Lower Esophageal Sphincter Pressure Research Articles

Advanced achalasia: good candidate for peroral endoscopic myotomy.

Peroral endoscopic myotomy (POEM) has been increasingly accepted as the first-line treatment of achalasia. However, laparoscopic Heller myotomy or esophagectomy still remains as the mainstay treatment for advanced achalasia featured with megaesophagus and/or sigmoid-shaped esophagus. Although the efficacy of POEM for advanced achalasia with sigmoid-shaped esophagus has been described, little is known about the role of POEM for patients with megaesophagus. The aim of our study is to evaluate the efficacy and safety of POEM for advanced achalasia with megaesophagus. Patients who received initial examinations and underwent POEM in our hospital from June 2013 to December 2018 were identified and data were retrospectively analyzed. The advanced achalasia was defined as megaesophagus with a diameter of ≥6cm. The primary outcome was clinical success. The secondary outcomes were technical success and adverse events. A total of 112 patients (50 females, 44.6%) were included with a mean age of 44.8years. The median symptom duration was 6.5years (IQR:3.0-13.0years). Modified POEM techniques were used in 27.7% (31/112) of patients. Technical success rate was 99.1% (112/113) per procedure. Clinical success was seen in 93.1% patients with median Eckardt score decreasing from 8.0 to 1.0 (P < 0.001) during a median 31.0months of follow-up. The mean LES pressure decreased from 29.5mmHg to 14.2mmHg after POEM (P < 0.05). Procedure-related adverse events occurred in 8.9% patients. Reflux disease was observed postoperatively in 26.7% of patients. POEM is also indicated for patients with advanced achalasia with a favorable safety and efficacy.

Magnet-assist endoscopic augmentation of the lower esophageal sphincter for treatment of gastroesophageal reflux disease: cadaveric and survival studies in a porcine model (with video).

Augmentation of the lower esophageal sphincter (LES) is the primary goal of both surgical and endoscopic therapies for gastroesophageal reflux disease (GERD). The feasibility, efficacy, safety, and reversibility of a newly developed endotherapy for GERD using intraluminal magnets referred to as a magnet closure device (MCD) were evaluated. This study involved nine cadaveric and six survival pigs. The MCD consisted of a ring neodymium magnet attached to a 2-0 polypropylene suture and suture anchor. The MCD was deployed onto the esophageal wall at the region of the LES using an endoscopic suturing device. Two to three MCDs were placed on opposing walls to induce closure of the esophageal lumen. LES pressures were measured using high-resolution manometry at the index procedure (baseline and immediately post-MCD placement) and at survival endoscopy. Endoscopic removal of the devices was performed followed by necropsy at week 2. MCDs were successfully deployed in all cadaveric (n = 22) and survival animals (n = 12). In cadavers, 20/22 (91%) sutures were full-thickness with no adjacent organ injury. In survival animals, mean LES pressure increased from 8.4mmHg (baseline) to 32.4mmHg immediately post-procedure (p < 0.01). No clinically significant adverse events occurred. Repeat endoscopy at two weeks showed intact MCDs in 4/6 (67%) animals with significant increase in median LES pressure (n = 4, 24.0mmHg versus 7.4mmHg [baseline], p < 0.05). Endoscopic removal of MCDs was successfully achieved. Endoscopic augmentation of the LES using a new MCD was feasible, safe and reversible with significantly increased LES pressures recorded. Future studies are needed to enhance durability. These preliminary results on a reversible technique are promising and may represent an attractive alternative to endoluminal GERD therapy.

S0430 The Effect of Hiatal Hernia on High-Resolution Esophageal Pressure Topography Measures in Patients With Esophagogastric Junction Outflow Obstruction

INTRODUCTION: High resolution esophageal pressure topography (HREPT) is used to diagnose esophagogastric junction outflow obstruction (EGJOO), a motility disorder with impairment of lower esophageal sphincter (LES) opening defined by an elevated integrated relaxation pressure (IRP) with preserved peristalsis. Many of these patients also have concomitant hiatal hernia (HH) that may independently affect LES relaxation pressures. This study aimed to evaluate the effect of HH on the diagnosis of EGJOO by comparing manometric outcomes at a single US tertiary care academic medical center. METHODS: This retrospective, observational, cohort study identified patients who had undergone HREPT between January 2017 and March 2018. Patients diagnosed with EGJOO were eligible for inclusion and further evaluated for HH via manometry. Those with obstructive dysphagia, pseudo-achalasia, or other neuromuscular disorders affecting esophageal motility were excluded. LES integrated relaxation pressures (IRP), basal pressure (BP), distal contractile integral (DCI), intrabolus pressure (IBP), and incomplete bolus transit (IBT) were collected. Student’s t- tests were used to compare groups and Chi-square analysis was used for independent variables. RESULTS: A total of 90 total patients were identified (n = 54 EGJOO without HH, n = 36 EGJOO with HH). In general, baseline characteristics were similar between groups with no significant differences in gender or age. Comparing patients with only EGJOO to those with both EGJOO and HH, there was a statistically significant difference in basal LES pressures (50.9 mmHg vs. 42.2 mmHg, P = 0.029) but no difference in IRP (22.5 mmHg vs. 20.3 mmHg, P = 0.173) between groups. Additionally there were no intergroup differences in DCI, IBP, or IBT. CONCLUSION: EGJOO is a heterogenous manometric diagnosis with many patients also experiencing anatomic defects including HH. Our study reports among the largest real-world comparisons of these groups. The observed higher basal LES pressures in patients with only EGJOO compared to those with both EGJOO and HH suggests a possible anatomic effect on LES pressures. However, this difference does not have affect other manometric measures including IRP which is currently the principal measure of outflow obstruction. Further work exploring the anatomic and physiologic components of LES pressure is needed to understand the development of EGJOO and guide therapeutic interventions.Table 1.: Outcomes

