Lower Esophageal High Pressure Zone Research Articles

Influence of Full-body Water Immersion on Esophageal Motor Function and Intragastric Pressure

Background/AimsIn Japan, it is customary to take a daily bath during which the body is immersed in water to the neck. During full-body immersion, hydrostatic pressure is thought to compress the chest and abdomen, which might influence esophageal motor function and intra-gastric pressure. However, whether water immersion has a significant influence on esophageal motor function or intragastric pressure has not been shown. The aim of this study was to clarify the influence of full-body water immersion on esophageal motor function and intragastric pressure.MethodsNine healthy male volunteers (mean age 40.1 ± 2.8 years) were enrolled in this study. Esophageal motor function and intragastric pressure were investigated using a high-resolution 36-channel manometry device.ResultsAll subjects completed the study protocol. Intragastric pressure increased significantly from 4.2 ± 1.1 to 20.6 ± 1.4 mmHg with full-body water immersion, while the lower esophageal high pressure zone (LEHPZ) value also increased from 20.5 ± 2.2 to 40.4 ± 3.6 mmHg, with the latter being observed regardless of dietary condition. In addition, peak esophageal peristaltic pressure was higher when immersed as compared to standing out of water.ConclusionsEsophageal motor function and intragastric pressure were altered by full-body water immersion. Furthermore, the pressure gradient between LEHPZ and intragastric pressures was maintained at a high level, and esophageal peristaltic pressure was elevated with immersion.

Outcome 5 years after 360 degree fundoplication for gastro-oesophageal reflux disease.

Forty patients with a mean age of 45 (range 22-65) years were operated on between 1982 and 1985 for gastro-oesophageal reflux disease with a short floppy 360 degree fundoplication. The results of the operation were determined by endoscopy, oesophageal manometry, ambulatory 24-h pH recording and symptom evaluation 6 months and 5 years after operation. These results were compared with findings in healthy controls. The median pressure in the lower oesophageal high-pressure zone was 13.3 (interquartile range (i.q.r.) 11.3-21.3) mmHg after 5 years, which did not differ significantly from the value at 6 months' follow-up or from that in controls. It was, however, significantly higher than the preoperative pressure. The median intra-abdominal length of the high-pressure zone was 1.7 (i.q.r. 1.3-2.3) cm after 5 years, significantly less than at 6 months but equal to control length. Measurement of the proportion of total time at pH < 4 at 5 years (median 0.2 (i.q.r. 0.0-0.6) per cent) and 6 months after operation revealed a significant reduction in acid reflux compared with preoperative values and normal controls. There was no significant difference in acid exposure between the two postoperative investigations. Endoscopy showed that 27 patients had no oesophagitis, three had erythema and three persistent Barrett's oesophagus 5 years after operation. Normal belching was possible in 22 patients and 18 experienced increased flatulence 5 years after fundoplication. An independent gastroenterologist found that the result was excellent in 16 patients, good in 16 and fair in four; two patients had a poor overall outcome of the operation. It is concluded that a 360 degree fundoplication provides good long-term control of reflux and that slight symptoms of overcompetence are common among patients operated on without affecting the overall result.

Evidence for the flutter valve mechanism of the lower oesophageal high pressure zone.

Simultaneous oesophageal manometry and pH monitoring was performed at rest and during abdominal compression in 189 subjects. The force exerted by the high pressure zone (HPZ) and by its intra-abdominal segment was reduced to the same extent in the 102 subjects who refluxed and the 87 who did not. Reflux during abdominal compression occurred in the subjects whose HPZ force fell into a critical range and in whom the contribution by the abdominal segment was reduced to less than 50 per cent of the total force exerted by the HPZ. These results are more in keeping with a mechanical flutter valve theory of lower oesophageal competence than sphincteric reflux control. Furthermore, the results indicate that measurements of oesophageal pressure, length or force in the resting state do not account for reflux or gastrooesophageal competence, but that it is the reserve of pressure, length or force during stress which is responsible.

Effect of gastrointestinal hormone infusions on lower oesophageal competence of Rhesus monkeys

The lower oesophageal high pressure zone (HPZ) was studied in 5 non-refluxing and 3 refluxing Rhesus monkeys. The changes in HPZ and reflux status in response to infusion of various doses of secretin, cholecystokinin and glucagon were measured in all animals, and, in the 5 non-refluxing monkeys, after oesophagogastrectomy with replacement of the lower oesophagus by a stomach tube. All three hormones consistently produced a transient decrease in the HPZ pressure. The only change in response following oesophagagastrectomy and gastric tube replacement was a significant delay in the response to each hormone. Neither hormone infusion nor operation altered gastro-oesophageal reflux status. It appears that lower oesophageal competence in primates is more dependent on the presence of narrow, muscular, intra-abdominal tube than on a specialized segment of the lower oesophagus.

