Lower Esophageal Sphincter Dysfunction Research Articles

When less is more: lower esophageal sphincter-preserving peroral endoscopic myotomy is effective for non-achalasia esophageal motility disorders.

Non-achalasia esophageal motility disorders (NAEMDs), encompassing distal esophageal spasm (DES) and hypercontractile esophagus (HCE), are rare conditions. Peroral endoscopic myotomy (POEM) is a promising treatment option. In NAEMDs, unlike with achalasia, the lower esophageal sphincter (LES) functions normally, suggesting the potential of LES preservation during POEM. This retrospective two-center observational study focused on patients undergoing LES-preserving POEM (LES-POEM) for NAEMD. Eckardt scores were assessed pre-POEM and at 6, 12, and 24 months post-POEM, with follow-up endoscopy at 6 months to evaluate for reflux esophagitis. Clinical success, defined as an Eckardt score ≤3, served as the primary outcome. 227 patients were recruited over 84 months until May 2021. Of these, 16 underwent LES-POEM for an NAEMD (9 with HCE and 7 with DES). The median pre-POEM Eckardt score was 6.0 (interquartile range [IQR] 5.0-7.0), which decreased to 1.0 (IQR 0.0-1.8; P<0.001) 6 months post-POEM. This was sustained at 24 months, with an Eckardt score of 1.0 (IQR 0.0-1.8; P<0.001). Two patients (12.5%) developed Los Angeles grade A or B esophagitis. LES-POEM for NAEMD demonstrates favorable clinical outcomes, with infrequent esophagitis and reintervention for LES dysfunction rarely required.

Clinicopathological characteristics of patients with oesophageal squamous papilloma in Turkey and comparison with the literature data: The largest case series ever reported from Turkey.

Oesophageal squamous papilloma (ESP) is a rare tumoural lesion of the oesophagus considered to have a benign course. Due to the fact that they are rare lesions, there are not many publications with large case series on ESPs in the literature. In this study, we aimed to investigate the clinical, endoscopic and histopathological characteristics of ESPs. Reports of upper gastrointestinal endoscopies performed in the endoscopy unit within the Division of Gastroenterology of a tertiary care hospital in the Southeastern Anatolia Region of Turkey in the last 8-year period were evaluated retrospectively. Patients who were determined to have oesophageal polypoid lesions during the endoscopic procedure and were then diagnosed with oesophageal squamous cell papilloma in the histopathological examination were included in the study. Of 11541 patients who underwent upper gastrointestinal endoscopy, 51 were diagnosed with a total number of 55 ESPs (0.44%). In addition, 26 of these patients (51%) were female, and the mean age of the patients at the time of diagnosis was 42.2years. The average size of the ESPs was 3.47mm, and the most frequent location was the middle oesophagus with 51%. No statistically significant relationship was found between the location of ESPs and gender, endoscopy indication, oesophagitis, lower oesophageal sphincter dysfunction, hiatal hernia, gastroesophageal reflux disease (GERD) and Helicobacter pylori positivity. In this study with the largest case series ever reported from Turkey, it was determined that ESPs were seen in younger ages in Turkey and were also smaller in size, which is not in agreement with the literature data. Besides, this study, in which ESPs were most frequently detected in the middle oesophagus, supports the view that GERD may not be the main factor in ESP aetiology.

Preoperative physiological esophageal assessment for anti-reflux surgery: A guide for surgeons on high-resolution manometry and pH testing.

