Manometric Changes Research Articles

Comparison of Manometric Changes in Achalasia Pre & Post Poem Procedure

Abstract Background Achalasia is characterized by the absence of peristaltic movement in the lower esophageal sphincter, resulting in impaired relaxation during food ingestion. The incidence of achalasia is similar between men and women, affecting approximately 1 in 100,000 individuals annually, with a prevalence of 10 in 100,000 people. It is most commonly diagnosed in individuals between the ages of 30 and 60 years. High-resolution esophageal manometry is considered the gold standard for diagnosis, revealing esophageal body aperistalsis and hypertensive lower esophageal sphincter. While laparoscopic myotomy has been the standard treatment, peroral endoscopic myotomy (POEM) has emerged as a safe and effective alternative with positive short-term and medium-term outcomes. Aim of the Work The aim of this study was to evaluate the changes in esophageal motility following POEM in patients with achalasia by conducting repeated high-resolution esophageal manometry after the procedure. The study focused on patients diagnosed with achalasia using UGI endoscopy, barium swallow, and high-resolution esophageal manometry, with an Eckardt score above 3. Methods A total of 21 patients participated in the study, with a mean age of 35.23±7.2 years. Females accounted for 61.9% of the sample, and the mean height was 164.66±10.5 cm. Clinical symptoms assessed included dysphagia, retrosternal pain, regurgitation, and weight loss. Additionally, previous medical history, pneumatic dilatation, and Heller's myotomy were documented. The type of achalasia was classified as type I or type II. Key parameters of lower esophageal sphincter (LES) relaxation were analyzed pre- and post-POEM. Results All patients presented with dysphagia, retrosternal pain, and regurgitation, while 71.4% experienced weight loss. Four patients (19.1%) had type I achalasia, and 17 patients (80.9%) had type II achalasia. Significant differences were observed between pre-POEM and post-POEM measurements of integrated relaxation pressure (IRP) and LES parameters, as well as Eckardt scores. However, no statistically significant differences were found in weight and LES length between pre- POEM and post-POEM measurements. The type of achalasia did not significantly impact LES parameters pre- and post-POEM. Eckardt score, IRP, and LES length were identified as relevant predictors of the outcome in achalasia patients. Conclusion Peroral endoscopic myotomy (POEM) effectively reduces lower esophageal sphincter pressure in achalasia and partially restores esophageal body motility. It represents an advanced therapeutic- surgical endoscopic procedure with high short-term and medium-term success rates in treating achalasia and other esophageal motor disorders. Adverse events associated with POEM are minor and easily manageable. POEM is considered a safe and feasible treatment option for different types of achalasia. However, the efficacy of POEM may not be reflected by the clinical subtypes of achalasia.

Manometric and Symptomatic Changes in Patients Undergoing Heller's Myotomy and Fundoplication by Acalasia

Introduction: Achalasia occurs in up to 10 out of every 100,000 people worldwide, is associated with a large number of symptoms that can impact the patient's quality of life; laparoscopic myotomy of Héller with fundoplication represents the gold standard surgery in the treatment of this condition, has shown symptomatic improvement of the patient, However, studies have reported that there are no significant manometric and symptomatic changes in postoperative follow-up, and little has been reported in the literature, particularly in our population. Objective: To determine manometric and symptomatic changes in patients undergoing heller's myotomy and achalasia fundoplication. Material and methods: Prospective analytical observational study to be performed in patients undergoing Heller's myotomy and fundoplication due to achalasia performed by the Surgery Service of the UMAE25 of the IMSS, the symptomatology (eckardt) and manometric changes (Chicago) will be evaluated during the pre and post-surgical, it will be established if there are statistically significant differences in the postoperative using t student, Anova and Chi Square with a 95% confidence level and 5% margin of error. Conclusion: Through this protocol we can conclude thatthere are significant symptomatic and manometric changes in patients undergoing heller's myotomy and fundoplication due to achalasia, in the contrast of an adequate presurgical assessment, the technical knowledge to avoid falling into biases of the operator (surgeon), with an adequate technique and follow-up, as well as close monitoring of patients

ASSOCIATION BETWEEN OPIOID USE AND OUTPATIENT VISITS FOR DYSPHAGIA: AN ANALYSIS OF THE NATIONAL AMBULATORY MEDICAL CARE SURVEY IN 2008-2018.

