Lower Esophageal Sphincter Pressure Research Articles

Changes in esophageal physiology after paraesophageal hernia repair and Collis gastroplasty.

The surgical approach and technique for paraesophageal hernia (PEH) repair is much debated. The changes in the esophageal physiology after PEH repair with a concomitant Collis gastroplasty (PEH-CG) are not clearly known. The aim of this study was to determine the changes in high resolution esophageal manometry (HREM) and esophageal pH testing after PEH-CG. Retrospective analysis of all patients who underwent PEH-CG at our institution between 2006 and 2013 was performed. Patients had esophageal pH testing, HREM, barium swallow and an upper endoscopy before and after PEH-CG. A total of 182 patients underwent PEH-CG during the study period. Majority of patients had Nissen fundoplication (176, 96.7%) with Toupet in 6 (3.3%). Basal lower esophageal sphincter pressure (LESP) was lower after fundoplication (20.3mmHg ± 11.3 vs. 25.8mmHg ± 15.6, p < 0.001), whereas residual LESP was noted to be higher after fundoplication (7.7mmHg ± 4.9 vs. 6.1mmHg ± 6.7, p < 0.009). There were no significant changes in the esophageal motility patterns. There was an improvement in total pH and upright pH but not supine pH post PEH-CG. Normalization of total acid exposure after fundoplication was noted in 31 (59.6%) of the 52 patients who had abnormal total acid exposure prior to fundoplication. Objective clinical assessment in patients undergoing PEH-CG demonstrates an effective operation for this complex problem. There was an increase in residual LESP but interestingly, decrease in basal LESP. Additionally, there was an improvement in esophageal acid exposure afterwards. These findings will facilitate future management of PEH.

High-resolution manometry features of paraesophageal hernia.

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

Effects of Lixisenatide Versus Liraglutide (Short- and Long-Acting GLP-1 Receptor Agonists) on Esophageal and Gastric Function in Patients With Type 2 Diabetes

Short-acting glucagon-like peptide 1 receptor agonists (GLP-1 RAs) decelerate gastric emptying more than long-acting GLP-1 RAs. Delayed gastric emptying is a risk factor for gastroesophageal reflux disease. We aimed to measure esophageal reflux and function as well as gastric emptying and acid secretion during treatment with short-acting (lixisenatide) and long-acting (liraglutide) GLP-1 RAs. A total of 57 subjects with type 2 diabetes were randomized to a 10-week treatment with lixisenatide or liraglutide. Changes from baseline in the number of reflux episodes during 24-h pH registration in the lower esophagus, lower esophagus sphincter pressure, gastric emptying (13C-sodium octanoate acid breath test), and gastric acid secretion (13C-calcium carbonate breath test) were analyzed. Gastric emptying half-time was delayed by 52 min (Δ 95% CI 16, 88) with lixisenatide (P = 0.0065) and by 25 min (3, 46) with liraglutide (P = 0.025). There was no difference in the number of reflux episodes (mean ± SEM 33.7 ± 4.1 vs. 40.1 ± 5.3 for lixisenatide and liraglutide, respectively, P = 0.17) or the extent of gastroesophageal reflux (DeMeester score) (35.1 ± 6.7 vs. 39.7 ± 7.5, P = 0.61), with similar results for the individual GLP-1 RAs. No significant changes from baseline in other parameters of esophageal motility and lower esophageal sphincter function were observed. Gastric acidity decreased significantly by -20.7% (-40.6, -0.8) (P = 0.042) with the GLP-1 RAs. Lixisenatide exerted a more pronounced influence on gastric emptying after breakfast than liraglutide. Neither lixisenatide nor liraglutide had significant effects on esophageal reflux or motility. Gastric acid secretion appears to be slightly reduced by GLP-1 RAs.

Efficacy and Safety of Peroral Endoscopic Myotomy in Achalasia Patients with Failed Previous Intervention: A Systematic Review and Meta-Analysis.