Gastroesophageal reflux disease (GERD) is one of the most commonly encountered digestive diseases in the world, with the prevalence continuing to increase. Many patients are successfully treated with lifestyle modifications and proton pump inhibitor therapy, but a subset of patients require more aggressive intervention for control of their symptoms. Surgical treatment with fundoplication is a viable option for patients with GERD, as it attempts to improve the integrity of the lower esophageal sphincter (LES). While surgery can be as effective as medical treatment, it can also be associated with side effects such as dysphagia, bloating, and abdominal pain. Therefore, a thorough pre-operative assessment is crucial to select appropriate surgical candidates. Newer technologies are becoming increasingly available to help clinicians identify patients with true LES dysfunction, such as pH-impedance studies and high-resolution manometry (HRM). Pre-operative evaluation should be aimed at confirming the diagnosis of GERD, ruling out any major motility disorders, and selecting appropriate surgical candidates. HRM and pH testing are key tests to consider for patients with GERD like symptoms, and the addition of provocative measures such as straight leg raises and multiple rapid swallows to HRM protocol can assess the presence of underlying hiatal hernias and to test a patient’s peristaltic reserve prior to surgery.

Prevalence and Risk Factor of Gastro-esophageal Reflux Disease among Hail Population, Saudi Arabia

Aims: Gastroesophageal reflux disease (GERD) is a common gastrointestinal disorder that develops when the contents of the stomach reflux into the esophagus due to large hiatal hernia or lower esophageal sphincter dysfunction. The common symptoms of the disease include heartburn and regurgitation. It takes place mainly among youngers, females, and obese people. The aims of the study include GERD prevalence among Hail population and the related risk factors.&#x0D; Study Design: Cross-sectional study.&#x0D; Place and Duration of Study: Hail, Kingdom of Saudi Arabia. Between July to December 2020.&#x0D; Methodology: A cross-sectional study conducted with 704 subjects aged more than 15 years, through self-administered questionnaire consisting of 22 questions. The questionnaire included demographic data, GERD clinical symptoms, and individual behaviour. Statistical data analyzed by using SPSS version 22.&#x0D; Results: Out of 704 subjects, nearly half of the participants were males (51.7%). GERD was found in 408 (58%) participants among them 276 (39.2%) had mild symptoms, 9.9%, had moderate symptoms and 62 (8.8%) had severe condition. Most significant predictors of GERD (P &lt;0.05) were Females with chronic health problems, anxiety, and having Spicy food. The participants with sports activity had less risk to develop GERD.&#x0D; Conclusion: The results showed high prevalence of GERD among Hail population with many significant predictors. Public health providers should increase awareness about GERD and its significant effects on community.

Gastroesophageal Intussusception in Canine

Background: Gastroesophageal intussusception is characterized by the invagination of the stomach into the esophagus, with or without the involvementof adjacent organs such as the spleen, pancreas, and omentum. In dogs, this condition has no breed or sex predisposition. As it is an infrequent disease in routine veterinary medical practice, this study reports a case of gastroesophageal intussusception in a dog necropsied at the Veterinary Hospital of the Federal Rural University of Pernambuco (HOVET - UFRPE), Recife, Brazil.Case: The body of a 12-year-old black mixed breed male dog was sent to the Pathology Department (Necropsy Sector of the Federal Rural University of Pernambuco - UFRPE) for a necropsy. The animal had a previous 4-year history of recurrent emesis and limb weakness, primarily in the anterior limbs, that worsened in the previous months and progressed to death. No previous treatments were reported by the owner. On external examination, the animal had a low body score (cachectic), forelimb joints with great flexibility, congested oral and ocular mucous membranes, enophthalmos, and increased volume in the perianal region. At the opening of the thoracic cavity, the final third of the esophagus was dilated and gastroesophageal intussusception, edema, and pulmonary congestion were noted. In the abdominal cavity, there was hepatic and renal congestion and large intestine and rectal ampoule dilation, with a large amount of solid and retained feces (fecaloma), perianal hernia, and testicular neoformation. These findings were consistent with those observed in death caused by cardiorespiratory failure secondary to gastroesophageal intussusception.Discussion: The pathophysiology of gastroesophageal intussusception is still not elucidated and is probably multifactorial. This condition causes reverse gastric peristalsis associated with a sudden and sustained increase in abdominal pressure. Some probable predisposing factors for this pathological condition are esophageal motility disorders, lower esophageal sphincter dysfunction, and hiatal enlargement. In dogs, gastroesophageal intussusception is associated with increased intra-abdominal pressure owing to emesis or blunt trauma, negative intrathoracic pressure caused by respiratory, and previous esophageal diseases, especially megaesophagus. Partial or total obstruction caused by intussusception leads to circulatory disorders in the organs, especially decreased venous return. Persistence of this condition can lead to gastric necrosis and rupture followed by endotoxic (or septic) shock and release of inflammatory mediators that can cause cardiovascular and respiratory dysfunction and rapid death. Impaired circulation is macroscopically evident in several organs, characterized by mucosal, lung, liver, and kidney congestion, in addition to cardiac dilation and mitral valve endocardiosis. The occurrence of stomach invagination into the esophagus dilated in the final portion is characteristic of gastroesophageal intussusception. Moreover, death owing to cardiorespiratory failure is related to cardiac (dilatation and endocardiosis) and pulmonary (edema and congestion) involvement secondary to gastroesophageal intussusception. Since thispotentially fatal condition has a low incidence in small animals and often goes unnoticed by professionals, early and correct diagnosis along with surgical treatment are essential for a good prognosis and favorable progression.