Opioids-induced esophageal dysfunction has been described with characteristic manometric patterns, but the population burden of dysphagia attributable to opioid use remains unclear. National Ambulatory Medical Care Survey (NAMCS) from 2008-2018 was used to assess the relationship between opioid use and outpatient visits for dysphagia. After controlling for potential confounders there were no significant difference in ambulatory visits for dysphagia between opioid users and non-users (adjusted odds ratio=0.98, confidence interval: 0.59-1.65). No correlation between opioid use and ambulatory visits for dysphagia was found in a nationwide sample. Opioid-related manometric changes may be clinically relevant only in a small proportion of patients.

Impact of laparoscopic sleeve gastrectomy on esophageal physiology.

Introduction. Laparoscopic sleeve gastrectomy (LSG) is a popular weight loss surgery technique, but the impact on esophageal physiology and esophagogastric junction is still debatable. The aim of our study was to evaluate the manometric changes of the lower esophageal sphincter (LES) after LSG in order to indicate LES manometry pre- procedure. Methods. In a prospective study we evaluated clinically, with upper gastrointestinal endoscopy, and high-resolution esophageal manometry 45 morbidly obese patients before, and 6-12 months after LSG. Results. The BMI (body mass index) decreased from 46.28±5.79 kg/m2 to 32.28±4.65 kg/m2 postoperatively (p <0.01), with a reduction of ~14 kg/m2 of BMI, 39.9 (±11.9) kg body weight and 29.9 (± 6.2)% of the TWL (Total Weight Loss index), in a median interval of 7.9 months. Gastroesophageal reflux disease (GERD) prevalence increased from 17.8% to 31.1% postoperatively, with new GERD onset in 22.2%, but mild symptomatology (the median GERD-HRQL score increased from 1.56 to 2.84 points). Postoperatory reflux was associated with lower esophageal sphincter (LES) hypotonia, shortening of LES length and IIGP (increased intragastric pressure). Hiatal hernia repair rate was 17.8%, and proton pump inhibitor consumption 20%. After weight loss, the 10 cases of esophagitis discovered preoperatively cured, but 3 patients were diagnosed with de novo esophagitis. The prevalence of manometric dysmotility after LSG was 28.9%, lower than before surgery (44.4%). Conclusion. Even if GERD remains the main limitation of LSG, the high-resolution esophageal manometry has proved useful and should be implemented in morbidly obese evaluation protocol, to better select the bariatric procedure.

Importance of some technical aspects of the procedure of percutaneous posterior tibial nerve stimulation in patients with fecal incontinence

IntroductionThe results of percutaneous posterior tibial nerve stimulation (PTNS) in the treatment of fecal incontinence (IF) are modest. The aim of the study is to assess the relationship of some technical aspects with the clinical response: location of the nerve, distal response (motor or sensory) and accommodation. MethodsProspective study of patients with FI undergoing PTNS therapy. The clinical response was assessed using the Wexner scale, defecation diary and anorectal manometry. Results32 patients were studied. The intensity of localization (proximity to the nerve) was not correlated with clinical or manometric changes. Motor response was associated with a decrease on the Wexner scale [12.12 (±5.39) to 7.71 (±4.57) P < .005], the number of episodes of passive incontinence [8.78 (±9.64) to 4.11 (±7.11) P = .025], the total number of incontinence episodes [16.11 (±16.03) to 7.78 (±11.34) P = .009] and the number of days with fecal soiling [6.89 (±5.53) to 2.56 (±4.13) P = .002] and with an increase in the length of the manometric anal canal at rest [4.55 (±0.596) to 4.95 (±0.213) P = .004]. The increase in stimulation (accommodation) was inversely correlated with the decrease in the Wexner scale (r = −0.677 P < .005) and the number of days with soiling (r = −0.650 P = .022). ConclusionsThe motor response during PTNS seems to be related to a better clinical response. The accommodation phenomenon could be associated with worse results. The proximity of the electrode to the nerve does not seem to be important as long as a good distal response is achieved.

