or to provide definitive treatment only once an EGJOO diagnosis has been confirmed over time. Ultimately, these data support the need for a large randomized controlled trial to identify a definitive approach.

Subtle lower esophageal sphincter relaxation abnormalities in patients with unexplained esophageal dysphagia.

Esophageal dysphagia is a relatively common symptom. We aimed to evaluate whether subtle, presently not acknowledged forms of dysfunction of the lower esophageal sphincter (LES) could explain dysphagia in a subset of patients with normal findings at high-resolution manometry (HRM) according to the Chicago classification v3.0. We used HRM to compare LES relaxation characteristics in 97 patients with unexplained dysphagia with those in 44 healthy subjects. In addition, normative values for time to LES relaxation and completeness of LES relaxation were calculated. Patients with delayed or incomplete LES relaxation were compared with patients with normal relaxation. Dysphagia patients had a higher nadir LES pressure (P=.001) and a longer time to LES relaxation (P=.012) than healthy subjects. Based on the findings in healthy subjects, normal values of LES relaxation were defined as: ≥50% of swallows with normal LES relaxation time (<5seconds) and ≤20% of swallows with incomplete LES relaxation (not reaching a value below 10mm Hg). Dysphagia patients had significantly more often >50% swallows with delayed and/or incomplete LES relaxation than healthy controls (25% vs 4.5%; P=.004). Dysphagia patients with >50% delayed and/or incomplete LES relaxation had a significantly higher LES resting pressure (P<.001) and a significantly higher intrabolus pressure (P<.001) than dysphagia patients who did not fulfill the criteria. Subtle LES relaxation abnormalities, such as a delayed relaxation of the LES and/or incomplete LES relaxation, could be a cause of dysphagia in approximately one quarter of the patients with otherwise unexplained esophageal dysphagia.

Frequency of Jackhammer Esophagus as the Extreme Phenotypes of Esophageal Hypercontractility Based on the New Chicago Classification.

Jackhammer Esophagus is defined as intact esophageal peristaltic contractions with extremely elevated amplitudes. We conducted a retrospective study to identify the frequency of esophageal hypercontractility and the clinical characteristics of Jackhammer Esophagus. Charts for the patients referred for manometric study at a tertiary-care motility center were reviewed. Data were collected utilizing the new Chicago classification criteria for Jackhammer Esophagus. Concomitant clinical variables were also explored. Eight patients were identified with Jackhammer Esophagus from a total of 205 (127 female/77 male) patients referred for high-resolution esophageal manometry. Jackhammer patients had an average distal contractile integral (DCI) of 9061 mmHg/ sec/ cm and median maximal DCI of 16,433 mmHg/ sec/ cm. The greatest DCI from 15 swallows was 28,875 mmHg/ sec/ cm. Hypercontractility was associated with multipeaked contractions in every Jackhammer patient. The mean lower esophageal sphincter (LES) pressure was 41 mm Hg with 4 patients having a hypertensive pressure of >40 mm Hg. Three of the 8 (37.5%) Jackhammer group had incomplete LES relaxation by integrated relaxation pressure criteria (>15 mm Hg residual pressure). Dysphagia (8/8) was the dominant indication for the manometric study, whereas the clinical background setting was gastroesophageal reflux disease (4/8) and hiatal hernia (1/8). Treatments included smooth muscle relaxation, antireflux regimens, and pneumatic dilation of the LES. Jackhammer Esophagus, an extreme manometric phenotype, was identified in 4.0% of patients referred to a University Motility Center. The patients with these esophageal hypercontractility states present mainly with dysphagia. A subgroup of Jackhammer did have accompanying incomplete LES relaxation and responded to targeted therapy with pneumatic dilatation.

Clinical management of achalasia: current state of the art.

