Manometry Data Research Articles

A Case of Post-fundoplication Dysphagia: Another Possible Interpretation of the Manometric Findings.

TO THE EDITOR: A recent case presentation, 1 featuring a sample tracing from high-resolution manometry, reports findings for a 40-year-old male patient with persistent severe dysphagia and weight loss some 2 years after laparoscopic fundoplication. The author states the manometric findings supported a diagnosis of hypertensive lower esophageal sphincter (LES) with impaired esophagogastric junction (EGJ) relaxation. We would like to raise another possible interpretation of the findings: If the accompanying figure is typical of the entire manometric recording, then the pressure patternhas been incorrectly interpreted. In the image shown, the pressure pattern below the “high pressure zone” (at 44-47 cm) is similar to the pressure pattern above the “high pressure zone,” indicative of a curled or bent catheter. The irregular pressure pattern at the bottom of the image suggests the distal end of the catheter has not entered the stomach. This previously described “butterfly” pattern, 2 with a mirror image of pressure at the level of catheter curling, needs to be identified during acquisition to enable adjustments to be made to avoid a technically inadequate study. Also, the observation that “a sudden increase was noted in the LES pressure up to 300 mmHg after each wet swallow” is an artifact generated by an occluded sidehole of the bent catheter and is not attributable to the LES. To correctlyevaluate the luminal EGJ pressures in this post fundoplication patient, a repeat manometryis advised, with gentle maneuvres to guide the catheter tip across the EGJ; 3 if this fails, then catheter placement under endoscopic guidance is recommended. 2 Additionally, a radiological contrast swallow will be helpful in identifying anyfunctional or anatomical anomaly, such as impaired esophageal outflow or a slipped fundoplication. 4 Both objective assessments can better inform clinical management decisions. This case presentation highlights the need for greater awareness of the technical pitfalls and limitations that can occur with high-resolution esophageal manometry data acquisition and interpretation. Pressure pattern recognition during the performance of studies and critical assessment of semi-automated data analysis output is required. In conclusion, the presented interesting case of post fundoplication dysphagia shows manometric data that should be interpreted with caution.

Sa1972 Bolus Flow Time Calculated From High-Resolution Impedance and Manometry (HRIM) Data Correlates With Timed Barium Esophagram Measures

Example of esophageal impedance topography (EIT) plot showing the method for deriving EIT parameters Z1, Z2 and the Z2/Z1 ratio from a HRIM study. The pressure contours at 20 mmHg intervals (black solid lines) are overlaid with the enhanced impedance data (purple colorization) with the same resolution as pressure data in both time and spatial domain after interpolation. A region of interest (ROI, red dashed rectangle) is selected and the swallow event is divided into two sections by the contractile wave defined by the pressure isobaric contour. The impedance clearance contour (white curve) defines an impedance value of 50% drop from the mean baseline impedance to the mean nadir impedance and these white contours are superimposed on the EIT plot within the ROI for calculation of EIT parameters including bolus area in zone 1 (Z1), bolus area in zone 2 (Z2), and a ratio of Z2/ Z1, calculated to define the percentage of bolus that is retained in the esophagus after the swallow.

Reply to: “Comparison of results from a randomized trial 1 year after laparoscopic Nissen and Toupet fundoplications”

The fundoplication of choice for the surgical treatment of gastroesophageal reflux disease (GERD) still is debated. Multichannel intraluminal impedance monitoring (MII) has not been used to compare objective data, and comparative subjective data on laparoscopic Nissen and Toupet fundoplications are scarce.This study randomly allocated 125 patients with documented chronic GERD to either laparoscopic floppy Nissen fundoplication (LNF; n = 62) or laparoscopic Toupet fundoplication (LTF; n = 63). The Gastrointestinal Quality of Life Index (GIQLI), symptom grading, esophageal manometry, and MII data were documented preoperatively and 1 year after surgery. The pre- and postprocedure data were compared. Statistical significance was set at a p value lower than 0.01 (NCT01321294).Both procedures resulted in significantly improved GIQLI and GERD symptoms. Preoperative dysphagia improved in both groups, but the improvement reached significance only in the LTF group. The ability to belch was shown to be significantly more decreased after LNF than after LTF. Gas-bloat and "atypical" extraesophageal symptoms also were decreased after surgery (p < 0.01). However, bowel symptoms were virtually unchanged in both groups. Both procedures resulted in significantly improved lower esophageal sphincter pressures. The improvement was greater in the LNF group than in the LTF group (p < 0.01). The DeMeester score and the numbers of total, acid, proximal, upright, and recumbent reflux episodes decreased in both groups after surgery (p < 0.01). No significant difference between the procedures in terms of MII data was found. Six patients (4.8 %) had to undergo reoperation because of intrathoracic slipping of the wrap. All the patients had undergone LNF.Both procedures proved to be equally effective in improving quality of life and GERD symptoms. However, the reoperation and dysphagia rates were lower and the ability to belch was higher after LTF than after LNF.

