Intragastric Pressure Research Articles

The Feasibility of Gastroesophageal Manometry for Continuously Evaluating the Degree of Expiratory Effort During Successful Crescendo Phonation

This study aimed to assess the feasibility of gastroesophageal manometry for continuously evaluating the degree of expiratory effort by measuring the pressures in the digestive tract during crescendo phonation. Each of 18 healthy nondysphonic speakers had a probe with a four-channel gastroesophageal manometer inserted through the nasal cavity to place four pressure sensors in the hypopharynx, cervical-/thoracic esophagus, and stomach, and was asked to gradually increase the vocal loudness during sustained phonation of the vowel /e:/ (vowel-crescendo task), while the sound pressure level and the pressures were simultaneously recorded. 50% of the successful vowel-crescendo task samples with a gradual and adequate sound pressure level increase showed a concomitant gradual increase in both the intra-thoracic-esophageal/intra-gastric pressure values from approximately -5 mmHg /6 mmHg to -10 mmHg/20 mmHg, respectively. The maximum pressure value was the highest in the intra-gastric pressure followed by the intra-thoracic-esophageal and intra-cervical-esophageal pressures in order. However, most of the samples showed less than one of atypical pressure changes, such as fluctuations in the intra-thoracic-esophageal and intra-gastric pressure changes and dispersion in the intra-cervical-esophageal and intra-hypopharyngeal pressure values (perhaps due to the peristaltic motions, and the contact of the sensors to the membranous wall). These results show that, during successful crescendo phonation, gastroesophageal manometry reveals a gradual increase in the intra-thoracic and intra-abdominal pressures with increasing the vocal intensity, even though showing some systematic errors, suggesting the usefulness of gastroesophageal manometry for continuously evaluating the degree of expiratory effort without influence by the laryngeal condition.

Chicago Classification update (v4.0): Technical review of high-resolution manometry metrics for EGJ barrier function.

Esophagogastric junction (EGJ) barrier function is of fundamental importance in the pathophysiology of gastroesophageal reflux disease. Impaired EGJ barrier function leads to excessive distal esophageal acid exposure or, in severe cases, esophagitis. Hence, proposed high-resolution manometry (HRM) metrics assessing EGJ integrity are clinically important and were a focus of the Chicago Classification (CC) working group for inclusion in CC v4.0. However, the EGJ is a complex sphincter comprised of both crural diaphragm (CD) and lower esophageal sphincter (LES) component, each of which is subject to independent physiological control mechanisms and pathophysiology. No single metric can capture all attributes of EGJ barrier function. The working group considered several potential metrics of EGJ integrity including LES-CD separation, the EGJ contractile integral (EGJ-CI), the respiratory inversion point (RIP), and intragastric pressure. Strong recommendations were made regarding LES-CD separation as indicative of hiatus hernia, although the numerical threshold for defining hiatal hernia was not agreed upon. There was no agreement on the significance of the RIP, only that it could localize either above the LES or between the LES and CD in cases of hiatus hernia. There was agreement on how to measure the EGJ-CI and that it should be referenced to gastric pressure in units of mmHgcm, but the numerical threshold indicative of a hypotensive EGJ varied widely among reports and was not agreed upon. Intragastric pressure was endorsed as an important metric worthy of further study but there was no agreement on a numerical threshold indicative of abdominal obesity.

The effect of prucalopride on gastric sensorimotor function and satiation in healthy volunteers.

Gastric motor function alterations have been implicated in the pathogenesis of functional dyspepsia with postprandial distress syndrome (PDS). Prucalopride, a 5-TH4 agonist, is known to stimulate gastrointestinal motility. We aimed to evaluate the effect of prucalopride on gastric sensorimotor function in healthy subjects (HV). Barostat and intragastric pressure (IGP) measurements were performed in 17 HV (59% females, age 29.4±2.7y) after treatment with placebo or prucalopride (2mg) (single-blind cross-over). Isobaric stepwise distensions and gastric sensations were assessed to determine gastric compliance and sensitivity. Gastric accommodation (GA) with the barostat was quantified before and after ingestion of 200ml of a nutrient drink (ND). GA measured by IGP was quantified as the drop of IGP from baseline during the intragastric infusion of ND until maximal satiation (60ml/min). Prucalopride did not affect barostat assessed gastric compliance or sensitivity. No differences were observed in GA after prucalopride. During the barostat study, 10min after the meal, 7 HVs reported significantly higher ratings for nausea after prucalopride (p<0.001), and vomiting was induced in 4 of the HVs. A positive correlation was observed between the delta mean perception of nausea with the delta mean increase of intra-balloon volume before and after meal ingestion (r=0.37, p=0.03). During IGP measurements, no effect on nutrient tolerance was observed and increased cramp severity scores were observed which were associated with a significant increase of distal IGP (r=0.78, p<0.0001). Prucalopride does not enhances gastric accommodation but it might increase sensitivity to gastric distention. Furthermore, the increase in sensitivity seems to be related to an increase in nausea with distension. Clinicaltrials.gov: NCT04429802.