Peroral endoscopic myotomy (POEM) has emerged as a rescue treatment for recurrent or persistent achalasia after failed initial management. Therefore, we aimed to investigate the efficacy and safety of POEM in achalasia patients with failed previous intervention. We searched the MEDLINE, Embase, Cochrane, and PubMed databases using the queries “achalasia,” “peroral endoscopic myotomy,” and related terms in March 2019. Data on technical and clinical success, adverse events, Eckardt score and lower esophageal sphincter (LES) pressure were collected. The pooled event rates, mean differences (MDs) and risk ratios (RR) were calculated. A total of 15 studies with 2,276 achalasia patients were included. Overall, the pooled technical success, clinical success and adverse events rate of rescue POEM were 98.0% (95% confidence interval [CI], 96.6% to 98.8%), 90.8% (95% CI, 88.8% to 92.4%) and 10.3% (95% CI, 6.6% to 15.8%), respectively. Seven studies compared the clinical outcomes of POEM between previous failed treatment and the treatment naïve patients. The RR for technical success, clinical success, and adverse events were 1.00 (95% CI, 0.98 to 1.01), 0.98 (95% CI, 0.92 to 1.04), and 1.17 (95% CI, 0.78 to 1.76), respectively. Overall, there was significant reduction in the pre- and post-Eckardt score (MD, 5.77; p<0.001) and LES pressure (MD, 18.3 mm Hg; p<0.001) for achalasia patients with failed previous intervention after POEM. POEM appears to be a safe, effective and feasible treatment for individuals who have undergone previous failed intervention. It has similar outcomes in previously treated and treatment-naïve achalasia patients.

State of Evidence in Minimally Invasive Management of Gastroesophageal Reflux: Findings of a Scoping Review

Endoscopic management of gastroesophageal reflux disease (GERD) is being employed increasingly. The aim of this scoping review was to assess the volume of available evidence on the benefits of endoscopic and minimally invasive surgical therapies for GERD. criteria were used to perform an extensive literature search of data regarding the reported benefit of endoscopic therapies in GERD. Randomized controlled studies were utilized when available; however, data from observational studies were also reviewed. A formal review of evidence was performed in 22 studies. Inclusion and exclusion criteria and study duration were noted and tabulated. Assessment of outcomes was based on symptoms and objective criteria reported by investigators. Reported outcomes for the interventions were tabulated under the heading of subjective (symptom scores, quality of life metrics, and change in proton pump inhibitor use) and objective metrics (pH parameters, endoscopic signs, and lower esophageal sphincter pressure changes). Adverse events were noted and tabulated. The majority of studies showed symptomatic and objective improvement of GERD with the device therapies. Adverse events were minimal. However, normalization of acid exposure occurred in about 50% of patients and, for some modalities, long-term durability is uncertain. This scoping review revealed that the endoluminal and minimally invasive surgical devices for GERD therapy are a promising alternative to proton pump inhibitor therapy. Their place in the treatment algorithm for GERD will be better defined when important clinical parameters, especially durability of effect, are better understood.

Experimental Study of the Effect of Helicobacter pylori Infection on Barrett Esophagus and Its Correlation with Immune Function

Background: Helicobacter pylori is an important pathogen in the upper digestive tract. It is of great significance to properly understand the risk factors for the transformation of Barrett esophagus into esophageal carcinoma. However, the relationship between H. pylori and gastroesophageal reflux disease (GERD) and Barrett esophagus remains controversial, and the correlation with immune function has been rarely reported. Objectives: This study investigated the effect of H. pylori infection on Barrett esophagus and its correlation with immune function. Methods: We recruited 40 patients with Barrett esophagus (Barrett esophagus group) and 40 patients with GERD (GERD group). In addition, 40 healthy controls were selected for the control group. Esophageal function and its correlation with immune function were measured in each group. Results: The positivity rate of H. pylori (P &lt; 0.05) and sphincter pressure were lower in both Barrett esophagus and GERD groups than in the control group, while the levels of PGI, PGII, PGI/II, and G-17 were higher (P &lt; 0.05). The levels of CD3+, CD4+, and CD4+/CD8+ were lower in the Barrett esophagus group than in the GERD group, but they were negatively correlated (P &lt; 0.05) with H. pylori infection. The level of CD8+ was higher in the Barrett esophagus group, and it was positively correlated (P &lt; 0.05) with H. pylori infection. Conclusions: Helicobacter pylori infection may protect against Barrett esophagus by reducing gastric acid secretion and increasing lower esophageal sphincter pressure. Besides, it has a certain correlation with immune function.

Lower prevalence of gastroesophageal reflux disease in patients with noncardiac chest pain on opiates: a cross-sectional study.

Opiates can cause heartburn and spastic esophageal dysmotility but their role in noncardiac chest pain (NCCP) is not known. Our aim was to characterize opiate effects on esophageal function using esophageal pH monitoring and high-resolution manometry (HREM) in these patients.We performed a cross sectional study of opiate users with NCCP who underwent HREM and esophageal pH study from 2010 to 2017 using opiate nonusers as a comparison group. Demographic data, symptoms, opiate use, endoscopic findings, esophageal pH study parameters, and HREM data were abstracted.Thirty three patients with NCCP on opiates were compared to 144 opiate non-users. Compared to opiate nonusers, opiate users had lower total acid exposure (2.3% vs. 3%, P = 0.012), lower upright acid exposure (1.2% vs. 3.1%, P = 0.032) and lower DeMeester score (6.5 vs. 12.7, P = 0.016). Opiate users also had higher lower esophageal sphincter integrated relaxation pressure (LES-IRP) (7.0 mm Hg [2.2, 11.7] vs. 3.7 mm Hg [1.1, 6.2] P = 0.011) and greater mean distal contractile integral (DCI) (2575 mm.Hg.s.cm [1134, 4466] vs. 1409 mm.Hg.s.cm [796, 3003] P = 0.03) than opiate non-users. The prevalence of hypertensive motility disorders (15.2% vs. 11.1%) and achalasia (12.1% vs. 2.1%) was higher in opiate users (P = 0.039) but did not reach significance on multivariate analysis.In patients presenting with NCCP, opiate users had lower esophageal acid exposure compared to opiate nonusers. This might be due to higher LES pressures preventing reflux and higher DCI leading to more rapid acid esophageal clearance.

Peroral endoscopic myotomy versus pneumatic dilation for achalasia: a systematic review and meta-analysis.

Presently, the primary endoscopic options for the treatment of achalasia are peroral endoscopic myotomy (POEM) and pneumatic dilation. But the clinical outcomes of POEM and pneumatic dilation for achalasia have not yet to be fully evaluated. So, we aimed to compare the clinical outcomes between the two treatment modalities. We searched all the relevant studies published up to September 2019 examining the comparative efficacy between POEM and pneumatic dilation. Outcomes included success rate, Eckardt score, lower esophageal sphincter pressure and adverse events. Outcomes were documented by pooled risk ratios and mean difference with 95% confidence interval (CI) using Review Manager 5.3. Seven studies with a total of 619 patients were identified. There were 298 patients underwent POEM treatment and 321 patients underwent pneumatic dilation treatment. The clinical success rate was higher in the POEM group than that in the pneumatic dilation group at 6, 12 and 24 months' follow-up, with a risk ratio of 1.14 (95% CI, 1.06-1.22, P = 0.0002, I= 0%), 1.34 (95% CI, 1.24-1.45, P < 0.00001, I= 17%) and 1.35 (95% CI, 1.10-1.65, P = 0.004, I= 70%), respectively. The change of Eckardt scores was more obvious in the POEM group than in the pneumatic dilation group, with a mean difference of 1.19 (95% CI, 0.78-1.60, P < 0.00001, I= 70%). The rate of gastroesophageal reflux and other complications for POEM was significantly higher than for pneumatic dilation, with a risk ratio of 4.17 (95% CI, 1.52-11.45, P = 0.006, I= 61%) and 3.78 (95% CI, 1.41-10.16, P = 0.008, I= 0%). Our current evidence suggests that the long-term efficacy of POEM was superior to that of pneumatic dilation, but accompanied by higher complications.

Sa1262 A LARGE SINGLE-CENTER STUDY ON THE CLINICAL OUTCOMES OF PER-ORAL ENDOSCOPIC MYOTOMY FOR SIGMOID TYPE 2 ACHALASIA

Per-oral endoscopic myotomy (POEM) has been recognized as a safe and effective minimally-invasive endoscopic treatment for achalasia. Good clinical outcomes have been reported on the application of POEM in straight type achalasia. On the other hand, results of POEM in sigmoid type achalasia, especially sigmoid type 2, are limited. This study aims to report the clinical outcomes of POEM for sigmoid type 2 achalasia. A single-center retrospective study was conducted. A prospectively collected database of 2000 patients who underwent POEM in Showa University between September 2008 to June 2019 has been reviewed. Patients who were diagnosed as sigmoid type 2 achalasia and underwent POEM were included in this study. Sigmoid type 2 achalasia was defined as an enormously dilated and tortuous esophagus in barium esophagram and double esophageal lumen in some CT slices. The primary outcome was the success rate, defined as an Eckardt Symptom Score(ESS) of less than 3 without additional treatments such as balloon dilation or redo POEM. The secondary outcomes were integrated relaxation pressure(IRP), mean lower esophageal sphincter(LES) pressure, and GERD after POEM. Patient’s characteristics: A total of 108 patients (age: 58.4±14.7 y/o, 51 females(47%), BMI: 21.7±4.6kg/m2) were included. Based on Chicago Classification, the type of achalasia seen were as follows: Type I/II/III= 28/8/1, and there were 71 unidentified cases due to the difficulty of inserting catheters. Diameter of esophagus was 48.1±17.5mm. Duration of symptoms was 17.4(7.7-29)years. ESS was 5(3-7). As pre-treatment, 49 patients had balloon dilation, Hellor-Dor in 8 patients, and Heller myotomy in 2 patients. Procedure-related parameters: Operation time was 95.9±32.1min. Myotomy length was 7(5-9)cm at the esophageal side, and 3(2-3)cm at the gastric side. Post-operative hospital stay was 4(4-5) days. The following complications were noted: mucosal perforation in 3 patients, submucosal hematoma or bleeding in 3 patients. Treatment outcomes: Success rate after 2 months was 89.1%(82/92). Pre- and 2-months post-POEM ESS were 5.0±2.5 and 1.1±1.0 (p<0.0001), respectively. Pre- and 2-months post-POEM IRP were 15.7±9.9 and 8.6±5.5 mmHg (p=0.0012), respectively. Pre- and 2-months post-POEM mean LES pressure were 19.9±13.9 and 14.6±7.7 mmHg (p=0.066), respectively. GERD 2-months post-POEM were as follows: Grade(N/A/B/C/D=37/29/13/7/1). Patients with GERD symptoms were 11.3%(10/88). PPI usage rate was 16.1%(13/81). Success rate after 1 year was 87.8%(43/49). Since good results of the short- and mid-term success rate and significant improvement of ESS and IRP value were achieved, POEM shows to be an effective procedure for sigmoid type 2 achalasia. Long-term results are expected in future studies.CT slice showing double esophageal lumenView Large Image Figure ViewerDownload Hi-res image Download (PPT)

Sa1282 PERORAL ENDOSCOPIC MYOTOMY FOR ACHALASIA PATIENTS WITH PRIOR HELLER MYOTOMY: A SYSTEMATIC REIVEW AND META-ANALYSIS

Heller myotomy (HM) is considered the standard surgical treatment for achalasia patients. However, approximately 10-20% of achalasia patients after HM have persistent or recurrent symptoms requiring further therapy. Several studies have reported the outcomes of peroral endoscopic myotomy (POEM) in these patients. Objective: A systematic review and meta-analysis were performed to evaluate the efficacy and safety of POEM in achalasia patients with prior HM. The databases of PubMed, EMBASE, The Cochrane library were systematically searched. Studies evaluating the outcomes of POEM in achalasia patients with prior HM were eligible for inclusion. Two reviewers independently reviewed the studies, extracted data and assessed study quality. Heterogeneity among studies was assessed using the I2 statistic. Pooled estimates were calculated using random or fixed-effects models, according to the level of heterogeneity. A total of 9 studies with 272 achalasia patients were recruited in this review. POEM was successfully performed in 270 (99.3%) patients after prior HM. There was a significant reduction in Eckardt score by 5.14 (weighted mean differences (WMD) 5.14, 95%CI, 4.19-6.09, P< 0.001, I2=86.4%). Clinical success (post-POEM Eckardt score≤3) was achieved in 90% (95%CI, 83%-98%, I2=58.5%) of patients after POEM. Lower esophageal sphincter (LES) pressure was significantly lowered by 12.01 mmHg (WMD 12.01, 95%CI, 6.74–17.27, P< 0.001, I2 = 85.1%). The pooled rates of postoperative symptomatic gastroesophageal reflux, esophagitis based on after-POEM endoscopy, and abnormal acid exposure at pH monitoring were 37% (95% CI, 21%-53%), 33% (95% CI, 10%-56%), 48% (95%CI, 33%-62%), respectively. Most of the adverse effects related to POEM procedure were self-limiting and could be managed conservatively. No publication bias was found using Egger's test. POEM is a safe and effective treatment for achalasia patients with prior HM. Further data from large randomized controlled trials are needed to confirm these findings.

Sa1234 A THOUSAND AND A HUNDRED FORTY PERORAL ENDOSCOPIC MYOTOMY FOR ESOPHAGEAL ACHALASIA: 10 YEARS’EXPERIENCE FROM A SINGLE TERTIARY CENTER

Esophageal achalasia is most commonly treated with endoscopic dilation or laparoscopic Heller myotomy. Peroral endoscopic myotomy (POEM) has recently been described as a novel treatment for achalasia in humans. The aim of this study was to assess the clinical effectiveness and safety of POEM for treating esophageal achalasia performed in a single tertiary center within 10 years. Between June 2010 to May 2019, POEM was performed in 1140 consecutive patients with achalasia. POEM procedure consisted of the following step: firstly, submucosal tunnel was created and extended below the lower esophageal sphincter (LES) onto the gastric cardia after a mucosal incision was made; then endoscopic myotomy of circular muscle bundles was done; finally, the mucosal entry was closed by hemostatic clips. The Eckardt score and manometry were used to evaluate the outcomes. POEM was successfully performed in 1115 of 1140 cases (97.8%). Mean procedure time was 47.1 min (range 33-86) and mean myotomy length was 9.5 cm (range 7-16). Mucosal perforations occurred in 23 (2%) patients during submucosal tunnel creation, major bleeding occurred in 15 (1.3%) patients, and 29 (2.5%) patients suffered pneumothorax immediate after procedure. All the complications were managed conservatively. During a mean follow-up period of 49.3 months (range 5-89 months), treatment success was achieved in 1005/1140 patients (88.2%). Mean LES pressure was 57.5 mmHg (29.2-83.1) and 15.6 mmHg (5.2-23.1) before and after the procedure (P = 0.000), respectively. Mean Eckardt score was 6.1 (4-11, median 6) and 0.6 (0-3, median 1) before and after POEM, respectively (P = 0.000). In a multivariate analysis, no independent predictors of treatment success was found. 215 patient (18.9%) developed mild reflux symptoms and required intermittent medication with proton pump inhibitors during the follow-up. Our study demonstrated that POEM is a safe, and effective treatment for achalasia during a long-term follow-up. Further studies are warranted to compare the clinical outcomes of POEM with other treatment modalities.

Stretta radiofrequency treatment vs Toupet fundoplication for gastroesophageal reflux disease: a comparative study

BackgroundOutcomes of gastroesophageal reflux disease (GERD) using Toupet fundoplication (TF) and Stretta radiofrequency (SRF) have not been compared and this study was conducted to compare therapeutic efficacy of the two methods.MethodsThis retrospective study analyzed a total of 230 patients undergoing TF or SRF at our hospital. Baseline data, reflux symptoms, the DeMeester scores, lower esophageal sphincter (LES) pressure and adverse events were compared over 1 year period.ResultsA total of 226 patients were included in the study. The time and frequency of reflux and percentage of reflux time before and 12 months after therapy were not significantly different. There were significantly interactions between the therapy method and follow-up time on the DeMeester score and LES pressure. Twelve months post therapy, the DeMeester score was significantly higher in SRF than in TF group, while the LES pressure was lower. At 12 months after therapy, multivariate Cox proportional regression analysis showed that reflux frequency, the DeMeester score and LES pressure were risk factors for poor prognosis in TF group, while reflux frequency and the DeMeester score, and LES pressure were risk factors for poor prognosis in SFR group.ConclusionsCompared with TF, SFR can significantly improve the esophageal pH and pressure in GERD patients without increasing the risk of poor prognosis.