Laparoscopic Posterior Partial Fundoplication for Gastroesophageal Reflux Disease.

Gastroesophageal reflux disease (GERD) is a common condition that greatly impacts quality of life. Management options include medical and surgical therapies. Nonoperative management typically relies on longitudinal use of acid-suppressive medications such as proton pump inhibitors, which is associated with a significant financial burden and an increasing number of recognized side effects. The surgical management of GERD is focused on correction of the lower esophageal sphincter dysfunction by means of a fundoplication, thus limiting acid and nonacid gastroesophageal reflux. Multiple techniques have been described, including use of complete (360°) fundoplication or partial fundoplication in either an anterior (180°) or posterior (220-270°) position. Recent studies have shown that the total and the partial fundoplications are similarly effective in controlling GERD. A partial fundoplication may also be advantageous when treating patients with GERD and poor esophageal motility. This article focuses on the posterior partial (modified Toupet) fundoplication, with attention to the key elements of the preoperative workup, appropriate patient selection, and important technical steps that are associated with the best outcomes.

Distal esophageal spasm: Update on diagnosis and management in the era of high-resolution manometry.

Distal esophageal spasm (DES) is a rare major motility disorder in the Chicago classification of esophageal motility disorders (CC). DES is diagnosed by finding of ≥ 20% premature contractions, with normal lower esophageal sphincter (LES) relaxation on high-resolution manometry (HRM) in the latest version of CCv3.0. This feature differentiates it from achalasia type 3, which has an elevated LES relaxation pressure. Like other spastic esophageal disorders, DES has been linked to conditions such as gastroesophageal reflux disease, psychiatric conditions, and narcotic use. In addition to HRM, ancillary tests such as endoscopy and barium esophagram can provide supplemental information to differentiate DES from other conditions. Functional lumen imaging probe (FLIP), a new cutting-edge diagnostic tool, is able to recognize abnormal LES dysfunction that can be missed by HRM and can further guide LES targeted treatment when esophagogastric junction outflow obstruction is diagnosed on FLIP. Medical treatment in DES mostly targets symptomatic relief and often fails. Botulinum toxin injection during endoscopy may provide a temporary therapy that wears off over time. Myotomy through peroral endoscopic myotomy or via surgical Heller myotomy can provide long term relief in cases with persistent symptoms.