Impact of joint hypermobility syndrome on gastric accommodation and nutrient tolerance in functional dyspepsia.

FD patients filled out a dyspepsia symptom severity score. Intragastric pressure (IGP) was measured with high-resolution manometry (HRM) during the intragastric infusion of nutrition drink (ND, 1.5Kcal/ml, 60ml/min) until maximal satiation in healthy subjects and FD. We compared IGP profiles and nutrient tolerance in HS and FD with or without JHS. JHS was present in 54% of FD patients (n=39, 41.2±2.2years old) and 7% of healthy subjects (n=15, 27.3±2.3years old). IGP drop and nutrient tolerance were lower in non-JHS-FD compared with JHS-FD and HS (AUC JHS-FD: -17.9±2.5 vs. non-JHS-FD: -13.0±3.3mmHgmin, p=0.2, HS:-19.6±2.9mmHgmin; ND tolerance non-JHS-FD: 671.0±96.0 vs. JHS-FD: 842.7±105.7Kcal, p=0.25, HS: 980.0±108.1Kcal). JHS often co-exists with FD. Non-JHS-FD was characterized by decreased accommodation and lower nutrient tolerance characterized compared with JHS-FD. Clinicaltrials.gov, reference number NCT04279990.

The Clinical and Functional Characteristics of Chronic Duodenal Insufficiency

Purpose : to study the clinical course and features of violations of the motor-evacuation function of the gastrointestinal tract in chronic duodenal insufficiency. Materials and methods . The study included 40 patients with chronic duodenal insufficiency (CDI): 18 (48.2%) women, 22 (51.8%) men, mean age 37.1 ± 13.8 years. The control group consisted of 30 healthy individuals: 10 (33.3%) women, 20 (66.7%) men, mean age 40.5 ± 13.47 years. In the examination of patients, anamnestic and physical data, the results of biochemical, X-ray and endoscopic studies, intracavitary manometry, and electrogastroenterography were used. Parameters reflecting psycho-emotional state and vegetative status were evaluated. Results . In 19 (46.8%) patients with CDI, the pain syndrome occurred after eating, most often localized in the right hypochondrium in 11 (29.0%) and in the epigastric region in 18 (44.9%) patients. Patients with CDF presented some dyspeptic complaints that were not observed in the control group: 22 (57%) noted belching with bitterness, 31 (77.6%) — a feeling of bitterness in the mouth, 21 (53%) — heartburn, flatulence — 25 (53.3%) and mushy stools 28 (71%). In patients with CDI, compared with the control group, there was a decrease in the content of total protein (62.24 ± 0.17 and 72.3 ± 0.21 g/l, p = 0.0002), triglycerides (0.42 ± 0.0021 and 1.5 ± 0.04 mmol/L, p = 0.022), fat-soluble vitamin B12 (188.0 ± 0.21 and 328.6 ± 18.9 pg/ml, p = 0.0048), 25-OH vitamin D (26.87 ± 0.12 and 64.7 ± 1.25 ng/ml, p = 0.018). With CDI, compared with control, a significant increase in gastrin (29.7 [25.7; 32.5] and 19.2 [18.8; 20.1] pmol/L, p = 0.0004) and cortisol (471, 8 ± 1.09 and 365.3 ± 2.6 nmol/L, p = 0.0001). The insulin level was significantly lower than the values of the control group: (2.89 [2.5; 3.0] and 3.8 [2.2; 4.5] μmol/L, p = 0.006). According to the gastroenteromanitor in the postprandial period, impaired propulsive motility in all parts of the digestive tube was established, which proves a decrease in the rhythm coefficient (K-ritm) of the duodenum, jejunum and ileum on an empty stomach by 1.5 times in both phases of the study (p = 0.000). The ratio of intraduodenal pressure to intragastric pressure in chronic heart failure was 1.26 [1.19; 1.32], which is significantly lower than the values in the control group (1.7 [1.0; 2.4], p = 0.0004) and indicates a violation of the closure function of the gatekeeper. Alarm scale RH. Spielberger (adaptation of Yu.L. Khanin) showed an increase in comparison with the control group in the levels of situational (57 [54; 60] and 47.0 [45; 50] points, p = 0.0021) and personal anxiety (25.1 [22.6; 27.4] and 21.9 [19.5; 23.9] points, p = 0.003) in patients with CDI. Conclusion . In connection with the non-manifest course and the absence of specific symptoms of chronic duodenal insufficiency, in the examination of patients for the diagnosis, it is necessary to use, in addition to clinical data, X-ray, endoscopic, manometric and electrophysiological studies.