Short–term effects of neoadjuvant chemoradiation therapy on anorectal function in rectal cancer patients: a pilot study

BackgroundNeoadjuvant chemoradiation therapy followed by curative surgery has gained acceptance as the therapy of choice in locally advanced rectal cancer. However, deterioration of anorectal function after long-course neoadjuvant chemoradiation therapy combined with surgery for rectal cancer is poorly defined. The aim of this study was to evaluate the physiological and clinical change of anorectal function after neoadjuvant chemoradiation therapy for rectal cancer.MethodsWe analyzed 30 patients on whom preoperative anorectal manometry data were available both before and after chemoradiation from October 2010 to September 2011. All patients underwent long-course neoadjuvant chemoradiation therapy. We compared manometric parameters between before and after neoadjuvant chemoradiation therapy.ResultsOf 30 patients, 20 were males and 10 females. The mean age was 64.9 ± 9.9 years (range, 48-82). Before nCRT, the rectal compliance was higher in patients with ulceroinfiltrative type (P = 0.035) and greater involvement of luminal circumference (P = 0.017). However, there was the tendency of increased rectal sensory threshold for desire to defecate when the patient had decreased circumferential ratio of the tumor (P = 0.099), down-graded T stage (P = 0.016), or reduced tumor volume (P = 0.063) after neoadjuvant chemoradiation.ConclusionsNeoadjuvant chemoradiation therapy did not significantly impair overall sphincter function before radical operation. The relationship between tumor response of chemoradiation and sensory threshold for desire to defecate may suggest that neoadjuvant chemoradiation may be helpful for defecatory function as well as local disease control, at least in the short-term period after the radiation in locally advanced rectal cancer patients.

Classification of High‐Resolution Manometry Data According to Videofluoroscopic Parameters Using Pattern Recognition

To determine if pattern recognition techniques applied to high-resolution manometry (HRM) spatiotemporal plots of the pharyngeal swallow can identify features of disordered swallowing reported on the Modified Barium Swallow Impairment Profile (MBSImP). Case series evaluating new method of data analysis. University hospital. Simultaneous HRM and videofluoroscopy was performed on 30 subjects (335 swallows) with dysphagia. Videofluoroscopic studies were scored according to the MBSImP guidelines while HRM plots were analyzed using a novel program. Pattern recognition using a multilayer perceptron artificial neural network (ANN) was performed to determine if 7 pharyngeal components of the MBSImP as well as penetration/aspiration status could be identified from the HRM plot alone. Receiver operating characteristic (ROC) analysis was also performed. MBSImP parameters were identified correctly as normal or disordered at an average rate of approximately 91% (area under the ROC curve ranged from 0.902 to 0.981). Classifications incorporating two MBSImP parameters resulted in classification accuracies over 93% (area under the ROC curve ranged from 0.963 to 0.989). Pattern recognition coupled with multiparameter quantitative analysis of HRM spatiotemporal plots can be used to identify swallowing abnormalities, which are currently assessed using videofluoroscopy. The ability to provide quantitative, functional data at the bedside while avoiding radiation exposure makes HRM an appealing tool to supplement and, at times, replace traditional videofluoroscopic studies.

Tu2068 Spatial Aliasing of Colonic Manometry Data: What Have We Been Missing or Mislabeling?

While colonic manometry has helped to defined dysmotility in patients with functional colonic or anorectal disorders, identification of specific manometric markers that assist in subtyping these disorders remains elusive. Typically colonic manometry is recorded with sensor spacing ≥10cm, however we have shown that colonic propagated sequences (PS) can extend over segments as short as 3-5cm(1). It is likely, therefore that traditional manometry is overlooking potentially relevant motor patterns. Aim: To determine the influence of pressure sensor spacing on our ability to accurately identify colonic motility patterns. Method: A fibre-optic catheter containing 72-90 sensors spaced at 1cm intervals was placed colonoscopically to the caecum in 11 patients with scintigraphically confirmed slow transit constipation. Controls comprised 11 patients with neurogenic fecal incontinence and 9 healthy subjects. From each of these recordings a 2hr section of trace was selected to assess motor response to either the response to a 1000kCal meal (healthy controls) or the colonic response to sacral nerve stimulation (patient population). Each data set was analysed in 6 different ways by sub-sampling different sets of the full array to simulate inter-recording site distances of 10, 7, 5, 3, 2 and 1cm. In blinded fashion, in each manometric trace antegrade and retrograde propagating sequences (PS) were identified. Against the 1cm spaced data (gold standard), we compared all the PSs identified at each test sensor spacing (2-10cm). Results: In all three groups as sensor spacing increased; i) the frequency of identified antegrade and retrograde PSs decreased; , 5% of the propagating activity observed at 1cm spacing could be seen at 10cm (P , 0.0001); ii) the ratio of antegrade to retrograde PSs increased (P , 0.0001), from pre-dominantly retrograde activity at 1cm spacing to predominantly antegrade at 10cm spacing; & iii) the number of falsely labeled PSs (when compared to 1cm data) increased (P , 0.003). At a sensor spacing .5cm the only PSs that can be reliably detected are those of high amplitude and slow propagation velocity; (real vs false amplitude: 138 vs 29 (+/12 SEM) mmHg; real vs false velocity: 5 vs 20 (+/3 SEM) mm/s). Conclusions: 1) Inadequate proximity between recording sites (resolution) results in both missed and mis-labeling of colonic propagating sequences. 2) An inter-recording site distance . 5cm grossly misrepresents colonic manometric patterns. 3) High resolution colonic manometry is likely to assist in the identification of diagnostically relevant manometric markers of colonic motor disorders. Supported by NHMRC and CSIRO Australia (1) Dinning PG et al. