Lower Esophageal Sphincter Pressure Research Articles

Heller Cardiomyotomy in end stage of achalasia with mega esophagus: Results in five cases

Achalasia is a motility disorder of esophagus with poor emptying and, characterised by a lack of peristalsis and impaired relaxation of the lower esophageal sphincter with high LES pressure,diameter of esophsgous can increase, and some patients progress to develop end-stage achalasia as megaesophagus or sigmoid esophagus and significant form dilation and tortuosity.These omplications occurs in between 5% and 20% of patients with acha­lasia. This group of patients if untreated are at risk of aspiration, aspiration pneumonia, and malnutrition. The management of this type of achalasia, aims to palliate symptoms by improving esophagus emptying and reducing the pressure gradient. In this group of patients, pneumatic dilatation (PD), surgical myotomy, or peroral endoscopic myotomy (POEM) may be less or not effective. Esophagectomy for the treatment of end-stage achalasia remains a controversial topic and has been recommended by some authors. We describe 5 patients with end-stage achalasia who was been successfully managed with laparotomy heller cardiomyotomy . In 4,12,18,24 months follow- up the condition of patients was good.

Therapeutic effect of Wendan Decoction combined with mosapride on gastroesophageal reflux disease after esophageal cancer surgery.

Gastroesophageal reflux disease (GERD) is a common complication of esophageal cancer surgery that can affect quality of life and increase the risk of esophageal stricture and anastomotic leakage. Wendan Decoction (WDD) is a traditional Chinese herbal formula used to treat various gastrointestinal disorders, such as gastritis, functional dyspepsia, and irritable bowel syndrome. Mosapride, a prokinetic agent, functions as a selective 5-hydroxytryptamine 4 agonist, enhancing gastrointestinal motility. To evaluate the therapeutic effects of WDD combined with mosapride on GERD after esophageal cancer surgery. Eighty patients with GERD were randomly divided into treatment (receiving WDD combined with mosapride) and control (receiving mosapride alone) groups. The treatment was conducted from January 2021 to January 2023. The primary outcome was improved GERD symptoms as measured using the reflux disease questionnaire (RDQ). The secondary outcomes were improved esophageal motility (measured using esophageal manometry), gastric emptying (measured using gastric scintigraphy), and quality of life [measured via the Short Form-36 (SF-36) Health Survey]. The treatment group showed a notably reduced RDQ score and improved esophageal motility parameters, such as lower esophageal sphincter pressure, peristaltic amplitude, and peristaltic velocity compared to the control group. The treatment group showed significantly higher gastric emptying rates and SF-36 scores (in both physical and mental domains) compared to the control group. No serious adverse effects were observed in either group. WDD combined with mosapride is an effective and safe therapy for GERD after esophageal cancer surgery. It can improve GERD symptoms, esophageal motility, gastric emptying, and the quality of life of patients. Further studies with larger sample sizes and longer follow-up periods are required to confirm these findings.

Journey into the Esophageal Complications: Decoding Systemic Sclerosis with Cutting-Edge Endoscopy, Manometry, and Ambulatory pH-Study.

Systemic Sclerosis (SSc) is a rare connective tissue disorder characterized by autoimmunity, fibrosis, and vasculopathy that affects the skin and internal organs, including the gastrointestinal tract, particularly the esophagus. This article highlights the characteristics and clinical symptoms of esophageal involvement in patients with SSc. This study was conducted between November 2022 to August 2023, including 26 already diagnosed cases of SSc in the Department of Rheumatology and Rehabilitation and Kurdistan Center for Gastroenterology and Hepatology-Sulaymaniyah, Iraq. Esophageal involvement was investigated using esophageal manometry, esophagogastroduodenoscopy (EGD), and 24-hour impedance-pH monitoring. Females were significantly predominant (P = 0.019) regarding the symptoms; 76.9% of the patients had heart burn, 76.9% dysphagia, 73.1% water brush, and 69.2% regurgitation. In total, 69.2% of the patients showed erosive gastrointestinal reflux disease (GERD) on EGD, 76.9% had decreased lower esophageal sphincter pressure (DLESP) and decreased distal esophageal peristaltic contractions (DDEPC) on esophageal manometry, and 84.6% had reflux on pH monitoring. Raynaud's phenomenon is the most common and typically the earliest clinical manifestation of SSc. The presence of erosive GERD was found to significantly increase the risk of developing dysphagia (B = 4.725, P = 0.014, OR = 3.482) and regurgitation (B = 3.521, P = 0.006, OR = 4.030). It is crucial to take gender-specific considerations into account when diagnosing and managing esophageal complications in patients with systemic sclerosis (SSc). Additionally, employing various diagnostic assessments to detect esophageal involvement during SSc is essential. Erosive GERD has been identified as a risk factor that contributes to the development of dysphagia and regurgitation in individuals with SSc.

