Lower Esophageal Sphincter In Patients Research Articles

Docking Proteins Upregulate IL-1β Expression in Lower Esophageal Sphincter Muscle in Esophageal Achalasia.

Background/Objectives: Esophageal achalasia is an archetypal esophageal motility disorder characterized by abnormal peristalsis of the esophageal body and impaired lower esophageal sphincter (LES) relaxation. Methods: In this study, the mRNA expression of docking proteins 1 and 2 (DOK1 and DOK2, respectively) were analyzed and the mechanisms underlying achalasia onset were investigated. Results:DOK1 and DOK2 mRNA levels significantly increased in the LES of patients with achalasia. Moreover, significant correlations were observed between IL-1β and DOK1, IL-1β and DOK2, ATG16L1 and DOK1, and HSV1-miR-H1-3p and DOK2 expression levels. However, a correlation between ATG16L1 and DOK2 or between HSV-miR-H1-3p and DOK1 expression was not observed. In addition, a positive correlation was observed between patient age and DOK1 expression. Microarray analysis revealed a significant decrease in the expression of hsa-miR-377-3p and miR-376a-3p in the LES muscle of patients with achalasia. Conclusions: These miRNAs possessed sequences targeting DOK. The upregulation of DOK1 and DOK2 expression induces IL-1β expression in the LES of achalasia patients, which may contribute to the development of esophageal motility disorder.

The interplay between alterations in esophageal microbiota associated with Th17 immune response and impaired LC20 phosphorylation in achalasia.

Achalasia is an esophageal motility disorder with an unknown etiology. We aimed to determine the pathogenesis of achalasia by studying alterations in esophageal smooth muscle contraction and the associated inflammatory response, and evaluate the role of esophageal microbiota in achalasia development. We analyzed esophageal mucosa and lower esophageal sphincter (LES) samples, obtained from patients with type II achalasia who underwent peroral endoscopic myotomy. Esophageal conditioned media obtained from patients were transferred into the mouse esophagus to determine whether the esophageal intraluminal environment is associated with achalasia. Approximately 30% of 20-kDa myosin light chains (LC20) was phosphorylated in LES from the control group under resting and stimulated conditions, whereas less than 10% of LC20 phosphorylation was detected in achalasia under all conditions. The hypophosphorylation of LC20 in achalasia was associated with the downregulation of the myosin phosphatase-inhibitor protein CPI-17. Th17-related cytokines, including IL-17A, IL-17F, IL-22, and IL-23A, were significantly upregulated in achalasia. α-Diversity index of esophageal microbiota and the proportion of several microbes, including Actinomyces and Dialister, increased in achalasia. Actinomyces levels positively correlated with IL-23A levels, whereas Dialister levels were positively associated with IL-17A, IL-17F, and IL-22 levels. Esophageal IL-17F levels increased in mice after oral administration of the conditioned media. In LES of patients with achalasia, hypophosphorylation of LC20, a possible cause of impaired contractility, was associated with CPI-17 downregulation and an increased Th17-related immune response. The esophageal intraluminal environment, represented by the esophageal microbiota, could be associated with the development and exacerbation of achalasia.

ОСОБЕННОСТИ НАРУШЕНИЙ МОТОРНОЙ ФУНКЦИИ ЖЕЛУДКА ПРИ ДИСРЕГЕНЕРАТОРНЫХ ИЗМЕНЕНИЯХ ЕГО СЛИЗИСТОЙ ОБОЛОЧКИ

The study was conducted at the Department and Clinic of Hospital Therapy of the Military Medical Academy. CM. Kirov. The work studied the relationship of motor disorders of the stomach with morphological changes in the gastric mucosa in 90 patients with chronic atrophic gastritis and 93 patients with chronic non-atrophic gastritis aged 20 to 73 years (the average age of patients was 52.7+1.7 years and 48.5+ 3.6 respectively). Motor disorders were characteristic of 87% of patients with chronic atrophic gastritis and 79.6% of patients with chronic non-atrophic gastritis. It was found that in patients with chronic atrophic gastritis significantly more often (p<0.01) than in patients with chronic non-atrophic gastritis, there was an insufficiency of the lower esophageal sphincter. At the same time, insufficiency of the pylorus in comparison with its spasm was significantly more often (p<0.01) detected in chronic atrophic gastritis. Duodenogastric reflux in combination with insufficiency of the lower esophageal sphincter in patients with chronic atrophic gastritis significantly more often (p<0.01) atrophy was observed in the body and antrum of the stomach. When atrophy was localized only in the antrum, pyloric insufficiency was observed significantly more often than spasm (p<0.01). Duodenogastric reflux in combination with insufficiency of lower esophageal sphincter in patients with chronic atrophic gastritis significantly more often (p<0,01) atrophy in the body and antral part of the stomach was observed. Thus, the relationship between insufficiency of the lower esophageal and pyloric sphincters with a diffuse atrophic process has been established.