Importancia de algunos aspectos técnicos del procedimiento de estimulación percutánea del nervio tibial posterior en pacientes con incontinencia fecal

The results of percutaneous posterior tibial nerve stimulation (PTNS) in the treatment of fecal incontinence (IF) are modest. The aim of the study is to assess the relationship of some technical aspects with the clinical response: location of the nerve, distal response (motor or sensory) and accommodation. Prospective study of patients with FI undergoing PTNS therapy. The clinical response was assessed using the Wexner scale, defecation diary and anorectal manometry. 32 patients were studied. The intensity of localization (proximity to the nerve) was not correlated with clinical or manometric changes. Motor response was associated with a decrease on the Wexner scale [12.12 (± 5.39) to 7.71 (± 4.57) p < 0.005], the number of episodes of passive incontinence [8.78 (± 9.64) to 4.11 (± 7.11) p = 0.025], the total number of incontinence episodes [16.11 (± 16.03) to 7.78 (± 11.34) p = 0.009] and the number of days with faecal soiling [6.89 (± 5.53) to 2.56 (± 4.13) p = 0.002] and with an increase in the length of the manometric anal canal at rest [4.55 (± 0.596) to 4.95 (± 0.213) p = 0.004]. The increase in stimulation (accommodation) was inversely correlated with the decrease in the Wexner scale (r = -0.677 p < 0.005) and the number of days with soiling (r = -0.650 p = 0.022). The motor response during PTNS seems to be related to a better clinical response. The accommodation phenomenon could be associated with worse results. The proximity of the electrode to the nerve does not seem to be important as long as a good distal response is achieved.

The effect of colonic tissue electrical stimulation and celiac branch of the abdominal vagus nerve neuromodulation on colonic motility in anesthetized pigs.

Knowledge on optimal electrical stimulation (ES) modalities and region-specific functional effects of colonic neuromodulation is lacking. We aimed to map the regional colonic motility in response to ES of (a) the colonic tissue and (b) celiac branch of the abdominal vagus nerve (CBVN) in an anesthetized porcine model. In male Yucatan pigs, direct ES (10Hz, 2ms, 15mA) of proximal (pC), transverse (tC), or distal (dC) colon was done using planar flexible multi-electrode array panels and CBVN ES (2Hz, 0.3-4ms, 5mA) using pulse train (PT), continuous (10min), or square-wave (SW) modalities, with or without afferent nerve block (200Hz, 0.1ms, 2mA). The regional luminal manometric changes were quantified as area under the curve of contractions (AUC) and luminal pressure maps generated. Contractions frequency power spectral analysis was performed. Contraction propagation was assessed using video animation of motility changes. Direct colon ES caused visible local circular (pC, tC) or longitudinal (dC) muscle contractions and increased luminal pressure AUC in pC, tC, and dC (143.0±40.7%, 135.8±59.7%, and 142.0±62%, respectively). The colon displayed prominent phasic pressure frequencies ranging from 1 to 12cpm. Direct pC and tC ES increased the dominant contraction frequency band (1-6cpm) power locally. Pulse train CBVN ES (2Hz, 4ms, 5mA) triggered pancolonic contractions, reduced by concurrent afferent block. Colon contractions propagated both orally and aborally in short distances. In anesthetized pigs, the dominant contraction frequency band is 1-6cpm. Direct colonic ES causes primarily local contractions. The CBVN ES-induced pancolonic contractions involve central neural network.

Hypotonic Low Esophageal Sphincter Is Not Predictive of Gastroesophageal Reflux Disease After Sleeve Gastrectomy.

Sleeve gastrectomy is the most commonly performed bariatric surgery these days but is associated with de novo reflux. We aimed to study the influence of hypotonic lower esophageal sphincter (LES) on postoperative gastroesophageal reflux disease (GERD). Patients with pre- and postoperative esophageal high-resolution manometry (HRM) and 24-h pH monitoring (pHM) were included retrospectively in our study. Preoperative hypotonic LES was defined by a mean residual pressure of the lower esophageal sphincter < 4mmHg. Postoperative GERD was defined by a DeMeester's score > 14.72. We also evaluated postoperative manometric changes at the esophageal-gastric junction. Sixty-nine patients (54 females and 15 males) had pre- and postoperative HRM and pHM. The mean age was 45.9 ± 9.8years. The mean body mass index (BMI) was 47.5 ± 7.5kg/m2. Hypotonic LES concerned 21 patients (30.4%) before sleeve gastrectomy. The mean time between the two esophageal monitorings was 32.1 ± 24.1months. The sensitivity, specificity, positive predictive value, and negative predictive value of hypotonic LES to predict GERD were 31, 70, 52, and 48% respectively. The LES minimal residual pressure was not statistically decreased after sleeve gastrectomy (p= 0.24). Only the wave speed, esophageal length, and LES length were significantly reduced after SG (p = 0.029, 3.8 × 10-7 and 0.00032). Hypotonic LES has a poor predictive value on postoperative GERD. The LES's length is significantly reduced after SG and this could be a factor explaining de novo reflux.