Three-Dimensional Pressure Profile of the Lower Esophageal Sphincter and Crural Diaphragm in Patients with Achalasia Esophagus

Smooth muscles of the lower esophageal sphincter (LES) and skeletal muscle of the crural diaphragm (esophagus hiatus) provide the sphincter mechanisms at the esophagogastric junction (EGJ). We investigated differences in the 3-dimensional (3D) pressure profile of the LES and hiatal contraction between healthy subjects and patients with achalasia esophagus. We performed a prospective study of 10 healthy subjects (controls; 7 male; mean age, 60 ± 15 years; mean body mass index, 25 ± 2) and 12 patients with a diagnosis of achalasia (7 male; mean age, 63 ± 13 years; mean body mass index, 26 ± 1), enrolled at a gastroenterology clinic. Participants underwent 3D high-resolution manometry (3DHRM) with a catheter equipped with 96 transducers (for the EGJ pressure recording). A 0.5-mm metal ball was taped close to the transducer number 1 of the 3DHRM catheter. EGJ pressure was recorded at end-expiration (LES pressure) and at the peak of forced inspiration (hiatal contraction). Computed tomography (CT) scans were performed to localize the circumferential location of the metal ball on the catheter. Esophagus, LES, stomach, right and left crus of the diaphragm, and spine were segmented in each CT scan slice images to construct the 3D morphology of the region. The metal ball was located at the 7 o'clock position in all controls. The circumferential orientation of metal ball was displaced 45 to 90 degrees in patients with achalasia compared with controls. The 3D-pressure profile of the EGJ at end-expiration and forced inspiration revealed marked differences between the groups. The LES turns to the left as it entered from the chest into the abdomen, forming an angle between the spine and LES. The spine-LES angle was smaller in patients with achalasia (104°) compared with controls (124°). Five of the 10 subjects with achalasia had physical breaks in the left crus of the diaphragm CONCLUSIONS: Besides LES, the 3D pressure profile of the EGJ can indicate anatomic and functional abnormalities of the crural diaphragm muscle in patients with achalasia esophagus. Further studies are needed to define the nature of hiatal and crural diaphragm dysfunction in patients with achalasia of the esophagus.

Anticholinergic, anti-depressant and other medication use is associated with clinically relevant oesophageal manometric abnormalities.

Medications can affect gastrointestinal tract motility. However, their effects on oesophageal motility in particular are often not as widely known or may be underestimated. To review the effect of existing medication use on high-resolution oesophageal manometry (HRM) in a 'real-world' setting. Adult patients with upper gut symptoms and normal endoscopy or imaging who had HRM over a 22-month period were analysed. Achalasia and major disorders of peristalsis were excluded. All medications taken within 24hours of the procedure were prospectively recorded and compared with HRM results, controlling for age, gender and proton pump inhibitor use. A total of 502 patients (323 female, mean age 51) were recruited. Of these, 41.2% had normal oesophageal HRM, while 41.4% had ineffective oesophageal motility (IOM) and 7.6% had oesophagogastric junction outflow obstruction (OGJOO). Serotonin/norepinephrine reuptake inhibitors (SNRI) and opioids were associated with significantly higher resting lower oesophageal sphincter pressure. Benzodiazepines and opioids were associated with elevated integrated relaxation pressure. SNRI and inhaled beta-agonists were associated with increased distal contractile index, whereas calcium channel blockers were associated with a lower distal contractile index. Odds ratio of being on anticholinergics was higher in IOM patients vs normal (3.6, CI 1.2-10.8). Odds ratio for anticholinergics, inhaled beta-agonists, anticonvulsants, SNRIs and opioids (trend) were all>3 for OGJOO patients vs normal. Many medication classes are associated with abnormal HRM variables and diagnoses such as OGJOO and IOM; some of these associations are probably causal. These possible links should be taken into consideration during manometry interpretation.

Mosapride Improves Lower Esophageal Sphincter and Esophageal Body Function in Patients With Minor Disorders of Esophageal Peristalsis.