Direct optogenetic stimulation of smooth muscle cells to control gastric contractility

Rationale: Antral peristalsis is responsible for gastric emptying. Its failure is called gastroparesis and often caused by dysfunction of enteric neurons and interstitial cells of Cajal (ICC). Current treatment options, including gastric electrical stimulation, are non-satisfying and may improve symptoms but commonly fail to restore gastric emptying. Herein, we explore direct optogenetic stimulation of smooth muscle cells (SMC) via the light-gated non-selective cation channel Channelrhodopsin2 (ChR2) to control gastric motor function.Methods: We used a transgenic mouse model expressing ChR2 in fusion with eYFP under the control of the chicken-β-actin promoter. We performed patch clamp experiments to quantify light-induced currents in isolated SMC, Ca2+ imaging and isometric force measurements of antral smooth muscle strips as well as pressure recordings of intact stomachs to evaluate contractile responses. Light-induced propulsion of gastric contents from the isolated stomach preparation was quantified in video recordings. We furthermore tested optogenetic stimulation in a gastroparesis model induced by neuronal- and ICC-specific damage through methylene blue photo-toxicity.Results: In the stomachs, eYFP signals were restricted to SMC in which blue light (460 nm) induced inward currents typical for ChR2. These depolarizing currents led to contractions in antral smooth muscle strips that were stronger than those triggered by supramaximal electrical field stimulation and comparable to those evoked by global depolarization with high K+ concentration. In the intact stomach, panoramic illumination efficiently increased intragastric pressure achieving 239±46% (n=6) of the pressure induced by electrical field stimulation and triggered gastric transport. Within the gastroparesis model, electric field stimulation completely failed but light still efficiently generated pressure waves.Conclusions: We demonstrate direct optogenetic stimulation of SMC to control gastric contractility. This completely new approach could allow for the restoration of motility in gastroparesis in the future.

The bitter tastant denatonium benzoate has no influence on the number of transient lower esophageal sphincter relaxations in health.

Administration of a bitter compound can alter the intragastric pressure (IGP) after a meal. Additionally, a negative correlation between IGP and the number of transient lower esophageal sphincter relaxations (TLESRs) has been demonstrated. However, the effect of a bitter tastant on the number of TLESRs and subsequent reflux episodes has never been investigated and it is unclear whether bitter food items should be avoided in gastro-esophageal reflux disease. We hypothesize that bitter administration in healthy volunteers (HVs) will lead to an increase in the number of TLESRs. After an overnight fast, 20 female HVs (36years [21-63]) underwent a high-resolution impedance manometry (HRiM) measurement. After placement of the HRiM probe, 0.1ml/kg of a 10mM denatonium benzoate solution (bitter) or an identical volume of water (placebo) was administered directly into the stomach. The number of TLESRs and reflux episodes was quantified 30min before and 2h after consumption of a high caloric meal. There was no significant difference in the number of TLESRs or reflux episodes between the bitter and placebo condition. Additionally, no differences were observed in the nature (gas or liquid) and extent of reflux events. Lower esophageal sphincter pressures dropped significantly in the first postprandial hour to start recovering slowly back to baseline values during the second postprandial hour (p<0.0001), without any difference between both conditions. Administration of the bitter tastant denatonium benzoate has no influence on the number of TLESRs or reflux episodes.

The gastro-sphincteric pressure gradient: A new parameter to diagnose a rumination episode.

