Lower Esophageal Sphincter Research Articles

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

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

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

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

Long Term Paired Outcomes of Index and Redo per Oral Endoscopic Myotomy

Introduction: Per-Oral Endoscopic Myotomy (POEM) is a specialized procedure designed to improve symptoms by minimizing lower esophageal sphincter pressure in patients with achalasia. Despite excellent reported success rates, about 10% of patients have persistent or recurrent symptoms after procedure. There are limited studies looking at the efficacy of redo POEMS for these patients. In particular, there is no published data on comparing the paired effect of index POEM and redo POEM individually. We aimed to compare paired data of index and redo POEMs and provide election criteria for redo POEM. Methods: We conducted a retrospective observational study of all patients who underwent both index and redo POEM between August 2014 and January 2020 at Emory University. All patients underwent standard POEM protocol. We defined clinical success by an Eckardt score &lt;3 post procedure. Results were analyzed with t tests, Chi squared tests where appropriate, or were otherwise reported as means with corresponding ranges. Results: 15 patients underwent redo POEM (ages 25-79, 53% female). One was lost to long-term follow up. There was no significant difference noted between index and redo POEM in procedure time (61.9 minutes vs. 62.2 minutes) (p=0.96), myotomy length (6.9 cm vs.6.1 cm) (p=0.13). 10 out of 15 patients (67%) achieved clinical success post-procedure with an Eckhardt score &lt;3. Conclusion: Redo POEM procedure can be safely performed even on the same side of index POEM. Patients with previous interventions, those who clinically failed index POEM (never-responders), and those who initial responded (recurred) all can benefit from and should be offered redo POEM procedure. However, patients with severely diffusely dilated esophagus may not benefit from redo POEM and warrant surgical consultation for esophagectomy, if necessary.

Manometric identikit of a functioning and effective fundoplication for gastroesophageal reflux disease in the high-resolution manometry ERA.

The pathophysiological and clinical value of performing High-Resolution Manometry (HRM) after laparoscopic fundoplication (LF) for gastroesophageal reflux disease (GERD) is still unclear and debated. We sought to establish the HRM parameters indicative of functioning fundoplications, and whether HRM could distinguish them from tight or defective ones. The study involved patients with GERD who underwent laparoscopic Nissen (LN) or Toupet (LT) fundoplication between 2010 and 2022. HRM and 24-h pH monitoring were performed before and 6months after surgery. The study population was divided into 5 groups: LN and LT patients with normal 24h-pH findings (LNpH- and LTpH-, respectively); LN and LT patients with pathological 24h-pH findings (LNpH+ and LTpH+groups, respectively); and patients with a postoperative dysphagia intensity score >2 (Dysphagia group). The novel Hiatal Morphology (HM) classification was applied, envisaging 3 different subtypes: HM1 (normal), HM2 (intrathoracic fundoplication), and HM3 (slipped fundoplication). Among the 132 patients recruited during the study period, 46 were in the LNpH- group, 51 in the LTpH- group, 15 in the LNpH+group, 7 in the LTpH+group, and 5 in the Dysphagia group. In multivariate analysis, postoperative abdominal lower esophageal sphincter length (p=0.001) and HM2 (p<0.001) were both independently associated with surgical failure. Integrated relaxation pressure was significantly higher in the Dysphagia group than in the LNpH- group. This study generated reference HRM values for an effective LF, and confirms that using HRM to assess the neo-sphincter and HM improves the clinical assessment in cases of symptom recurrence.

Relationship Between Health Education on Breastfeeding Techniques and Burping Babies After Breastfeeding With Regusrgitation Incidents in Babies in Panyaungan Village in 2023

Background Regurgitation in infants is often caused by physiological reflux, which is a normal condition. The lower esophageal sphincter in infants is not fully mature, so food can go back up into the esophagus and out through the mouth. Purpose of Writing: for the relationship between health education on breastfeeding techniques and burping babies after breastfeeding with the incidence of regurgitation in babies in Panyaungan Village in 2023. Research Methods: The sample size in this study used a total side, namely 65 mothers who had babies aged 0-6 months in Panyaungan Village who were taken by total sampling. Collecting data to determine mother's knowledge about breastfeeding techniques and burping babies and the incidence of regurgitation was measured using a questionnaire. The data analysis used is the method of this research is an analytic survey with a case control design or retrospective study. Research Results In the chy-square test, the results obtained were P value 0.000 &gt; 0.05, so the analysis was that there was a relationship between burping techniques and regurgitation events in Panyaungan Village in 2023. The OR calculation results were 5.556, which means that babies aged 0-6 months have more regurgitation events 5.556 times higher by not or rarely doing burping techniques compared to doing burping techniques (95% CI 3.075 -10.038. Conclusions and Suggestions: It is hoped that the results of this study can be used as a reference that in order to reduce regurgitation it is necessary to provide education on breastfeeding techniques until breastfeeding mothers understand proper and correct breastfeeding techniques.