Morphologic Restoration After Peroral Endoscopic Myotomy in Sigmoid-type Achalasia

Background/AimsAchalasia is a chronic, progressive motility disorder of the esophagus. The sigmoid-type achalasia is an advanced stage of achalasia characterized by severe dilatation and tortuous angulation of the esophageal body. Peroral endoscopic myotomy (POEM) has been reported to provide excellent clinical outcomes for achalasia, including the sigmoid type, but the restoration of esophageal morphology and function remain poorly described. The aim of our study is to investigate esophageal restoration after POEM for sigmoid-type achalasia.MethodsFrom 98 patients with achalasia who underwent POEM in the Yonsei University Health System from 2013 to 2018, we recruited 13 patients with sigmoid-type achalasia (7 male; mean age 53.3 years) and assessed morphological and manometric changes in the esophagus.ResultsClinical success (Eckardt score < 3) was achieved in all cases. After POEM, the average angle of esophageal tortuosity became more obtuse (91.5° vs 114.6°, P = 0.046), esophageal body diameter decreased (67.6 vs 49.8 mm, P = 0.002), and esophagogastric junction opening widened (6.4 vs 9.5 mm, P = 0.048). Patients whose esophageal tortuosity did not improve had longer durations of symptoms than patients with improvement (80.2 vs 636 months, P < 0.001). An absence of peristalsis was observed in all patients pre- and post-POEM.ConclusionsPOEM resulted in excellent clinical outcomes and morphologic improvement in sigmoid-type achalasia. These results suggest that the improvement of esophageal tortuosity through POEM reflects a reduced esophageal burden.

Esophageal manometry in systemic sclerosis: findings and association with clinical manifestations.

Systemic sclerosis (SSC) is an autoimmune disorder that affects several organs of unknown etiology, characterized by vascular damage and fibrosis of the skin and organs. Among the organs involved are the esophagus and the lung. To relate the profile of changes in esophageal electromanometry (EM), the profile of skin involvement, interstitial pneumopathy (ILD), and esophageal symptoms in SSC patients. This is an observational, cross-sectional study carried out at the SSC outpatient clinic of the Hospital de Clínicas of the Federal University of Uberlândia. After approval by the Ethics Committee and signed the terms of consent, 50 patients were initially enrolled, from 04/12/2014 to 06/25/2015. They were submitted to the usual investigations according to the clinical picture. The statistical analysis was descriptive in percentage, means, and standard deviation. The Chi-square test was used to evaluate the relationship between EM, high-resolution tomography, and esophageal symptoms. 91.9% of the patients had some manometric alterations. 37.8% had involvement of the esophageal body and lower esophageal sphincter. 37.8% had ILD. 24.3% presented the diffuse form of SSC. No association was found between manometric changes and clinical manifestations (cutaneous, pulmonary, and gastrointestinal symptoms). The present study confirms that esophageal motility alterations detected by EM are frequent in SSC patients, but may not be related to cutaneous extension involvement, the presence of ILD, or the gastrointestinal complaints of patients.

Evaluation of upper oesophageal sphincter in unilateral vocal fold paralysis.

To evaluate dysphagia and manometric changes in the upper oesophageal sphincter in patients with unilateral vocal fold paralysis. Thirty patients with unilateral vocal fold paralysis due to vagal nerve paralysis scheduled for evaluation were enrolled in the study group; 24 healthy subjects were included in the control group. Upper oesophageal sphincter basal and residual pressure, relaxation time, and pharyngeal pressure values were evaluated by manometry. All patients completed the Turkish Eating Assessment Tool 10 questionnaire, the MD Anderson dysphagia questionnaire and the reflux symptom index form. Swallowing assessment questionnaires and reflux symptom index results were significantly higher in the study group. Upper oesophageal sphincter basal and relaxation pressures were lower in the study group. Upper oesophageal sphincter relaxation time was shorter in the study group, but pressure values recorded from the pharynx were higher. Upper oesophageal sphincter manometric pressure was lower in patients with unilateral vocal fold paralysis. A hypotonic sphincter likely contributes to dysphagia and aspiration.

