Lower Esophageal Sphincter Pressure Research Articles

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

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

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

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

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

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

Per-oral endoscopic myotomy in cases with prior Heller's myotomy: Outcomes at a median follow-up of 5years.

Per-oral endoscopic myotomy (POEM) is an established treatment for achalasia cardia. However, data on the long-term efficacy of POEM in patients with failed Heller's myotomy (HM) are limited. The purpose of this study was to evaluate the long-term outcomes of POEM in patients with persistent or recurrent symptoms following HM. Data of patients with recurrence of symptoms after HM who underwent POEM (September 2013 to December 2022) were analyzed, retrospectively. Primary outcome was clinical success [Eckardt score (ES)≤3]. Secondary outcomes included improvement of manometry parameters, barium emptying at 5min and gastroesophageal reflux (esophagitis and increased esophageal acid exposure) after POEM. Seventy-two cases (45.9±13.4years, 43 men) with history of HM were included in the study. The subtypes of achalasia were type 1 (40.3%), type 2 (37.5%), and unknown (19.4%). Prior treatment included HM in 48 (66.7%), HM plus pneumatic dilatation in 20 (27.8%), and HM plus pneumatic dilatation and Botox in 4 (5.5%). Technical success was achieved in all cases. Mean length of myotomy was 10.7±3.3cm, and mean procedure duration was 59.2±25.9min. There was significant improvement in ES (pre-POEM 6.5±1.8 vs post-POEM 0.7±0.7), lower esophageal sphincter pressure pressures (31.7±12.5 vs 13.3±5.7mmHg) and barium emptying (14.2±4.2 vs 2.4±3.1cm) after POEM. At a median follow-up of 63months (IQR 40-95), clinical success (ES≤3) was documented in 58 (80.6%) patients. Reflux esophagitis and increased esophageal acid exposure were recorded in 28 of 49 (57.1%) and 11 of 20 (55%) patients, respectively. POEM is a durable treatment modality in cases with relapse of symptoms after HM.

Systematic Review With Meta-Analysis: Chronic Opioid Use Is Associated With Esophageal Dysmotility in Symptomatic Patients.

We aimed to conduct a systematic review and meta-analysis to assess the impact of chronic opioid exposure on esophageal motility in patients undergoing manometric evaluation. Multiple databases were searched through October 2022 for original studies comparing the manometric results of patients who have used chronic opioids (for >90 days) with those who do not. The primary outcomes were esophageal dysmotility disorders. Three high-resolution manometry parameters were conducted as secondary outcomes. A random-effects model was applied to calculate the odds ratio (OR) and means difference (MD) along with a 95% confidence interval (CI). Nine studies were included in this meta-analysis. Opioid use was associated with higher esophageal dysmotility disorders, including distal esophageal spasm (pooled OR 4.84, 95% CI 1.60-14.63, P = 0.005, I 2 = 96%), esophagogastric junction outflow obstruction (pooled OR 5.13, 95% CI 2.11-12.43, P = 0.0003, I 2 = 93%), and type III achalasia (pooled OR 4.15, 95% CI 2.15-8.03, P < 0.0001, I 2 = 64%). No significant differences were observed for hypercontractile esophagus, type I achalasia, or type II achalasia. The basal lower esophageal sphincter pressure (MD 3.02, 95% CI 1.55-4.50, P < 0.0001, I 2 = 90%), integrated relaxation pressure (MD 2.51, 95% CI 1.56-3.46, P < 0.00001, I 2 = 99%), and distal contractile integral (MD 640.29, 95% CI 469.56-811.03, P < 0.00001, I 2 = 91%) significantly differed between the opioid use and nonopioid use group. However, opioid use was associated with a lower risk of ineffective esophageal motility (pooled OR 0.68, 95% CI 0.49-0.95, P = 0.02, I 2 = 53%). Chronic opioid exposure is associated with an increased frequency esophageal dysmotility disorders. Our results revealed that opioid use is significantly associated with type III achalasia but not with type I and II achalasia. Therefore, opioid treatment should be taken into account as a potential underlying risk factor when diagnosing these major esophageal motor abnormalities.