The role of intraoperative endoscopic guidance during laparoscopic repair of esophageal achalasia

Purpose The aim was to assess the advantage of using intraoperative endoscopic guidance during laparoscopic repair of esophageal achalasia. Materials and methods This was a retrospective study conducted at Ain Shams Specialized Hospitals that included 84 patients. A total of 42 patients had Heller cardiomyotomy procedure with dor fundoplication and another 42 patients had the same procedure with intraoperative endoscopic guidance. Results Preoperative symptoms included dysphagia in 80 (95%) patients, regurgitation and vomiting in 60 (71.5%) patients, heartburn in 56 (66%) patients, and postprandial chest pain in 40 (49%) patients. Weight loss occurred in 42 (50%) patients. Overall, 72 (85%) patients had tried 2–3 pneumatic dilation. Mean lower esophageal sphincter pressure preoperatively was 33 and was 13.3 mmHg postoperatively (4.1–28.4). The operative time was 45±20 min in the endoscopic group and was 40±10 in the nonendoscopic guidance. Overall, 5 patients of the nonendoscopic group had perforation and one case of bleeding. Postoperatively, dysphagia was seen in one (2.25%) patient of the endoscopic group and four (9.5%) patients of the nonendoscopic group. Postprandial heart pain was seen in two (4.6%) patients of the endoscopic group and four (9.2%) patients of the nonendoscopic group. Moreover, 2 (4.6%) patients of the endoscopic group and four (9.5%) patients of the nonendoscopic group had postoperative regurgitation. Weight regain was seen in 19 (90%) patients of the endoscopic group and 17 (80%) patients of the patients of nonendoscopic group after 12-month follow-up. Conclusion Heller cardiomyotomy with endoscopic guidance is very important not only as a guide to ensure adequate myotomy but also to limit the extent of the myotomy, thereby minimizing the postoperative reflux symptoms.

S0421 Lower Esophageal Sphincter Pressures Are Significantly Reduced in Patients With a Hiatal Hernia but No Major Abnormality on Esophageal Manometry

INTRODUCTION: A hiatal hernia (HH) eliminates the normal alignment of the lower esophageal sphincter (LES) and crural diaphragm (CD), separating the two components of the esophago-gastric junction high pressure zone (EGJHPZ). This separation may affect parameters measured during high resolution esophageal manometry (HREM), including measurements of resting lower esophageal sphincter (LES) pressure. The effect of a HH on LES relaxation, as measured by integrated relaxation pressure (IRP), is less well studied. The aim of this study was to determine how a HH affects HREM parameters. METHODS: HREM performed at a large referral-based motility center between 2013 and 2019 were reviewed. Patients with any major/minor peristaltic disorder based on Chicago Classification version 3.0 (CC3), or where the catheter did not traverse the LES, were excluded. Key manometric parameters including LES resting pressure and IRP, distal contractile integral (DCI), contractile front velocity (CFV), distal latency (DL) and esophageal length were collected. Patients were further subdivided into 3 groups according to HH size on HREM for analysis: no HH, HH 0.1–1.9cm, and HH ≥ 2 cm. RESULTS: A total of 1330 HREM reports were reviewed, with 479 studies not showing a CC3 abnormality. These patients had no HH (189, 39.5%), HH 0.1–1.9 cm (172, 35.9%), and HH ≥ 2 cm (118, 24.6%) (Figure 1). Analysis demonstrated that the presence of a HH was associated with a significantly lower mean LES resting pressure, IRP, and DCI (all P-values < 0.02, Table 2). Esophageal length was consistently shorter in HH patients (P < 0.01). For all 3 parameters, values decreased as HH size increased. There was no statistical difference between groups with respect to CFV or DL. CONCLUSION: In patients without a CC3 peristaltic abnormality, HH patients show significant decreases in LES resting pressure, IRP, and esophageal length. Separating the CD from the EGJHPZ may be partially responsible for the drop in pressures. However, HREM analysis software is supposed to isolate the LES from any CD contribution. Additional investigation is necessary to determine whether and what HH-related changes to the LES itself are contributing to this significant difference, and if they affect related conditions such as gastro-esophageal reflux. Shorter esophageal length may impact the success of a HH repair. Further studies exploring the outcomes of different surgical approaches in varying esophageal lengths are warranted.Figure 1.: Study Flow Diagram.Table 1.: Baseline Demographic CharacteristicsTable 2.: High Resolution Esophageal Manometry Findings