Manometric esophagogastric junction barrier metrics as predictors of gastroesophageal reflux.

High-resolution manometry (HRM) tools, like esophagogastric junction contractile integral (EGJ-CI), assess EGJ barrier function. This study aimed to evaluate the relationships between manometric EGJ metrics with esophageal acid exposure. We conducted a retrospective review of 284 patients who underwent HRM and ambulatory reflux testing between 11/2017-1/2020. EGJ-CI and total-EGJ-CI were manually calculated. Pathologic acid exposure was defined as pH < 4 with esophageal acid exposure time (EAET) exceeding 6.0%. Pearson's correlation, univariable and multivariable regression models were utilized to assess the relationships between pathologic acid exposure and EGJ parameters. Sensitivity and specificity thresholds for EGJ-CI and total EGJ-CI were optimized with ROC analyses. On univariable analysis, patients with pathologic acid exposure had increased odds of having lower mean basal LES pressures, EGJ-CI, and total EGJ-CI than patients without pathologic acid exposure. On multivariable analysis, age, EGJ-CI and mean DCI were significant predictors of pathologic acid exposure. There were significant, though weak, correlations between EAET and EGJ-CI and total EGJ-CI (r = - 0.18, - 0.19, p < 0.01, respectively). An EGJ-CI cutoff of 44.16 as a predictor for pathologic acid exposure had a sensitivity of 46% and specificity of 42% (AUC 0.60). Total EGJ-CI cutoff of 11,461.3 for pathologic acid exposure had a sensitivity of 44% and a specificity of 43% (AUC 0.62). EGJ-CI can independently predict pathologic acid exposure. However, the poor correlation between EGJ-CI and acid exposure, as well as the low sensitivity and specificity of calculated thresholds, indicate that mechanisms other than EGJ barrier function may impact acid exposure.

Analysis of the Correlation Between Dynamic Characteristics and Symptoms of Gastroesophageal Reflux Disease.

To investigate the esophageal motility characteristics of gastroesophageal reflux disease (GERD) and their relationship with symptoms. We examined 101 patients diagnosed with GERD by endoscopy and divided them into 3 groups as follows: nonerosive reflux disease (NERD), reflux esophagitis, and Barrett esophagus. Esophageal high-resolution manometry and the GERD Questionnaire were used to investigate the characteristics of esophageal dynamics and symptoms. In addition, the reflux symptom index was completed and the patients were divided into 7 groups according to symptoms. We then determined the correlation between dynamic esophageal characteristics and clinical symptoms. Upper (UES) and lower (LES) esophageal sphincter pressures and the 4-second integrated relaxation pressure in the RE group were lower than those in the NERD group. The 4-second integrated relaxation pressure in the Barrett esophagus group was also lower than that in the NERD group. In the analysis of extraesophageal symptoms, high-resolution manometry showed significant differences in UES pressures among all groups. Further subgroup analysis showed that compared with the group without extraesophageal symptoms, the UES pressure of the groups with pharyngeal foreign body sensation, throat clearing, and multiple extraesophageal symptoms was lower. As GERD severity increases, motor dysfunction of the LES and esophageal body gradually worsens, and the LES plays an important role in GERD development. Decreased UES pressure plays an important role in the occurrence of extraesophageal symptoms, which is more noticeable in patients with pharyngeal foreign body sensation and throat clearing.

Efficacy of different endoscopic treatments for gastroesophageal reflux disease: a systematic review and network meta-analysis

BackgroundThere are no direct comparisons across different endoscopic therapies for gastroesophageal reflux disease (GERD). This study aimed to evaluate the relative effects of different endoscopic therapies in GERD. MethodsFive databases were searched until August 2023 for randomized controlled trials (RCTs) that compared the efficacy of endoscopic band ligation (EBL), Stretta, endoscopic fundoplication (transoral incisionless fundoplication [TIF], endoscopic full-thickness plication [EFTP], and EndoCinch plication procedure [EndoCinch, CR BARD, Billerica, Mass., USA]), or proton pump inhibitors (PPIs)/sham procedure for GERD. Bayesian network meta-analysis was performed. ResultsA total of 19 trials comprising 1181 patients were included. EBL (mean difference [MD], −7.75; 95% credible interval [CrI], −13.90 to −1.44), Stretta (MD, −9.86; 95% CrI, −19.05 to −0.58), and TIF (MD, −12.58; 95% CrI, −20.23 to −4.91) all significantly improved patients’ health-related quality of life score with equivalent efficacy compared with PPIs. TIF and EBL achieved equivalent efficacy in reducing PPIs utility (risk ratio [RR], 0.66; 95% CrI, 0.40–1.05) and both were significantly superior to other endoscopic interventions (Stretta, EFTP, and EndoCinch). Besides, EBL and TIF also could significantly decrease the esophagitis incidence compared with PPIs (EBL [RR, 0.34; 95% CrI, 0.22–0.48] and TIF [RR, 0.38; 95% CrI, 0.15–0.88]). In terms of lower esophageal sphincter (LES) pressure, only TIF could significantly increase the LES pressure (MD, 6.53; 95% CrI, 3.65–9.40) to PPIs. In contrast, TIF was inferior to PPIs in decreasing esophageal acid exposure (MD, 2.57; 95% CrI, 0.77–4.36). ConclusionCombining the evidence, EBL and TIF may have comparable efficacy and both might be superior to Stretta, EFTP, or EndoCinch in GERD treatment.

The Therapeutic Effect of Biling Weitong Granules Combined with Oryz-Aspergillus Enzyme and Pancreatin Tablet on Reflux Esophagitis with Functional Dyspepsia

Objective: To investigate the therapeutic effect of Biling Weitong Granules combined with oryz-aspergillus enzyme and pancreatin tablets on patients with reflux esophagitis with functional dyspepsia. Methods: Sixty patients diagnosed with reflux esophagitis with functional dyspepsia who were admitted to the Affiliated Hospital of Hebei University between June 2020 and June 2023 were selected and divided into two groups: the control group and the observation group, each consisting of 30 cases. The control group received oryz-aspergillus enzyme and pancreatin tablets only, while the observation group received Biling Weitong Granules in addition to the tablets. The clinical efficacy, Chinese medicine syndrome points, esophageal kinetic indexes, gastrointestinal hormone levels, and therapeutic safety of both groups were evaluated. Results: The total efficiency of the observation group reached 93.33%, significantly higher than the 73.33% of the control group (P &lt; 0.05). After treatment, patients in the observation group exhibited significantly lower scores for Chinese medicine symptoms such as early satiety, belching, abdominal distension, abdominal pain, and loss of appetite compared to the control group (P &lt; 0.05). Furthermore, the observation group showed significantly higher upper esophageal sphincter pressure, lower esophageal sphincter pressure, and distal esophageal contraction scores compared to the control group (P &lt; 0.05). Additionally, levels of gastric motility hormone, vasoactive intestinal peptide, and gastrin were significantly higher in the observation group compared to the control group (P &lt; 0.05). Throughout the treatment period, there was no significant difference in the incidence of adverse reactions between the two groups, indicating comparable safety of the two treatment modalities (P &gt; 0.05). Conclusion: The combination of Biling Weitong Granules with oryz-aspergillus enzyme and pancreatin tablets demonstrates significant efficacy in the treatment of reflux esophagitis with functional dyspepsia, with a better safety profile. This finding warrants further clinical promotion.

Efficacy and safety of endoscopic cardia peripheral tissue scar formation (ECSF) for the treatment of refractory gastroesophageal reflux disease: A systematic review with meta-analysis.