Double-peaked high-pressure zone at the esophagogastric junction in controls and in patients with a hiatal hernia: a study using high-resolution manometry.

The lower esophageal high-pressure zone (HPZ) consists of the intrinsic lower esophageal sphincter (LES) and the diaphragmatic sphincter. In patients with a hiatal hernia these constituents are separated. We performed high-resolution manometry of the esophagogastric HPZ in six controls, six patients with a small hernia, and six patients with a large hernia. Prevalence of a double-peak pressure profile of the HPZ was noted. Pressures and distances between the peaks were assessed. Prevalence of the double-peak profile was similar between patients with a small hernia and controls, but patients with a large hernia showed a higher prevalence with inspiration (P < 0.05) than the others. The distance between the two peaks was larger in patients with a large hernia (P < 0.05). In conclusion, high-resolution manometry makes it possible to distinguish the diaphragmatic pressure component from the LES. Two pressure peaks can be found both in hernia patients and in healthy volunteers.

Manometric study of hiatal hernia and its correlation with esophageal peristalsis.

The pathogenesis of gastroesophageal reflux disease (GERD) is considered multifactorial, but alterations of the esophagogastric junction (EGJ) and hiatal hernia play a prominent role. The correlations between hiatal hernia and the other pathogenetic factors are as yet unclear, and they need to be investigated by a methodological approach based on new anatomic and functional criteria. Our aim was to study, by stationary manometry, the relationships between small reducible hiatal hernia, identified by endoscopy, and esophageal peristalsis, in patients with and without GERD. According to the absence or presence of esophagitis (E), and the absence or presence of hiatal hernia (H), 58 subjects were divided into four groups: controls 10; H 14; E 10; and HE 24. Stationary manometry was performed by the rapid pull-through (RPT) technique, with catheter water perfused, to study the lower esophageal high pressure zone [lower esophageal sphincter (LES) and diaphragmatic crura] and the parameters of esophageal peristalsis. In patients with hiatal hernia, the various combinations of peak and/or deflection of manometric line pressure identified five EGJ profiles, only one of which reveals (by one-peak profile due to superimposed LES and diaphragmatic crura) the reducibility of the hernia. The frequency of the five profiles was calculated in the HE and H groups: a two-peak profile was significantly more prevalent in these patients, although less so in the group with esophagitis. In E patients the distal amplitude and the distal propagation of esophageal waves were significantly lower than in the other three groups (P < 0.05 vs controls and group HE; P < 0.01 vs group H). Furthermore, the distal amplitude was significantly higher in the group H than in the HE (P < 0.01). Our results show a better definition of hiatal hernia morphology, via the RPT technique, disclosing five pressure profiles. In addition, a significant link was found between small reducible hiatal hernia without GERD and wave amplitude of the distal esophagus. The amplification of peristaltic clearing may be considered the initial protective process against acid reflux; the breakdown of this mechanism may trigger the pathological sequence of GERD.

STUDY FOR ON THE QUALITY OF LIFE IN PATIENTS UNDERGONE ILEO-COLIC INTERPOSITION AFTER PROXIMAL GASTRECTOMY FOR UPPER-HALF GASTRIC CANCER

Some problems still lie in the quality of life for the patients undergone proximal gastrectomy for the upper gastric cancer. Because there are some postoperative complications, such as reflux esophagitis. The aim of this study was to examine whether an extended proximal gastrectomy including D2 lymph node dissection reconstructed with a normoperistaltically aligned insertion of an ileocolic segment reduced postoperative complications or improved the quality of life. Subjects were six patients including four men and two women. To know the quality of life, a questionnaire survey asking about postoperative unpleasant symptoms was conducted more than 1 year after the surgery. Endoscopic findings, esophageal manometric study, body weight, amount of feeding and laboratory data were also investigated until postoperative one year. Postoperative endoscopy did not show any findings of esophagitis in all the patients. In contrast to patients with total gastrectomy, a lower esophageal high pressure zone newly constructed by ileocecal valve was detected in each patient in the esophageal manometric study. The body weight loss at one year after the surgery was 7.1% as compared with the postoperative body weight. The amount of feeding was restored to 95.0% of that of before surgery. All the laboratory data after the surgery were within normal range. It is consequently concluded that the extended proximal gastrectomy including D2 lymph node dissection reconstructed with an insertion of an ileocolic segment is a prominent method for the patients with early or proper muscle cancers located at the upper half of the stomach.