S3427 Cannabis in Relation to Gastroesophageal Reflux Disease

INTRODUCTION: There is a wide distribution of cannabinoid receptors (CBR) in the enteric nervous system, highlighting the role of cannabis in GI health and disease. Of these, CB1 is most often expressed and has been shown to decrease intra-gastric pressure, affect transient LES relaxation (TLESR), and concurrently delay gastric emptying via inhibition of excitatory neurons. We compared three different articles on their studies of cannabinoid receptors in relation to the upper GI tract. The goal of this systematic review is to assess the current knowledge of cannabis implementation, effectiveness, and its adverse side effects, in addition to identifying areas for expanding research. CASE DESCRIPTION/METHODS: In a study conducted by Calabrese et al, 87 total subjects consisting of 10 controls, 39 with non-erosive esophageal reflux (NERD), and 38 with erosive esophageal reflux (ERD) who had typical symptoms for >1 year had eight specimens of macroscopically normal esophageal mucosa taken and analyzed for expression of CBRs. Beaumont et al assessed the response of 10 mg and 20 mg Δ9-THC, a cannabinoid agonist, given three doses each a week apart in healthy volunteers. LES pressure, spontaneous swallows, and reflux episodes were measured. Scarpenllini et al studied the effects of a CB1 receptor antagonist Rimonabant on fasting and postprandial LES function in healthy subjects. Twelve healthy volunteers underwent esophageal manometry studies with administration of wet swallows and a meal after 3 days of premedication with placebo or 20 mg of Rimonabant. Transient LES relaxations and reflux episodes were measured. DISCUSSION: There is a need for more research to be performed, not only on the effects of THC on the GI system, but also for dosing to determine whether or not cannabis can be used as a therapy for esophageal disorders. With increased regulation of cannabis products and further research, consumers would be able to reduce the risks of experiencing unpleasant side effects. It is important to note that cannabis use can also lead to complications, including cannabinoid hyperemesis syndrome. No definitive recommendations can be made at this time on whether or not cannabis use will be a useful therapy for GI disorders until more research is completed.

S0358 Role of Endoscopic Functional Luminal Imaging Probe (EndoFLIP) for the Management of Post Myotomy Clinical Failure

INTRODUCTION: Peroral Endoscopic Myotomy (POEM) and Laparoscopic Heller myotomy (LHM) have evolved as effective management tools in relieving lower esophageal sphincter (LES) pressure in patients with esophageal motility disorders. However, a small percentage of patients fail to improve or relapse after time. The challenge remains in identifying the patients who might benefit from repeat myotomy as opposed to conservative managements. In the following study, we describe the role of endolumenal functional lumen imaging probe (EndoFLIP), in addition to high-resolution manometry (HRM), for managing such patients. METHODS: This was a multicenter, international retrospective study conducted between January 2015 and October 2019. Patients with a diagnosis of achalasia, esophagogastric junction outflow obstruction (EGJOO), diffuse esophageal spasm (DES), or jackhammer esophagus (JE) who underwent a prior failed myotomy were included. Clinical success of post repeat myotomy in the form of POEM was considered the primary outcome. RESULTS: A total of 72 patients [Female = 28 (39%), mean age 55 ± 17.3] with clinical failure and Eckardt score (ES) > 3 who underwent post LHM (33) or POEM (39) were included. On HRM evaluation, 27 were deemed candidates for repeat myotomy based on abnormal integrated relaxation pressure (IRP) measurements >15mmHg. On EndoFLIP evaluation,13/27 had an abnormal distensibility index (DI) < 2.8 mm2/mmHg at 40 ml balloon volume distension (Figure 1). A total of 30 patients underwent conservative management - pneumatic balloon dilation (n = 9) and repeat myotomy (n = 33) (Table 1). Post repeat myotomy mean ES improved from 5.8 ± 2.7 to 1.1 ± 1.4, (P < 0.001), and median DS improved from 2 (IQR: 1-3) to 1 (0-2), (P = 0.03), at a median follow-up time of 2 (IQR: 0-4.5) months post-procedure. Clinical success was achieved in 23/33 (70%) of the patients (Table 2). DI at 40 m balloon distension volume (P = 0.01; odds ratio, 1.51; 95% confidence interval, 1.02-2.1) was identified to be the best independent predictors of clinical success post repeat myotomy, with DI < 3.3 mm2/mmHg having sensitivity and specificity of 64% and 80%, respectively, for predicting clinical success. Therefore, the theoretical impact of EndoFLIP utilization for the management and diagnosis was in 16/72 (22%). CONCLUSION: The findings of this study demonstrate the important role of using EndoFLIP, in addition to HRM, in evaluating patients with clinical failure post myotomy.Figure 1Table 1Table 2

