Lower Esophageal Sphincter Residual Pressure Research Articles

Does preoperative symptom duration affect outcomes following per oral endoscopic myotomy (POEM)?

Per oral endoscopic myotomy (POEM) is a safe therapy for the treatment of achalasia. Long-term effects of untreated achalasia include worsening dysmotility and disruptions in esophageal anatomy, i.e., tortuosity and dilation. We hypothesize that long-standing achalasia prior to intervention will have worse outcomes following POEM than in patients with symptoms for shorter duration. We retrospectively analyzed achalasia patients who underwent POEM at our institution from 2011 to 2023, categorizing them into symptom duration cohorts (< 1year, 1-3years, 4-10years, > 10years). Inclusion criteria comprised patients with documented achalasia diagnosis who received POEM treatment at our facility. Exclusion criteria encompassed individuals lacking data pertaining to achalasia diagnosis, the time frame before intervention, or those missing pre and postoperative Eckardt scores. POEM failure was defined as symptom recurrence, necessity for repeat intervention, or high postoperative Eckardt score. We compared demographic, preoperative, and postoperative outcomes across these cohorts, and employed multivariable logistic regression to explore the link between symptom duration and POEM response. During the study period, in our increased cohort 234 patients met inclusion criteria. 75 patients had symptoms for < 1year, 78 patients had symptoms from 1 to 3years, 47 patients had symptoms from 4 to 10years, and 34 patients had symptoms > 10years. Patient demographics such as age, sex, BMI, Charleson-Deyo-Comorbidity-Index, and diabetes did not differ amongst cohorts. High-resolution manometry data, including achalasia type, Median IRP, LES residual pressure, and Basal LES pressure did not differ between groups. Preoperative Eckardt scores ranged from 4 to 5 across groups (p 0.24). Patients endorsed an average of three total preoperative symptoms across groups (p 0.13). Patients with symptoms greater than 4years had significantly more endoscopic interventions prior to POEM (37% vs, 68% p .001). There was no significant difference in post-procedure mean Eckardt scores between cohorts. All cohorts experienced the same number of post-POEM symptoms. Post-POEM manometric measurements remained consistent across cohorts. Similarly, there were no significant differences in terms of symptom recurrence, requirement for repeat interventions, or repeat POEM among the cohorts. Multivariable logistic regression analysis determined achalasia symptoms greater than a decade did not result in increased odds of having a higher postoperative Eckardt score, worse dysphagia, regurgitation, or weight loss. In this increased cohort, this data once again suggests that longer symptom duration is not associated with increased rates of POEM failure.

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.

Characterization of Laryngopharyngeal Reflux in the Elderly Population

Laryngopharyngeal reflux (LPR) often is not diagnosed due to its presentation without heartburn. The aim of this study was to analyze the signs and symptoms of elderly patients undergoing treatment for LPR using subjective as well as objective measures including strobovideolaryngoscopies, 24-hour pH studies, and manometry to highlight appropriate considerations for diagnosis and treatment. This was a retrospective review of patients with laryngopharyngeal reflux who were seen from January 2010 to February 2021 in the practice of the senior author (Robert T. Sataloff) who had undergone 24-hour pH testing, and for whom all data were available. Patients aged 60 years and older were considered elderly and compared to patients younger than 40 and between the ages of 40 and 59. However, patients in their 60s, 70s, and 80s were evaluated and compared separately. Objective reflux findings, 24-hour pH studies, and manometry were compared between groups. Two hundred and eighty-eight patients being treated for LPR were included, 100 of whom were over the age of 60. While 94.1% of patients younger than 40 had a chief complaint of hoarseness, 71% percent of those aged 60 and older complained of hoarseness. Patients aged 60 and older were more likely to present with no voice complaint as their age increased (P = 0.001). Lower esophageal sphincter residual pressure was 12.15 ± 6.28 in elderly patients compared to 4.90 ± 3.38 in patients younger than 40 (P < 0.001). Upper esophageal sphincter (UES) basal pressure was decreased in elderly patients at 83.84 ± 50.53 compared to 105.92 ± 51.49 in patients younger than 60 or younger (P = 0.029). Older patients in their 70s and 80s also had lower UES basal pressures at 75.79 ± 47.66 and 63.45 ± 14.50 (P = 0.003). Additionally, while 71.4% of patients younger than 40 had normal esophageal motility (Chicago classification v4), only 40% of elderly patients had normal esophageal motility (P < 0.001). More severe ventricular obliteration also was present in elderly patients compared to non-elderly patients (P = 0.032), and thick endolaryngeal mucus was less likely to be present in elderly patients (P = 0.007). Reflux finding score differed between age groups with patients aged less than 40 scoring 14.78 ± 2.5, 40-59 year olds scoring 15.83 ± 2.13 and patients 60 and older scoring 15.48 ± 2.43 (P = 0.018). Elderly patients diagnosed with LPR have different presentations of the disease compared with younger patients.