Rumination is defined as the repetitive, effortless regurgitation of recently ingested food into the mouth. These episodes are preceded by a rise in intragastric pressure (IGP) and mainly occur postprandially. IGP peaks >30mmHg have been proposed as a cutoff to differentiate rumination from reflux events. In clinical practice, we observed that this cutoff, which does not consider esophagogastric junction (EGJ) resistance, is not always reached. We studied 27 patients with rumination syndrome [age: 43.6, 59% female] and 28 gastro-esophageal reflux disease patients [age: 45.9, 54% female]. For each rumination episode, reflux event, transient lower esophageal sphincter relaxation (TLESR), or straining without regurgitation, the following parameters were registered: maximal IGP, IGP, and EGJ pressure preceding the respective episodes. We also quantified the gastro-sphincteric pressure gradient (GSPG) prior to the respective episodes. Five reflux episodes were characterized by a maximal IGP >30mmHg. In 28% of the rumination episodes, the IGP peak did not exceed 30mmHg. Median GSPG was positive for rumination episodes and significantly higher compared with TLESRs, reflux episodes, and straining without regurgitation (7 [3-13] vs. 0 [-1-0] vs. 0 [-1-0] vs. -9 [-13--2]; p<0.0001). Applying the proposed cutoff of 30mmHg, 28% of the rumination episodes were missed. We found that the GSPG differentiates between rumination (positive GSPG), TLESRs and reflux events (GSPG around 0), and straining without regurgitation (negative GSPG). We propose a GSPG value ≥2mmHg to distinguish rumination from reflux episodes, TLESRs, and straining without regurgitation.

Characterization of intragastric pressure waveform in endoscopic pressure study integrated system: Novel diagnostic device for gastroesophageal reflux disease.

Endoscopic pressure study integrated system (EPSIS) is a novel diagnostic tool for gastroesophageal reflux disease (GERD). EPSIS has been developed to evaluate lower esophageal sphincter function by monitoring the intragastric pressure (IGP) while insufflating the stomach during gastroscopy. Based on previous data, EPSIS could diagnose GERD with good accuracy by assessing IGP waveform pattern. This study aimed to further characterize the waveform to improve the diagnostic yield of EPSIS. We conducted a retrospective analysis of patients with typical GERD symptoms who underwent both EPSIS and 24-h impedance-pH monitoring (MII-pH) at a single tertiary referral center from October 2018 to May 2020. EPSIS was performed by using a through-the-scope catheter connected to the pressure measuring system (TR-W550, TR-TeH08, AP-C35; Keyence, Osaka, Japan) to monitor IGP. Abnormal acid reflux was defined as acid exposure time (AET) over 6.0%. Pressure waveform was characterized as follows: (i) Basal IGP, (ii) Maximum IGP, (iii) Pressure difference, (iv) Gradient of the waveform. A total of 57 patients with GERD symptoms were analyzed. Twenty-one patients presented abnormal AET on MII-pH. Among EPSIS parameters, pressure difference during insufflation correlated with AET (ρ=-0.66, P<0.01) and showed the best diagnostic accuracy for AET with the cutoff value of 4.7mmHg (area under the curve [AUC], 0.87). The gradient of EPSIS waveform also revealed good diagnostic accuracy for abnormal AET with the cutoff value of 0.07mmHg/s (AUC, 0.81). Endoscopic pressure study integrated system waveform parameters, especially pressure difference, presented high diagnostic accuracy for the presence of abnormal acid reflux.

The place and role of domperidone in the practice of a gastroenterologist. Overview of options at the present stage

Diseases of the gastrointestinal tract (GIT) occupy a significant place in the overall structure of somatic diseases worldwide. Apart from functional diseases (the incidence of functional dyspepsia (FD) in population is 20 %), the following inflammatory and destructive diseases are widespread: gastroesophageal reflux disease (GERD) in up to 40 % of the population, chronic gastritis and chronic duodenitis in 45 — 50 % of the population, peptic ulcer of the stomach and duodenum in 14 — 15 % of the population. Each of these diseases has its own features of etiopathogenesis and approaches to treatment. However, a common pathological factor contributing to the development of these nosologies is a violation of motor‑evacuation function. The administration of drugs for the normalization of peristaltic activity is a component of treatment. The range of existing drugs with prokinetic activity against the gastrointestinal tract is quite large.One of the effective and safe prokinetics registered in October 2020 in Ukraine is the domperidone preparation Doprokin (World Medicine). This drug has a proven effectiveness in the treatment of patients with FD, GERD, chronic gastritis, especially in comorbidity with Diabetes mellitus II (diabetic gastroparesis) and gastroparesis of other etiology. This is a selective dopamine antagonist, that blocks D2‑receptors in the central and peripheral nervous systems. It increases the pressure of the lower esophageal sphincter, esophageal clearance, reduces intragastric pressure, activates peristalsis of the esophagus and antrum of the stomach, increases the frequency, amplitude and duration of contractions of the duodenum, reduces the time of passage of food masses through the small intestine. The indications for domperidone administration include relief of symptoms of nausea, vomiting, heartburn, belching, early satiety, bloating. In contrast to metoclopramide, it almost does not cross the blood‑brain barrier and does not cause unwanted central adverse reactions. Doprokin is over the counter preparation. For adults, the recommended dose is 1 tablet (10 mg) 3 times a day (15 — 30 minutes before the meals). The maximal daily dose is 30 mg, maximal treatment duration should not exceed 1 week.