Anterior Cervical Idiopathic Hyperostosis and Dysphagia: The Impact of Surgical Management—Study of a Series of 11 Cases

To assess the efficacy and safety of surgery for dysphagia in anterior cervical idiopathic hyperostosis. This retrospective study included 11 consecutive patients presenting with dysphagia and anterior cervical idiopathic hyperostosis. Computed tomography scans and dynamic swallowing fluoroscopies were performed. The site of compression and the size and position of osteophytes were measured. The clinical outcomes and complications were recorded. Two patients with anterior esophageal compression were found to have dysphagia caused by lower esophageal sphincter dysfunction. In the remaining 9patients, the level of maximal compression was between C3 and C5 with the size of the osteophytes ranging from 8 to 17 mm. Intubation was challenging in 7 patients. Postoperative transient worsening of dysphagia was encountered in 3 patients. Two patients experienced severe complications including aphagia and respiratory compromise. Within 2 months of the operation, all patients reported satisfactory improvement of symptoms and a considerable gain in quality of life. No recurrence had occurred at final follow-up. Anterior cervical hyperostosis causing dysphagia typically affects older men and results from compression between C3 and C5 from osteophytes of variable sizes. Operative intervention can provide long-lasting resolution of symptoms but is complicated by difficulty in endotracheal intubation, postoperative dysphagia, and rarely respiratory compromise. A systematic preoperative ear, nose, and throat consultation is recommended to reduce these complications.

3099 Endoscopic Botulinum Toxin Injection for Tacrolimus-Induced Achalasia in a Renal Transplant Recipient

INTRODUCTION: Multiple medications have been associated with secondary achalasia. Here we present a patient who developed dysphagia 4 days after his renal transplant and was found to have achalasia thought to be due to his tacrolimus; he was successfully treated with botulinum injection. To our knowledge, this is the first case of tacrolimus-induced achalasia ever reported in a renal transplant patient; it is also the first case in a transplant patient to be treated endoscopically with botulinum injection. CASE DESCRIPTION/METHODS: A 58 year old man with a history of end stage renal disease secondary to focal segmental glomerulosclerosis presented with progressive renal failure and underwent deceased kidney transplant without complications. At clinic, follow-up on post-operative day #4, the patient reported difficulty in swallowing since post-operative day two. A modified barium swallow study (Figure 1) demonstrated severe esophageal dysmotility and lower esophageal sphincter dysfunction concerning for achalasia. Upper endoscopy (Figure 2) one week later revealed a dilated esophagus with mild edema but without focal lesions or ulcerations. Esophageal manometry (Figure 3) evidenced outflow obstruction of the esophagogastric junction and weak peristalsis in the esophageal body, confirming the diagnosis of achalasia. Surgical therapy and changing his calcineuron inhibitor for achalasia were considered too high risk in this patient so shortly after transplant. The patient ultimately underwent therapy with endoscopic botulinum toxin injection (100 units) of the lower esophageal sphincter. He had excellent results with immediate and complete resolution of dysphagia. DISCUSSION: The proposed mechanism for CNI induced changes in esophageal motility involves inhibition of nitric oxide synthase by CNIs. Nitric oxide (NO) is responsible for esophageal peristalsis as well as relaxation of the lower esophageal sphincter (LES). Although it is unclear why switching between different CNIs would lead to symptom resolution, individual variation in the reaction to the different chemical structures of tacrolimus and cyclosporine has been proposed. Botulinum toxin can be considered as a therapeutic option in those patients who are not candidates for a change in their immunosupression. To our knowledge, this is the first case of botulinum induced achalasia reported after a kidney transplant and also the first successfully treated with botulinum toxin injection.

Tu1283 – Esophagogastric Junction Outflow Obstruction Associated with Hypercontractility May Represent Primary Lower Esophageal Sphincter Dysfunction in Patients with Suspected Gastroesophageal Reflux Disease

Tu1283 – Esophagogastric Junction Outflow Obstruction Associated with Hypercontractility May Represent Primary Lower Esophageal Sphincter Dysfunction in Patients with Suspected Gastroesophageal Reflux Disease

Prevalence and risk factors of gastroesophageal reflux disease among Shaqra University students, Saudi Arabia.