Impact of CYP2C19 metabolizer status on esophageal mucosal inflammation, acid exposure, and motility among patients on chronic proton-pump inhibitor therapy with refractory symptoms of gastroesophageal reflux disease.

The extent of disease severity remains unclear among CYP2C19 rapid and ultra-rapid metabolizers with refractory symptoms of gastroesophageal reflux disease (GERD) on chronic proton-pump inhibitors (PPIs). To determine the impact of CYP2C19 metabolizer status in relation to chronic PPI therapy with a focus on the extent of esophageal inflammation, acid exposure, and motor function. This retrospective study included 54 patients with refractory GERD symptoms who underwent CYP2C19 genotyping for PPI metabolism, esophagogastroduodenoscopy, ambulatory pH study, and high-resolution esophageal manometry. Patients were divided into three groups: normal metabolizer (NM) group, intermediate metabolizer/poor metabolizer (IM/PM) group, and rapid metabolizer/ultra-rapid metabolizer (RM/UM) group. The Chi-square test was used to analyze categorical variables, and one-way ANOVA for comparing means. Rapid metabolizer/ultra-rapid metabolizer (RM/UM) group more frequently had either Los Angeles grade C or D GERD (7/19, 36.8% vs 1/21, 4.8%, P = 0.011) and metaplasia of the esophagus (9/19, 47.4% vs 2/21, 9.5%, P = 0.007) when compared to the NM group. RM/UM group were more frequently offered dilatation for nonobstructive dysphagia (8/19, 42.1% vs 3/21, 14.3%, P = 0.049) and more exhibited a hypotensive lower esophageal sphincter (LES) resting pressure compared to the NM group (10/19, 52.6% vs 4/21, 19%, P = 0.026). All three groups exhibited comparable DeMeester scores when PPIs were discontinued 72 hours before the ambulatory pH study. CYP2C19 RMs and UMs on chronic PPI with refractory GERD symptoms exhibited greater esophageal mucosal inflammation, as observed both endoscopically and histologically, and more were found to have hypotensive LES resting pressures and more were offered esophageal dilatation.

When less is more: lower esophageal sphincter-preserving peroral endoscopic myotomy is effective for non-achalasia esophageal motility disorders.

Non-achalasia esophageal motility disorders (NAEMDs), encompassing distal esophageal spasm (DES) and hypercontractile esophagus (HCE), are rare conditions. Peroral endoscopic myotomy (POEM) is a promising treatment option. In NAEMDs, unlike with achalasia, the lower esophageal sphincter (LES) functions normally, suggesting the potential of LES preservation during POEM. This retrospective two-center observational study focused on patients undergoing LES-preserving POEM (LES-POEM) for NAEMD. Eckardt scores were assessed pre-POEM and at 6, 12, and 24 months post-POEM, with follow-up endoscopy at 6 months to evaluate for reflux esophagitis. Clinical success, defined as an Eckardt score ≤3, served as the primary outcome. 227 patients were recruited over 84 months until May 2021. Of these, 16 underwent LES-POEM for an NAEMD (9 with HCE and 7 with DES). The median pre-POEM Eckardt score was 6.0 (interquartile range [IQR] 5.0-7.0), which decreased to 1.0 (IQR 0.0-1.8; P<0.001) 6 months post-POEM. This was sustained at 24 months, with an Eckardt score of 1.0 (IQR 0.0-1.8; P<0.001). Two patients (12.5%) developed Los Angeles grade A or B esophagitis. LES-POEM for NAEMD demonstrates favorable clinical outcomes, with infrequent esophagitis and reintervention for LES dysfunction rarely required.

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.

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

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

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.