КАЧЕСТВО ЖИЗНИ ПАЦИЕНТОВ С АХАЛАЗИЕЙ КАРДИИ В ОТДАЛЕННОМ ПОСЛЕОПЕРАЦИОННОМ ПЕРИОДЕ ПРИ 2–4 СТАДИЯХ ЗАБОЛЕВАНИЯ

Evaluation of life quality in patients with achalasia cardia (AC) during the postoperative period, regardless of the method of surgical treatment, remains an urgent topic. The purpose of the study was to assess the quality of life of patients with AC in the long-term postoperative period, depending on the stage of the disease at the time of surgery, by analyzing the results of patient questionnaires and data from instrumental methods for studying the function of the esophagus. Results. The data of 95 patients were analyzed, of which 32 people were with stage 2, 33 people with stage 3 and 30 patients with stage 4 of the disease. All patients underwent the same type of surgical intervention, video endoscopic myotomy according to Heller with fundoplication according to Dor. The long-term period of postoperative follow-up ranged from 2 to 5 years. The results of traditional esophageal manometry and esophageal fluoroscopy were evaluated and the data from the Eckardt symptom score and GIGLI scale questionnaires were evaluated. The anthropometric data showed a statistically significant decrease in the tone of the lower esophageal sphincter in patients in all study groups to normal values (p =0.001). Data obtained during contrast X-ray examination of the esophagus and stomach after surgery revealed the restoration of the evacuation function of the esophagus in all patients (p=0.001). Motor function of the esophagus could not be restored in 6 patients with stage 4 AC, according to manometric data, atony of the esophagus was observed in these patients. The severity and frequency of dysphagia after surgical treatment, according to questionnaires, decreased significantly in patients with all stages of AC, in the long-term postoperative period, patients with stage 2 showed a decrease in the number of points scored by 68.9%, patients with stage 3 by 70.5% and patients with stage 4 of AC by 66.7% (p<0.05). Conclusions. According to Eckardt score and GIGLI questionnaires and instrumental methods of examination of esophageal function, video endoscopic esophagocardiomyotomy according to Heller with Dor fundoplication leads to a decrease in the main symptoms of achalasia of the cardia in patients with stages 2-4 of the disease and increases quality of life, while the best indicators were obtained in patients with stage 2 of the disease, which allows us to consider that it is advisable to perform this organ preservation operation already at the second stage of AC.

Detection of cytokine storm in patients with achalasia using ELISA.

Esophageal achalasia is characterized by abnormal peristaltic movements of the esophageal body and impaired relaxation of the lower esophageal sphincter (LES). However, its etiology remains unknown. In our previous study, it was shown that in the LES of patients with achalasia, hsv1-miR-H1 was overexpressed, ATG16L1 expression was downregulated and interleukin (IL)-1β levels were upregulated. However, systemic features were not evaluated. Herein, the plasma cytokine levels in patients with achalasia were determined. Plasma was collected from patients at Nagasaki University Hospital between February 2013 and March 2016, both before and after peroral endoscopic myotomy (POEM). Cytokine analysis was performed using plasma collected from 10 healthy individuals (control group) and 12 patients with achalasia using the Bio-Plex Pro™ Human Cytokine 27-plex assay kit. The levels of IL-17, IL-1β, C-C motif chemokine ligand 2, IL-4, IL-5, IL-1ra, IL-7, IL-12, interferon-γ, IL-2, fibroblast growth factor-2, colony-stimulating factor (CSF)2 and CSF3 were significantly higher in patients with achalasia compared with the control subjects. However, the levels did not differ between plasma samples collected before and after POEM. Thus, the occurrence of a cytokine storm was confirmed in the patients with achalasia.