Introduction:Gastroesophageal reflux disease (GERD) is one of the most common chronic gastrointestinal disorders in adults, it develops when the stomach contents reflux and rise up into the esophagus as a result from lower esophageal sphincter dysfunction. Stomach acid that touches the lining of the esophagus causes symptoms and complications. The classical symptoms of GERD include heartburn, usually after eating, chest pain, and regurgitation.Aim:To measure the prevalence of gastroesophageal reflux disease and determine its risk factors among the students of Shaqra University.Methods:A cross-sectional study was conducted using a structured questionnaire distributed among Shaqra University students after multistage stratification and random sampling technique to stratify students according to gender and the three main colleges in Shaqra city, Saudi Arabia. The sample size was determined to be 435 with the precision of ± 5% and a 95% confidence interval (CI). The questionnaire included demographic data like age, gender, height and weight, lifestyle, and dietary habits. Statistical data were analyzed using the Statistical Package for Social Sciences (SPSS) version 16. Results with a P value of <0.05 were considered statistically significant.Results:A total of 400 [227 (56%) male and 173 (43%) female] participants were evaluated. And 95 participants got a gastroesophageal reflux disease questionnaire score of ≥8 thus determining the prevalence of GERD to be 23.8%. Univariate analysis revealed that gender, smoking, familial history of GERD, high body mass index (>25 kg/m2), fast food, tea, carbonated beverages consumption, quick eating, and sleeping within 1 hour of dinner are associated with symptomatic GERD (P < 0.05).Conclusion:The results show a high prevalence of GERD in Shaqra university students and the presence of many modifiable risk factors which merits the conduction of public health campaigns to raise awareness about the disease and its risk factors.

Esophageal Dysmotility in Patients following Total Laryngectomy.

Objectives Dysphagia is common in total laryngectomees, with some symptoms suggesting esophageal dysmotility. Tracheoesophageal (TE) phonation requires effective esophagopharyngeal air passage. Hence, esophageal dysmotility may affect deglutition or TE phonation. This study aimed to determine (1) the characteristics of esophageal dysmotility in laryngectomees, (2) whether clinical history is sensitive in detecting esophageal dysmotility, and (3) the relationship between esophageal dysmotility and TE prosthesis dysfunction. Study Design Multidisciplinary cross-sectional study. Setting Tertiary academic hospital. Subjects and Methods For 31 participants undergone total laryngectomy 1 to 12 years prior, clinical histories were taken by a gastroenterologist and a speech pathologist experienced in managing dysphagia. Esophageal high-resolution manometry was performed and analyzed using Chicago Classification v3.0. Results Interpretable manometric studies were obtained in 23 (1 normal manometry). Esophageal dysmotility patterns included achalasia, esophagogastric junction outflow obstruction, diffuse esophageal spasm, and other major (30%) and minor (50%) peristaltic disorders. The sensitivity of predicting any esophageal dysmotility was 28%, but it is noteworthy that patients with achalasia and diffuse esophageal spasm (DES) were predicted. Two of 4 participants with TE puncture leakage had poor esophageal clearance. Of 20 TE speakers, 12 had voice problems, no correlation between poor voice, and any dysmotility pattern. Conclusions Peristaltic and lower esophageal sphincter dysfunction are common in laryngectomees. Clinical history, while not predictive of minor motor abnormalities, predicted correctly cases with treatable spastic motor disorders. Dysmotility was not associated with poor phonation, although TE puncture leakage might be linked to poor esophageal clearance. Esophageal dysmotility should be considered in the laryngectomees with persisting dysphagia or leaking TE puncture.