Esophagogastric Junction Outflow Obstruction Is Likely to Be a Local Manifestation of Other Primary Diseases: Analysis of Single-Center 4-Year Follow-Up Data.

Whether esophagogastric junction outflow obstruction (EGJOO) is a variant of achalasia cardia (AC) or an esophageal motility state of certain organic or systemic diseases remains controversial. We aimed to investigate the differences between EGJOO and AC in clinical characteristics and outcomes through a 4-year follow-up. Patients diagnosed with primary EGJOO or AC were included. Based on the presence of concomitant disease, EGJOO patients were divided into a functional and an anatomical EGJOO group; similarly, patients with AC were divided into an AC with organic disease group and a true AC group. Disease characteristics and high-resolution manometry (HRM) parameters were retrospectively compared between the groups, and the development of organic diseases that could affect esophageal motility disorders and responses to treatment were examined during the follow-up. Symptom relief was defined as an Eckardt score of ≤3 after the treatment. The study included 79 AC patients and 70 EGJOO patients. Compared with patients with AC, EGJOO patients were older, had shorter disease duration, a lower Eckardt score, and were more likely to have concurrent adenocarcinoma of the esophagogastric junction (AEG) and autoimmune disease (p < 0.05 for all). The severity of dysphagia and Eckardt scores were higher in the anatomical EGJOO group than in the functional EGJOO group. Significant differences were seen in HRM parameters (UES residual pressure, LES basal pressure, and LES residual pressure) between AC and EGJOO patients. However, no significant differences in HRM parameters were observed between the functional EGJOO and anatomical EGJOO groups. Sixty-seven (95.71%) patients with EGJOO and sixty-nine (87.34%) patients with AC experienced symptom relief (p = 0.071). Among patients achieving symptom relief, a relatively large proportion of patients with EGJOO had symptom relief after medications (37/67, 55.22%), the resolution of potential reasons (7/67, 10.45%), and spontaneous relief (15/67, 22.39%), while more patients with AC had symptom relief after POEM (66/69, 95.65%). Among EGJOO patients achieving symptom relief, more patients (7/20, 35%) with anatomical EGJOO had symptom relief after the resolution of potential reasons for EGJOO, while more patients (32/47, 68.09%) with functional EGJOO had symptom relief with medications. Concurrent AEG and autoimmune diseases are more likely in EGJOO than in AC. A considerable part of EGJOO may be the early manifestation of an organic disease. Anatomical EGJOO patients experience symptom improvement with the resolution of primary diseases, while most functional EGJOO patients experience symptom relief with pharmacotherapy alone or even without any treatment.