Achalasia is a primary disorder of esophageal motility. It classically presents with dysphagia to both solids and liquids but may be accompanied by regurgitation and chest pain. The gold standard for the diagnosis of achalasia is esophageal motility testing with manometry, which often reveals aperistalsis of the esophageal body and incomplete lower esophageal sphincter relaxation. The diagnosis is aided by complimentary tests, such as esophagogastroduodenoscopy and contrast radiography. Esophagogastroduodenoscopy is indicated to rule out mimickers of the disease known as “pseudoachalasia” (eg, malignancy). Endoscopic appearance of a dilated esophagus with retained food or saliva and a puckered lower esophageal sphincter should raise suspicion for achalasia. Additionally, barium esophagography may reveal a dilated esophagus with a distal tapering giving it a “bird’s beak” appearance. Multiple therapeutic modalities aid in the management of achalasia, the decision of which depends on operative risk factors. Conventional treatments include medical therapy, botulinum toxin injection, pneumatic dilation, and Heller myotomy. The last two are defined as the most definitive treatment options. New emerging therapies include peroral endoscopic myotomy, placement of self-expanding metallic stents, and endoscopic sclerotherapy.

39-Year-Old Man With Dysphagia

39-year-old manwithnonotablemedical history presented for evaluation of dysphagia. He reported a several-year history of intermittent but progressive difficulty swallowing both solids and liquids. He had been able to manage his symptoms by using water to flush foods, drinking carbonated beverages, and elevating the head of his bed. He did not experience choking or coughing with swallowing. Two weeks before presentation, he began to feel generally unwell, with worsening dysphagia and regurgitation of undigested food, chest discomfort, and decreased oralintake.Hedidnothavenausea,abdominal pain, diarrhea, constipation, melena, hematochezia, hematemesis, odynophagia, unexplained weight loss, night sweats, exertional chest pain, dyspnea, orthopnea, neck pain, recent trauma, or recent travel outside the United States. Onphysicalexamination,thepatient’sbody

Frequency of Jackhammer Esophagus as the Extreme Phenotypes of Esophageal Hypercontractility Based on the New Chicago Classification

Introduction: Jackhammer Esophagus defined as intact esophageal peristaltic contractions with extremely elevated amplitudes. We conducted a retrospective study to identify the frequency of esophageal hypercontractility and the clinical characteristics of Jackhammer Esophagus. Methods: Charts for the patients referred for manometric study at a tertiary-care motility center were reviewed. Data were collected utilizing the new Chicago classification criteria for Jackhammer Esophagus. Concomitant clinical variables were also explored. Results: From a total of 205 patients (127 F/77 M), 8 patients met criteria for Jackhammer Esophagus from a total of. Jackhammer patients had an average distal contractile integral (DCI) of 9,061 mm Hg-sec-cm and median maximal DCI of 16,433 mm Hg-sec-cm. The greatest DCI from 15 swallows was 28,875 mm Hg-sec-cm. Hypercontractility was associated with multipeaked contractions in every Jackhammer patient. The mean lower esophageal sphincter (LES) pressure was 41 mmHg (4 patients > 40). 37.5% of Jackhammer group had incomplete LES relaxation by Integrated Relaxation Pressure (IRP) criteria. Dysphagia (8/8) was the dominant indication for the manometric study, while the clinical background setting was gastroesophageal reflux disease (4/8) and hiatal hernia (1/8). Treatments included smooth muscle relaxation, anti-reflux regiments, and pneumatic dilation of the LES. Conclusion: 1) Jackhammer Esophagus, an extreme manometric phenotype, was identified in 4.0% of patients referred to a University Motility Center; 2) The patients with these esophageal hypercontractility states present mainly with dysphagia; 3) a subgroup of Jackhammer did have accompanying incomplete LES relaxation and responded to a targeted therapeutic with pneumatic dilatation.