Catheter-based acoustic interrogation device for real-time monitoring of the dynamics of the lower esophageal sphincter: in vitro and pilot canine studies

This paper presents a novel minimally-invasive catheter-based acoustic interrogation device for real-time monitoring the dynamics of the lower esophageal sphincter (LES). Dysfunction of the LES could result gastrointestinal (GI) diseases, such as gastroesophageal reflux disease (GERD). A micro-oscillator actively emitting sound wave at 16 kHz is located at one side of the LES, and a miniature microphone is located at the other side of the LES to capture the sound generated from the oscillator. Thus, the dynamics of the opening and closing of the LES can be monitored. The device was tested in vitro by utilizing a custom-designed LES simulator, as well as in vivo in a pilot canine model. In the in vitro test, the sound was captured by the microphone and its strength was correlated with the level of LES opening and closing which was controlled by the simulator. The measurements showed statistically significant (p < 0.05) Pearson correlation coefficients (0.905 on the average in quiet environment and 0.736 on the average in noisy environment, DOF = 9). In the in vivo test, the LES was forced open and closed by a transoral endoscope, which was monitored in real-time by a transpyloric endoscope inserted from the duodenum and positioned into the distal stomach. Frame-by-frame video analysis validated the interrelation between the sound strength and the LES opening and closing. The LES dynamics monitored by the proposed device has the potential to become a valuable minimally-invasive technique for understanding LES dysfunction.

Hydrogen sulfide synthesis enzymes reduced in lower esophageal sphincter of patients with achalasia.

The etiology of achalasia remains largely unknown. Considerable evidence reveals that the lower esophageal sphincter dysfunction is due to the lack of inhibitory neurotransmitter, secondary to esophageal neuronal inflammation or loss. Recent studies suggest hydrogen sulfide may act as an inhibitory transmitter in gastrointestinal tract, but study about hydrogen sulfide in human esophagus still lack. The aim of the study was to investigate if hydrogen sulfide synthesis enzymes could be detected in human esophagus and if the synthesis of the endogenous hydrogen sulfide could be affected in achalasia patients. Tissue samples in cardia, lower esophageal sphincter, 2 cm and 4 cm above lower esophageal sphincter were obtained from achalasia patients undergoing peroral endoscopic myotomy. Control tissues in lower esophageal sphincter were obtained from esophageal carcinoma patients. Expression of cystathionine-β-synthase and cystathionine-γ-lyase in lower esophageal sphincter of achalasia patients and control were detected by immunohistochemical staining. In addition, expression of cystathionine-β-synthase and cystathionine-γ-lyase were compared among different parts of esophagus in achalasia patients. Compared with control, the expression of cystathionine-β-synthase and cystathionine-γ-lyase in lower esophageal sphincter of achalasia patients was significantly reduced (χ2 = 11.429, P = 0.010). The expression of cystathionine-β-synthase and cystathionine-γ-lyase were lower in lower esophageal sphincter than that in 2 cm and 4 cm above lower esophageal sphincter, respectively (all P < 0.05). In conclusion, the expression of hydrogen sulfide synthesis enzymes, cystathionine-β-synthase and cystathionine-γ-lyase, can be detected in human esophagus and is reduced in patients with achalasia, which implicates the involvement of the two hydrogen sulfide synthesis enzymes in the pathophysiology of achalasia.

Mechanisms of cough provocation and cough resolution in neonates with bronchopulmonary dysplasia.

Cough and deglutition are protective mechanisms that defend against aspiration. We identified mechanisms associated with cough provocation as well as those associated with cough resolution in infants with bronchopulmonary dysplasia (BPD). Manometry signatures of cough were recognized in 16 premature infants with BPD undergoing concurrent esophageal manometry, respiratory inductance plethysmography, and nasal air flow measurements. Pretussive and post-tussive pharyngo-esophageal motility changes were analyzed. Mechanisms associated with cough and mechanisms that restored respiratory and esophageal normalcy were analyzed. We analyzed 312 cough events during 88 cough clusters; 97% were associated with recognizable manometric patterns. Initial mechanisms related with coughing included nonpropagating swallow (59%), upper esophageal sphincter (UES) reflex contraction (18%), and lower esophageal sphincter (LES) relaxation (14%). UES and LES dysfunction was present in 69% of nonpropagating swallow-associated cough clusters. Mechanisms restoring post-tussive normalcy included primary peristalsis (84%), secondary peristalsis (8%), and none recognized (8%). UES contraction reflex was associated with cough clusters more frequently in infants on nasal continuous positive airway pressure (NCPAP) (OR = 9.13, 95% CI = 1.88-44.24). Cough clusters in infants with BPD had identifiable etiologies associated with esophageal events; common initial mechanisms were of upper aerodigestive origin, while common clearing mechanisms were peristaltic reflexes.