A132 ACHALASIA FOLLOWING A SARS-COV-2 INFECTION: A CASE REPORT

BackgroundSARS-CoV-2 is a novel virus currently causing a major pandemic. Recent studies have shown that SARS-CoV-2 has an affinity to ACE2 receptors which are present in the olfactory epithelium as well as the pulmonary and gastrointestinal (GI) systems. It is stipulated that these receptors are responsible for the entry of the virus into cells explaining the respiratory and GI symptoms of this infection. The anosmia related to COVID-19 is likely due to an aberrant immune response to the virus rather than direct damage to the olfactory epithelium. Similarly, achalasia is also believed to result from an aberrant immune response through which there is degeneration of inhibitory neurons in the myenteric plexus. In this case report, we present the first case of achalasia thought to be linked to a SARS-CoV-2 infection in contemporary literature.AimsWe hypothesize that SARS-CoV-2 caused an aberrant immune response in our patient, leading him to develop achalasia. We hope to expose clinicians to this potential complication of COVID-19, allowing them to consider it sooner in their differential.MethodsThe patient’s file was reviewed to extract the relevant information. A second gastroenterologist’s opinion was obtained on the manometry to confirm the diagnosis of type III achalasia.ResultsA 61-year-old man with a medical history of myasthenia gravis, chronic obstructive pulmonary disease, hypothyroidism, and chronic renal failure was treated in our establishment for a SARS-CoV-2 pneumonia. He experienced new severe dysphagic symptoms, regurgitations, and lost 10 pounds during his hospitalization. He also developed anosmia and diarrhea. A CT-scan of his neck and thorax showed no extrinsic compression of his esophagus. No neoplasm was found on his gastroscopy. A barium study was then conducted showing a stagnation of contrast in the distal third of his esophagus. No relaxation of the inferior gastroesophageal sphincter was noted. A manometry was then performed and confirmed a type III achalasia. The mean lower esophageal sphincter residual pressure was elevated at 43.7 mmHg. A calculated 69% of wet swallows were premature contractions with a distal latency value less than 4.5 seconds. The mean distal contractile integral was 13613 mmHg. This corroborates the spastic nature of type III achalasia.ConclusionsConsidering that our patient developed anosmia and knowing its pathogenesis in the context of COVID-19, an inappropriate immune response to SARS-CoV-2 could have equally taken place in the esophagus. This inflammatory response might have caused the degeneration of the inhibitory neurons in the myenteric plexus responsible for the achalasia. Furthermore, given the fact that our patient had diarrhea, this suggests that the virus has a GI tropism supporting our hypothesis. We therefore believe that achalasia may be a potential complication of COVID-19. High resolution esophageal motility study showing a type III achalasia pattern.Funding AgenciesNone

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.

O32 LYON CONSENSUS CRITERIA SIGNIFICANTLY CHANGES THE PH IMPEDANCE DIAGNOSIS OF GASTROESOPHAGEAL REFLUX DISEASE (GERD)

Abstract Aim To investigate the Lyon Consensus Criteria impact on Ph-Impedance diagnosis of GERD and their relation to high resolution manometric tracing results. Background &amp; Methods GERD is a complex disease with a heterogeneous symptom profile and a multifaceted pathogenic basis that defies a simple diagnostic algorithm or categorical classification. The Lyon Consensus defines parameters on esophageal testing that conclusively establish the presence of GERD and characteristics that rule out GERD. We retrospectively evaluated according the new criteria our patients underwent pH-Impedance one year before the publication of Lyon Consensus Criteria and analyzed the differences in relation to the older diagnostic criteria. Results 130 patients (56 M, median age 52,03 R18-77) Ph-impedance exams for suspected typical and atypical GERD were re-evaluated. According to Lyon criteria for conclusive evidence of GERD 15,38% of them were over-diagnosticated and 1,53% had inconclusive evidence of the disease using the past criteria. In the evaluation of 94 patients with typical symptoms 23,4% were over-diagnosticated in according to the past diagnostic criteria. Statistical analysis of manometric values of the patients highlight that LES basal pressure (median 108.95, R38.7-283.4) (p=0,049) and UES residual pressure (median 7.8 R0.6-63.5) (p=0,003) significantly predict the Lyon criteria pH-impedance outcome. Analysis of manometric values of the patients with typical symptoms revealed that LES residual pressure (median 5,21 R0,1-20,7) (p=0,007) and Total Number of refluxes (median 28,03 R1-122) (p=0,013) significantly predict the Lyon criteria pH-impedance outcome. Conclusion Lyon Consensus Criteria significantly changes the pH-impedance diagnosis in patients undergoing testing for suspected GERD. In patients with typical symptoms new criteria allow not to overdiagnose 25% of GERD patient. Manometric values analysis significantly correlates and predict the Lyon criteria pH-impedance outcome.

P33 UPPER ESOPHAGEAL SPHINCTER (UES) ABNORMALITIES ARE SIGNIFICANT DIAGNOSTIC FINDINGS IN PATIENTS WITH ATYPICAL GERD UNDERWENT PH-IMPEDANCE AND HIGH RESOLUTION MANOMETRY (HRM)

Abstract Aim To investigate UES function in patients underwent esophageal testing with pH-impedance and HRM for suspected GERD Background &amp; Methods GERD is a complex condition with a typical: heartburn, regurgitation or epigastric pain and an atypical presentation with symptoms such as chronic cough, hoarseness, globus, dysphagia or throat clearing caused by the retrograde movement of gastric contents above the UES into the laryngopharynx. The association between GERD and abnormalities of UES and esophageal motility is not clearly known. HRM has allowed accurate measurement and evaluation of UES and esophageal function. We evaluate the UES function of the HRM exams in patients underwent pH-impedance for suspected GERD with typical or atypical symptoms. Results HRM tracings of 60 patients (35F, median age 53,08 R23-74), 35 with typical (20F, m.a 51,42 R24-74) and 25 with atypical (15F, m.a 51,73 R29-74) symptoms who underwent Ph-impedance for suspected typical and atypical GERD were evaluated. 40% of those with typical presentation had a positive pH-impedance for GERD versus 8% of those with atypical symptoms. Patients with typical symptoms presented in 42,85% UES abnormalities versus 60% of the patients with atypical presentation. From those patients with typical GERD symptoms that had a positive pH-impedance the 40% had a concomitant UES abnormality versus 100% of the patients with atypical presentation and a confirmed GERD diagnosis. Statistical analysis revealed a significant association between positive pH-impedance result and LES residual pressure in patients with typical (p=0,045) and atypical (p=0,038) symptoms. Conclusion UES abnormalities is the prevalent diagnostic finding in patients with atypical GERD underwent pH-impedance. UES dysfunction characterize all patients diagnosticated with atypical GERD by Ph-impedance.

Per oral endoscopic myotomy: Another tool in the toolbox

ObjectiveUse of per oral endoscopic myotomy is increasing for the treatment of achalasia, with potential for rapid recovery and less invasiveness. We report our experience with per oral endoscopic myotomy to better understand how it fits into a modern paradigm of achalasia management. MethodsA total of 152 patients with achalasia underwent per oral endoscopic myotomy from April 2014 to March 2018. Type II achalasia was the most prominent subtype in 69 patients (49%), and 33 patients (21.5%) had a prior Heller myotomy. Postoperative Eckardt scores, integrated relaxation pressure, and timed barium esophagram column height and width at 2 months were compared with preoperative measurements. ResultsPer oral endoscopic myotomy was completed in 149 patients (98%). Median operative time was 96 minutes (75 minutes for the last 30 cases), and length of stay was 1 day (interquartile range, 1-2). The most common morbidities were mucosal perforation in 2 patients (1.3%) and bleeding in 3 patients (2.0%), although no nonendoscopic intervention was required. Mortality was zero. Postoperatively, the median Eckardt score decreased from 6 to 0 (P < .001), residual lower esophageal sphincter pressure decreased from 22 mm Hg to 6 mm Hg (P < .001), and timed barium esophagram column height and width at 5 minutes decreased from 8 and 2.5 cm to 1.5 and 0.8 cm (P < .001), respectively. Median time to return to daily activity was 7 days; 49 patients (49.5%) had abnormal acid reflux on 24-hour pH testing postprocedure. ConclusionsPer oral endoscopic myotomy is a safe and effective intervention that provides clear subjective and objective improvement in patients with achalasia. High postprocedure acid reflux raises concern about future sequelae if used in a nonselective fashion.

Surgical Management of Gastroesophageal Reflux Disease in Patients with Severe Esophageal Dysmotility

BackgroundGastroesophageal reflux disease (GERD) and esophageal dysmotility are often disqualifying criteria for fundoplication due to dysphagia complications. A tailored partial fundoplication may improve GERD in patients with severe esophageal motility disorders. We evaluate this approach on GERD improvement in non-achalasia esophageal dysmotility patients. MethodsA single-institution prospective database was reviewed (2007–2016), with inclusion criteria of GERD, previous diagnosis of non-achalasia esophageal motility disorder, and laparoscopic partial fundoplication. Diagnosis of previous achalasia diagnosis or diffused esophageal spasm was excluded. Motility studies, pre- and post-upper gastrointestinal imaging (UGI), esophageal symptom scores, antacid, and PPI use were collected pre-op, 6 months, 12 months, and long-term (LT). Statistical analysis was made using SPSS v.23.0.0, α = 0.05. ResultsFifty-two patients met the inclusion criteria. A total of 17.3% had esophageal body amotility, 79.6% had severe esophageal dysmotility. A total of 65.9% women (mean age 64 ± 15.7), mean peristalsis 45.3 ± 32.6%, and failed peristalsis 36.0 ± 32.2%. Mean LES residual pressure was 15.0±18.0 mmHg, and 40.7% had hypotensive LES. Mean follow-up time was 25 months [1–7 years], with significant improvement in symptoms and reduction in PPI and antacid use at all time-points compared to pre-op. A total of 74% had UGI studies at 12 months; all showed persistent dysmotility. Six patients had radiographic hiatal hernia recurrence, with only one being clinically symptomatic postoperatively. Three required dilation for persistent dysphagia. ConclusionsA tailored partial fundoplication may be effective in symptom relief for non-achalasia patients with esophageal motility disorders and GERD. Significant symptom improvement, low HHR, and PPI use clearly indicate this approach to be effective for this population.

Upper Esophageal Sphincter (UES) Abnormalities Are a Frequent Finding on High Resolution Manometry (HREM) and Associated With Esophageal Motility Disorders (EMD)

Introduction: While there has been an increased frequency of UES abnormalities noted among patients with esophageal motility disorders (EMD), the Chicago Classification for manometric disorders does not comment on UES findings. Here, we assess the frequency and type of UES abnormalities among patients referred for HREM; the frequency of UES abnormalities among patients with EMD (achalasia and esophagogastric junction outflow obstruction (EGJOO)); bolus clearance, lower esophageal sphincter (LES) and UES residual pressures to determine the severity of disease in patients with both EMD and a UES abnormality and; if presence of UES abnormalities in patients with EMD is associated with poor treatment response. Methods: This retrospective study at 3 tertiary care hospitals identified 136 consecutive patients referred for HREM to assess for a suspected motility disorder from 10/2016-10/2017. UES pressures were measured before 10 wet swallows. HREM reports were analyzed for UES, LES and bolus transit abnormalities. Medical records were reviewed for demographic data. Results: UES abnormalities were present in 38% (n=51) of all patients referred for HREM (n=136) and in 43% of 54 patients with EMD. Of those with UES abnormalities present, 45% (n=23) had an EMD. Of these individuals, 61% (n=14) were diagnosed with EGJOO and 39% (n=9) with achalasia (predominantly Type II (n=7/9)). There was a significant correlation between impaired LES residual pressure and UES residual pressure (r=0.238, P=0.005) in patients with EMD. Incomplete bolus clearance was not significantly associated with UES pressure abnormalities (p=0.48, CI: 0.5699 to 3.3019). Data on treatment response was captured in 35 patients with EMD (57% had pharmacological treatment, 1 had fundoplication, and 46% had combined pharmacological and procedural treatment). There was a trend towards presence of UES abnormalities in EMD with poorer outcomes but was not statistically significant (p=0.37). Botox therapy was performed more commonly in the treatment of EMD with normal UES (62%) compared to those with abnormal UES (24%). Conclusion: There appears to be a significant correlation between impairment in UES and LES relaxation, suggesting a shared pathophysiological mechanism. A stratification scheme, based on pathophysiological defect, and inclusion of UES findings while evaluating EMD patients may help in understanding this increasingly common but undoubtedly heterogeneous syndrome and facilitate the development of targeted therapies.

The early efficacy of Heller myotomy in the treatment of Iranian patients with achalasia.

The purpose of this study was to determine the efficacy of Heller myotomy for the treatment of achalasia in a referral center in Tehran, and investigate the clinical characteristics, manometric results and treatment responses among three achalasia subtypes in Iranian patients. Esophageal achalasia is an unusual swallowing disorder, characterized by high pressure in the lower esophageal sphincter (LES) on swallowing, failure relaxation of the LES and the absence of peristalsis in esophageal. In this cross sectional study, clinical symptom and esophageal manometry before and 2 months after treating with Heller myotomy in 20 patients with achalasia who were referred to Taleghani Hospital, Tehran, in 2013 were evaluated. Patients' demographic, clinical features and response to treatment were analyzed using SPSS software (version 20, Chicago, IL, USA). All the diagnostic criteria measured after the treatment were significantly different (P<0.05) before and after the therapy. The average decline in the length of the esophagus was 1.8 cm and dysphasia score was 7.25 units. Also an average decline in LES Resting Pressure, LES Residual Pressure, PIP, and IRP were 23.2 mmHg, 14.3 mmHg, 3.4 mmHg and 17.8 mmHg, respectively. Results of this study showed that the Heller myotomy is highly effective in relieving dysphasia in patients with achalasia. Also, type II achalasia is the most common subtype of achalasia with a better response to Heller myotomy compared to the other types.