Assessment of esophageal motor function using combined multichannel intraluminal impedance and manometry in patients with achalasia

Summary Background Achalasia is characterized by esophageal aperistalsis and a failure of lower esophageal sphincter (LES) relaxation. Combined multichannel intraluminal impedance and manometry (MII-EM) allows the simultaneous recording of esophageal peristalsis and bolus transport patterns. The aim of this study was to evaluate the feasibility of MII-EM for the assessment of esophageal motility and to characterize patterns of esophageal bolus transport in patients with achalasia with or without Heller myotomy. Materials and methods A total of nine patients (2 men and 7 women, age range 25–46 years) were enrolled in this study. Two of the patients had previously undergone Heller myotomy. All patients underwent combined MII-EM with a nine-channel esophageal function testing catheter containing four impedance measuring segments and five solid-state pressure transducers. Each patient received 10 liquid and 10 viscous swallows in a sitting position. All tracings were recorded and analyzed for esophageal contractions and bolus transit. Results None of the patients with achalasia, whether they had undergone a Heller myotomy or not, had manometrically normal esophageal peristalsis during saline or viscous swallowing. They had a normal LES resting pressure, incomplete LES relaxation, and lower distal esophageal contraction. The LES relaxation percentages in the patients who had undergone Heller myotomy (97% and 51%) were higher than those of the untreated patients (mean 47%). All patients demonstrated a low baseline impedance level in the distal esophagus. Air trapping in the proximal esophagus was also detected in nearly all of the patients. None of the patients in either group had complete bolus transit with either saline or viscous swallows. Conclusion Patients with achalasia are characterized by poor esophageal contraction and absent esophageal bolus clearance and such abnormalities are still noticeable after Heller myotomy. Although combined MII-EM can provide additional information regarding esophageal bolus transit, a low baseline impedance level and air trapping in the proximal esophagus may limit its utility in the diagnosis of esophageal dysmotility in patients with achalasia.

Oesophageal achalasia misdiagnosed as uncontrolled asthma

Achalasia is characterized by incomplete lower oesophageal sphincter relaxation and aperistalsis of the oesophagus. It may present with dyspnea symptom. An 18-years-old male patient applied to a clinic with the complaints of cough, dyspnea, wheezing and diagnosed as asthma. Although his asthma treatment was increased in time while he did not recover, he was reffered to our hospital with the diagnosis of uncontrolled asthma. On chest X-ray there was a mild upper mediastinal enlargement and chest computed tomography revealed an over-dilated oesophagus constricting the trachea. The patient was referred to chest surgery clinic with a suspected diagnosis of achalasia. Barium-oesophagogram and endoscopic evaluation of the oesophagus confirmed the diagnosis of achalasia. The patient underwent Heller myotomy and oesophagogastrostomy. He was recovered in one week after the surgery without any complaint of dyspnea. Spirometry tests and chest X-ray resulted normal in one year. With this case of achalasia who used asthma treatment unnecessarily,we wanted to emphasize the importance of differential diagnosis of difficult asthma.

Mo1732 Transplantation for HCC Improves Progression Free Survival but Not Overall Survival When Compared to Resection