Endoscopic gastric plication for the treatment of GERD and underlying class I obesity.

Endoscopic gastric plication for the treatment of GERD and underlying class I obesity.

Duodenal acidification induces gastric relaxation and alters epithelial barrier function by a mast cell independent mechanism

Duodenal hyperpermeability and low-grade inflammation in functional dyspepsia is potentially related to duodenal acid exposure. We aimed to evaluate in healthy volunteers the involvement of mast cell activation on the duodenogastric reflex and epithelial integrity during duodenal acidification. This study consisted of 2 parts: (1) Duodenal infusion of acid or saline during thirty minutes in a randomized, double-blind cross-over manner with measurement of intragastric pressure (IGP) using high resolution manometry and collection of duodenal biopsies to measure epithelial barrier function and the expression of cell-to-cell adhesion proteins. Mast cells and eosinophils were counted and activation and degranulation status were assessed. (2) Oral treatment with placebo or mast cell stabilizer disodiumcromoglycate (DSCG) prior to duodenal perfusion with acid, followed by the procedures described above. Compared with saline, acidification resulted in lower IGP (P < 0.01), increased duodenal permeability (P < 0.01) and lower protein expression of claudin-3 (P < 0.001). Protein expression of tryptase (P < 0.001) was increased after acid perfusion. Nevertheless, an ultrastructural examination did not reveal degranulation of mast cells. DSCG did not modify the drop in IGP and barrier dysfunction induced by acid. Duodenal acidification activates an inhibitory duodenogastric motor reflex and, impairs epithelial integrity in healthy volunteers. However, these acid mediated effects occur independently from mast cell activation.

Erythromycin stimulates phasic gastric contractility as assessed with an isovolumetric intragastric balloon pressure measurement.

A novel technique to assess gastric motility by measuring the pressure in a low-volume intragastric balloon was developed to monitor (disordered) motility. We previously showed that this technique allows measuring pharmacologically induced inhibition of motility. In this study, we assessed whether it is possible to measure pharmacologically induced stimulation of gastric motility using 200mg erythromycin. Erythromycin is a highly effective stimulator of gastric emptying and contractility. After an overnight fast, a nasogastric balloon catheter was introduced in healthy subjects. After inflation with 120ml of air, the catheter was connected to a pressure sensor. Intraballoon pressure was continuously recorded for 4h. After a baseline recording of 2h, 200mg erythromycin was infused intravenously over 20min while the recording continued for 2h. Epigastric symptoms were surveyed on 100-mm visual analogue scales. Motility was quantified from the pressure recording as a gastric balloon motility index. Wilcoxon signed-rank tests were performed. Data are shown as median (interquartile range). Six subjects were enrolled and five completed the procedures (age: 28 (25-29) years, body mass index: 24.0 (23.8-24.5) kgm-2 ). One subject could not tolerate tube placement. Bloating, nausea, and epigastric sensation scores were 0 (0-3), 0 (0-1), and 1 (0-1) mm, respectively. Erythromycin significantly increased the motility index from 0.48 (0.41-0.51) to 0.79 (0.70-0.82) (p=0.03). Gastric motility assessed via pressure measurement in a low-volume intragastric balloon is able to detect pharmacologically stimulated motility in healthy subjects, which further validates this technique.