Endoscopic treatment is increasingly used for refractory gastroesophageal reflux disease (rGERD). Unlike the mechanism of conventional surgical fundoplication, gastroesophageal junction ligation, anti-reflux mucosal intervention, and radiofrequency ablation have extremely similar anti-reflux mechanisms; hence, we collectively refer to them as endoscopic cardia peripheral tissue scar formation (ECSF). We conducted a systematic review and meta-analysis to assess the safety and efficacy of ECSF in treating rGERD. We performed a comprehensive search of several databases, including PubMed, Embase, Medline, China Knowledge Network, and Wanfang, to ensure a systematic approach for data collection between January 2011 and July 2023. Forest plots were used to summarize and combine the GERD-health-related quality of life (HRQL), gastroesophageal reflux questionnaire score, and DeMeester scores, acid exposure time, lower esophageal sphincter pressure, esophagitis, proton pump inhibitors use, and patient satisfaction. This study comprised 37 studies, including 1732 patients. After ECSF, significant improvement in gastroesophageal reflux disease health-related quality of life score (mean difference [MD] = 18.27 95% CI: 14.81-21.74), gastroesophageal reflux questionnaire score (MD = 4.85 95% CI: 3.96-5.75), DeMeester score (MD = 42.34, 95% CI: 31.37-53.30), acid exposure time (MD = 7.98, 95% CI: 6.03-9.92), and lower esophageal sphincter pressure was observed (MD = -5.01, 95% CI: -8.39 to 1.62). The incidence of serious adverse effects after ECSF was 1.1% (95% CI: 0.9%-1.2%), and postoperatively, 67.4% (95% CI: 66.4%-68.2%) of patients could discontinue proton pump inhibitor-like drugs, and the treatment outcome was observed to be satisfactory in over 80% of the patients. Subgroup analyses of the various procedures showed that all 3 types improved several objective or subjective patient indicators. Based on the current meta-analysis, we conclude that rGERD can be safely and effectively treated with ECSF as an endoscopic procedure.

Short and long term effect of anti-reflux mucosectomy with cap-assisted endoscopic mucosal resection for refractory gastroesophageal disease.

Anti-reflux mucosectomy with cap-assisted endoscopic mucosal resection (ARMS-C) is a safe and effective treatment for managing refractory gastroesophageal reflux disease (GERD). This study aimed to investigate the short and long-term outcomes of ARMS-C. This study was conducted from 2018 to 2022, during which 115 eligible patients underwent ARMS-C. The primary endpoints of this study were to evaluate the GERD-Q questionnaire score and determine the number of patients who reduced their proton pump inhibitor (PPI) dosage or discontinued PPI usage. The secondary endpoints included the evaluation of the DeMeester score, acid exposure time (AET), gastroesophageal flap valve grade (GEFV), lower esophageal sphincter pressure, the rate of successful esophageal peristalsis, and GERD-Q questionnaires. Additionally, we analyzed the long-term efficacy of ARMS-C. Out of the 120 patients, 115 underwent ARMS-C, 96 were followed up for at least six months after the procedure, and 22 were followed up for at least two years. The primary outcome showed a significant improvement in GERD-Q scores, decreasing from 10.67 to 7.55 (p < 0.001). Out of the 96 patients, 36 were able to reduce or completely stop using PPIs. The DeMeester score, GEFV, AET, and the proportion of intact peristalsis also demonstrated improvement. As for the long-term efficacy of ARMS-C, 86% of patients showed improvement in symptoms, and no serious adverse effects were reported after the procedure. ARMS-C is a safe and effective endoscopic technique to treat refractory GERD patients.

Efficacy of Pneumatic Dilation (PD) in Treatment-Naïve Achalasia Patient: A North African Experience Center

Background: Pneumatic dilation (PD) is often presented today as a “short term” treatment for achalasia but, in truth, it can last for years. our study aims to determine the short and long-term efficacy of pneumatic dilatation on clinical remission in a treatment-naïve achalasia patient. Materials and Methods: A single center retrospective, descriptive and analytical study conducted between January 2007 and September 2022. Treatment naïve patients with manometric diagnosis of primary achalasia (subtype I and II) were included. We evaluated the clinical outcomes; single vs multiple PD, complications, and estimated duration of effect. Results: 121 patients were included, (mean age 42,2±14,5; 53,8% male), 88,4% (n=104) underwent 2 PD and 11,6% (n=17) underwent 3 PD, 23,1% (n=28) needed repeated PD at one year, The PD procedure was completed without major complications in all patients. Patients with subtype II had a better response to PD than subtype I(p=0,003). In the long-term follow up (median time: 50 months), the mean Eckardt score was 2.2. A subsequent 35 mm dilatation was associated with long-term clinical remission than an initial dilatation with 35 mm.(p=0.003). On univariate analysis, the non-responders more often was male gender, had age&lt; 40 years (p=0.0006), and had high baseline LESP (lower esophageal sphincter pressure&gt;50 mmHg), p=0.004). On multivariate analysis only age&lt;or= 40 years (p=0.02) was associated with poor outcome. Conclusion: PD is an effective, durable and safe treatment for achalasia. A graded-protocol PD starting with a 30 mm dilation applied in the appropriate achalasia subtypes was shown to be a highly effective approach, in both the short- and long-term. Age&lt;40 years, male patients and hight LESP have poorer outcomes following PD.