Сhronic gastritis: impaired motor-evacuation function of the stomach

The effect of morphological changes in the gastric mucosa on the motor-evacuation function of the stomach was evaluated in 90 patients with chronic atrophic gastritis and 93 patients with chronic non-atrophic gastritis aged 18 to 82 years. Motor function disturbances were discovered of 90% of patients with chronic atrophic gastritis and 80,6% with chronic non-atrophic gastritis. It was established that the pyloric insufficiency compared with its spasm was significantly more (p0,01) often in chronic atrophic gastritis. Insufficiency of the lower esophageal sphincter in patients with atrophic gastritis was significantly (p0,01). Insufficiency of the lower esophageal sphincter in combination with duodenogastric reflux in patients with chronic atrophic gastritis was significantly more (p0,01) often observed during diffuse atrophy, i. e. when mucous membrane of stomach corpus and antrum is involved in the process. With the localization of atrophy in the antrum alone, pyloric insufficiency was observed significantly more (p 0,01) often than spasm. Thus, an interrelation between the insufficiency of the lower esophageal and pyloric sphincters with the diffuse atrophic process has been established. There are no significant differences of disorders of gastric motor function in patients with different types of chronic gastritis. Accelerated evacuation from the stomach with localization of atrophy in the mucous membrane of the stomach corpus is more (p 0,01) often observed in patients with chronic atrophic gastritis.

Mast cell infiltration associated with loss of interstitial cells of Cajal and neuronal degeneration in achalasia.

Achalasia is a motility disorder of unknown etiology. Previous studies supported the hypothesis that autoimmune-mediated inflammatory responses produce inhibitory neuronal degeneration. This study was designed to explore the role of mast cells in achalasia. We collected information from 116 patients with achalasia who underwent peroral endoscopic myotomy between December 2016 and May 2017. Lower esophageal sphincter (LES) muscle biopsy was performed in all patients with achalasia, as well as 20 control subjects. The number of mast cells, interstitial cells of Cajal (ICCs), nNOS-positive cells, and S-100-positive cells in the LES were evaluated by immunohistochemistry. Pathological and clinical data were compared between groups. Compared with controls, the LES of patients with achalasia had significantly fewer ICCs, nNOS-positive cells, and S-100-positive cells and a higher number of mast cells (all P<0.001). Furthermore, the increased mast cell infiltration was significantly associated with decreased ICCs, nNOS-positive cells, and S-100-positive cells in patients with achalasia (all P<0.05). Clinically, the number of strongly positive mast cells was highest in patients with type I achalasia and lowest in those with type III achalasia (P<0.001). In addition, patients with a history of autoimmune disease or viral infection had greater mast cell infiltration in the LES muscle (P=0.040). In patients with achalasia, mast cell infiltration in the LES muscle is increased, in association with loss of ICCs and neuronal degeneration. Mast cells may thereby play a crucial role in the development of achalasia.

The acid pocket - a novel target for the treatment of gastro-esophageal reflux disease

Increased acid reflux after meals is a key feature of gastro-esophageal reflux disease (GERD) and is the most important cause for patient symptoms, particularly heartburn and acid regurgitation. Chronic acid exposure also predisposes to associated pathologies including reflux esophagitis, esophageal stricture, Barrett's esophagus, and Barrett's carcinoma (esophageal adenocarcinoma). The severity of esophageal symptoms and mucosal damage is related to two key factors, (i) the acidity of the refluxate, which depends primarily on the gastric secretory output and its distribution within the stomach, and (ii) the frequency and duration of reflux events which depends on the efficacy of the reflux barrier at the gastro-esophageal junction and the esophageal clearance function. The concept of the acid pocket is an attempt to bring these two factors into a unified patho-mechanism.The acid pocket describes an area of unbuffered, highly acidic, gastric secretion in the proximal stomach adjacent to the esophago-gastric junction (GEJ) which forms in the postprandial period and is the source of acid refluxate into the esophagus. It is observed both in healthy individuals as well as in reflux patients. However, the presence of a hiatus hernia and/or a weak lower esophageal sphincter in patients allows the acid pocket to encroach on the gastro-esophageal junction. This results in very high acid exposure of the squamous epithelium of the distal esophagus, leading to mucosal damage and symptoms. Recently, the acid pocket has been proposed as a target for pharmacological and surgical therapies of GERD. Proton pump inhibitors and related medications reduce its acidity; whereas, alginate preparations, prokinetics, and fundoplication displace it away from the gastro-esophageal junction.

Esophagogastric junction distensibility measurements during hydraulic dilation therapy in achalasia patients

SUMMARYIncreasing evidence suggests that esophagogastric junction (EGJ) distensibility is predictive of long-term clinical success after achalasia treatment. A new commercially available hydraulic dilation balloon is capable of measuring EGJ opening diameters whilst simultaneously dilating the EGJ. Deployed alongside the endoscope under direct visualization, it is used for dilation of the lower esophageal sphincter in patients with achalasia. Impedance measurement electrodes are incorporated in the catheter shaft in the dilation balloon, which allows measuring the diameter of the EGJ and displaying it in real time before, during and after dilation. This obviates the need for fluoroscopy during the dilation procedure. The extent of recoil of the EGJ after dilation potentially provides a measurement that could be incorporated into a clinical rule for predicting therapeutic success after dilation.

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.

Esophageal motility in eosinophilic esophagitis.

Eosinophilic esophagitis (EoE) is characterized by eosinophilic infiltration of the esophagus and is a potential cause of dysphagia and food impaction, most commonly affecting young men. Esophageal manometry findings vary from normal motility to aperistalsis, simultaneous contractions, diffuse esophageal spasm, nutcracker esophagus or hypotonic lower esophageal sphincter (LES). It remains unclear whether esophageal dysmotility plays a significant role in the clinical symptoms of EoE. Our aim is to review the pathogenesis, diagnosis, and effect of treatment on esophageal dysmotility in EoE. A literature search utilizing the PubMed database was performed using keywords: eosinophilic esophagitis, esophageal dysmotility, motility, manometry, impedance planimetry, barium esophagogram, endoscopic ultrasound, and dysphagia. Fifteen studies, totaling 387 patients with eosinophilic esophagitis were identified as keeping in accordance with the aim of this study and included in this review. The occurrence of abnormal esophageal manometry was reported to be between 4 and 87% among patients with EoE. Esophageal motility studies have shown reduced distensibility, abnormal peristalsis, and hypotonicity of the LES in patients with EoE, which may also mimic other esophageal motility disorders such as achalasia or nutcracker esophagus. Studies have shown conflicting results regarding the presence of esophageal dysmotility and symptoms with some reports suggesting a higher rate of food impaction, while others report no correlation between motor function and dysphagia. Motility dysfunction of the esophagus in EoE has not been well reported in the literature and studies have reported conflicting evidence regarding the clinical significance of dysmotility seen in EoE. The correlation between esophageal dysmotility and symptoms of EoE remains unclear. Larger studies are needed to investigate the incidence of esophageal dysmotility, clinical implications, and effect of treatment on patients with EoE.

Esophageal motility in eosinophilic esophagitis

BackgroundEosinophilic esophagitis (EoE) is characterized by eosinophilic infiltration of the esophagus and is a potential cause of dysphagia and food impaction, most commonly affecting young men. Esophageal manometry findings vary from normal motility to aperistalsis, simultaneous contractions, diffuse esophageal spasm, nutcracker esophagus or hypotonic lower esophageal sphincter (LES). It remains unclear whether esophageal dysmotility plays a significant role in the clinical symptoms of EoE. AimOur aim is to review the pathogenesis, diagnosis, and effect of treatment on esophageal dysmotility in EoE. MethodsA literature search utilizing the PubMed database was performed using keywords: eosinophilic esophagitis, esophageal dysmotility, motility, manometry, impedance planimetry, barium esophagogram, endoscopic ultrasound, and dysphagia. ResultsFifteen studies, totaling 387 patients with eosinophilic esophagitis were identified as keeping in accordance with the aim of this study and included in this review. The occurrence of abnormal esophageal manometry was reported to be between 4 and 87% among patients with EoE. Esophageal motility studies have shown reduced distensibilty, abnormal peristalsis, and hypotonicity of the LES in patients with EoE, which may also mimic other esophageal motility disorders such as achalasia or nutcracker esophagus. Studies have shown conflicting results regarding the presence of esophageal dysmotility and symptoms with some reports suggesting a higher rate of food impaction, while others report no correlation between motor function and dysphagia. ConclusionsMotility dysfunction of the esophagus in EoE has not been well reported in the literature and studies have reported conflicting evidence regarding the clinical significance of dysmotility seen in EoE. The correlation between esophageal dysmotility and symptoms of EoE remains unclear. Larger studies are needed to investigate the incidence of esophageal dysmotility, clinical implications, and effect of treatment on patients with EoE.