S0383 Prevalence of Barrett’s Esophagus in Female Scleroderma Patients

INTRODUCTION: Scleroderma renders the esophagus prone to significant gastroesophageal reflux due to impairment in esophageal clearance (aperistalsis in the lower third of the esophagus) and reduced lower esophageal sphincter (LES) pressure. Scleroderma mainly affects women, whereas Barrett’s esophagus (BE) predominantly affects men. The reported prevalence of BE in women with scleroderma varies widely from 6% to 37%, and is mainly derived from older small studies. We aimed to assess the true prevalence of BE in a large cohort of women with scleroderma. METHODS: Clinical data were collected from two prospectively maintained databases at a single academic tertiary referral center. One database consisted of scleroderma patients referred for high-resolution esophageal manometry (HREM). The other database consists of all patients with BE and associated clinical and endoscopic data. The diagnosis of scleroderma was confirmed by a rheumatologist with expertise in scleroderma according to the 2013 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) criteria for systemic sclerosis/scleroderma. Inclusion criteria included female sex, confirmed scleroderma, and a diagnosis of Barrett’s esophagus confirmed by an expert gastrointestinal pathologist. Prevalence data were tabulated for each database and in aggregate. RESULTS: There were 286 women with scleroderma who underwent HREM (Table 1). There were 17 patients with histologically proven Barrett’s esophagus, representing 5.9% of the group. Of these Barrett’s patients, 11 had non-dysplastic Barrett’s esophagus, 2 had indefinite dysplasia, 3 had low grade dysplasia (LGD), and 1 had esophageal adenocarcinoma (EAC) (Table 2). Of 616 women with Barrett’s esophagus, 33 had scleroderma (5 diffuse, 25 limited and 3 unclassified). CONCLUSION: In this large cohort of female patients, the prevalence of BE in patients with scleroderma presenting for esophageal evaluation was 5.9% and the prevalence of scleroderma in women with Barrett’s esophagus was 5.4%. Although uncommon, both LGD and EAC were found in this population. BE is a prevalent complication of scleroderma and screening for its presence should be considered.Table 1

S0448 Characterizing Regurgitation and Heartburn Symptoms in Patients Undergoing High Resolution Esophageal Manometry With Esophageal pH-Impedance Monitoring

INTRODUCTION: Studies that characterize GERD often fail to describe regurgitation as well as they do heartburn. The study aims to: 1) describe the frequency and severity of heartburn and regurgitation in patients referred for esophageal function evaluation; 2) describe the esophageal disorders with these symptoms; and 3) investigate the pathophysiology of these symptoms. METHODS: We retrospectively reviewed data from patients undergoing High Resolution Esophageal Manometry with Impedance (HREMI) and Esophageal pH Impedance monitoring (EpHI) between December 2019 and March 2020. Patients filled out the Reflux Disease Questionnaire (RDQ) and the Patient Assessment of Upper GI symptoms (PAGI-SYM). The RDQ evaluates both severity and frequency of heartburn, regurgitation, and dyspeptic symptoms. Mean symptom severity was calculated as (symptom frequency [days per week] x symptom intensity)/7 (scoring is from 0 to 3). RESULTS: Of the 171 patients (average age 55 ± 15 years; 69% female), 164 completed HREMI (7 were unable to tolerate procedure) and 108 completed EpHI. 74 were determined to have GERD by esophageal acid exposure time and/or impedance episodes. Regurgitation movement (RDQ score 0.8; present in 52%) and regurgitation taste (RDQ score 0.6; present in 48.5%) was more prevalent than substernal burning (RDQ score 0.5, present in 35.1%) and substernal pain (RDQ score 0.5, present in 35.1%). Regurgitation taste correlated with regurgitation movement (r = 0.50, P < 0.001), substernal burning (r = 0.53, P < 0.001), and substernal pain (r = 0.39, P < 0.001). Acid exposure time correlated with substernal burning (r = 0.22, P = 0.029) and dyspepsia burning (r = 0.26, P = 0.010). The presence/absence of a hiatal hernia (HH) did not affect regurgitation symptoms. Patients with GERD had similar LES pressures (P = 0.09), hiatal hernia sizes (P = 0.07), and RDQ symptoms. Regurgitation was present in 47% of patients with ineffective esophageal motility, 20% with absent contractility, 33% achalasia, and 39% with no abnormalities (P = 0.21). CONCLUSION: Regurgitation is correlated with heartburn and dyspepsia. It is a common symptom of patients undergoing HREMI and EpHI and is present in many disorders. Additionally, increasing acid exposure was related to substernal burning and dyspepsia burning but was not correlated to regurgitation.(image 3) These results suggest that although acid suppression therapy may be helpful for heartburn, it may not be helpful for treating regurgitation.Table 1Table 2Figure 1