Intraoesophageal pressure in patients receiving proximal gastrectomy with hinged double flap method for gastric cancer: a retrospective cohort study

Background: Objective functional assessment of esophagogastric anastomosis in patients who underwent proximal gastrectomy with the hinged double flap method for gastric cancer has not been well investigated. This study aimed to perform a functional analysis of reconstruction using high-resolution impedance manometry (HRIM). Materials and methods: The authors enroled 25 patients who underwent proximal gastrectomy for gastric cancer between May 2015 and April 2020 and subsequently underwent HRIM postoperatively. Eligible questionnaires [Postgastrectomy Syndrome Assessment Scale-37 (PGSAS-37)] were retrieved from 16 patients. The association between HRIM data and PGSAS-37 was analyzed. Results: The amplitudes of distal oesophageal peristaltic waves, contractile front velocity, and distal latency assessed by HRIM were almost normal after surgery. Most patient’s lower oesophageal sphincter (LES) resting pressure created by the hinged double flap was within normal limits. Conversely, LES residual pressure values during swallowing-induced relaxation were abnormally high in most patients, and the lower the values, the more severe the reflux and diarrhoea symptoms (P=0.038, P=0.041, respectively). In addition, even when the integrated relaxation pressure (IRP) was normal, lower values corresponded to more severe reflux symptoms (P=0.020). The required LES pressure may be higher after proximal gastrectomy because of the relatively higher intragastric pressure due to the reduced volume of the remnant stomach. This also suggests that swallowing-induced relaxation of the LES was considered a trigger for oesophageal reflux in post-proximal gastrectomy patients. Conclusion: LES residual pressure and IRP values in HRIM correlated with reflux symptoms in patients after proximal gastrectomy.

Oestrogen and Gastroesophageal Reflux Disease Dynamics in Premenopausal and Postmenopausal Women: A Cross-sectional Study

Introduction: Gastroesophageal Reflux Disease (GERD) is a common clinical disorder characterised by the reflux of stomach contents into the oesophagus, primarily due to the temporary relaxation of the Lower Oesophageal Sphincter (LES). The aetiology of GERD is multifactorial. The prevalence of GERD in females has been found to sharply increase throughout the postmenopausal period compared to the reproductive phase. Aim: To study the relationship between serum oestrogen levels in premenopausal and postmenopausal women with GERD. Materials and Methods: In this cross-sectional study, 60 patients with GERD were divided into 30 premenopausal and 30 postmenopausal groups. The study subjects underwent high-resolution oesophageal manometry. The Cobas e 411 immunoassay analyser was utilised to measure serum oestrogen levels through electrochemiluminescence. The independent, unpaired Student's t-test was employed to analyse the collected data. Results: The statistical analysis revealed that the mean reduced LES pressure of 9.76±3.80 mmHg and the mean reduced Oesophagogastric Junction Contractile Integral (EGJ-Cl) of 14.503±10.64 mmHg were lower in women with postmenopausal GERD who exhibited lower oestrogen levels compared to those with premenopausal GERD. An increase in LES pressure was also associated with an increase in EGJ-CI, demonstrating a statistically significant positive linear correlation between LES pressure and EGJ-CI. The p-value &lt;0.05 was deemed highly statistically significant. Conclusion: Parameters such as basal LES pressure and EGJCl were observed to be reduced in postmenopausal women with GERD who had low oestrogen levels. This study suggests that oestrogen plays a crucial role in safeguarding the oesophageal epithelium against the reflux of gastric contents.

Comparing Pre- and Post-Operative Findings in Patients Who Underwent Laparoscopic Proximal Gastrectomy With a Double-Flap Technique: A Study on High-Resolution Manometry, Impedance pH Monitoring, and Esophagogastroduodenoscopy Findings.

Laparoscopic proximal gastrectomy (LPG) is a viable choice for treating proximal gastric lesions. However, the occurrence of severe reflux has limited its widespread adoption. To address this issue, the double flap technique (DFT), which incorporates artificial lower esophageal sphincteroplasty, has been developed to prevent reflux problems after proximal gastrectomy. In this study, we aimed to investigate the usefulness of this technique using high-resolution manometry (HRM), impedance pH monitoring, and esophagogastroduodenoscopy (EGD). The findings of pre- and postoperative 6-month HRM, pH monitoring, and EGD were compared for 9 patients who underwent LPG with DFT for various proximal gastric lesions at Incheon St. Mary's Hospital from January 2021 to December. A total of 9 patients underwent proximal gastrectomy. Approximately half of the patients had Hill's grade under II preoperatively, whereas all patients had Hill's grades I and II in EGD findings. In the HRM test, there was no significant difference between distal contractile integral (1,412.46±1,168.51 vs. 852.66±495.62 mmHg·cm·s, P=0.087) and integrated relaxation pressure (12.54±8.97 vs. 8.33±11.30 mmHg, P=0.27). The average lower esophageal sphincter (LES) pressure was 29.19±14.51 mmHg preoperatively, which did not differ from 19.97±18.03 mmHg after the surgery (P=0.17). DeMeester score (7.02±6.36 vs. 21.92±36.17, P=0.21) and total acid exposure time (1.49±1.48 vs. 5.61±10.17, P=0.24) were slightly higher, but the differences were not statistically significant. There is no significant functional difference in HRM and impedance pH monitoring tests after DFT. DFT appears to be useful in preserving LES function following proximal gastrectomy.

NREL-5MW Wind Turbine Noise Prediction by FWH-LES

This paper deals with large onshore wind turbine aeroacoustics. Noise from the NREL 5 MW device is predicted by the permeable-surface Ffowcs Williams–Hawkings equation (FWH-P), starting from the postprocessing of LES data on different acoustic surfaces S. Their size and placement is aimed at embedding most of the aerodynamic sources of sound surrounding rotor and nacelle. Due to the presence of eddies that inevitably cross S, this paper compares results from open and closed acoustic surfaces, and the outflow disk averaging technique. The issues related to the interpolation process of LES data on S is discussed as well. In order to assess the LES/FWH-P aeroacoustic platform, LES and FWH-P pressures are compared in the very-near field. It is shown that, within the limits of the discretization settings imposed by the interpolation procedure and for the Reynolds number working condition investigated herein, the lack of quadrupole sources outside the permeable surface(s) deeply affect the quality of FWH-P acoustic pressures with respect to direct LES signals.

10-year follow-up results of the European Achalasia Trial: a multicentre randomised controlled trial comparing pneumatic dilation with laparoscopic Heller myotomy

ObjectiveAs achalasia is a chronic disorder, long-term follow-up data comparing different treatments are essential to select optimal clinical management. Here, we report on the 10-year follow-up of the European Achalasia...

Roles of swallowing and belching in different phenotypes of gastroesophageal reflux disease.

The contributions of swallowing and belching to specific gastroesophageal reflux disease (GERD) phenotypes are unclear. This study retrospectively analyzed esophageal pH/impedance studies, comparing reflux events preceded by gastric belching (GB), supragastric belching (SGB), air swallowing, and liquid/solid swallowing based on reflux position, lower esophageal sphincter (LES) pressure, and acid exposure time (AET). 20 GERD patients and 10 controls were studied. Upright GERD patients and controls had a higher proportion of reflux events with a preceding swallow or belch (0.64, 0.64) than the supine group (0.38, p = 0.043). The upright group and controls trended toward a higher proportion of reflux events preceded by overall swallowing (0.61, 0.50) and air swallowing (0.55, 0.48) than the supine group (0.32, 0.31 p = 0.064, p = 0.11), but the three groups had similar rates of liquid/solid swallowing (0.032, 0.024, 0.017, p = 0.69). LES pressure did not correlate with reflux events preceded by swallowing (R2 = 0.021, p = 0.44). There was a higher rate of events preceded by gastric belching in the control group (0.14) than in the upright (0.032) and supine groups (0.066, p = 0.049). LES pressure did not correlate with the rate of events preceded by belching (R2 = 0.000093, p = 0.96). Normal AET patients had a higher rate of events preceded by GB (0.12) than those with increased acid exposure (0.030, p = 0.0083), but the two groups had similar rates of preceding air (0.43, 0.47, p = 0.68), liquid/solid (0.018, 0.032, p = 0.30), and overall swallowing (0.44, 0.53, p = 0.38). Swallowing more than belching is a dominant mechanism for reflux irrespective of GERD position, LES pressure, and AET.

EFFICACY OF LAPROSCOPIC HELLER'S MYOTOMY IN THE TREATMENT OF ACHALASIA

In a retrospective study conducted from September 6, 2021, to September 6, 2022, at the Thoracic Surgery Department of Bakhtawar Amin Trust Hospital in Multan, the objective was to evaluate the impact of laparoscopic Heller's Myotomy on patients with achalasia. Additionally, the study sought to identify pre-operative factors that influence treatment outcomes. The methodology involved recording pre-operative patient data, including dysphagia scores, and conducting pre-operative manometry to diagnose achalasia. The diagnostic criteria included a non-relaxing lower esophageal sphincter (LES) and abnormal esophageal contractions. Post-operative changes in dysphagia scores (delta) were calculated, and a dysphagia score falling below a specified cutoff was considered an unsuccessful treatment outcome. The study's results revealed that the patients had an average age of 48.5 years, with a standard deviation of 1.6. After Heller myotomy, the average decrease in dysphagia scores was 7.2, with a standard deviation of 2.5. A change in score of ≥5 was indicative of successful treatment, leading to dysphagia relief in 69 out of 80 patients (86%). The sole pre-operative variable that significantly predicted successful dysphagia relief was the pre-operative LES pressure. The responder group displayed higher LES pressure than the non-responder group, with 41.5 mm Hg ± 12.1 and 22.9 mm Hg ± 7.1, respectively (P = 0.001). No significant correlation was observed between post-operative LES pressure and changes in dysphagia scores. In conclusion, Heller's myotomy demonstrated excellent efficacy in providing dysphagia relief for achalasia patients. Notably, a high pre-operative LES pressure was identified as a significant predictor of an excellent treatment outcome.

Esophageal Infusion of Menthol Does Not Affect Esophageal Motility in Patients with Gastroesophageal Reflux Disease.

Menthol is thought to trigger gastroesophageal reflux disease (GERD) symptoms by influencing esophageal peristalsis and lower esophageal sphincter (LES) function. We evaluated the effect of esophageal menthol infusion on esophageal motility and the LES in healthy volunteers and in patients with GERD. High resolution manometry (HRM) catheter with attached thin tube for menthol infusion was placed transnasally. Protocol which included baseline recording, 16 water swallows (5ml, 10ml, and 15ml) and the multiple rapid swallows was performed before and after esophageal infusion of menthol (3mM, 20min, 8ml/min). We evaluated the effect of this infusion on the HRM parameters of esophageal peristalsis (distal contractile integral, distal latency, contractile front velocity) and the lower esophageal sphincter (LES) barrier function (integrated relaxation pressure and the inspiratory augmentation of the LES). Simultaneously we evaluated the quality and intensity of the symptoms during the menthol infusion. Esophageal infusion of menthol did not appreciably affect HRM measurements characterizing esophageal peristalsis and LES pressure in healthy subjects (N = 13) or GERD patients (N = 11). The magnitude of the distal contractile integral (5ml) was changed neither in the healthy volunteers' group, (735 ± 127 vs. 814 ± 117mmHg, p = 0.5), nor in the GERD patients (295 ± 78 vs. 338 ± 96mmHg, p = 0.99). In healthy volunteers menthol did not change the inspiratory augmentation of the LES (8.67 ± 1.09 vs. 7.69 ± 0.96mmHg, p = 0.15) and neither did for GERD patients (8.8 ± 1.18 vs. 8.22 ± 0.91mmHg, p = 0.43). We observed no significant difference in any HRM parameter following menthol infusion, except for distal latency in 10ml swallows. By contrast, menthol infusion induced significantly more intense discomfort in GERD patient than in healthy volunteers. Our results suggest no significant temporal effect of menthol on the esophageal motility or LES function, neither in healthy volunteers, nor in GERD. Arguably, other mechanisms are responsible for menthol-related heartburn.