Three-dimensional pressure image and muscular structure of the human lower esophageal sphincter

The structural equivalent to the manometric high pressure zone separating the stomach from the esophagus is still a matter of dispute. We compared the three-dimensional (3D) manometric pressure image with muscular thickness and architecture at the human gastroesophageal junction. Three-dimensional manometric images were obtained in 25 volunteers by using a stepwise pullback technique of a catheter with eight radially oriented pressure transducers. Muscle thickness was measured in four radial directions at 10 levels between the midesophagus and stomach in 37 specimens obtained from organ donors. Muscular architecture was assessed in specimens from 10 organ donors and 12 human cadavers and was related to muscle thickness. Manometric 3D images of the lower esophageal high pressure zone showed a marked radial and longitudinal asymmetry. Radial pressures peaked at the respiratory inversion point and were highest toward the left posterior direction. Anatomic evaluation showed an asymmetric thickening of the muscular layer at the gastroesophageal junction that mirrored the manometric image. Muscle thickness was highest toward the greater curvature side corresponding to the gastric "sling" fibers and toward the lesser curvature corresponding to the semicircular "clasp" fibers. The human lower esophageal sphincter is not a muscular ring. Rather, the perfect match between the manometric pressures and the arrangement of muscular structures at the gastroesophageal junction indicates that the gastric sling fibers and the semicircular clasps are the anatomic correlate of the manometric lower esophageal sphincter in human beings.

Intraoperative manometric study: How to create the lower esophageal high pressure zone: M. Nagaya, M. Tsuda, and Y. Watanabe. J Jpn Soc Pediatr Surg 25:797–802, (May), 1989.

Intraoperative manometric study: How to create the lower esophageal high pressure zone: M. Nagaya, M. Tsuda, and Y. Watanabe. J Jpn Soc Pediatr Surg 25:797–802, (May), 1989.

Intraoperative esophageal manometry and early postoperative esophageal pH monitoring in children.

Intraoperative esophageal manometry has not been correlated with early postoperative extended esophageal pH monitoring (EEpHM) in children with gastroesophageal reflux. Twenty-seven children were studied with the following design: (1) abnormal preoperative EEpHM; (2) intraoperative measurement of lower esophageal high pressure zone (LEHPZ) pressure and length prior to and upon completion of an antireflux procedure; and (3) EEpHM seven to ten days postoperatively. Sixteen had a Nissen or modified Thal fundoplication and eleven a Boerema gastropexy. The postoperative EEpHM was normal in patients with fundoplication regardless of the increase in LEHPZ pressure (-4 to 36 mmHg) or length (0 to 2.5 cm). Four of the patients (36%) who had a gastropexy had abnormal EEpHM. The postoperative frequency of reflux was related inversely to the elevation of LEHPZ pressure (-3 to 39 mmHg), but not to the LEHPZ length (0 to 4.5 cm). Duration of reflux was independent of observed intraoperative manometric changes. In conclusion, early postoperative EEpHM in children having a gastropexy correlates with intraoperative increases in the LEHPZ pressure. There is no such correlation in children having a fundoplication procedure.

Intraoperative Manometric Study: How to Create the Lower Esophageal High Pressure Zone

Intraoperative Manometric Study: How to Create the Lower Esophageal High Pressure Zone