Evaluation of upper esophageal sphincter in benign vocal lesions.

To evaluate upper esophageal sphincter (UES) activity in patients with benign glottic lesions. Twenty-three patients with benign vocal fold (VF) lesions scheduled for manometric evaluation were enrolled as the study group (SG); 20 healthy subjects without vocal pathology or dysphagia were included as the control group (CG). UES residual, basal, relaxation time and peak pharyngeal pressures were evaluated by manometry. The reflux symptom index (RSI) and reflux finding score (RFS) were used to estimate the clinical findings of laryngopharyngeal reflux, and the voice handicap index (VHI) was measured in both groups. The patients' data were compared using the Mann-Whitney test and t test. The diagnoses in the SG were vocal nodules, vocal polyps, vocal cysts, sulcus vocalis, or Reinke's edema. The evaluation scores (RSI, RFS, and VHI) were significantly higher in the SG than in the CG (P < 0.05). UES basal and relaxation pressures, relaxation time, and peak pharyngeal pressures did not differ between the SG and the CG (P > 0.05). UES manometric pressure was similar in patients with VF mucosal lesions and controls. Studies involving larger populations are necessary to confirm the manometric changes in the UES and to elucidate the pathogenesis of benign VF lesions.

Bethanechol Does Not Improve Dysphagia in Patients With Ineffective Esophageal Motility and Defective Bolus Transit

Introduction: Ineffective esophageal motility (IEM) is a common motility disorder, defined as ≥ 50% weak swallows (distal contractile integral (DCI) < 450 mmHg-cm-sec). It is frequently associated with defective bolus transit and may present with dysphagia. Bethanechol, a direct-acting muscarinic receptor agonist, has been shown in pilot studies to increase distal esophageal contraction amplitude in healthy volunteers and patients with IEM. Methods: 9-weeks, randomized, double-blind, placebo-controlled, cross-over study was conducted in patients with severe IEM with a main presenting complaint of dysphagia. Aim of study: Assess the effect of bethanechol (50 mg TID) on dysphagia & manometric changes in patients with IEM. Patients were given placebo or bethanechol for 4 weeks each in a stepwise fashion, then were crossed-over after a 1-week washout. Mayo Dysphagia Questionnaire-30 (MDC-30) and high-resolution impedance manometry (HRIM) obtained at baseline and at the completion of each arm. Adverse effects profile was assessed during the study. Statistical analysis: Non-parametric Friedman’s test was used to compare outcomes for bethanechol, placebo, and baseline. Mean differences and confidence intervals were estimated for the 3 groups<./p> Results: 10 patients completed the study (70% females). Mean age 57.3 years (SD+/-11.9). 1 patient dropped-out because of chest pain while on placebo. 44% of patients developed transient adverse effects that resolved within a week of bethanechol initiation. Median DCI for bethanechol was slightly higher, although it did not reach significance level: 307, Interquartile range (IQR) 39-1306 bethanechol; 208, IQR 72-1171 placebo; 225, IQR 62-495 baseline (P=0.39) (Figure 1). MDC-30 score was slightly lower for bethanechol: 4 (on scale of 0-10), IQR 0-8 bethanechol; 5, IQR 1-8 placebo; 5, IQR 3-10 baseline (P=0.34) (Figure 2).399_A Figure 1 No Caption available.399_B Figure 2 No Caption available.Conclusion: Bethanechol increased distal esophageal contraction amplitude to some extent and decreased sensation of dysphagia at 30-days compared to placebo and more profoundly to baseline. Though, these differences did not reach significance level. Our study’s small sample size likely underestimated the effect of bethanechol. Bethanechol was well-tolerated with absence of serious adverse events, with less than half of patients experienced minor adverse effects that resolved within 1 week of therapy. This pilot study opens the door to explore more the utility of bethanechol in the treatment of IEM.