Resultados clínicos y manométricos de la miotomía endoscópica peroral en pacientes con acalasia: experiencia en un centro de referencia latinoamericano

IntroductionCurrently there is little information in Latin America on the clinical outcome and manometric evolution of patients with Achalasia undergoing peroral endoscopic myotomy (POEM). Primary outcomeEvaluate the manometric and clinical changes in adult patients with achalasia after peroral endoscopic myotomy at a referral center in Bogotá, Colombia. MethodsObservational, analytical, longitudinal study. Adult patients with achalasia according to the Chicago 4.0 criteria were included. Sociodemographic, clinical and manometric variables were described. To compare the pre- and post-surgical variables, the Student's or Wilcoxon's t test was used for the quantitative variables according to their normality, and McNemar's chi-square for the qualitative variables. Results29 patients were included, 55.17% (n=16) women, with a mean age at the time of surgery of 48.2 years (±11.33). The mean post-procedure evaluation time was 1.88±0.81 years. After the procedure, there was a significant decrease in the proportion of patients with weight loss (37.93% vs 21.43% p 0.0063), chest pain (48.28% vs 21.43, p 0.0225) and the median Eckardt score (8 (IQR 8 -9) vs 2(IQR 1-2), p <0.0001). In addition, in fourteen patients with post-surgical manometry, significant differences were found between IRP values (23.05±14.83mmHg vs 7.69±6.06mmHg, p 0.026) and in the mean lower esophageal sphincter tone (9.63±7.2mmHg vs 28.8±18.60mmHg, p 0.0238). ConclusionPeroral endoscopic myotomy has a positive impact on the improvement of symptoms and of some manometric variables (IRP and LES tone) in patients with achalasia.

Laparoscopic Heller myotomy after multiple endoscopic injections and dilations: a case report

Achalasia is a primary esophageal disease that affects the esophagus and lower esophageal sphincter (LES). Many medications have been used for achalasia. However, adverse reactions and a prevailing absence of potency have been reported with these therapies. The best management leads to disturbing LES with endoscopic dilation or surgically. This is a 58-year-old woman with a 25-year history of achalasia who has experienced laparoscopic Heller myotomy (LHM) with Toupet fundoplication due to persistent symptoms despite previous endoscopic interventions. The procedure successfully addressed thickened LES muscle layers and achieved positive postoperative results, with the patient's Eckardt score dropping from &gt;9 to &lt;3. LHM with Toupet fundoplication proved its effectiveness in managing refractory type III achalasia. Despite concerns about postoperative reflux, the procedure offered substantial relief. Ongoing research will refine the balance between invasiveness and efficacy in such conditions.

Esophageal body adaptation to Nissen fundoplication: Increased esophagogastric outflow resistance yields delayed and sustained peristaltic contractions without increased amplitude.

Improvement in lower esophageal sphincter (LES) competency after laparoscopic Nissen fundoplication (LNF) is well established, yet esophageal body physiology data are limited. We aimed to describe the impact of LNF on whole esophagus physiology using standard and novel manometric characteristics. A cohort of patients with an intact fundoplication without herniation and no postoperative dysphagia were selected and underwent esophageal manometry at one-year after surgery. Pre- and post-operative manometry files were reanalyzed using standard and novel manometric characteristics and compared. A total of 95 patients were included in this study. At 16.1 (8.7) months LNF increased LES overall and abdominal length and resting pressure (p < 0.0001). Outflow resistance (IRP) increased [5.8 (3-11) to 11.1 (9-15), p < 0.0001] with a 95th percentile of 20 mmHg in this cohort of dysphagia-free patients. Distal contractile integral (DCI) also increased [1177.0 (667-2139) to 1321.1 (783-2895), p = 0.002], yet contractile amplitude was unchanged (p = 0.158). There were direct correlations between pre- and post-operative DCI [R: 0.727 (0.62-0.81), p < 0.0001] and postoperative DCI and postoperative IRP [R: 0.347 (0.16-0.51), p = 0.0006]. Contractile front velocity [3.5 (3-4) to 3.2 (3-4), p = 0.0013] was slower, while distal latency [6.7 (6-8) to 7.4 (7-9), p < 0.0001], the interval from swallow onset to proximal smooth muscle initiation [4.0 (4-5) to 4.4 (4-5), p = 0.0002], and the interval from swallow onset to point when the peristaltic wave meets the LES [9.4 (8-10) to 10.3 (9-12), p < 0.0001] were longer. Esophageal length [21.9 (19-24) to 23.2 (21-25), p < 0.0001] and transition zone (TZ) length [2.2 (1-3) to 2.5 (1-4), p = 0.004] were longer. Bolus clearance was inversely correlated with TZ length (p = 0.0002) and time from swallow onset to proximal smooth muscle initiation (p < 0.0001). Bolus clearance and UES characteristics were unchanged (p > 0.05). Increased outflow resistance after LNF required an increased DCI. However, this increased contractile vigor was achieved through sustained, not stronger, peristaltic contractions. Increased esophageal length was associated with increased TZ and delayed initiation of smooth muscle contractions.