Evaluating the efficacy and safety of acotiamide in patients with esophagogastric junction outflow obstruction: study protocol for an investigator-initiated, multi-center, randomized, double-blind, placebo-controlled phase II trial

BackgroundWe have determined that the impaired accommodation of the lower esophageal sphincter (LES) underlies the pathogenesis of esophagogastric junction outflow obstruction (EGJOO). We have also found that acotiamide may treat EGJOO by improving impaired LES accommodation. The effects of acotiamide in patients with EGJOO need to be further confirmed in a prospective study.MethodsThis trial is a multicenter, randomized, double-blind, placebo-controlled study to compare the efficacy and safety of acotiamide (300 mg/day or 600 mg/day) with those of a placebo in the treatment of patients with EGJOO. The primary endpoint will be the proportion of patients who report an improvement in symptom of food sticking in the chest after 4 weeks of treatment period 1. The secondary endpoints will be the proportion of patients with normalized integrated relaxation pressure (IRP), the value of change from baseline in the distal contractile integral, basal LES pressure, EGJOO–quality of life score, Gastrointestinal Symptom Rating Scale, and the correlation between IRP and each symptom score. During the 2-year trial period, 42 patients from five institutions will be enrolled.DiscussionThis trial will provide evidence to clarify the efficacy and safety of acotiamide as a treatment for patients with EGJOO. Acotiamide might help improve the quality of life of patients with EGJOO and is expected to prevent the progression of EGJOO to achalasia.Trial registrationThis study was approved by the Institutional Review Board (IRB) of Kyushu University Hospital as well as the local IRBs of the participating sites for clinical trials and registered in the Japan Registry of Clinical Trials (jRCT: 2071210072). The registration date is on October 11, 2021.

Esophageal Inlet Patch: Association with Barrett's Esophagus.

Esophageal inlet patch (IP) with heterotopic gastric mucosa is an incidental finding on esophagogastroduodenoscopy (EGD). Although IP is thought to be embryologic in nature, IP has been associated with Barrett's esophagus (BE). The aim of this study was to compare prevalence, symptoms, demographic factors, and esophageal testing in patients with IP and BE. We retrospectively analyzed endoscopic findings of EGDs, high-resolution esophageal manometry and esophageal pH impedance studies from January 2010 to January 2021 at a single academic medical center. Patients were grouped by presence or absence of IP and BE. Of 27,498 patients evaluated, 1.3% had endoscopic evidence of IP and 4.9% had BE. Of 362 patients with IP, 17.1% had BE; of 1356 patients with BE, 4.6% had IP. Both IP and BE patients presented primarily with heartburn and/or regurgitation. Patients with BE and/or IP were older and had higher BMI than those without (p < 0.001). Mean lower esophageal sphincter pressure was lower and mean acid exposure time (AET) was higher in patients with IP and/or BE than those without (p < 0.05). Our study reports an IP prevalence of 1.3%, with 17.1% patients having concomitant BE; and a BE prevalence of 4.9%, with 4.6% also having IP. Patients with IP alone presented with similar symptoms to patients with concomitant BE. Esophageal function testing showed that patients with either IP or BE had decreased LES pressures and increased esophageal AET. During endoscopy, patients found to have one of these findings should be carefully examined for the other.

Endoscopic plication compared to laparoscopic fundoplication in the treatment of gastroesophageal reflux disease: a systematic review and meta-analysis.