S3598 L.A Grade D Erosive Esophagitis With Incidental Ectopic Pancreas

INTRODUCTION: Grade D erosive esophagitis and ectopic pancreas are both rare findings. We describe a patient that presented for an upper GI bleed with several risk factors for esophagitis. On endoscopy, L.A grade D erosive esophagitis was found along with an asymptomatic ectopic pancreas within the antrum of the stomach. CASE DESCRIPTION/METHODS: 58-year-old male with a history of tobacco usage, alcohol abuse, and GERD presented with alcoholic intoxication, black stools, and coffee-ground emesis for one day. He was found to have a hemoglobin of 7.7 from 13.5, hematocrit 21.3, elevated BUN and ALT. He was tachycardic and hypotensive. His skin showed pallor, abdomen was soft and tender to palpation in the epigastrium. Rectal exam was positive for black stool. He was given fluids and started on a PPI drip. The patient was admitted to the MICU for hemorrhagic shock. He received 2 unit’s FFP and 2 units PRBC prior to Endoscopy. EGD showed LA Grade D erosive esophagitis, a single lesion of aberrant pancreas in the stomach and gastritis. His hospital stay was uncomplicated and he was discharged with follow up. DISCUSSION: We describe a patient with L.A. grade D erosive esophagitis and ectopic pancreas. Both are rare conditions and present as a source of bleeding. Ectopic pancreas has an incidence of 0.2%, while grade C and D erosive esophagitis combined are 1% of all erosive esophagitis cases. The severity of erosive esophagitis in our patient is due to several factors, one being the patient’s 40 pack-year smoking history of which causes the LES pressures to be significantly lower. He had a hiatal hernia. The GE junction becomes both dilated and shorter, allowing for LES relaxation and increased acid reflux. His excessive alcohol drinking history can also reduce the LES tone and cause pyroptosis.On EGD our patient also had ectopic pancreas finding. This usually presents asymptomatically. This finding can pose a problem, as it can cause asymptomatic bleeding and can later develop into pancreatitis. Being a ETOH abuser, he is at risk for pancreatitis by both his ETOH usage and his ectopic pancreas.Periodic upper endoscopy must be done to monitor for cancer transformation, as ectopic pancreas can turn malignant at a rate of .7% to 1.8%. The extensive bleeding in our patient could have been due to the erosive esophagitis, aberrant pancreatitis or a combination of both. While both are rare findings, they can independently cause life-threatening complications and it is crucial to be aware that they can coexist together.Figure 1.: Aberrant pancreas in the Antrum of the Stomach.Figure 2.: Esophagitis.

Effects of Diaphragmatic Breathing on the Pathophysiology and Treatment of Upright Gastroesophageal Reflux: A Randomized Controlled Trial.

Uncontrolled results suggest that diaphragmatic breathing (DB) is effective in gastroesophageal reflux disease (GERD) but the mechanism of action and rigor of proof is lacking. This study aimed to determine the effects of DB on reflux, lower esophageal sphincter (LES), and gastric pressures in patients with upright GERD and controls. Adult patients with pH proven upright GERD were studied. During a high-resolution impedance manometry, study patients received a standardized pH neutral refluxogenic meal followed by LES challenge maneuvers (Valsalva and abdominal hollowing) while randomized to DB or sham. After that, patients underwent 48 hours of pH-impedance monitoring, with 50% randomization to postprandial DB during the second day. On examining 23 patients and 10 controls, postprandial gastric pressure was found to be significantly higher in patients compared with that in controls (12 vs 7 mm Hg, P = 0.018). Valsalva maneuver produced reflux in 65.2% of patients compared with 44.4% of controls (P = 0.035). LES increased during the inspiratory portion of DB (42.2 vs 23.1 mm Hg, P < 0.001) in patients and healthy persons. Postprandial DB reduced the number of postprandial reflux events in patients (0.36 vs 2.60, P < 0.001) and healthy subjects (0.00 vs 1.75, P < 0.001) compared with observation. During 48-hour ambulatory study, DB reduced the reflux episodes on day 2 compared with observation on day 1 in both the patient and control groups (P = 0.049). In patients, comparing DB with sham, total acid exposure on day 2 was not different (10.2 ± 7.9 vs 9.4 ± 6.2, P = 0.804). In patients randomized to DB, esophageal acid exposure in a 2-hour window after the standardized meal on day 1 vs day 2 reduced from 11.8% ±6.4 to 5.2% ± 5.1, P = 0.015. In patients with upright GERD, DB reduces the number of postprandial reflux events pressure by increasing the difference between LES and gastric pressure. These data further encourage studying DB as therapy for GERD.