The effect of various types of gastrostomy on the lower esophageal sphincter

Previous studies have demonstrated a cause and effect relationship between standard Stamm gastrostomy (SG) and subsequent gastroesophageal reflux (GER). To further investigate this clinical problem, three additional types of gastrostomy were evaluated in regard to their influence on the lower esophageal high pressure zone (LEHPZ). Twenty-three male cats were entered in the study weighing 2.6 to 3.6 kg. Baseline manometric studies of the LEHPZ were determined after ketamine anesthesia. In group I (n = 9), Witzel gastrostomy was performed over a 12 Fr catheter without fixation of the stomach to the anterior abdominal wall. In group II (n = 7), percutaneous gastrostomy was performed without fixation of the stomach to the anterior abdominal wall. In group III (n = 7), percutaneous gastrostomy was performed but the stomach was firmly fixed to the abdominal wall. LEHPZ pressures were then repeated 2 weeks postoperatively. Mean preoperative LEHPZ pressure for group I was 16.2 +/- 3.72 mmHg, group II was 16.5 +/- 6.91 mmHg, and group III was 18.3 +/- 5.59 mmHg. Mean postoperative pressure for group 1 was 14.7 +/- 4.26 mmHg, group II was 16.5 +/- 5.77 mmHg, and group III was 10.8 +/- 3.97 mmHg. LEHPZ pressure was similar preoperatively and postoperatively in groups I and II but was significantly decreased postoperatively (P less than .01) in group III. Contrast studies demonstrated maintenance of the angle of His in group 1 and II and alteration of the angle of His in group III. Gastrostomy associated with fixation of the stomach to the anterior abdominal wall results in decreased LEHPZ pressures. This predisposes the subject to GER.(ABSTRACT TRUNCATED AT 250 WORDS)

Diverticula of the mid- and lower esophagus: pathogenesis and surgical management.

AbstractTen patients with diverticula of the mid‐ or lower esophagus are reviewed with a focus on esophageal function, particularly motility, and its relation to surgical treatment. Median age is 56 years (range 16–79). There are 5 males and 5 females. The predominant symptoms were dysphagia and regurgitation, generally of 3 to 4 years' duration. All diverticula were identified by both barium upper gastrointestinal tract series and endoscopy. Three patients had 2 diverticula. The lower esophageal high pressure zone (LEHPZ) was assessed manometrically in 7 patients and the function of the esophageal body in all. LEHPZ pressure, length, and relaxation were normal in 4 patients, incomplete relaxation was present in 1 patient, and 2 had increased pressure. All 10 had abnormal esophageal body function including abnormalities of amplitude, duration, or propagation of contractions. pH assessment for reflux and clearance was performed in 4 patients. The acid clearance test was abnormal in all 4, and 2 patients had gastroesophageal reflux. One patient was managed medically and the other 9 surgically. Surgical treatment included diverticulectomy, myotomy, and an antireflux procedure in 7 patients; diverticulopexy, myotomy, and antireflux procedure in 1, and myotomy and antireflux procedure in 1. There was no operative mortality. Longterm clinical results are good. We conclude that symptomatic midesophageal and epiphrenic diverticula are caused by an abnormality of esophageal body or LEHPZ function which can be identified manometrically. These should, therefore, be thought of as pulsion diverticula. Surgery that addresses the underlying motor disorder can be performed safely and provides relief of symptoms.

Lower esophageal pressure changes with tube gastrostomy: A causative factor of gastroesophageal reflux in children?

In children, Stamm tube gastrostomy can initiate gastroesophageal reflux (GER) or worsen preexisting GER. We identified a possible mechanism for this problem in 25 children with GER who had esophageal manometry performed in conjunction with an antireflux operation. Intraoperative lower esophageal high pressure zone (LEHPZ) pressure and length were recorded for a simulated gastrostomy in all patients prior to performing the antireflux operation. These same parameters were then recorded for a simulated (11 patients) or real gastrostomy (14 patients) following the antireflux procedure. The LEHPZ pressure decreased with simulated Stamm gastrostomy (7.8 +/- 1.1----6.6 +/- 1.1 mm Hg, NS: Normal = 11.2 +/- 0.9 mm Hg). This decrease was less significant than the decrease in LEHPZ length (1.1 +/- 0.1----0.8 +/- 0.1 cm, P less than .01: Normal = 1.3 +/- 0.1 cm). Following Boerema gastropexy, simulated gastrostomy produced a similar decrease in LEHPZ pressure (20.8 +/- 3.8----17.1 +/- 2.7 mm Hg, NS) and length (3.3 +/- 0.4----2.5 +/- 0.3 cm, P less than .025). The LEHPZ pressure and length were not decreased by real gastrostomy performed with modified Thal fundoplication or with Nissen fundoplication. Thus, a decrease in LEHPZ length may be one mechanism whereby GER is initiated or worsened by tube gastrostomy in children. Tube gastrostomy has a similar effect when performed with a Boerema gastropexy, but not when performed with a Nissen or modified Thal fundoplication.