Endoscopic plication offers an alternative to surgical fundoplication for treatment of gastroesophageal reflux disease (GERD). This systematic review and meta-analysis evaluate outcomes following endoscopic plication compared to laparoscopic fundoplication. Systematic search of MEDLINE, Embase, Scopus, and Web of Science was conducted in September 2022. Study followed PRISMA guidelines. Studies comparing endoscopic plication to laparoscopic fundoplication with n > 5 were included. Primary outcome was PPI cessation, with secondary outcomes including complications, procedure duration, length of stay, change in lower esophageal sphincter (LES) tone, and DeMeester score. We reviewed 1544 studies, with five included comparing 105 (46.1%) patients receiving endoscopic plication (ENDO) to 123 (53.9%) undergoing laparoscopic fundoplication (LAP). Average patient age was 47.6years, with those undergoing plication being younger (46.4 ENDO vs 48.5 LAP). BMI (26.6kg/m2 ENDO vs 26.2kg/m2 LAP), and proportion of females (42.9% ENDO vs 37.4% LAP) were similar. Patients undergoing laparoscopic procedures had worse baseline LES pressure (12.8mmHg ENDO vs 9.0mmHg LAP) and lower preoperative DeMeester scores (34.6 ENDO vs. 34.1 LAP). The primary outcome demonstrated that 89.2% of patients undergoing laparoscopic fundoplication discontinued PPI compared to 69.4% for those receiving plication. Meta-analysis revealed that plication had significantly reduced odds of PPI discontinuation (OR 0.27, studies = 3, 95% CI 0.12 to 0.64, P = 0.003, I2 = 0%). Secondary outcomes demonstrated that odds of complications (OR 1.46, studies = 4, 95% CI 0.34 to 6.32, P = 0.62, I2 = 0%), length of stay (MD - 1.37, studies = 3, 95% CI - 3.48 to 0.73, P = 0.20, I2 = 94%), and procedure durations were similar (MD 0.78, studies = 3, 95% CI - 39.70 to 41.26, P = 0.97, I2 = 98%). This is the first meta-analysis comparing endoscopic plication to laparoscopic fundoplication. Results demonstrate greater likelihood of PPI discontinuation with laparoscopic fundoplication with similar post-procedural risk.

Preoperative manometric data can predict symptom improvement after per oral endoscopic myotomy for treatment of achalasia.

While per oral endoscopic myotomy (POEM) has been shown to be efficacious in the treatment of achalasia, it can be difficult to predict who will have a robust and durable response. Historically, high lower esophageal sphincter pressures have been shown to predict a worse response to endoscopic therapies such as botox therapy. This study was designed to evaluate if modern preoperative manometric data could predict a response to therapy after POEM. This was a retrospective study of 144 patients who underwent a POEM at a single institution by a single surgeon over an 8-year period (2014-2022) who had high-resolution manometry performed preoperatively and had an Eckardt symptom score performed both preoperatively and postoperatively. The achalasia type and integrated relaxation pressures (IRP) were then tested for potential correlation with need for any further achalasia interventions postoperatively as well as the degree of Eckardt score reduction using univariate analysis. The achalasia type on preoperatively manometry was not predictive of need for further interventions or degree of Eckardt score reduction (p = 0.74 and 0.44, respectively). A higher IRP was not predictive of need for further interventions however it was predictive of a greater reduction in postoperative Eckardt scores (p = 0.03) as shown by a nonzero regression slope. In this study, achalasia type was not a predictive factor in need for further interventions or degree of symptom relief. While IRP was not predictive of need for further interventions, a higher IRP did predict better symptomatic relief postoperatively. This result is opposite that of other endoscopic treatment modalities. Therefore, patients with higher IRP on high-resolution manometry would likely benefit from myotomy which provides significant symptomatic relief postoperatively.

Need for frequent dilations after magnetic sphincter augmentation: an assessment of associated factors and outcomes.

Dysphagia is the most common complaint after magnetic sphincter augmentation (MSA), with nearly one-third of patients requiring at least one dilation following MSA. A subset of patients require frequent dilations, but there is a paucity of data on the characteristics of this population. This study aimed to identify predictors of the need for frequent dilations within the first year after implant and to assess these patients' outcomes. This is a retrospective review of prospectively collected data of patients who underwent MSA over an 8-year period. Frequent dilations were defined as 2 or more dilations within 1year of surgery. Patients completed baseline and 1-year postoperative GERD-HRQL questionnaires and objective physiology testing. Baseline demographic, clinical characteristics, and objective testing data were compared between patients who did and did not require frequent dilations. A total of 697 (62.7% female) patients underwent MSA, with 62 (8.9%) patients requiring frequent dilation. At a mean (SD) of 12.3 (3.4) months follow-up, the frequent dilation group had higher median GERD-HRQL total scores (21.0 vs. 5.0, p < 0.001), PPI use (20.8% vs.10.1%, p = 0.023), dissatisfaction (46.7% vs. 11.6%, p < 0.001), and device removal (25.8% vs. 2.2%, p < 0.001) rates. Acid normalization was comparable (p = 0.997). Independent predictors of frequent dilation included preoperative odynophagia (OR 2.85; p = 0.001), IRP > 15mmHg (OR 2.88; p = 0.006), and > 30% incomplete bolus clearance (OR 1.94; p = 0.004). At a mean (SD) of 15.7 (10.7) months, 28 (45.1%) patients underwent device removal after frequent dilation. Independent predictors of device removal after frequent dilation within 5years of surgery were preoperative odynophagia (OR 7.18; p = 0.042), LES resting pressure > 45mmHg (OR 28.5; p = 0.005), and ≥ 10% failed swallows (OR 23.5; p < 0.001). The need for frequent dilations after MSA is a marker for poor symptom control, dissatisfaction, and device removal. Patients with preoperative odynophagia, high LES pressures, and poor esophageal motility should be counseled of their risk for these poor outcomes.