Utility of Intraprocedural Luminal Diameter and Distensibility Measurements During the Esophageal Peroral Endoscopic Myotomy Procedure.

Through evaluation of the lower esophageal sphincter immediately before and after myotomy using an endoluminal functional lumen imaging probe (EFLIP), our study aimed to determine the clinical response to peroral endoscopic myotomy (POEM) and the incidence of postprocedure reflux. Achalasia is a rare esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter (LES) and diminished peristalsis. POEM is a therapeutic option for durable management of achalasia. However, symptomatic acid reflux and esophagitis are well-known adverse effects of the procedure. Electronic medical records of 168 patients who underwent POEM for achalasia at 2 tertiary care referral centers from May 2014 to May 2021 were reviewed. EFLIP was used at a range of catheter fill volumes to assess LES dynamics. Preprocedure and postprocedure Eckardt Symptom Scores were recorded. Significant clinical improvement from POEM was sustained in over 94% of patients after 1 year. EFLIP changed intraprocedural management 5% of the time by means of myotomy extension. In patients with reflux>1 year following POEM, there was no significant difference in post-POEM LES diameter or change in LES diameter compared with those without reflux. However, post-POEM LES distensibility index (DI) was significantly higher in patients with reflux after 1 year compared with those without reflux. POEM is a safe and increasingly effective therapy for patients with symptomatic achalasia. Intraprocedural EFLIP measurements suggest that post-POEM reflux may be correlated more with DI than LES diameter. Yet, more data is needed to substantiate these outcomes.

Pathophysiology of gastro-oesophageal reflux disease: implications for diagnosis and management.

Gastro-oesophageal reflux disease (GERD) is a common gastrointestinal disorder in which retrograde flow of gastric content into the oesophagus causes uncomfortable symptoms and/or complications. It has a multifactorial and partially understood pathophysiology. GERD starts in the stomach, where the refluxate material is produced. Following the trajectory of reflux, the failure of the antireflux barrier, primarily the lower oesophageal sphincter and the crural diaphragm, enables the refluxate to reach the oesophageal lumen, triggering oesophageal or extra-oesophageal symptoms. Reflux clearance mechanisms such as primary and secondary peristalsis and the arrival of bicarbonate-rich saliva are critical to prevent mucosal damage. Alterations of the oesophageal mucosal integrity, such as macroscopic oesophagitis or microscopic changes, determine the perception of symptoms. The intensity of the symptoms is affected by peripheral and central neural and psychological mechanisms. In this Review, we describe an updated understanding of the complex and multifactorial pathophysiology of GERD. It is now recognized that different GERD phenotypes have different degrees of reflux, severity of mucosal integrity damage and type, and severity of symptoms. These variations are probably due to the occurrence of a predominant pathophysiological mechanism in each patient. We also describe the main pathophysiological mechanisms of GERD and their implications for personalized diagnosis and management.

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

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

Comparison of laparoscopic Heller myotomy and endoscopic balloon dilation in the treatment of achalasia: Effects on quality of life and patient satisfaction.