S3427 Cannabis in Relation to Gastroesophageal Reflux Disease

INTRODUCTION: There is a wide distribution of cannabinoid receptors (CBR) in the enteric nervous system, highlighting the role of cannabis in GI health and disease. Of these, CB1 is most often expressed and has been shown to decrease intra-gastric pressure, affect transient LES relaxation (TLESR), and concurrently delay gastric emptying via inhibition of excitatory neurons. We compared three different articles on their studies of cannabinoid receptors in relation to the upper GI tract. The goal of this systematic review is to assess the current knowledge of cannabis implementation, effectiveness, and its adverse side effects, in addition to identifying areas for expanding research. CASE DESCRIPTION/METHODS: In a study conducted by Calabrese et al, 87 total subjects consisting of 10 controls, 39 with non-erosive esophageal reflux (NERD), and 38 with erosive esophageal reflux (ERD) who had typical symptoms for >1 year had eight specimens of macroscopically normal esophageal mucosa taken and analyzed for expression of CBRs. Beaumont et al assessed the response of 10 mg and 20 mg Δ9-THC, a cannabinoid agonist, given three doses each a week apart in healthy volunteers. LES pressure, spontaneous swallows, and reflux episodes were measured. Scarpenllini et al studied the effects of a CB1 receptor antagonist Rimonabant on fasting and postprandial LES function in healthy subjects. Twelve healthy volunteers underwent esophageal manometry studies with administration of wet swallows and a meal after 3 days of premedication with placebo or 20 mg of Rimonabant. Transient LES relaxations and reflux episodes were measured. DISCUSSION: There is a need for more research to be performed, not only on the effects of THC on the GI system, but also for dosing to determine whether or not cannabis can be used as a therapy for esophageal disorders. With increased regulation of cannabis products and further research, consumers would be able to reduce the risks of experiencing unpleasant side effects. It is important to note that cannabis use can also lead to complications, including cannabinoid hyperemesis syndrome. No definitive recommendations can be made at this time on whether or not cannabis use will be a useful therapy for GI disorders until more research is completed.

Usage of Laryngeal Mask Airway Devices in Veterinary Medicine

Abstract Providing a secure airway management during general anesthesia could be problematic in some medical cases, especially when there is a risk of regurgitation and aspiration of the gastric content due to increased intragastric pressure. The current study aimed to test the applicability of two types of LMA in several animal species and to compare its effectiveness to the endotracheal intubation method in securing sealed airway respiration as an alternative to using endotracheal tubes. The study was conducted in dogs (n=33), cats (n=9), swine (n=9), rabbits (n=5), sheep (n=7) and roe deer (n=1). One or both types of laryngeal masks were used for each animal species: LMA Classic™-cLMA and LMA ProSeal™-PLMA. The assessment of each laryngeal mask was performed by determining the insertion technique, the possibilities of first-attempt insertion and malposition, the compliance with various animal species, ventilation time, cuff pressure, and sealing capacity. The highest LMA size compatility in dogs (23,87±14,30 kg) was size-3 in six and size-4 in forteen subjects; In swine (43,22±12,32 kg), size-4; In rabbits (3,84±0,36 kg) size-1; and in sheep (48,29±4,65 kg) size-3 and size-4. Ventilation time was highest in swine and roe deer (121,11±42,85 min and 300,00 min, respectively) and lowest in cat (28,33±16,96 min). First-attempt LMA insertion success was lowest in rabbits (60%), and highest in sheep and roe deer (100%). Malposition was with highest rate in rabbits (40%) and lowest in cat, sheep and roe deer (0%). Gastric reflux was most frequently observed in sheep (71,4%) and roe deer (100%). The usage of LMA in the veterinary anesthetic practice significantly improves airway management in animals during general anesthesia. The inflated LMA cuff does not prevent its disposition. Therefore, both the drain and respiratory tubes must be fixed. The usage of LMA in rabbits was associated with higher incidence of malposition and other complications. Our findings suggest that LMA designed for humans can be used for airway management in veterinary medicine.

Laparoscopic Clip Gastroplasty with the BariClip.