Background: Roux-en-Y gastric bypass (RYGB) is an effective surgery for weight loss in obese patients. Current guidelines recommend advancement to regular diet in 1-2 months postRYGB. Failure to advance or dietary intolerancemay have clinical and nutritional implications. A prior study suggested that up to 30% of post-RYGB patients may develop dysphagia. RYGB may affect the Vagal innervation to the esophagus, and the resultant esophageal dysmotility may play a role in post-RYGB dietary complications. Understanding esophageal motor functions by high-resolution manometry (HRM) and their association with dietary outcome post-RYGB may allow more effective, targeted therapy for symptoms and dietary complications. Aim: To investigate the association between esophageal motor dysfunctions on HRM and intolerance to solid diet among post-RYGB patients. Methods: This was a retrospective cohort study of post-RYGB patients who underwent HRM at a tertiary care center in 6/2007-5/2012. Patients with underlying esophageal dysmotility pre-RYGB, HRM performed less than 2 months after RYGB, or need for parenteral or tube feeding were excluded. The primary outcome was diet at the time of HRM (liquid [LD] vs solid [SD]). Esophageal motor characteristics were extracted from HRM. Fisher-exact or chi-squared test for binary variables and student's t-test for continuous variables were used to assess for differences between LD and SD groups. Multivariate analysis was performed using forward stepwise logistic regression. Results: 63 patients met inclusion criteria (age 51±10.3 yrs, 91% F), and 21 subjects (33.3%) could only tolerate LD. Patients on LD were more likely to have at least one abnormal parameter on HRM than those on SD (61.9% vs 28.6%, p= 0.01). Univariate analyses showed that elevated basal lower esophageal sphincter (LES) pressure (9.52% vs 0%, p=0.04), incomplete LES relaxation (22% vs 0%, p= 0.04), increased esophageal body contraction amplitude (119±56 vs 93±41 mmHg, p=0.05), and dysphagia (52% vs 16%, p= 0.003) were significantly associated with LD. On multivariate analysis, incomplete LES relaxation remained an indepedent predictor for LD (OR 11.73, p=0.02). Conclusions: Post-RYGB patients unable to tolerate SD are more likely to have abnormal findings on HRM. Incomplete LES relaxation is independently associated with LD use, while other hypermotility patterns (hypertensive LES and increased esophageal body contraction) are also more prevalent. In addition to pouch or anastomotic abnormalities, esophageal motor dysfunction should be considered in assessing post-RYGB patients' failure to tolerate SD. HRM should play a role in evaluating post-RYGB dietary complications. Future studies should examine the potential causes of this dysfunction and explore the effect of therapies targeting LES relaxation on clinical and dietary outcome.

Mo1731 Incomplete Lower Esophageal Sphincter Relaxation on High-Resolution Manometry Is an Independent Predictor of Solid Diet Failure in Post-Roux-en-Y Gastric Bypass Patients

Background: Roux-en-Y gastric bypass (RYGB) is an effective surgery for weight loss in obese patients. Current guidelines recommend advancement to regular diet in 1-2 months postRYGB. Failure to advance or dietary intolerancemay have clinical and nutritional implications. A prior study suggested that up to 30% of post-RYGB patients may develop dysphagia. RYGB may affect the Vagal innervation to the esophagus, and the resultant esophageal dysmotility may play a role in post-RYGB dietary complications. Understanding esophageal motor functions by high-resolution manometry (HRM) and their association with dietary outcome post-RYGB may allow more effective, targeted therapy for symptoms and dietary complications. Aim: To investigate the association between esophageal motor dysfunctions on HRM and intolerance to solid diet among post-RYGB patients. Methods: This was a retrospective cohort study of post-RYGB patients who underwent HRM at a tertiary care center in 6/2007-5/2012. Patients with underlying esophageal dysmotility pre-RYGB, HRM performed less than 2 months after RYGB, or need for parenteral or tube feeding were excluded. The primary outcome was diet at the time of HRM (liquid [LD] vs solid [SD]). Esophageal motor characteristics were extracted from HRM. Fisher-exact or chi-squared test for binary variables and student's t-test for continuous variables were used to assess for differences between LD and SD groups. Multivariate analysis was performed using forward stepwise logistic regression. Results: 63 patients met inclusion criteria (age 51±10.3 yrs, 91% F), and 21 subjects (33.3%) could only tolerate LD. Patients on LD were more likely to have at least one abnormal parameter on HRM than those on SD (61.9% vs 28.6%, p= 0.01). Univariate analyses showed that elevated basal lower esophageal sphincter (LES) pressure (9.52% vs 0%, p=0.04), incomplete LES relaxation (22% vs 0%, p= 0.04), increased esophageal body contraction amplitude (119±56 vs 93±41 mmHg, p=0.05), and dysphagia (52% vs 16%, p= 0.003) were significantly associated with LD. On multivariate analysis, incomplete LES relaxation remained an indepedent predictor for LD (OR 11.73, p=0.02). Conclusions: Post-RYGB patients unable to tolerate SD are more likely to have abnormal findings on HRM. Incomplete LES relaxation is independently associated with LD use, while other hypermotility patterns (hypertensive LES and increased esophageal body contraction) are also more prevalent. In addition to pouch or anastomotic abnormalities, esophageal motor dysfunction should be considered in assessing post-RYGB patients' failure to tolerate SD. HRM should play a role in evaluating post-RYGB dietary complications. Future studies should examine the potential causes of this dysfunction and explore the effect of therapies targeting LES relaxation on clinical and dietary outcome.