166. ROBOTIC-ASSISTED BILATERAL EPIPHRENIC DIVERTICULECTOMY WITH HELLER MYOTOMY AND DOR FUNDOPLICATION: A SURGICAL TECHNIQUE

Abstract Background Epiphrenic diverticula are rare esophageal diseases often associated with motility disorders such as achalasia. We present a case of bilateral epiphrenic diverticula in a patient with achalasia type III who presented with dysphagia. This video demonstrates the surgical technique of robotic-assisted bilateral epiphrenic diverticulectomy with Heller myotomy and Dor fundoplication, highlighting the six essential surgical steps. Methods A 72-year-old female presented with dysphagia for 3 years. An esophagogastroduodenoscopy revealed two epiphrenic diverticula without food content retention. A barium swallow revealed two epiphrenic diverticula, measuring 3.3 cm and 1.2 cm in diameter, on right and left side walls of distal esophagus, respectively. Esophageal manometry showed the lower esophageal sphincter (LES) pressure was 25.6 mmHg (normal &amp;lt;15 mmHg). Subsequently, both the acid exposure time and the DeMeester score indicated normal levels of acid exposure. The patient underwent robotic-assisted surgery. The diverticulectomy was performed using stapling device under endoscopic guidance, followed by standard myotomy. Additionally, Dor fundoplication was performed to complete procedure. Results Postoperatively, the patient recovered well. An upper gastrointestinal study demonstrated an adequate myotomy without evidence of leak or residual epiphrenic diverticula. Further postoperative evaluation, including esophageal manometry, showed normal LES pressure of 12.8 mmHg, the postoperative acid exposure time of 0.0%, and the DeMeester score of 0.20, that indicating normal levels of acid exposure. The patient resumed a liquid diet on postoperative day 4 and a soft diet on postoperative day 7. Based on these results, the patient’s dysphagia was resolved, and there was an absence of gastroesophageal reflux symptoms. Conclusion Bilateral epiphrenic diverticula are extremely rare, and require complex procedure. Robotic-assisted surgery has the potential to enhance the facilitation of surgical treatment for this condition. The robotic tools are precise and maneuverable, making it possible to perform intricate surgical procedures in tight angles and confined spaces, such as the hiatal area. This technique offers several advantages over conventional laparoscopic surgery, and should therefore be considered for the treatment of bilateral epiphrenic diverticula.

47. PERORAL ENDOSCOPIC MYOTOMY VS HELLER MYOTOMY WITH FUNDOPLICATION IN OUR CENTER

Abstract Heller myotomy with fundoplication (HF) is one of the established treatments for esophageal achalasia. However, the less invasive Peroral endoscopic myotomy (POEM) is rapidly spreading. Several papers report short-term efficacy and safety of POEM is as well as HF, but GERD is more frequent after POEM. Moreover, the long-term outcome is still unknown. This is a single center retrospective study. In our center, HF was carried out for 59 patients between 1999 and 2014. Among them, 58 cases underwent laparoscopic procedure, 52 were with Dor fundoplication and 7 were with Toupet. From 2015 we performed POEM for 224 patients until Dec 2022. For POEM, grade of dilatation was lower (I/II/III=POEM;76/131/17, HF;6/44/9, p &amp;lt; 0.001) and esophageal myotomy length was longer (8.5 ± 3.4 cm vs 5.7 ± 0.8 cm, P &amp;lt; 0.001). Median IRP and Eckardt score decreased for them (24.3 ± 13.0 to 7.8 ± 4.8 mmHg/5.37 ± 2.09 to 0.54 ± 0.84). HF improved their LES pressure (40.2 ± 20.3 to 18.0 ± 7.1 mmHg, p &amp;lt; 0.001). Postoperative LA grade B GERD was more often for POEM (26.9% vs 4.7%, p &amp;lt; 0.001), however grade C or D were comparable. All of them were controlled by PPIs, except one POEM patient considering further treatment. For HF, median follow-up period was longer (78 vs 19 mo), however, additional treatment was more necessary (6.8% vs 1.3%, p = 0.033). Postoperative grade B GERD was more common for POEM, but almost all of them were controlled by PPIs. POEM was less likely to require additional treatment, though follow-up time was relatively short. Further observation and re-evaluation are warranted.