349 LAPAROSCOPIC MANAGEMENT OF ACHALASIA CARDIA IN CHILDREN

Abstract Achalasia Cardia is a rare motility disorder of esophagus and is characterized by increased pressure of Lower Esophageal Sphincter (LES) and reduced motility of the body. This results in functional obstruction and failure of relaxation of LES. This condition is relatively rare in young children (about 0.11/100,000 children) Methods A retrospective study was done on 16 Paediatric patients with Achalasia Cardia over a 9 year period from 2010–2018. All patients underwent Barium Swallow and also upper GI endoscopy. Among the 16 patients, 8 of the patients underwent CT scanning and 6 patients had undergone manometry which is the gold standard method for diagnosis. Laparoscopic Heller’s Cardiomyotomy is the primary treatment modality for Achalasia Cardia. All patients underwent Cardiomyotomy along with Anterior Dor Fundoplication. Of the 16 patients, 6 had undergone Pneumatic Dilation previously. Results Of the 16 patients, 14 underwent Laparoscopic Heller’s Cardiomyotomy and 2 had open surgery. There were no intraoperative or postoperative complications. Normal feeds were started after 24 hours and the feeds were well tolerated. All the patients had complete resolution of dysphagia with score reducing from 4 to 0. All of them were discharged within 2–3 days. Conclusion Laparoscopic Heller’s Cardiomyotomy is the gold standard treatment for treating Achalasia Cardia. It is a safe, successful and efficient treatment modality for children with Achalasia Cardia due to shorter hospital stay, lower complication rates due to increased level of expertise and immediate and long lasting symptomatic relief.

Quantitative assessment of crural closure for laparoscopic anti-reflux surgeries: A novel technique to reduce post-operative dysphagia.

Background:Long-term dysphagia is a known complication of laparoscopic anti-reflux surgery (LARS). Of the several factors, inadequate hiatal closure is one of the major reasons for its occurrence. The aim of this study is to develop a technique for the quantitative assessment of crural closure during LARS to reduce dysphagia.Materials and Methods:It is an analysis of prospectively collected data of 109 patients who underwent LARS at a tertiary healthcare centre in India. To identify the adequacy of hiatal closure intraoperatively, a 7 French Fogarty catheter was used, and its balloon was inflated with 1 cc air at the repaired hiatus. This inflated balloon in the repaired hiatus following cruroplasty gives an accurate quantitative assessment of the adequate closure and adequate space for food bolus to pass without causing mechanical obstruction after hiatus repair. Pre- and post-operative 12 months’ DeMeester scores and lower oesophageal sphincter (LES) pressures were calculated.Results:The patients had a significant reduction in DeMeester scores postoperatively from a mean of 68.5–12.3 (P < 0.0001). None of the patients had long-term dysphagia or the need for long-term proton-pump inhibitors. The mean LES pressures on post-operative manometry showed increase to 15.1 mmHg from a mean of 6.4 mmHg, which was statistically significant (P = 0.0001). None of the patients had a recurrence of hiatus hernia.Conclusion:Quantitative assessment of adequacy for crural closure during LARS using a 7 French Fogarty catheter balloon is a novel technique which may decrease the incidence of post-operative dysphagia or intrathoracic wrap migration or recurrence of hiatus hernia.

Lack of Correlation Between Subjective and Objective Measures of Gastroesophageal Reflux Disease: Call for a Novel Validated Assessment Tool

Background. Objective measures including the DeMeester score, lower esophageal sphincter (LES) pressure, acid exposure time, and body mass index (BMI) are used to determine gastroesophageal reflux disease (GERD) severity and eligibility for various antireflux surgical procedures. The GERD Health-Related Quality of Life (GERD-HRQL) survey is widely used to evaluate patients' subjective severity of symptoms and GERD-related quality of life. The purpose of this project was to identify whether or not the subjective measure (GERD-HRQL) correlated with objective measures (DeMeester score, LES, acid exposure time, and BMI) of GERD severity. Methods. A retrospective review of the medical records of patients who underwent antireflux surgery from 2013-2018 was completed. Patients' GERD severity was measured preoperatively and postoperatively using the GERD-HRQL. Statistical analysis included the calculation of Spearman correlation coefficients, Wilcoxon rank sum, sign, and chi-square tests. Results. 151 patients were included in the study; 64% were female. The mean age and BMI were 54.6 ± 14.6years and 30.1 ± 4.1kg/m2, respectively. The mean preoperative DeMeester score was 43.1 ± 36.1, LES pressure was 19.9 ± 18.4mmHg, and acid exposure time was 11.4 ± 9.6. Mean GERD-HRQL scores decreased from 27.3 ± 9.2 preoperative to 5.3 ± 4.5 postoperative; P < .0001. Preoperative GERD-HRQL scores were not correlated with the DeMeester score (r = .11; P = .389), LES pressure (r = -.20; P = .089), acid exposure time (r = .05; P = .755), BMI (r = .10; P = .329), or age (r = -.16; P = .118). Conclusions. Total GERD-HRQL scores significantly decreased from pre- to postoperative. There was no correlation between subjective and objective GERD scoring. These data indicate the need for both physiologic evaluation and subjective assessment of patient symptoms during preoperative workup. There is a need for a contemporary, validated GERD questionnaire that correlates with objective pH testing.