Achalasia cardia sub-types in children: Does it affect the response to therapy?

Achalasia sub-types affect treatment response in adults, but there is no similar data in children. We studied the differences in clinico-laboratory features and response to therapy between achalasia sub-types in children. Forty-eight children (boys:girls-25:23, 14 [0.9-18] years) with achalasia (clinical, barium, high-resolution manometry [HRM], gastroscopy) were evaluated. The sub-type was determined by Chicago classification at HRM. Pneumatic dilatation (PD) or surgery was the primary therapy. Success was defined as Eckhardt score of ≤ 3. Dysphagia (95.8%) and regurgitation (93.8%) were the most common symptoms. Forty of 48 cases had an adequate HRM study: Type I (n-19), II (n-19) and III (n-2). Types I and II had similar clinical profile. Type II had higher basal lower esophageal sphincter (LES) pressure (30.5 [16.5-46] vs. 22.5 [13-43] mmHg; p = 0.007) and less dilated esophagus on timed barium esophagogram (TBE, 25 [13-57] vs. 34.5 [20-81] mm; p = 0.006) than type I. Both types had similar success (86.6% [13/15] vs. 92.8% [13/14]; p = 1) after first PD and need of post-PD myotomy (5/17 vs. 1/16; p = 0.1) in follow-up. Twenty-three cases had TBE before and after PD; 15 (65.2%) had good clearance. These subjects required myotomy (1/15 vs. 4/8; p = 0.03) and repeat PD (5/15 vs. 4/8; p = 0.08) less often than those with poor clearance on TBE. Types I and II achalasia have similar frequency and clinical profile. Type II has higher LES pressure and less dilated esophagus than Type I. Both respond equally well to initial PD. Type I required post-PD myotomy more often, though not significantly. TBE is useful for assessing therapeutic response.

Measurement of oesophageal hiatus surface area by multiplanar reconstruction of MDCT: relationship with lower oesophageal sphincter pressure and acid reflux

To evaluate the relationship between oesophageal hiatus surface area (OHSA) and gastro-oesophageal reflux disease (GERD). Patients who underwent 24-h pH monitoring, oesophageal high-resolution manometry, and upper abdominal contrast-enhanced multidetector computed tomography (MDCT) during 2014-2021 were enrolled. Patients with a hiatus hernia (HH) on MDCT or who had a history of gastro-oesophageal surgery were excluded. Multiplanar reconstruction (MPR) of the MDCT image was used for the measurement of OHSA. Correlations of OHSA with acid exposure time (AET) and lower oesophageal sphincter (LOS) pressure of all patients were analysed. Seventy-eight patients were included in the study. OHSA was much less in the AET <4% group than in the AET >6% group (1.61±0.42 versus 2.09±0.55 cm2, p<0.001). Correlation analysis reveals that OHSA correlated positively with AET (correlation coefficient=0.47, p<0.001). Receiver operating characteristic (ROC) curve analysis reveals that OHSA can significantly distinguish patients in different groups divided by AET (area under the ROC curve [AUC]=0.76, 95% confidence interval [CI]: 0.63-0.90). OHSA was not related to LOS pressure (correlation coefficient=-0.268, p=0.051). There was no difference in OHSA between the low LOS pressure group and the normal LOS pressure group (1.84±0.61 versus 1.74±0.50 cm2, p=0.52). OHSA significantly correlated with AET but has no relationship with LOS pressure. It may be an independent risk factor of GERD.