Manometric Changes to the Lower Esophageal Sphincter After Magnetic Sphincter Augmentation in Patients With Chronic Gastroesophageal Reflux Disease.

To evaluate the manometric changes, function, and impact of magnetic sphincter augmentation (MSA) on the lower esophageal sphincter (LES). Implantation of a MSA around the gastroesophageal junction has been shown to be a safe and effective therapy for gastroesophageal reflux disease, but its effect on the LES has not been elucidated. Retrospective case control study (n = 121) evaluating manometric changes after MSA. Inclusion criteria consisted of a confirmed diagnosis of gastroesophageal reflux disease by an abnormal esophageal pH study (body mass index <35 kg/m, hiatal hernia <3 cm, and absence of endoscopic Barrett disease). Manometric changes, pH testing, and proton pump inhibitor use were assessed preoperatively and 6 and 12 months after MSA. MSA was associated with an overall increase in the median LES resting pressure (18 pre-MSA vs 23 mm Hg post-MSA; P = 0.0003), residual pressure (4 vs 9 mm Hg; P < 0.0001), and distal esophageal contraction amplitude (80 vs 90 mm Hg; P = 0.02). The percent peristalsis remained unaltered (94% vs 87%; P = 0.71).Overall, patients with a manometrically defective LES were restored 67% of the time to a normal sphincter with MSA. Those with a structurally defective or severely defective LES improved to a normal LES in 77% and 56% of patients, respectively. Only 18% of patients with a normal preoperative manometric LES deteriorated to a lower category. MSA results in significant manometric improvement of the LES without apparent deleterious effects on the esophageal body. A manometrically defective LES can be restored to normal sphincter, whereas a normal LES remains stable.

Chagasic Esophagus: An Unusual Presentation of Late Onset Dysphagia

The patient is a 78 year old female who was born in Buenos Aires before moving to the United States 40 years before her initial visit. She presented with progressive dysphagia, heartburn and epigastric pain. She did not have any cardiac symptoms or constipation. An EGD was performed which showed no signs of esophageal dilation or retention. The LES was easily traversed. An esophageal manometry (EM) showed that the LES relaxed well with most swallows, but several simultaneous contractions were present alternating with normal peristaltic waves. She was treated with an anti-reflux program with transient improvement. A year later, her symptoms recurred with chest pain, dysphagia to solids and liquids, and regurgitation. A repeat EM revealed over 30% simultaneous contractions that alternated with normally conducted peristaltic waves but also a poorly relaxing LES. BOTOX injection was done with symptomatic improvement. A year later, her symptoms recurred. A repeat EM was performed using a high-resolution manometry system. Findings were those of EGJ outlet obstruction with a mean IRP of 23.8 mmHg. No peristalsis was present and there was evidence of pan esophageal pressurization, overall consistent with the diagnosis of Achalasia (type II) as per the Chicago classification. A trypanosome antibody IgG was noted to be abnormal at 15 units. To her knowledge she was never exposed to any known tropical diseases. She underwent a laparoscopic Heller myotomy. She had improved relaxation of her LES, however, had persistent simultaneous contractions of the esophageal body. Chagas disease is caused by infection with the protozoan parasite Trypanosoma cruzi. Chagasic esophagus is seen in patients with the chronic form of the disease. The diagnosis of Chagas esophagus requires at least 3 requirements: a compatible history and clinical presentation, radiological and manometric abnormalities and serology tests to detect IgG antibodies to T. cruzi. Many patients are asymptomatic but still exhibit manometric changes while those with manometric changes may be asymptomatic. Management focuses on symptom amelioration with endoscopic dilatation or surgical options, including Per Oral Endoscopic Myotomy (POEM), being considered on an individual basis. It is important to be cognizant that there is Chagasic esophagus in the United States and to consider this in certain populations presenting with achalasia and even non-classic motility disorders that may be progressive or intermittent.Figure 1Figure 2

The Use of Superselective Arteriography in the Evaluation of the Influence of Intracapsular Hip Joint Pressure on the Blood Flow of the Femoral Head