Background/AimsHigh-resolution manometry (HRM) has broadened the awareness of minor esophageal peristaltic disorders. However, the treatments for these minor disorders are limited and the role of prokinetics has been controversial. This study evaluates the effect of mosapride in patients with minor peristaltic disorders.MethodsThis study prospectively enrolled 21 patients with esophageal symptoms who were diagnosed with minor peristaltic disorders by gastroscopy and HRM using the Chicago classification version 3.0. Patients received mosapride 30 mg daily for 2 weeks. Symptoms were assessed using the abbreviated World Health Organization quality of life scale (WHOQOL-BREF) and a HRM study was performed before and after 2 weeks of treatment.ResultsHRM metrics of lower esophageal sphincter (LES) respiratory mean pressure (median 14.6 mmHg vs 17.3 mmHg; interquartile range [IQR] 8.7-22.5 mmHg vs 12.5-25.9 mmHg; P = 0.004) and distal contractile integral (median 343.8 mmHg·sec·cm vs 698.1 mmHg·sec·cm; IQR 286.5-795.9 mmHg·sec·cm vs 361.0-1127.6 mmHg·sec·cm; P = 0.048) were significantly increased after treatment. Complete response (≥ 80.0%), satisfactory response (≥ 50.0%), partial response (< 50.0%), and refractory response rates were 19.0%, 52.4%, 14.3%, and 14.3%, respectively. However, there was no statistical difference in all WHOQOL-BREF scores before and after treatment. Univariate analysis showed LES respiratory mean pressure (P = 0.036) was associated with symptom improvement (complete + satisfactory group). However, no statistical difference was found in other factors after multivariate analysis.ConclusionsMosapride improved esophageal symptoms and significantly increased LES respiratory mean pressure and distal contractile integral. Therefore, mosapride could enhance LES and esophageal body contraction pressures in patients with minor peristaltic disorders.

Influence of sildenafil on esophageal motor function in humans: Studies using high-resolution manometry.

Sildenafil induces smooth muscle relaxation of the esophagus by blocking type 5 phosphodiesterase that degrades cyclic guanine monophosphate. We aimed to characterize the effects of sildenafil on esophageal peristalsis and contraction reserve using high-resolution manometry (HRM). Fifteen healthy adults (12 men, age 21-39, mean 27years) participated in this study using HRM following either sildenafil 50mg or placebo. HRM with ten wet swallows and five multiple rapid swallows was performed in all participants. HRM metrics included esophagogastric junction contractile integral (EGJ-CI), basal lower esophageal sphincter (LES) pressure, 4-second integrated relaxation pressure (IRP-4s), distal contractile integral (DCI), distal latency, resting upper esophageal sphincter pressure (UESP), and the response to MRS. Sildenafil significantly lowered EGJ-CI (P<.001), LES pressure (P=.04), IRP-4s (P=.02), and DCI (P<.001). There was no difference in UESP (P=.87) between sildenafil and placebo. Sildenafil significantly decreased peristaltic vigor, inducing absent peristalsis in 12 subjects and ineffective esophageal motility in 3 subjects. Peristaltic response and augmentation following MRS were significantly inhibited following sildenafil (7% vs 100%, P<.001, and none vs 73%, P<.001). Sildenafil attenuates EGJ barrier function, resting LES pressure, and LES relaxation. Both esophageal body contractility and contraction reserve are inhibited by sildenafil in healthy adults.

Peroral endoscopic myotomy (POEM) for dysphagia and esophageal motor disorder after antireflux fundoplication.

Laparoscopic fundoplication is the treatment of severe and refractory gastroesophageal reflux disease (GERD). It induces dysphagia in 5 % - 10 % owing to a tight valve ± esophageal motility disorders (EMD), with challenging management. We assessed the first case series assessing peroral endoscopic myotomy (POEM) in such a situation. A retrospective case series including eight patients with severe dysphagia after laparoscopic fundoplication who were treated by POEM. They were assessed clinically by Eckardt and Mellow - Pinkas dysphagia scores, and by high resolution manometry (HRM). The procedure was a regular esophageal POEM, mainly posterior, including a myotomy of the wrap. The objectives were to evaluate the clinical efficacy, technical difficulties, and complications of this approach. HRM showed aperistalsis in 6 /8 patients and raised lower esophageal sphincter (LES) pressure in 5 /8. The median preoperative Eckardt and dysphagia scores were 5 and 3.5, respectively. The procedure was completed in 7 /8 patients, with a clinical efficacy rate (normalization of both scores) of 75 % (6 /8). Although the submucosa seemed more fibrotic and vascularized, no severe complications occurred. POEM is a newly described therapeutic option to consider for managing dysphagia due to EMD after laparoscopic fundoplication.