Achalasia is a rare neurodegenerative disease of the esophagus that causes impaired esophageal peristalsis and the inability of the lower esophageal sphincter (LES) to relax. This results in symptoms such as dysphagia, regurgitation, chest pain, and weight loss. Among the treatment options, Laparoscopic Heller Myotomy (LHM), Endoscopic Balloon Dilation (EBD), and Peroral Endoscopic Myotomy (POEM) are commonly used methods. The aim of this study was to compare the efficacy and clinical long-term results of LHM and EBD in treating achalasia. Patient records from Bezmialem Vakıf University Hospital were reviewed, and 36 patients diagnosed with achalasia who underwent LHM and EBD were included in the study. Patients were evaluated using the Pre-operative Eckardt Score (Pre-ES) for preoperative evaluation, the Post-operative Eckardt Score (Post-ES) for postoperative evaluation, the Achalasia Specific Quality of Life (ASQL) questionnaire, and the Patient Satisfaction Scoring (PSS). The mean age of the 19 patients who underwent LHM was 49.37±10.48 years. The mean age of the 17 patients who underwent EBD was 59.24±14.39 years. Perioperative complications included esophageal mucosal perforation in one patient in the LHM group, bleeding in three patients (17.64%), and esophageal perforation in one patient (5.88%) in the EBD group. At a mean follow-up of 90 months, gastroesophageal reflux developed in two patients (10.53%) in the LHM group and eight patients (47%) in the EBD group. The Pre-ES was similar in both groups. The Post-ES significantly decreased in the LHM group compared to the EBD group. When ASQL and PSS results were analyzed between the LHM and EBD groups, it was concluded that LHM was more effective than EBD in improving the quality of life and providing patient satisfaction (p-value: 0.001). In light of these findings, it was concluded that LHM is a safer intervention compared to EBD and should be prioritized, considering the low risk of complications, improved quality of life, and high level of satisfaction.

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

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

When symptoms are more than reflux.

45 year-old male patient with history of heartburn and regurgitation of non-acid food in the immediate postprandial period, with no symptomatic improvement after anti-acid treatment. The patient underwent an upper endoscopy that was unremarkable. A high-resolution impedance manometry (HRIM) was performed according to Chicago Protocol 4.0, as well as an additional solid test meal, with findings of rumination syndrome (RS) (figure 1). The study was completed with a 24-hour impedance pH monitoring that showed, in the immediate postprandial period, episodes of reflux that reached the proximal sensor followed by a normal swallow (figure 2). Abdominophrenic biofeedback was started with clinical improvement and anti-acid treatment was maintained at once a day. Discussion: RS is diagnosed by a complete clinical history, using the Rome IV or DSM-5 criteria (figure 3). Due to lack of knowledge of the disease and the fact that regurgitation can be present in other conditions including gastroesophageal reflux disease and achalasia, most patients undergo multiple tests and visit several physicians before reaching the diagnosis1. The gold standard investigation for RS, in cases where there are diagnostic doubts, is HRIM with solid meal administration, that shows a sudden increase in intragastric pressure > 30 mmHg concurrent with a drop in impedance and both simultaneous lower and upper esophageal sphincter relaxation, that may or may not be followed by re-swallowing food2. Rumination episodes can appear spontaneously (type 1) or may be preceded by a reflux episode (type 2) or a supragastric belch (type 3)3. 24-hour impedance pH monitoring cannot confirm de diagnosis, but during rumination, in the majority of episodes, the refluxed material reaches the proximal esophagus2.

INFLUENCE OF ESOPHAGEAL MOTILITY IMPAIRMENT ON UPPER AND LOWER ESOPHAGEAL SPHINCTER PRESSURE IN CHAGAS DISEASE.

Chagas disease causes digestive anatomic and functional changes, including the loss of the myenteric plexus and abnormal esophageal radiologic and manometric findings. To evaluate the association of abnormal esophageal radiologic findings, cardiac changes, distal esophageal contractions, and complaints of dysphagia and constipation in upper (UES) and lower (LES) esophageal sphincter basal pressure in Chagas disease patients. The study evaluated 99 patients with Chagas disease and 40 asymptomatic normal volunteers. The patients had normal esophageal radiologic examination (n=61) or esophageal retention without an increase in esophageal diameter (n=38). UES and LES pressure was measured with the rapid pull-through method in a 4-channel water-perfused round catheter. Before manometry, the patients were asked about dysphagia and constipation and submitted to electrocardiography and chest radiography. The amplitude of esophageal distal contraction decreased from controls to chagasic patients with esophageal retention. The proportion of failed and simultaneous contractions increased in patients with abnormal radiologic examination (P<0.01). There were no significant differences in UES and LES pressure between the groups. UES pressure was similar between Chagas disease patients with cardiomegaly (n=27, 126.5±62.7 mmHg) and those without it (n=72, 144.2±51.6 mmHg, P=0.26). Patients with constipation had lower LES pressure (n=23, 34.7±20.3 mmHg) than those without it (n=76, 42.9±20.5 mmHg, P<0.03). Chagas disease patients with absent or mild esophageal radiologic involvement had no significant changes in UES and LES basal pressure. Constipation complaints are associated with decreased LES basal pressure.