Presentation, Diagnosis, and Management of Achalasia

Presentation, Diagnosis, and Management of Achalasia

Single incision laparoscopic approach for esophageal achalasia: A case report

INTRODUCTIONEsophageal achalasia is an uncommon, benign, neurodegenerative disease that induces a transit disorder characterized by incomplete lower esophageal sphincter relaxation. PRESENTATION OF CASEA 56-year-old woman with dysphagia was admitted to our hospital. An esophagography revealed flask-type achalasia. Endoscopy revealed a dilated esophagus and some resistance at the esophagogastric junction. We used a capped wound protector, common straight forceps, and hook-type electrocautery to perform transumbilical single incision laparoscopic Heller myotomy with Dor fundoplication (SILHD). The left liver lobe and cardia were pulled by a thread. A 6-cm Heller myotomy of the esophagus was performed with an additional 2-cm myotomy of the gastric wall. Dor fundoplication was performed to cover the exposed submucosa. Intraoperative endoscopy confirmed the adequacy of the myotomy and Dor fundoplication. There were no postoperative complications. An esophagography and an endoscopic examination did not reveal stenosis or reflux at 1-year follow-up, and the patient has been satisfactorily symptom free. DISCUSSIONLHD is the most accepted surgical treatment for achalasia and has low invasiveness and long-term efficacy. SILHD for achalasia is a new approach and may provide improved cosmetics and less invasiveness compared with those by conventional LHD. The 1-year follow-up results in the present case are the longest reported to date. The evaluation of long-term results in a large-scale study is necessary in future. CONCLUSIONSILHD can be safe, widely accepted, mid-term minimal invasive and cosmetically superior surgical procedure for achalasia.

Multiple rapid swallow responses segregate achalasia subtypes on high-resolution manometry.

Multiple rapid swallows (MRS) inhibit esophageal peristalsis and lower esophageal sphincter (LES) tone; a rebound excitatory response then results in an exaggerated peristaltic sequence. Multiple rapid swallows responses are dependent on intact inhibitory and excitatory neural function and could vary by subtype in achalasia spectrum disorders. Consecutive subjects with incomplete LES relaxation on high-resolution manometry (HRM) (Sierra Scientific, Los Angeles, CA, USA) in the absence of mechanical obstruction were prospectively identified. Achalasia spectrum disorders were classified and HRM plots reviewed according to Chicago criteria. Esophageal peristaltic performance and LES function were assessed after 10 wet swallows and MRS (five 2 mL water swallows 2-3 s apart). Findings were compared with 18 healthy controls (28.5 ± 0.6 years, 44% women). A total of 46 subjects (57.1 ± 2.1 years, 52.2% women) met inclusion criteria. There was complete failure of peristalsis with MRS in all subjects with achalasia subtypes 1 and 2. In contrast, 80% of achalasia subtype 3 and incomplete LES relaxation (EGJ outflow obstruction) with preserved esophageal body peristalsis had a contractile response to MRS (P < 0.001 compared with subtypes 1 and 2); controls demonstrated 94.4% peristalsis. Percent decrease in LES residual pressure during MRS (compared to wet swallows) segregated achalasia subtypes; those with aperistalsis (subtypes 1 and 2) had a lesser decline (22.6%) compared to those with retained esophageal body peristalsis (40.5%) and controls (51.3%, P < 0.001 across groups). Multiple rapid swallow responses segregate achalasia spectrum disorders into two patterns differentiated by presence or absence of esophageal body contraction response to wet swallows. These findings support subtyping of achalasia, with pathophysiologic implications.