Feasibility Study on Endoscopic Balloon-Assisted Laser Treatment (EBLT) of Gastroesophageal Reflux Disease (GERD) in In Vivo Porcine Model.

Gastroesophageal reflux disease (GERD) has been growing globally, with an increasing burden on the healthcare system due to multiple factors, such as aging and obesity. The current study evaluated the feasibility of endoscopic balloon-assisted laser treatment (EBLT) in a porcine model. GERD was initially developed in three animals via botulinum toxin injection into lower esophageal sphincter (LES). A week after the injection, the EBLT was performed on the GERD-developed models (control = 1 vs. treated = 2). A dose of 30 W of 980 nm laser light was endoscopically applied for 90 s to the LES. Both endoscopic ultrasound and manometry were performed before and after the EBLT. After 12 weeks, esophageal tissues were extracted and prepared for histological analysis. The maximum mucosa temperature was below 50 °C during the EBLT. Compared to control, the treated group yielded thicker and shorter LES muscle layers and maintained LES pressure. Through histology, the EBLT reinforced the muscularis layer with preserved mucosa and mild remodeling of the intermuscular collagen in the LES. The current study demonstrated the feasibility of EBLT as a new endoscopic approach for GERD. Further studies will examine the EBLT in a larger number of animals to warrant efficacy and safety for clinical translations.

Peroral Endoscopic Myotomy (POEM) in a 19-Month-Old Girl with Primary Achalasia

Abstract Introduction Primary achalasia is an idiopathic motility disorder of the esophagus characterized by esophageal aperistalsis and incomplete relaxation of the lower esophageal sphincter (LES) in response to swallowing. The gold standard diagnostic method in adults is high-resolution manometry (HRM). Diagnostic criteria in adults are also used in children, but some HRM normal values may change depending on age. Case Report A 15-month-old girl was admitted to the hospital for evaluation due to persistent vomiting since birth. Vomiting included what she ate regardless of the amount of food she consumed. Barium esophagography revealed barium retention, esophageal dilatation, and a “bird's beak appearance” in the distal esophagus. Esophagogastroduodenoscopy revealed stenosis in the lower esophagus and bubbles at the esophagogastric junction.In HRM, the resting LES pressure was 43.4 mm Hg, there was pan-esophageal pressurization with 60% of swallows and no normal peristalsis. The patient was diagnosed with type II achalasia based on the Chicago 3.0 classification.First, the tube was inserted to ensure adequate nutrition of the patient, and approximately 4 months later, when the patient was 10 kg, the peroral endoscopic myotomy (POEM) procedure was performed.No complications developed during and after the procedure. At the 6th month after treatment, the patient was completely asymptomatic and her weight was within normal limits for her age. Conclusion POEM is an effective and safe method in the treatment of pediatric patients with idiopathic achalasia.

A048 Managing Post-fundoplication Dysphagia: Role of Intraoperative LES Pressure Measurements with EndoFLIP

A048 Managing Post-fundoplication Dysphagia: Role of Intraoperative LES Pressure Measurements with EndoFLIP

Acupuncture Improved the Function of the Lower Esophageal Sphincter and Esophageal Motility in Chinese Patients with Refractory Gastroesophageal Reflux Disease Symptoms: A Randomized Trial.