Taking the ‘sauer’ out of sauerkraut: a rapid update on the pathophysiology and treatment of gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease (GERD), in layman’s terms known as heartburn, is a condition characterised by frequent oesophageal contact with gastric acid. Contrary to what is generally accepted, GERD is not caused by excessive quantities of gastric acid. Rather, symptoms result from any combination of a number of contributing factors, including decreased lower oesophageal sphincter pressure, hiatus hernia (where the stomach protrudes through the diaphragm), reduced oesophageal and gastric clearance and compromised oesophageal mucosa barrier integrity. Although most patients are able to manage GERD symptoms by means of lifestyle changes, chronic and recurrent episodes of reflux may result in erosive oesophagitis, nasal inflammation, dysphagia, i.e. difficulty in swallowing, and even pulmonary complications, e.g. asthma.

Effects of Peroral Endoscopic Myotomy on Esophageal Function in the Treatment of Achalasia.

Peroral endoscopic myotomy (POEM) is a new technique to treat achalasia, but the effects on esophageal motor function and structure are still unclear. This study aimed to examine the esophageal function and anatomical changes of patients with achalasia treated with POEM. This was a retrospective study of 43 patients with achalasia treated with POEM between January 2013 and January 2016 at the Second Affiliated Hospital of Xi'an Jiaotong University. The patients were grouped as previous treatments for achalasia (n = 19) versus no previous treatment (n = 24). Surgical success (defined as Eckardt score ≤3 points or decreased by >3 points compared with baseline), recurrence, and reintervention were analyzed. Three patients (7.0%) were Eckardt grade I, 16 (37.2%) were grade II, and 24 (55.8%) were grade III. Operation time was 35 to 150 (median = 49) minutes. Both groups showed improvements in the Eckardt score after surgery (both P < .001), without a difference between the 2 groups (P = .749). The maximal mean diameter of the esophagus was reduced, and the lower esophageal sphincter pressure was improved after surgery (both groups, all P < .001), without difference between the 2 groups (all P > .05). One case of failure was probably due to the presence of an esophageal stent. POEM has a high success rate and is possibly unaffected by previous treatments, except maybe stent implantation. Clinical symptoms of achalasia are significantly relieved by POEM; the function of the esophageal sphincter and the esophagus structure are improved. Previous esophageal stent implantation could increase failure likelihood, but this will have to be confirmed.

CORRELATION BETWEEN SEVERITY OF EROSIVE REFLUX ESOPHAGITIS AND ITS MANOMETRIC FINDINGS IN A TERTIARY HOSPITAL AT EAST COAST, PENINSULAR MALAYSIA.

The burden of Gastroesophageal Reflux Disease, GERD in Asia-Pacific region is increasing. Objectives: To evaluate the manometric finding in erosive reflux esophagitis and its correlation with severity among patients who were seen at Surgical Department, Hospital Tengku Ampuan Afzan (HTAA), Kuantan. Methodology: This was a cross sectional study which involved 60 patients seen from September 2012 until January 2014. Patients were required to fill up the Reflux Disease Specific Questionaire and subsequently underwent manometric evaluation. Descriptive statistics and Pearson’s correlation were applied using SPSS version 18.0. Results: There was no correlation between the severity of Erosive Reflux Disease with the Lower Esophageal Sphincter Pressure or esophageal motility. There was positive correlation (r = + 0.54) between severity of Erosive Reflux Disease and velocity variables of esophageal motility but it was not statistically significant. Discussion: Few experts opined that Erosive Reflux Disease is associated with esophageal dysmotility but there was no specific pattern of esophageal mean wave amplitude in our study sample. The limitation of this study was the sample’s selection and size. Thus, we need further study with better methodology and sample size. Conclusion: In conclusion, there was no significant correlation between the severity of Erosive Reflux Esophagitis on the Lower Esophageal Sphincter pressure and the esophageal motility