Value of preoperative esophageal function studies before laparoscopic antireflux surgery

The value of esophageal manometry and ambulatory pH monitoring before laparoscopic antireflux surgery (LARS) has been questioned because tailoring the operation to the degree of hypomotility often is not required. This study evaluated a consecutive cohort of patients referred for esophageal function studies in preparation for LARS to determine the rates of findings that would alter surgical decisions. High-resolution manometry (HRM) was performed for each subject using a 21-lumen water-perfused system, and motor function was characterized. Gastroesophageal reflux disease (GERD) was evident from ambulatory pH monitoring if thresholds for acid exposure time and/or positive symptom association probability were passed. Of 1,081 subjects (age, 48.4±0.4years; 56.7% female) undergoing preoperative HRM, 723 (66.9%) also had ambulatory pH testing performed. Lower esophageal sphincter (LES) hypotension (38.9%) and nonspecific spastic disorder (NSSD) of the esophageal body (36.1%) were common. Obstructive LES pathophysiology was noted in 2.5% (achalasia in 1%; incomplete LES relaxation in 1.5%), and significant esophageal body hypomotility in 4.5% (aperistalsis in 3.2%; severe hypomotility in 1.3%) of the subjects. Evidence of GERD was absent in 23.9% of the subjects. Spastic disorders were more frequent in the absence of GERD (43.9% vs. 23.1% with GERD; p<0.0001), whereas hypomotility and normal patterns were more common with GERD. Findings considered absolute or relative contraindications for standard 360º fundoplication are detected in 1 of 14 patients receiving preoperative HRM. Additionally, spastic findings associated with persistent postoperative symptoms are detected at esophageal function testing that could be used in preoperative counseling and candidate selection. Physiologic testing remains important in the preoperative evaluation of patients being considered for LARS.

Botulinum toxin injection in dysphagia syndromes with preserved esophageal peristalsis and incomplete lower esophageal sphincter relaxation

Botulinum toxin injection into the lower esophageal sphincter (LES) treats dysphagia syndromes with preserved peristalsis and incomplete LES relaxation (LESR). We evaluated clinical and esophageal motor characteristics predicting response, and compared duration of efficacy to similarly treated achalasia patients. Thirty-six subjects (59 ± 2.2 years, 19F/17M) with incomplete LESR on high resolution manometry (HRM) treated with botulinum toxin injection were identified. Individual and composite symptom indices were calculated, and HRM characteristics extracted. Symptom resolution for 6 months was a primary outcome measure, and repeat botulinum toxin injection, dysphagia recurrence or employment of alternate therapeutic approaches were secondary outcome measures. Duration of response was compared using Kaplan-Meier survival curves to a historical cohort of similarly treated achalasia subjects. Response lasted a mean of 12.8 ± 2.3 months. Symptom relief for >6 months was seen in 58.3%; short (<6 months) response was associated with younger age, higher chest pain index, and esophageal body spastic features (P ≤ 0.04). On multivariate logistic regression, chest pain, younger age and contraction amplitudes >180 mmHg independently predicted <6 months relief (P < 0.05 for each). On survival analysis, relief with a single injection extended to 1 year in 54.8% and 1.5 years in 49.8%, statistically equivalent to that reported by 42 similarly treated achalasia subjects (59 ± 3.2 years, 24F/18M). Symptom relief was more prolonged compared to achalasia when repeat injections were performed on demand (P = 0.003). Botulinum toxin injections can provide lasting symptom relief in dysphagia syndromes with incomplete LESR. Prominent perceptive symptoms and non-specific spastic features may predict shorter relief.