Two-Person Technique of Peroral Endoscopic Myotomy for Achalasia with an Advanced Endoscopist and a Thoracic Surgeon: Initial Experience.

Background and Aims. We initiated peroral endoscopic myotomy (POEM) utilizing a two-person technique with combination of an advanced endoscopist and a thoracic surgeon with complementary skills. Our aim was to determine the feasibility and outcomes in initial 20 patients. Methods. In this observational study, main outcomes measured were therapeutic success in relieving symptoms (Eckardt score < 3), decrease in lower esophageal sphincter (LES) pressures, improvement in emptying on timed barium esophagogram (TBE), and complications. Results. POEM was successful in all 20 patients with a mean operative time of 140.1 + 32.9 minutes. Eckardt symptom scores decreased significantly at two-month follow-up (6.4 + 2.9 versus 0.25 + 0.45, p < 0.001). Both basal and residual LES pressures decreased significantly (28.2 + 14.1 mmHg versus 12.8 + 6.3 and 22.4 + 11.3 versus 6.3 + 3.4 mmHg, p = 0.025 and <0.001, resp.). Barium column height at 5 minutes on TBE reduced from 6.8 + 4.9 cm to 2.3 + 2.9 cm (p = 0.05). Two patients (10%) had mucosal perforations and one had delayed bleeding (5%). Conclusions. Two-person technique of POEM with combination of an advanced endoscopist and a thoracic surgeon is highly successful with low risk of complications.

EndoFLIP® in Comparison to High-Resolution Manometry and Eckardt Score in the Assessment of Achalasia Prior to Intervention

Introduction: Achalasia is defined by manometry that demonstrates aperistalsis of the esophageal body and incomplete relaxation of the lower esophageal sphincter (LES). The purpose of this study is to compare the EndoFLIP (FLIP) to high resolution manometry (HRM) and Eckardt score (ES) in the initial assessment of achalasia. Methods: Twenty-one patients with achalasia were enrolled at a single tertiary center. For each patient, diagnostics included: ES, HRM, and FLIP. The FLIP system is catheter based with a distal 14cm probe containing 17 electrodes, each 5mm apart and designed to make impedance planimetry measurements. Once the bag is filled to 40cc, distensibility index (DI), cross-sectional area (CSA), balloon pressure, and minimum diameter are measured at the most narrow point. Results: The patients had a mean age of 59 years and BMI of 26.3 + 1.4 Kg/M2. The mean ES across all patients was 7.0 + 2.9. The mean LES pressure was 37.8 + 5.1 mmHg and the residual LES pressure was elevated at 25.9 + 12.1 mmHg with incomplete relaxation. There were 9 patients with type 1 achalasia, 8 patients with type 2 achalasia, and 4 patients with type 3 achalasia. Using FLIP, the CSA was 54.2 + 9.7mm2 and the minimum diameter was 7.8 + 0.7mm. The mean distensibility in the patients was 1.6 + 1.3 mm2/mmHg. There was poor correlation between the ES and DI (r= -0.22; p= 0.34 ). However, the LES residual pressure and DI were significantly inversely correlated (r= -0.44; p= 0.047). The number of patients was insufficient to show variations in results between achalasia subtypes. Conclusion: This study shows 1) DI is decreased, showing decreased stretch, in symptomatic patients with achalasia and 2) the DI correlated significantly with residual LES pressure, but not symptoms. Thus the DI can be used as a parameter to monitor therapy of achalasia. Conclusion: Distensibility is a useful tool to assess achalasia, correlating with ES and correlating significantly with LES residual pressure in the pre-intervention assessment of achalasia.