A catheter-based acoustic interrogation device for monitoring motility dynamics of the lower esophageal sphincter.

This paper presents novel minimally-invasive, catheter-based acoustic interrogation device for monitoring motility dynamics of the lower esophageal sphincter (LES). A micro-oscillator actively emitting sound wave at 16 kHz is located at one side of the LES, and a miniature microphone is located at the other side of the sphincter to capture the sound generated from the oscillator. Thus, the dynamics of the opening and closing of the LES can be quantitatively assessed. In this paper, experiments are conducted utilizing an LES motility dynamics simulator. The sound strength is captured by the microphone and is correlated to the level of LES opening and closing controlled by the simulator. Measurements from the simulator model show statistically significant (p < 0.05) Pearson correlation coefficients (0.905 on the average in quiet environment and 0.736 on the average in noisy environment, D.O.F. = 9). Measuring the level of LES opening and closing has the potential to become a valuable diagnostic technique for understanding LES dysfunction and the disorders associated with it.

Mo1597 Impedance Planimetry as a Diagnostic Tool to Evaluate the Degree of Clinical Lower Esophageal Sphincter Dysfunction

INTRODUCTION Post-fundoplication dysphagia is a well-described side effect of antireflux surgery. Esophageal manometry is a standard part of the preoperative evaluation prior to antireflux surgery. However, controversy exists regarding the value of traditional manometry to predict post-operative dysphagia after fundoplication. Today, high-resolution manometry (HRM) has replaced traditional water perfused systems for the analysis of esophageal physiology. The aim of this study was to evaluate the utility of HRM in predicting post-operative dysphagia in patients with an otherwise functioning Nissen fundoplication. METHODS Patients who underwent a laparoscopic Nissen fundoplication at a single institution were identified through a prospectively collected database. Patients were asked to undergo routine post-operative testing 6-12 months after surgery. Patients who had normal post-operative 24-hour pH test scores were eligible for the study. Of these patients, those without available raw data from preoperative HRM were excluded. Traditional ineffective motility (IEM) was defined as mean distal esophageal contraction amplitude of <30mmHg or 30% or less peristaltic waves. Post-operative dysphagia was graded using a standard scoring system (0= never, 1=1-2 times a month, 2=1-2 times per week, 3=daily). A symptom score of 2-3 was used to define post-operative dysphagia. Regression and association analysis of pre-operative manometric risk-factors were performed to determine predictors of post-operative dysphagia. P-values <0.05 were considered significant. RESULTS 95 patients (41 male; 54 female) were included in the analysis. Mean post-operative length of follow up was 14.9 months (range: 2-73). 70.2% patients had normal scores on all HRM parameters. Any dysphagia was reported by 50% of patients (17% grade-1, 23.4% grade-2, and 9.5% grade-3) Nineteen patients had traditional IEM. Of those with dysphagia, one also had traditional IEM. On univariate analysis only distal latency (DL) was found to be a significant predictor (p<0.001) of grade-3 but not grade-2 dysphagia. On multivariate analysis, no preoperative factors were found to be significant predictors of grade-3 dysphagia, but contraction front velocity predicted grade2 dysphagia. CONCLUSION Persistent daily dysphagia occurs in ~10% of patients following an otherwise successful Nissen fundoplication. Advancements in manometric technology provide additional data points in the preoperative analysis of these patients. This analysis reveals that elevated integrated relaxation pressure (IRP) is a useful new metric to predict post-operative dysphagia in addition to traditional identification of weak distal esophageal contraction amplitudes. Pre-operative factors as predictors of post-fundoplication dysphagia