An Evidence of Esophageal Decompensation in Patients With Achalasia in the View of Its Subtype: A Retrospective Study

Background/AimsAchalasia is a primary motility disorder of esophagus. Many parameters represent esophageal function and morphologic changes, but their interrelationship is not yet established. We hypothesized that esophageal body would need to generate unusual pressure to empty the food bolus through the non-relaxing lower esophageal sphincter in patients with achalasia; therefore, higher is the residual lower esophageal sphincter pressure, greater would be the contraction pressure in the esophageal body in these patients. To verify the hypothesis, correlations among parameters from esophageal manometry, esophagography and esophageal transit study had been investigated.MethodsA retrospective review of 34 patients was conducted. Resting lower esophageal sphincter pressure and contraction pressure of esophageal body were obtained from conventional esophageal manometry. Diameter of esophageal body was measured from barium column under esophagography. Radionuclide imaging was performed to assess the esophageal transit, designated as R30, which was the residual radioactivity at 30 seconds after ingesting radioactive isotope.ResultsIn vigorous achalasia group, contraction pressure of esophageal body was negatively correlated to dilated diameter of esophageal body (P = 0.025, correlation coefficient = -0.596). Esophageal transit was more delayed as dimensions of esophageal body increased in classic achalasia group (P = 0.039, correlation coefficient = 0.627).ConclusionsDiameter of esophageal body in classic achalasia was relatively wider than that of vigorous achalasia group and the degree of delayed esophageal transit was proportionate to the luminal widening. Patients with vigorous achalasia had narrower esophageal lumen and relatively shorter transit time than that of classic achalasia group. Proper peristalsis is not present in achalasia patients but remaining neuromuscular activity in vigorous achalasia patients might have caused the luminal narrowing and shorter transit time.

Letter to “Functional Importance of Laparoscopic Sleeve Gastrectomy for the Lower Esophageal Sphincter in Patients with Morbid Obesity” OBES SURG (2012) 22:360–366 DOI 10.1007/s11695-011-0536-5

Letter to “Functional Importance of Laparoscopic Sleeve Gastrectomy for the Lower Esophageal Sphincter in Patients with Morbid Obesity” OBES SURG (2012) 22:360–366 DOI 10.1007/s11695-011-0536-5

Functional Importance of Laparoscopic Sleeve Gastrectomy for the Lower Esophageal Sphincter in Patients with Morbid Obesity

Background Obesity is characterized by excess body fat measured in body mass index (BMI), which is the weight in kilograms (kg) divided by the height in square meters [m2]. In the Northern Hemisphere, the prevalence of overweight has increased by up to 34%. This situation is associated with high incidence of comorbidities such as gastroesophageal reflux disease. Bariatric surgery is the only effective treatment for severe obesity, resulting in amelioration of obesity comorbidities. Data on LES competence following sleeve gastrectomy (SG), one of the several bariatric procedures, are conflicting.

Toward an Improved Understanding of Isolated Upright Reflux: Positional Effects on the Lower Esophageal Sphincter in Patients with Symptoms of Gastroesophageal Reflux

The purpose of this study was to assess the effect of body position on lower esophageal sphincter (LES) structure and function. Symptomatic patients underwent high-resolution manometry in the supine and upright positions followed by pH testing. Regardless of whether there was a positive DeMeester score, isolated upright reflux patterns were considered present when the supine fraction of time pH <4 = 0%. Predominant-upright and predominant-supine bipositional reflux (SBR) patterns were considered present when the supine fraction of time was <upright fraction of time pH <4 and the supine fraction was >upright fraction of time pH <4, respectively. Of 128 patients, 35 isolated upright, 55 predominant-upright bipositional, and 27 SBR patients were identified. When supine, LES pressure/length was higher in upright compared to bipositional reflux patients. When upright, there was no difference in LES pressure/length between groups. The LES in isolated upright reflux patients became defective when moved from supine to upright position compared to bipositional patients, where the LES was defective regardless of position. Although the incidence of laryngopharyngeal reflux (LPR) events was comparable between groups, isolated upright patients commonly had a normal DeMeester score. Position impacts LES competency in those with upright reflux and would not be detected with supine manometry. Upright reflux can be associated with GERD and LPR despite negative pH testing.