Objective: We aimed to analyze the intracapsular pressure of the hip joint following femoral neck fracture and its relationship to the position of the hip or to traction and (using superselective arteriography) to evaluate the blood supply to the femoral head and the influence of traction and hip position on the blood supply. Subjects and Methods: Twenty-six cases of fresh Garden type I-III femoral neck fractures were enrolled. After being placed in the neutral position, in internal rotation or with traction of 3 and 5 kg, respectively, intracapsular manometric changes were measured. Eight cases underwent superselective arteriography of the medial circumflex femoral artery and its branches under the manometric changes of the hip joint capsule. Results: Twenty-four to 48 h after the injury, the intracapsular pressure was significantly higher on the fractured side than on the normal side. The mean pressure was 28.41 ± 9.339 mm Hg in fully extended hips in the neutral position, 79.92 ± 12.80 mm Hg in internally rotated hips, 51.39 ± 15.41 mm Hg in hips with 3 kg of traction and 64.81 ± 13.56 mm Hg in hips with 5 kg of traction. The arteriographic findings revealed that traction and internal rotation reduced the perfusion of the femoral head at the medial circumflex femoral artery and its branches, and also negatively influenced venous reflux. Conclusion: Traction and internal rotation both caused the intracapsular pressure of the hip joint to rise considerably, which reduced the femoral head perfusion and impeded venous reflux. This could lead to avascular necrosis of the femoral head.

Tu1182 High Resolution Esophageal Manometry in Italian Healthy Volunteers: A Comparison With North-American and North-European Values

G A A b st ra ct s GERD symptoms before seeking medical attention, and so the manometric changes of new onset RE have not been evaluated prospectively in humans. To elucidate those changes, we induced acute RE by discontinuing PPI therapy in patients who had severe RE that was healed by PPIs, and we studied changes in esophageal motility using high resolution esophageal manometry. Methods: Patients with a prior endoscopy showing LA grade C RE were treated with BID PPIs for at least one month before a baseline endoscopy to document healing, after which PPIs were stopped. High resolution esophageal manometry, multichannel intraluminal impedance(MII)/pH monitoring, endoscopy, and GERD-HRQL symptom scoring were performed at baseline (on PPI) and 2 weeks after stopping PPIs. Esophageal mucosal baseline impedance was calculated at study start and 2 weeks after stopping PPIs, by measuring the impedance at the beginning of the MII/pH study, 5 cm above the LES. Results: 14 patients enrolled; 3 were excluded when baseline endoscopy showed LA B RE, 1 was withdrawn for an unrelated adverse event, and 10 completed the study (9 men, 1 woman, mean age 56.5, range 29-69 years). Comparing baseline values to those 2 weeks after stopping PPIs for the 10 patients, the mean esophageal acid exposure (total % time pH<4) increased from 6.0%±11.4% SD to 27.2%±23.0% (p=.005) and mean GERD-HRQL scores increased from 7.7±9.5 to 12.5±9.2 (p=.02). Esophageal mucosal baseline impedance decreased from 2519±340V at week 0 to 1509±194V (p=.009) 2 weeks after stopping PPIs. 8 of the 10 patients developed moderate-to-severe endoscopic RE by 2 weeks (4 LA grade B, 4 LA grade C). In those 8 patients, the mean distal contractile integral (DCI) decreased from 1184.9±932.8 mmHg.s.cm to 798.9±666.6 mmHg.s.cm (p=.025), the mean LES pressure decreased from 15.9±8.2 mmHg to 12.6±9.0 mmHg (p=.16), and the integrated relaxation pressure (IRP) decreased from 4.8±4.7 mmHg to 0.4±5.4 (p=.01) mmHg. Conclusions: Discontinuing PPIs for 2 weeks in patients who had LA C RE healed by PPI therapy is a valid model of acute RE. These patients can develop severe RE associated with a significant increase in esophageal acid exposure and a significant decrease in esophageal impedance values within those 2 weeks. Our finding that acute RE causes a significant decrease in DCI demonstrates that moderate-to-severe GERD is a cause of hypocontractile esophageal motility alterations.