Laryngoscopy findings and histological results in a rabbit gastroesophageal reflux model

The role of lower esophageal sphincter (LES) in laryngopharyngeal reflux is controversial. In this study, we used an animal model to investigate the association between LES dysfunction and reflux laryngitis. Twelve healthy New Zealand albino rabbits (2.5-3.5 kg) were utilized in this study. The animals were divided into two groups. Eight rabbits underwent total cardiomyectomy to induce reflux, and the remaining four rabbits underwent a control sham operation. A laryngoscopy and a 24-hour intra-esophageal pH-metry were performed prior to surgery and again 2 and 8 weeks postsurgery. After the final laryngoscopy, all animals were sacrificed to obtain histological results. Total cardiomyectomy significantly increased the reflux index, the duration of the longest reflux episode and the total number of episodes that occurred in 24 h postsurgery. No significant difference was observed in the reflux finding score (RFS) between preoperative and 2-week postoperative rabbits (P = 0.11). But there was a statistically significant change in the RFS before and 8 weeks after the induction of reflux from 4.6 ± 0.9 to 8.3 ± 3.6 (P = 0.02). Submucous gland hyperplasia and inflammation were significantly increased in the reflux group compared to the control group. The results of this study suggest that chronic lower esophageal sphincter dysfunction is associated with reflux laryngitis in rabbits.

Is internal anal sphincter degeneration associated with lower oesophageal sphincter dysfunction?

IntroductionInternal anal sphincter (IAS) degeneration is the cause of up to 13% of faecal incontinence referrals to a tertiary centre. The authors speculated that IAS degeneration may represent one aspect...

Atypical Variants of Classic Achalasia Are Common and Currently Under-Recognized: A Study of Prevalence and Clinical Features

Advances in esophageal manometry have facilitated identification of variants of achalasia, suggesting they are more common than previously thought. This study assesses the frequency and clinical characteristics of patients with motility abnormalities similar to, but not meeting criteria for, classic achalasia. Records of patients undergoing high-resolution esophageal manometry between January 2008 and January 2010 were screened for diagnosis of achalasia, impaired lower esophageal sphincter (LES) relaxation, or severe peristaltic dysfunction of the esophageal body. Forty-four patients with classic achalasia and 31 with variant characteristics were identified. Clinical and manometric characteristics were recorded and compared. Variant achalasia was almost as common as the classic type (31 versus 44 patients). Eighty-two percent (36 of 44) of those with classic and 48% (15 of 31) of those with variant characteristics had dysphagia. Classic achalasia patients' mean age was 62 years (SD 19 years) versus 53 years (SD 14 years) in the variant group. The classic achalasia group had 26 male patients and 18 female patients and the variant group had 9 male patients and 22 female patients. Two thirds (21 of 31) of the variant group had impaired LES relaxation. Three variant patterns emerged: impaired LES relaxation with normal/hypertensive peristalsis (n = 10), impaired/borderline LES relaxation with mixed peristalsis/simultaneous contractions (n = 14), and impaired/normal LES and aperistalsis with occasional short segment peristalsis (n = 7). Mean intrabolus pressure was 16.3 mmHg in variant patients with normal LES relaxation and 23.1 mmHg in those with impaired relaxation. Variants of achalasia are more common than previously recognized. LES dysfunction defined by high relaxation pressure occurs in two-thirds of variant achalasia patients and might be a hallmark that could direct therapy. The notion that esophageal body dysfunction/aperistalsis in achalasia is all or none should be reconsidered.