A prospective analysis of GERD after POEM on anterior myotomy

BackgroundPeroral endoscopic myotomy (POEM) is an emerging, minimally invasive procedure capable of overcoming limitations of achalasia treatments, but gastroesophageal reflux disease (GERD) after POEM is of concern and its risk factors have not been evaluated. This prospective study examined GERD and the association of POEM with reflux esophagitis.MethodsAchalasia patients were recruited from a single center. The pre- and postoperative assessments included Eckardt scores, manometry, endoscopy, and pH monitoring.ResultsBetween September 2011 and November 2014, 105 patients underwent POEM; 70 patients were followed up 3 months after POEM. Postoperatively, significant reductions were observed in lower esophageal sphincter (LES) pressure [from 40.0 ± 22.8 to 20.7 ± 14.0 mmHg (P < 0.05)], LES residual pressure [from 22.1 ± 13.3 to 11.4 ± 6.6 mmHg (P < 0.05)], and Eckardt scores [from 5.7 ± 2.5 to 0.7 ± 0.8 (P < 0.05)]. Symptomatic GERD and moderate reflux esophagitis developed in 5 and 11 patients (grade B, n = 8; grade C, n = 3), respectively, and were well controlled with proton pump inhibitors. Univariate logistic regression analysis revealed integrated relaxation pressure was a predictor of ≥grade B reflux esophagitis. No POEM factors were found to be associated with reflux esophagitis.ConclusionPOEM is effective and safe in treating achalasia, with no occurrence of clinically significant refractory GERD. Myotomy during POEM, especially of the gastric side, was not associated with ≥grade B (requiring medical intervention) reflux esophagitis. Extended gastric myotomy (2–3 cm) during POEM is recommended to improve outcomes.

The effect of position on esophageal structure and function determined with solid-state high-resolution manometry.

To investigate the influence of posture on the anatomy and function of esophageal sphincters using solid-state high-resolution manometry. Fifty individuals underwent esophageal manometry with a 36-channel solid-state catheter in the supine and upright positions. The length and pressure of the esophageal sphincters, as well as the esophageal and intra-abdominal lengths of lower esophageal sphincter (LES), were recorded. The residual pressure of the upper esophageal sphincter (UES) and the 4-s integrated relaxation pressure were also measured when the participants swallowed 10 consecutive servings of water (5 mL each). The Bland-Altman plot was used to assess agreement between these parameters in the supine and upright positions. The LES resting pressure was significantly decreased in the upright position compared with the supine position (13.85 ± 5.90 mmHg vs 18.09 ± 7.80 mmHg, P = 0.000). Weaker integrated relaxation pressures were observed when the participants were in the upright position (5.66 ± 3.33 mmHg vs 7.80 ± 3.25 mmHg, P = 0.000). Compared with the supine position, the upright esophageal length was longer (P = 0.004) and the upper border of the LES was lower (P = 0.050) when the individuals were in the upright position. The agreement between the two positions was acceptable for the esophageal length, LES upper border location and LES pressure measurements. Body position exerts a greater influence on the LES than on the UES. Thus, it is necessary to establish normal values for the LES basal pressure and residual pressure in different positions.

Peroral Endoscopic Myotomy Can Improve Esophageal Motility in Patients with Achalasia from a Large Sample Self-Control Research (66 Patients)

BackgroundPeroral endoscopic myotomy (POEM) as a new approach to achalasia attracts broad attention. The primary objective of this study was to evaluate the results with esophageal motility after POEM through the first large sample clinical research.Patients and MethodsWe have a self-control research with all patients (205 in total) who underwent POEM from 2010 to 2014 at our Digestive Endoscopic Center, 66 patients of which underwent high resolution manometry (HRM) before and after POEM in our motility laboratory. Follow-ups last for 5.6 months on average. Outcome variables analyzed included upper esophageal sphincter pressure (UESP), upper esophageal sphincter residual pressure (UESRP), lower esophageal sphincter pressure (LESP), lower esophageal sphincter residual pressure (LESRP) and esophageal body peristalsis. We have a statistical analysis to illustrate how POEM impacts on the change of esophageal motility.ResultsThe symptoms related to dysphagia were relieved in 95% of patients in recent term after POEM. While HRM showed a statistically significant reduction of URSRP, LESP and LESRP (P<0.01), however, peristalsis was not consistently affected. There were 11 patients who had undergone other prior endoscopic treatment (endoscopic dilation or botulinum toxin injection) and 55 patients had not. The statistical difference (P>0.05) did not occur for these two groups on LESP and LESRP reduction.ConclusionsPOEM clearly relieved the symptoms related to dysphagia by lowering the pressure of upper esophageal sphincter (UES) and lower esophageal sphincter (LES),and other endoscopic treatment before POEM did not affect the improvement of LES pressure. These results are concluded from our short-term follow-up study, while the long-term efficacy remains to be further illustrated.Trial RegistrationChinese Clinical Trial Register ChiCTR-TRC-12002204)

Predictive value of routine esophageal high-resolution manometry for gastro-esophageal reflux disease.