Acupuncture is therapeutic for refractory gastroesophageal reflux disease by an unclear mechanism. This study was aimed at investigating the effect of acupuncture on esophageal motility in patients with symptoms of refractory gastroesophageal reflux disease. Sixty-eight patients with refractory gastroesophageal reflux disease symptoms were prospectively enrolled from August 2014 to December 2018 and randomized into acupuncture and control groups (n = 33 and 35, respectively). The acupuncture group received acupuncture, and the control group received sham acupuncture. Pre- and post-acupuncture high-resolution manometry was performed to evaluate the effect of acupuncture on esophageal motility. The GerdQ questionnaire was used to evaluate the pre- and post-intervention symptoms. After acupuncture, there was a significant increase in the length of lower esophageal sphincter (3.10 ± 1.08 cm vs. 3.78 ± 1.01 cm), length of intra-abdominal lower esophageal sphincter (2.14 ± 1.05 cm vs. 2.75 ± 1.16 cm), and mean basal pressure of lower esophageal sphincter (22.02 ± 10.03 mmHg vs. 25.06 ± 11.48 mmHg) in the acupuncture group (P = 0.014); moreover, the numbers of fragmented contraction and ineffective contraction decreased from 36 to 12 (P < 0.001) and 43 to 18 (P = 0.001), respectively, in the acupuncture group. However, no significant difference was observed in the control group. The GerdQ score decreased significantly from 9.45 ± 2.44 to 7.82 ± 2.21 points in the first week after acupuncture (P < 0.001). Acupuncture, which improves esophageal motility, has short-term efficacy in patients with symptoms of refractory gastroesophageal reflux disease. This trial is registered with Chinese Clinical Trial Registry (ChiCTR1800019646).

Phosphodiesterase 5 (PDE-5) inhibitors (sildenafil, tadalafil, and vardenafil) effects on esophageal motility: a systematic review

BackgroundEsophageal motility disorders are a group of disorders associated with dysfunctional swallowing resulting from impaired neuromuscular coordination. Phosphodiesterase 5 (PDE-5) inhibitors induce smooth relaxation and are proposed as a treatment option for esophageal motility disorders such as achalasia.MethodsThis study is conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We systematically searched MEDLINE/ PubMed, Scopus, EMBASE, and Web of Science databases for esophageal outcomes of individuals treated with PDE5 inhibitors. A random effect meta-analysis was conducted.ResultsA total of 14 studies were included. They were conducted in different countries, with Korea and Italy having the highest number of articles. The main drug assessed was sildenafil. PDE-5 inhibitors resulted in a significant reduction in lower esophageal sphincter pressure (SMD − 1.69, 95% CI: -2.39 to -0.99) and the amplitude of contractions (SMD − 2.04, 95% CI: -2.97 to -1.11). Residual pressure was not significantly different between the placebo and sildenafil groups (SMD − 0.24, 95% CI: -1.20 to 0.72). Furthermore, a recent study reported contractile integral, stating that ingestion of sildenafil leads to a significant reduction in distal contractile integral and a significant increase in proximal contractile integral.ConclusionPDE-5 inhibitors significantly reduce LES resting pressure and esophageal peristaltic vigor, decreasing esophageal body contractility and contraction reserve. Therefore, using these drugs in patients affected by esophageal motility disorders may potentially improve their condition regarding symptom relief and prevention of further associated complications. Future reports investigating larger sample size is necessary in order to establish definite evidence regarding the efficacy of these drugs.

Exploring objective factors to predict successful outcomes after laparoscopic Nissen fundoplication.

Currently, the reported parameters that predict the resolution of symptoms after surgery are largely subjective and unreliable. Considering that fundoplication rebuilds the structural integrity of the lower esophageal sphincter (LES), the authors focused on searching for objective and quantitative predictors for the resolution of symptoms based on the anatomical issues and whether an antireflux barrier can be well established or not. The authors reviewed the prospectively collected data of 266 patients with gastroesophageal reflux disease (GERD) who had undergone laparoscopic Nissen fundoplication (LNF). All patients were diagnosed with GERD using preoperative esophagogastroduodenoscopy, 24-h ambulatory esophageal pH monitoring, and high-resolution esophageal manometry. The patients received GERD symptom surveys using the validated Korean Antireflux Surgery Group questionnaire twice: preoperatively and 3 months after the surgery. After excluding patients with insufficient follow-up data, 152 patients were included in the analysis. Multivariate logistic regression analyses revealed that a longer length of the LES and lower BMI determined better resolution of typical symptoms after LNF (all P <0.05). Regarding atypical symptoms, higher resting pressure of LES and DeMeester score greater than or equal to 14.7 were associated with better resolution after the surgery (all P <0.05). After LNF, typical symptoms improved in 34 out of 37 patients (91.9%) with a length of LES >greater than .05cm, BMI less than 23.67kg/m 2 , and atypical symptoms were resolved in 16 out of 19 patients (84.2%) with resting pressure of LES greater than or equal to 19.65mmHg, DeMeester score greater than or equal to 14.7. These results show that the preoperative length and resting pressure of LES is important in the objective prediction of symptom improvement after LNF.