ROLE OF PREOPERATIVE OESOPHGEALMANOMETRY IN OPERATIVE DECISION MAKING IN PATIENTS WITH CARDIAC ACHALASIA

Background: Surgery is considered the treatment of choice for esophageal achalasia, since it provides symptomatic relief that is stronger and longer lasting. Laparoscopic Heller cardiomyotomy is the preferred treatment for an anti reflux surgery with found oplication. Preoperative HRM is essential to the detection of sufficient fundoplication.Aim of the work: To assess the role of preoperative manometry in selection the type of antireflux surgery with Heller cardiomyotomy (Dor or Nissen fundoplication).Patients and methods: This prospective cohort study was conducted on twenty (20) patients presented to Ain-Shams University hospitals outpatient clinics suffering from chronic dysphagia from January 2018 through January 2020 to assess the role of preoperative manometry in selection of operative type and decision making in treatment of achalasia.Results: Using HRM ,14 patients (70%) with type 1 achalasia underwent Dor fundoplication and in these Dysphagia and regurgitation improved substantially in patients (p value = 0.001 and 0.001 respectively), also there were 4 patients (28.5%) with post-operative reflux. 6 Patients (30%) with type 2 achalasia underwent Nissen fundoplication and in these patients there was a significant improvement in dysphagia and regurgitation (p value = 0.034 and 0.023 respectively), 3 patients (50%) developed post-operative dysphagia, two of them improved on follow up. There was a significant reduction in LES pressure in both Dor and Nissen operation (p value = 0.001 and 0.026 respectively).Conclusion: Preoperative HRM is crucial in choosing type of fundoplication in achalasia as symptomatic responses vary depending on achalasia subtype.

The Prevalence of Esophageal Disorders Among Voice Patients With Laryngopharyngeal Reflux—A Retrospective Study

The goal of this study was to determine the prevalence of esophageal disorders among voice patients with intractable laryngopharyngeal reflux (LPR) who have undergone 24 pH impedance and esophageal manometry. A retrospective chart review was performed of patients with LPR-associated dysphonia in the absence of subjective dysphagia who presented between January 1, 2007 and June 30, 2019 and underwent 24 pH impedance and esophageal manometry studies after inadequate response to lifestyle modifications, high dose of Proton Pump Inhibitor (PPIs), H2 blockers, alkaline water, and Gaviscon (GlaxoSmithKline, Warren, NJ, USA). The comorbidities, medications, Strobovideolaryngoscopy findings, 24 pH impedance, and esophageal manometry results were analyzed. The study included 109 patients ages 19 to 80 years old, with a mean age of 51.5 (SD 16.8). About 24.8% of the 109 subjects were found to have peristaltic wave abnormalities indicating esophageal dysmotility (11% with esophageal stasis). Lower esophageal sphincter pressures were normotensive in 56.9% of patients, hypertensive in 24.8%, and hypotensive in 18.4% of patients. In addition, the upper esophageal sphincter pressures were normotensive in 57.8% of patients, hypertensive in 36.7%, and hypotensive in 2.8% of patients. About 12.6% had both lower esophageal sphincter and upper esophageal sphincter dysfunction (hypertensive or hypotensive). The average total reflux events in patients exhibiting dysmotility on manometry 101.81, which was significantly higher compared with the mean total of 61.28 in the group of patients without dysmotility (P= 0.0396). In addition, there was a significantly higher prevalence of total events that were weakly acidic in the group with dysmotility compared with the group without (all patients performed the study on reflux medications, mean of total weakly acidic events 70.2 in dysmotility group vs 44.2 in normal motility group, P= 0.0427).Finally, the average number of total supine reflux events and the total acidic supine events were both significantly higher in the dysmotility group compared with the group without motility problems (P = 0.0199 and P = 0.0213, respectively). Esophageal dysmotility may be a significant cofactor in voice patients with refractory LPR on appropriate reflux medications and lifestyle modifications. Further research is advised.

Sex differences in symptoms, high-resolution manometry values and efficacy of peroral endoscopic myotomy in Chinese patients with achalasia.

We aimed to identify the differences in symptoms, high-resolution manometry (HRM) characteristics, and the efficacy of peroral endoscopic myotomy (POEM) regarding patients' sex in achalasia. All patients diagnosed with achalasia by HRM who underwent POEM and were followed up for more than 6 months were included. The individual characteristics, symptoms and signs, POEM findings, HRM results and potentially related complications in male and female patients were reviewed. Prior to POEM, dysphagia was more severe in female than male patients (P = 0.044), while regurgitation was more severe (P = 0.013) and heartburn was more common in male patients (P = 0.003). Regarding HRM characteristics, the lower esophageal sphincter pressure (LESP) was higher (P = 0.01) and length of esophagus was shorter in female patients than in male patients. Eckardt scores, LESP and integrated relaxation pressure were significantly improved after the POEM procedure (P < 0.001). No significant difference was observed between the sexes regarding the efficacy of POEM, reflux symptoms, HRM data and complications after POEM. Before they seek treatment, female patients with achalasia may experience severe dysphagia and male patients are more likely to experience heartburn and more severe regurgitation. POEM is a safe and effective option for treating both male and female patients with achalasia.