Histopathology and Physiological Alterations After Procedure for Prolapsed Hemorrhoids

See Article on Page 198-204 Since the introduction of procedure for prolapsed hemorrhoids (PPH) into the treatment of hemorrhoids, PPH has been accepted as a standard treatment that can replace the conventional hemorrhoidectomy. However, some safety concerns were raised during the early period of its introduction into clinical practice. One of the concerns was the presence of smooth muscle in the resected specimen. The clinical importance of smooth muscle tissue in the specimen is possible injury to the internal sphincter and deterioration in continence. Even striated muscles have been reported in PPH specimens [1, 2]. These findings mean that the rectal wall or internal sphincters, as well as external sphincters, may be damaged during PPH. Many researchers have focused on the above issue and have tried to determine if this histological finding has any clinical significance for the postoperative functional outcome. The incidence of smooth muscle being observed in specimens after PPH ranged from 20% to 100% [3-5] while no significant manometric changes or deterioration in continence was observed. To date, the clinical significance of the smooth muscle in the PPH specimen is still not clear. Some authors have tried to correlate the amount of the smooth muscle in the PPH specimen to a decrease in manometric results [1]. However, a decrease in the resting pressure is observed not only after a PPH but also after a conventional hemorrhoidectomy [6]. Also, the presence of smooth muscles in the PPH specimen does not always mean an injury to the internal sphincter. Currently, it is impossible to differentiate the smooth muscles of rectum from the internal sphincter. It is more probable that the rectal proper muscle, rather than the internal sphincter, may be injured during a PPH because it is recommended to perform the procedure two to five centimeters above the dentate line [7]. If the staple line is at the level of the dentate line and the specimen involves smooth muscle, one can conclude that an injury to the internal sphincter happened during the PPH. However, there was no change in continence, not even in cases where an injury to the internal sphincter was highly suspected because the smooth muscles had been resected from the anal sphincter region. On the other hand, there have been reports that these inadvertent histological findings may be a cause of pain, tenesmus, or fecal urgency [8]. Although the PPH is devised to remove mucosa and submucosa, smooth muscle in PPH specimens is a frequently-observed finding whose clinical significance is unclear. However, any injury to the continuity of the bowel or sphincter mechanism may lead to serious complications, such as retroperitoneal abscess, dehiscence, or deterioration of continence. Therefore, taking care not to injure the internal sphincter or the rectum so as to prevent unexpected serious complications is reasonable.

Eosinophilic esophagitis: manometric and pHmetric findings

Eosinophilic esophagitis is an entity characterized by an esophageal inflammatory infiltrate of eosinophils, manifested by dysphagia, intermittent food impactions and symptoms similar to gastroesophageal reflux disease (GERD), that predominantly affects young adults. There may be association of eosinophilic esophagitis with GERD, and motor abnormalities have been described. The main objectives of this study are to describe the findings at esophageal manometry and pH monitoring in patients with eosinophilic esophagitis. Cross-sectional study of 20 patients with a diagnosis of eosinophilic esophagitis, submitted to esophageal manometry and 24h pH monitoring. Were analysed the manometric changes and the presence of abnormal reflux on pH monitoring. Twenty patients (15 men, 5 women) had a mean age of 29 years. Motility disorders were found in 25% (5/20) patients with ineffective esophageal motility being the most common finding. pH monitoring revealed abnormal reflux on 25%, without any relationship with manometric findings. Manometric abnormalities were observed in 25% of patients and abnormal reflux on pH monitoring also in 25%. This study showed no relationship between abnormal reflux and the presence of manometric changes.

Clinical and manometric evaluation of women with chronic anal fissure before and after internal subcutaneous lateral sphincterotomy

Objective: To evaluate clinical and manometric parameters of chronic anal fissure females undergoing lateral internal sphincterotomy (LIS). Methods: A total of eight women with chronic anal fissure who underwent LIS were included in this study. The preoperative assessment was performed one week before surgery and included general and anorectal examination, anorectal manometry, and Jorge Wexner questionnaire. The post operative follow up was made every 15 days until complete healing. Jorge Wexner questionnaires and anorectal manometry were repeated at 1 month and 3 months after the surgery. Time to healing, manometric changes and complications were assessed. Results: All patients had preoperative increased anal resting pressure. The resting pressures and anal canal length were significantly decreased 3 months after surgery. Patients' complaints of itching and bleeding were also reduced. Fissures healed in 7 patients and median healing time was 45 days. No complications were observed due to the procedure. One patient had transient incontinence to fla - tus. Conclusion: Lateral internal sphincterotomy provided clinical improvement and reduced resting pressure of the internal anal sphincter