Modern management of achalasia

Achalasia is a chronic esophageal motility disorder characterized by incomplete lower esophageal sphincter relaxation and aperistalsis resulting in delayed esophageal emptying. Management is aimed at palliation of symptoms and improvement in quality of life. Multiple factors including demographics, severity of disease, and existing comorbidities influence management options. Given its low rates of complications, surgical myotomy has become the preferred primary treatment, particularly in young males. However, recent studies describing favorable long-term outcomes for pneumatic dilation make this a reasonable option to consider as first-line therapy for achalasia. Pneumatic dilation and surgical myotomy are the most effective therapeutic options for achalasia. Depending on local expertise, either option is acceptable as first-line therapy. There continues to be a limited role for other treatment modalities such as pharamacologic agents and botulinum toxin in certain patient populations.

Long-term results of esophageal motor dysmotility after Heller's myotomy for achalasia

To investigate the long-term characteristics of both clinical manifestation and esophageal motor disturbance in achalasia patients after Heller's myotomy. After 3 to 10 years' follow-up, clinical manifestation, esophageal motor function and 24-hour continuous esophageal pH monitoring in 72 post-operative cases of achalasia were recorded. The mean LES pressure decreased from 44 + or - 12 mm Hg to 10 + or - 5 mm Hg, and the rate of L ES relaxation rised from 49% + or - 20% to 84% + or - 15% (paired t test, P < 0.05). Of 24 cases with choking feeling, 11 had the high LES pressure and dysfunction in two directions and 7 in three. During swallowing, incomplete lower esophageal sphincter relaxation and aperistalsis were detected in all patients. The long-term characteristics of esophageal function following successfully surgical treatment to patients with Achalasia are: (1) After Heller's myotomy, LESP in at least one direction is lower than the normal standard, while higher in at least one direction. (2) During swallowing, the esophageal rear wall is lack of complete LES relaxation. For patients with choking feeling, complete LES relaxation occurs in 2-3 directions. (3) Due to lack of esophageal peristalsis, food goes through esophagus by gravitation.

Endoscopic, Radiologic, and Manometric Features of an Incomplete Heller Myotomy for Achalasia

Purpose: Laparoscopic Heller myotomy is an effective surgical therapy for idiopathic achalasia. Unfortunately 5–10% of patients develop recurrent dysphagia or chest pain in the early postoperative period. The most common cause for recurrence is an incomplete myotomy, in which the muscle fibers at the distal end of the myotomy are not completely released. Proper recognition of an incomplete myotomy is poorly described in the literature and the best approach to therapy is unclear. Methods: A 63 yo female with diabetes and hypertension who presented with dysphagia to solids and liquids and a 40 pound weight loss was diagnosed with achalasia on barium esophogram and manometry. The manometry showed a hypertensive lower esophageal sphincter (LES), incomplete LES relaxation, and aperistalsis with low-amplitude, simultaneous contractions after all wet swallows. She underwent a laparoscopic Heller myotomy with Dor fundoplication which was initially successful. However, she returned one year later with recurrent dysphagia, chest pain and weight loss. Results: Evaluation with esophogram and endoscopy showed a focal distal stenosis lacking the appearance of a peptic or fibrotic stricture (see Figure). Repeat manometry showed an isolated high-pressure zone (HPZ) with failure of relaxation within the proximal margin of the LES. This HPZ was consistent with intact residual LES fibers from an incomplete myotomy. Thus, pneumatic dilation (PD) was chosen as the therapeutic approach instead of a repeat surgery. The dilation was performed with a 3 cm balloon and was successful – at follow-up 1 and 4 months later she reported resolution of dysphagia and chest pain and had a weight gain of 8 pounds.FigureConclusion: This case nicely illustrates what might be observed in a patient with achalasia and recurrent symptoms due to an incomplete myotomy. A focal residual HPZ at the proximal end of the LES was observed on endoscopy, radiology, and manometry. Our case is interesting in that the residual HPZ was located at the proximal rather than distal margin of the LES. The use of PD following incomplete myotomy has been reported in the literature with success rates as high as 80 percent. More studies are needed to improve recognition of an incomplete myotomy and to develop criteria for the selection of patients who would benefit most from PD after failed myotomy.