Intraoperative high-resolution esophageal manometry during peroral endoscopic myotomy

Peroral endoscopic myotomy is an accepted treatment of achalasia. Some of the treatment failures can be attributable to an insufficient length of the myotomy on the gastric side, because of a more technically challenging submucosal dissection. We assessed the feasibility and the impact of an intraoperative esophageal manometry during the peroral endoscopic myotomy procedure. A high-resolution manometry catheter was introduced through the nostril before the endoscope, and left in place during the peroral endoscopic myotomy procedure. The lower esophageal sphincter pressure was recorded throughout the peroral endoscopic myotomy. The myotomy was extended on the gastric side until the lower esophageal sphincter pressure dropped below 10 mmHg. We included 10 patients (mean age = 55 years old, 3 men) treated by peroral endoscopic myotomy for type I (3/10), type II (3/10), type III achalasia (3/10) or esophagogastric junction outflow obstruction (1/10). Manometric recording was possible in all patients. The median (IQR) lower esophageal sphincter resting pressure was 23 (17–37) mmHg before myotomy, 15 (13–19) mmHg at the end of the tunnel, and 7 (6–11) mmHg at the end of the myotomy. In 4 patients out of 10, the myotomy was extended on the base of the intraoperative manometry findings. High-resolution esophageal manometry is feasible during the peroral endoscopic myotomy procedure, and leads to increase the length of the gastric myotomy in 4 out of 10 patients. However, the cumbersome nature of intraoperative high-resolution manometry during peroral endoscopic myotomy and the high frequency of gastro-esophageal reflux disease after extended gastric myotomy suggest to limit this technique to selected patients refractory to a first myotomy.

Esophageal Pathophysiologic Changes and Adenocarcinoma After Bariatric Surgery: A Systematic Review and Meta-Analysis.

INTRODUCTION:To assess the effects of sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) on acid reflux and esophageal motor function and to evaluate the observation of esophageal adenocarcinoma (EAC) after bariatric surgery.METHODS:We searched 5 databases for adults who underwent SG or RYGB and had esophageal pH test and/or esophageal manometry before and after surgery. A separate systemic search of observational studies and a retrospective review at 3 institutions of adults who developed EAC after these surgeries were conducted. Outcomes were changes in manometric and pH parameters and EAC cases after SG and RYGB.RESULTS:A total of 27 nonrandomized studies (SG: 612 patients; RYGB: 470 patients) were included. After SG, lower esophageal sphincter pressure and esophageal body amplitude were decreased and the risk of ineffective esophageal motility was increased. Total and recumbent acid exposure times were increased. After RYGB, an increased risk of ineffective esophageal motility was observed. Total, upright, and recumbent acid exposure times were decreased. The total reflux episodes remained unchanged but with increased nonacid reflux and decreased acid reflux events. Including our largest series, 31 EAC cases have been reported to date after SG and RYGB.DISCUSSION:This systematic review demonstrates increased acid reflux after SG and decreased acid reflux after RYGB. An observed increased nonacid reflux after RYGB might contribute to failure of gastroesophageal reflux disease improvement. This refluxate might be noxious to the esophagus, warranting further studies. RYGB might not entirely preserve esophageal function as previously believed.

Laparoscopic sleeve gastrectomy and esophageal motility

Laparoscopic sleeve gastrectomy (LSG) is becoming popular between the bariatric procedures. There are few studies available in the literature about LSG impact on esophageal motility, with debatable results. Technically, it modifies the anatomy of the esophago-gastric junction; it can damage the phreno-esophageal ligament and decrease the lower esophageal sphincter pressure that will predispose to reflux. Gastroesophageal reflux disease (GERD) is already common in obese patients due to frequent hiatal hernia, high intraabdominal pressure, increased transient lower esophageal sphincter relaxations (TLESR), altered esophageal motility and poor esophageal clearance. LSG can worsen gastroesophageal reflux disease, but also the weight loss achieved after it and the decrease of acid production in the small gastric pouch will probably reduce the GERD symptoms. Dysphagia and odynophagia were reported after sleeve gastrectomy, but usually associated with anatomical narrowing of the gastric sleeve, caused by esophageal dismotility or secondary to diabetes mellitus, low tiamine level, the use of opioids and non-steroidal anti-inflammatory drugs, even hypothyroidism. In addition to upper GI tract endoscopy, high-resolution esophageal manometry (HRM) should be required for all patients planning to undergo a LSG, and in the follow-up period according to the contractility pattern.