遊離空腸移植による下咽頭頚部食道再建術における内圧測定からみた再建食道の運動機能

Nine cases with free jejunal reconstruction after hypopharyngolaryngoesophagectomy were evaluated reconstructed esophageal functions by manometric studies.The pharyngoesophageal high pressure zone disappeared, and the intra luminal pressure of freely transplanted jejunum was almost equal to atomospheric pressure, although the remaining intact esophagus including the lower esophageal high pressure zone had no significant changes on the resting pressure.Spontaneous movement of transplanted jejunum was observed for 26% of the examination time of four to five hours after meals. Movement similar to phase III intestinal contractions of Code's classification was seen intermittently for 43% of the spontaneous movement. Over night continuous recording showed that these rhythmic high pressure contractions were less predominant in the three hours after meals than in the four to twelve hours after meals.No propagating pressure waves were observed in the transplanted jejunum on deglutition with or without jejunal spontaneous movement, though synchronous spike waves were also seen in the pharynx and jejunum. However normal peristaltic waves in the residual esophagus and normal reluxation of lower esophageal sphincter also appeared.We speculate from this study that patients' symptoms of disswallowing or nasal regurgitation in the early postoperative period are mainly owing to phase III contractions occasionally encountered, because the pressure sometimes rise up to more than 100cmH2O and it may be higher than the degultition pressure or the obstructive pressure of nasopharyngeal cavity.

The Experimental Studies Related to the Lower Esophageal High Pressure Zone in Dogs

The Experimental Studies Related to the Lower Esophageal High Pressure Zone in Dogs

Effect of Nissen fundoplication on competence of the gastro-oesophageal junction.

The changes produced by the Nissen fundoplication were measured in 12 patients, who required surgery to control their reflux oesophagitis. The gastro-oesophageal junction of each patient was studied before and three months after operation by station pullthrough manometry and prolonged pH monitoring of the distal oesophagus. All patients were free from reflux symptoms post-operatively. The Nissen fundoplication resulted in a significant increase in the pressure, but not the length, of the lower oesophageal high pressure zone. A greater proportion of this zone was situated in the abdomen postoperatively. Prolonged pH monitoring showed a significant improvement in all the measured indices of acid reflux. Nissen fundoplication restores competence to the gastro-oesophageal junction as judged by manometry and pH monitoring. This kind of study should be performed to document the efficiency of other anti-relfux procedures.

The effect of small bowel resection and subsequent precise antrectomy on lower esophageal function in rhesus monkeys

The lower esophageal high pressure zone (HPZ) was characterized manometrically and reflux status determined in eight male rhesus monkeys. The studies were repeated six weeks and six months after 50 per cent distal small bowel resection. At the same time fasting serum gastrin and gastric inhibitory polypeptide values were assayed. In seven animals precise antrectomy with gastroduodenal anastomosis was performed and the studies repeated. HPZ pressure increased from 6.7 ± 0.67 mm Hg (± 1 SEM) to 10.3 ± 0.76 mm Hg at six weeks (p < 0.005). At six months the pressure was 9.3 ± 1.02 mm Hg (p < 0.02) and after antrectomy 15.2 ± 3.1 (not significant from 6 month value, p < 0.02 from control). Serum gastrin and GIP values showed significant elevations at six weeks, but six month and postantrectomy results were not statistically different from control. Reflux episodes for the group were reduced at six weeks and six months. After antrectomy increased reflux was noted.

Effect of pentagastrin infusion on gastroesophageal manometry and reflux status before and after esophagogastrectomy

The lower esophageal high pressure zone of eight Rhesus monkeys was characterized by manometry and reflux testing. It was found to respond characteristically to pentagastrin infusions. After excision of the lower esophageal segment and its replacement by a stomach tube, an apparently normal, functional high pressure zone was demonstrable within the substitute.

Effect of bowel resection on lower esophageal high pressure zone and reflux status in rhesus monkeys

Giles et al. [5] in 1969 and Caste11 and Harris [2] in 1970 have shown that gastrin has a tonic effect on the lower esophageal high pressure zone (HPZ). The physiologic significance, if any, of the influence of hormones on the gastroesophageal junction remains the subject of much controversy. Massive bowel resection increases gastric acid secretion, presumably by a humoral mechanism. Recently serum gastrin has been shown to be significantly elevated under these circumstances in both dog [16] and man [ 141. We investigated the effect of altering the humoral milieu by 50% small bowel resection on the HPZ pressure and functional integrity of the lower esophagus. The animal model used was the subhuman primate Macaca mulatta.