Orientation of Lower Esophageal Sphincter Pressure Using Three-Dimensional High-Resolution Manometry in Patients with Achalasia: A Pilot Study.

This study was performed to evaluate the orientation of lower esophageal sphincter (LES) pressure in patients with untreated achalasia using three-dimensional high-resolution manometry (3D-HRM). The study involved 20 patients with untreated achalasia (10 men, 60 [47-74] years of age). The 3D-HRM assembly had 32 standard channels and 12 3D channels. During basal LES pressure measurements, the orientations of the LES high- and low-pressure zones were evaluated at end-expiration. The directional relationships between the orientation of the LES high- and low-pressure zones were also evaluated. The LES high-pressure zones were located on the greater curvature side in nine (45%) patients, from the greater curvature to posterior wall side in six (30%), and from the greater curvature to anterior wall side in five (25%). The LES high-pressure zones were located mainly on the greater curvature side, but there were some variations of the orientation among the patients. The LES low-pressure zones were most frequently located from the lesser curvature to the posterior wall side in 11 (55%) patients, from the lesser curvature to anterior wall side in 6 (30%), on the posterior wall side in 2 (10%), and on the anterior wall side in 1 (5%). Significant differences were found in the directional relationships between the orientation of the LES high- and low-pressure zones (P = 0.0053). This is the first report from Japan focusing on the LES pressure orientation using 3D-HRM. Such evaluation may be useful for clarifying the pathophysiology of achalasia.

Repeat peroral endoscopic myotomy with simultaneous submucosal and muscle dissection as a salvage option for recurrent achalasia

For recurrent achalasia after initial peroral endoscopic myotomy (POEM) failure, repeat POEM (Re-POEM) has been reported as a treatment option. However, severe esophageal interlayer adhesions caused by previous procedures impede the successful establishment of a submucosal tunnel and lead to aborted Re-POEM procedures. Our team previously described POEM with simultaneous submucosal and muscle dissection (POEM-SSMD) as a feasible solution for achalasia with severe interlayer adhesions. To investigate the effectiveness and safety of Re-POEM with simultaneous submucosal and muscle dissection (Re-POEM-SSMD). A total of 1049 patients with achalasia who underwent successful endoscopic myotomy at the Digestive Endoscopic Center of Chinese PLA General Hospital from December 2014 to May 2022 were reviewed. Patients with recurrent achalasia who experienced initial POEM clinical failure were retrospectively included in this study. The primary endpoint was retreatment clinical success, defined as an Eckardt score ≤ 3 during the postretreatment follow-up and no need for additional treatment. Procedure-related adverse events, changes in manometric lower esophageal sphincter (LES) pressure and reflux complications, as well as procedure-related parameters, were recorded. Sixteen patients underwent Re-POEM (9 patients) or Re-POEM-SSMD (7 patients) successfully at a median of 45.5 mo (range, 4-95 mo) after initial POEM. During a median follow-up period of 31 mo (range, 7-96 mo), clinical success (Eckardt score ≤ 3) was achieved in 8 (88.9%) and 6 (85.7%) patients after Re-POEM and Re-POEM-SSMD, respectively (P = 0.849). The median Eckardt score dropped from 4 (range, 3-8) at preretreatment to 1 (range, 0-5) at postretreatment in the Re-POEM group (P = 0.025) and from 5 (range, 2-8) to 2 (range, 0-4) in the Re-POEM-SSMD group (P < 0.001). The mean manometric LES pressure decreased from 23.78 ± 9.04 mmHg to 11.45 ± 5.37 mmHg after Re-POEM (P < 0.001) and from 26.80 ± 7.48 mmHg to 11.05 ± 4.38 mmHg after Re-POEM-SSMD (P < 0.001). No serious adverse events were recorded in both groups. In conclusion, Re-POEM-SSMD appears to be a safe and effective salvage therapy for recurrent achalasia with severe interlayer adhesions.