Having the advantages of the reversibility by clipping and not cutting the stomach, the BariClip procedure reproduces the effect of the SG [1, 2] without adding the risk of leaks, and minimizes the occurrence of postoperative GERD by decreasing the intragastric pressure [3]. We present an edited video on the placement of a BariClip with the main steps of the procedure for a female patient with a BMI 41kg/sqm. A 36F bougie is placed to calibrate the size of the pouch. Using a laparoscopic approach, the BariClip is placed into the peritoneal cavity through a 12mm trocar. The BariClip is then closed around the stomach parallel to the lesser curvature, creating a small medial pouch and an excluded large lateral segment. To prevent slippage (rate is approximately 3%), the BariClip is sutured to the gastric wall both anteriorly and posteriorly at various levels of the stomach, as shown in the video. Despite the possibility to suture on either side of the BariClip, the left indentations are preferred in order to avoid vessels of the lesser curvature which are closer to the right indentations. The recovery was uneventful, and 4h after the surgery, the patient was tolerating liquids. She was discharged the following day with a prescription of PPI (pantoprazole 40mg) for 30days and of clexane 0.4 IM for 5days. As with most bariatric procedures, she was started on 2weeks of liquids, followed by 2weeks of soft diet, before experiencing solid food. At 1month after surgery, the patient had lost 10% of her TBW, and at 1-year follow-up, she had lost 31% of her TBW. She had no reflux, pain, or any other complaints and was very happy. The closing of the BariClip has been designed to be a low-pressure system, and in addition, it has a wide inferior outlet (2.5cm), which does not create high intraluminal pressure. Both of these factors result in a low risk of erosion and of GERD. The rate of erosion in the original series was 1.3% with up to a 7-year history of implantation. The most common complication encountered at the beginning of our experience has been a slippage of the BariClip, and with the learning curve, this rate dropped to 3%. The QOL has been studied on a first series of patients and showed good results comparable with those given with the LSG and the RYGB [4]. In conclusion, the BariClip accomplishes almost similar weight loss as a SG, without a gastrectomy, without risks of leaks, and without causing reflux, and at the same ,time the BariClip is reversible [5].

High-resolution impedance manometry and 24-hour multichannel intraluminal impedance with pH testing before and after sleeve gastrectomy: de novo reflux in a prospective series.

Laparoscopic sleeve gastrectomy (SG) is increasingly popular but concern regarding its effect on gastroesophageal reflux disease remain. The current literature is conflicting, and there have been little objective data. To objectively and more accurately assess the impact of SG on esophago-gastric physiology. Centre of Excellence in Metabolic and Bariatric Surgery, Private Hospital, Australia. Prospective cohort study of 31 patients undergoing SG with high-resolution impedance manometry (HRM), 24-hour multichannel intraluminal impedance combined with pH testing (MII-pH), and Gastroesophageal Reflux Disease Symptom Assessment Scale (GSAS) questionnaire 1 month before and 6 months after SG. There were 31 patients that underwent SG, 20 with synchronous hiatal repair and fixation, and 6 that were excluded. HRM demonstrated significantly increased intragastric pressures (15.5-29.6 mm Hg) and failed swallows (3.1-7.5%) but no other change in esophageal motility. MII-pH did not demonstrate significant changes in acid exposure time (8.5%-7.5%) or number of reflux episodes, although the numbers of long reflux episodes (2.3-4.7) and weak acid reflux episodes were significantly increased (15.4-55.2). DeMeester and GSAS scores were not significantly changed. There was no significant difference in patients with preexisting reflux. However, for patients without preexisting reflux, acid exposure time increased significantly (1.3%-6.7%), as did DeMeester scores (5.8-24.5) and the numbers of long reflux episodes (.1-4.4) and weakly acidic episodes (22.1-89.2). SG was associated with increased intragastric pressures, without changes in esophageal motility or acid exposure. For patients without preexisting reflux, there were increases in acid exposure time, long reflux episodes, weakly acidic reflux episodes, and DeMeester score.

High-resolution manometry features of paraesophageal hernia.

Paraesophageal hernias (PEH) can be associated with obstructive symptoms, but high-resolution manometry (HRM) characteristics have not been described in detail. HRM studies of confirmed PEH patients (n=60, 66.3±1.5years, 76.7% F), axial hernias (n=125, 56.1±1.1years, 58.4% F), and healthy controls (n=20, 27.9±0.7years, 45% F) were analyzed. Axial hernias (type 1) were compared to PEH subtyped as isolated PEH (type 2), PEH with axial hernia (type 3), PEH with herniated abdominal organs (type 4), and unknown. Distal contractile integral (DCI), esophageal length, lower esophageal sphincter pressures (LESP), EGJ contractile integral (EGJ-CI), and integrated relaxation pressure (IRP) were extracted. Intra-luminal pressures were measured proximal (intrabolus pressure, IBP) and distal (intragastric pressure, IGP) to EGJ. Univariate and multivariate analyses were performed to characterize esophageal and EGJ motor physiology in PEH. PEH patients had LESP and EGJ-CI similar to controls; axial hernia patients had lower LESP. While IRP was within normal limits, PEH had elevated IBP and IGP, and shorter esophageal length compared to axial hernia and normal controls (P≤.0001 across groups). Short esophageal length was consistent across PEH subtypes (P=.06). On multivariate regression analysis, IBP remained an independent predictor of PEH (P<.0001). Within PEH subtypes, gastric pressure was higher when axial HH was also present, in contrast to isolated PEH (P=.03); other metrics did not differ. Luminal pressure increase both upstream and downstream of the EGJ on HRM likely represents obstructive phenomena in PEH, identification of which may support suspicion of PEH.