Comment on: Functional Importance of Laparoscopic Sleeve Gastrectomy for the Lower Esophageal Sphincter in Patients with Morbid Obesity

Comment on: Functional Importance of Laparoscopic Sleeve Gastrectomy for the Lower Esophageal Sphincter in Patients with Morbid Obesity

Measurement of pH Values in Human Tissues by Two‐Photon Microscopy

pH values go live! A ratiometric two-photon (TP) probe (NP1, see scheme) that has a significant TP action cross-section, high photostability, negligible toxicity, and can estimate pH values in live cells and human tissues by two-photon microscopy is described. NP1 can detect the difference in pH between live cells from the gastroesophageal junction (GEJ) and the lower esophageal sphincter of patients with and without esophagitis.

Short‐term electrical stimulation of the lower esophageal sphincter increases sphincter pressure in patients with gastroesophageal reflux disease

Electrical stimulation (ES) of the lower esophageal sphincter (LES) increases resting LES pressure (LESP) in animal models. Our aims were to evaluate the safety of such stimulation in humans, and test the hypothesis that ES increases resting LESP in patients with gastroesophageal reflux disease (GERD). A total of 10 subjects (nine female patients, mean age 52.6 years), with symptoms of GERD responsive to PPIs, low resting LES pressure, and abnormal 24-h intraesophageal pH test were enrolled. Those with hiatal hernia >2 cm and/or esophagitis >Los Angeles Grade B were excluded. Bipolar stitch electrodes were placed longitudinally in the LES during an elective laparoscopic cholecystectomy, secured by a clip and exteriorized through the abdominal wall. Following recovery, an external pulse generator delivered two types of stimulation for periods of 30 min: (i) low energy stimulation; pulse width of 200 μs, frequency of 20 Hz and current of 5-15 mA (current was increased up to 15 mA if LESP was less than 15 mmHg), and (ii) high energy stimulation; pulse width of 375 ms, frequency of 6 cpm, and current 5 mA. Resting LESP, amplitude of esophageal contractions and residual LESP in response to swallows were assessed before and after stimulation. Symptoms of chest pain, abdominal pain, and dysphagia were recorded before, during, and after stimulation and 7-days after stimulation. Continuous cardiac monitoring was performed during and after stimulation. All patients were successfully implanted nine subjects received high frequency, low energy, and four subjects received low frequency, high energy stimulation. Both types of stimulation significantly increased resting LESP: from 8.6 mmHg (95% CI 4.1-13.1) to 16.6 mmHg (95% CI 10.8-19.2), P < 0.001 with low energy stimulation and from 9.2 mmHg (95% CI 2.0-16.3) to 16.5 mmHg (95% CI 2.7-30.1), P = 0.03 with high energy stimulation. Neither type of stimulation affected the amplitude of esophageal peristalsis or residual LESP. No subject complained of dysphagia. One subject had retrosternal discomfort with stimulation at 15 mA that was not experienced with stimulation at 13 mA. There were no adverse events or any cardiac rhythm abnormalities with either type of stimulation. Short-term stimulation of the LES in patients with GERD significantly increases resting LESP without affecting esophageal peristalsis or LES relaxation. Electrical stimulation of the LES may offer a novel therapy for patients with GERD.

Heterogeneity of Lower Esophageal Sphincter Function in Children With Achalasia

Achalasia is a rare esophageal motor disorder in children. The manometric hallmarks are esophageal body aperistalsis, lack of lower esophageal sphincter (LES) relaxation, and high LES pressure. However, LES relaxation and function may be heterogeneous, making the diagnosis difficult at times. The aim of the study was to describe LES function in children with achalasia. The present study is a retrospective review of manometric tracings of pediatric patients with achalasia and controls. LES response after each swallow was evaluated. LES parameters were defined as homogeneous (normal or abnormal) if the same response was observed in >75% of swallows. Otherwise, the LES parameters were considered heterogeneous. Twenty-nine patients with achalasia and 16 control patients were included. All of the controls had normal LES pressure and relaxation in all of the wet swallows. In the achalasia group, some LES relaxation was present in 74% of swallows and 25% of swallows had normal relaxation. Depending on the parameter, a heterogeneous LES (resting pressure, relaxation, residual pressure, and duration of relaxation) was observed in 27.6% to 34.5% of patients with achalasia versus 0% of the controls (P < 0.001). The rest of the patients with achalasia had homogeneous abnormal responses versus homogeneous normal responses in 100% of control patients (P < 0.001). The LES function in pediatric patients with achalasia is heterogeneous. The classic description of a nonrelaxing high-pressure LES in patients with achalasia is rarely found in children. Partial relaxations are common, and normal relaxations may be present.