Using conventional manometry, gastro-esophageal reflux disease (GERD) was associated with a reduced lower esophageal sphincter (LES) pressure and impaired peristalsis. However, with a large overlap between GERD patients and controls, these findings are of limited clinical relevance. It is uncertain whether the more detailed information of high-resolution manometry (HRM) can discriminate GERD patients. Therefore, we aimed to determine to which extent HRM findings can predict GERD. HRM measurements in 69 patients with GERD and 40 healthy subjects were compared and the predictive value of HRM for the diagnosis of GERD was explored. GERD patients had a significantly lower contraction amplitude (55 vs 64 mmHg; p = 0.045) and basal LES pressure (10 vs 13.2 mmHg; p = 0.034) than healthy controls. GERD patients more often had a hiatal hernia than healthy subjects (30% vs 7%; p = 0.005). Patients with reflux esophagitis had a lower DCI than patients without reflux esophagitis (558 vs 782 mmHg cm s; p = 0.045). No significant difference was seen in contractile front velocity, distal latency, number of peristaltic breaks, residual LES pressure and LES length. On multivariate logistic regression analysis, both esophagogastric junction type I (OR 4.971; 95% CI 1.33-18.59; p = 0.017) and mean wave amplitude (OR 0.95; 95% CI 0.90-0.98; p = 0.013) were found to be independent predictors of GERD. However, the sensitivity and specificity of these findings were low. Hiatal hernia, low contraction amplitude and LES pressure are associated with GERD, but do not predict the disease with sufficient accuracy. Routine esophageal HRM can therefore not be used to distinguish GERD patients from healthy subjects.

Tu1416 Swallow-Related Axial Shortening of the Esophagus Is Diminished in Patients With Type 3 Achalasia Esophagus

Introduction: Achalasia is a primary esophageal motility disorder characterized by loss of esophageal peristalsis and impaired lower esophageal sphincter (LES) relaxation. Pathophysiological studies have demonstrated loss of inhibitory nitrergic innervation in the esophagus of achalasia patients. The diagnosis of achalasia is made by a characteristic pattern of LES pressure and esophageal body contractions on esophageal manometry. However, the presence of atypical achalasia cases, or variant achalasia have been previously described with only a few case reports outlining the evolution of variant achalasia to achalasia. The identification and description of achalasia in evolution (AIE) can allow for a better understanding of the pathophysiology of the disease and for establishing early diagnosis. Objectives: To describe adult (age > 18 years) patients who have shown a temporal progression from AIE to achalasia with respect to their patient demographics, clinical presentation and esophageal manometry profiles. Methods: A retrospective chart review of all the high resolution esophageal manometry studies (EMS) in a tertiary referral center from January 2008 to July 2014. Results: Five confirmed cases of achalasia patients in whom AIE was initially described were identified. The mean age of the patients is 73.4 +/11. 1 years and 60% are males. All patients presented with varying durations (6 months to 15 years) of dysphagia to liquids and solids. Three of the five patients have a history of type 2 diabetes mellitus. AIE was applied when either the esophageal body peristalsis or LES relaxation did not meet manometric diagnostic criteria for achalasia. In all AIE patients the residual LES pressure was consistently elevated (25.5 +/9.6 mm Hg, normal < 15.0 mm Hg). Four of the five patients maintained some degree of esophageal body peristalsis. The progression of AIE to achalasia occurred over a range of 6 months to 10 years. When the diagnosis of achalasia was made, 3 patients had type 2 achalasia and 2 had type 3 achalasia. At the time of diagnosis of achalasia, all 5 patients demonstrated the characteristic manometry findings including simultaneous contractions and an elevated LES residual pressure at 29.5 +/17.6mmHg (range 19.6-60.9). Conclusions: Our observation that all AIE patients, albeit, a small number, progressed to either type 2 or type 3 achalasia suggests that type 1 achalasia may represent the later or more advanced disease. Thus, the identification of patients with AIE may allow for earlier awareness of possible disease progression, thereby facilitating the initiation of timely investigations and management strategies. Larger and longer-term study is warranted to further characterize the manometric criteria of AIE.

Residual lower esophageal sphincter pressure as a prognostic factor in the pneumatic balloon treatment of achalasia

Residual lower esophageal sphincter pressure as a prognostic factor in the pneumatic balloon treatment of achalasia