Postobesity Surgery Esophageal Dysfunction: A Combined Cross-Sectional Prevalence Study and Retrospective Analysis.

Esophageal dysmotility including features of achalasia may develop because of bariatric surgery. However, the prevalence of these complications is unknown. We sought to define the prevalence of dysphagia and major esophageal motility disorders including achalasia after bariatric surgery through a large retrospective database review. Patients with a history of laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass who underwent a diagnostic high-resolution impedance manometry (HRIM) either before or after bariatric surgery across 3 large tertiary referral sites from June 2012 through February 2019 were identified from a procedural database. HRIM studies were interpreted per the Chicago classification v3.0 by a blinded investigator (K.R.). Demographic/clinical features were collected. In addition, patients who underwent bariatric surgery from January 2014 to April 2015 were contacted and administered a validated symptom assessment survey to gauge the overall prevalence of dysphagia in a postbariatric population. A total of 137 patients were identified, including 97 who underwent HRIM after bariatric surgery (laparoscopic sleeve gastrectomy [n = 39, 40.1%]; Roux-en-Y gastric bypass [n = 58, 59.8%]) at a median of 5.84 years (interquartile range 2.1-12.5) postoperatively and 40 preoperative bariatric surgery candidates with medically complicated obesity. A manometric pattern consistent with achalasia was identified in 7 (7.2%) postsurgical patients compared with none in the preoperative group (P = 0.08). We further identified a separate achalasia-like pattern defined by aperistalsis and increased intragastric pressure (postobesity surgery esophageal dysfunction [POSED]) in 5 (5.2%) postsurgical patients vs none found preoperatively (P = 0.14). Achalasia or POSED was associated with postbariatric surgery (12.4% vs 0%, P = 0.02). Increasing time since surgery was independently associated with the development of achalasia (median 12.5 vs 5.8 years, P = 0.02), POSED (median 15.0 vs 5.8 years, P = 0.02) and major motility disorders (6.6 vs 4.9 years, P = 0.01). Furthermore, among 271 postbariatric surgery patients contacted for symptom assessment via survey, the prevalence of dysphagia was 13.7% at a mean 3.9 years after surgery. Postoperative dysphagia is a common long-term complication of bariatric surgery. This is potentially the consequence of a time-dependent association with the development of postoperative esophageal dysmotility, particularly achalasia and POSED. Consequently, esophageal dysmotility may be an important under-recognized complication of bariatric surgery.

Endokinin A/B stimulates rat gastric motility through myogenic NK1 receptors located in the fundus.

Endokinin A/B (EKA/B), the common C-terminal decapeptide in endokinins A and B, is a preferred ligand of the NK1 receptor and regulates pain and itch. The study focused on the effects of EKA/B on rat gastric motility in vivo and in vitro. Gastric emptying was measured to evaluate gastric motility in vivo. Intragastric pressure and the contraction of gastric muscle strips were measured to evaluate gastric motility in vitro. Moreover, various neural blocking agents and neurokinin receptor antagonists were applied to explore the mechanisms. TAC4 and TACR1 mRNAs were expressed throughout rat stomach. EKA/B promoted gastric emptying by intraperitoneal injection in vivo. Correspondingly, EKA/B also increased intragastric pressure in vitro. Additionally, EKA/B contracted the gastric muscle strips from the fundus but not from the corpus or antrum. Further studies revealed that the contraction induced by EKA/B on muscle strips from the fundus could be significantly reduced by NK1 receptor antagonist SR140333 but not by NK2 receptor antagonist, NK3 receptor antagonist, or the neural blocking agents used. Our results suggested that EKA/B might stimulate gastric motility mainly through the direct activation of myogenic NK1 receptors located in the fundus.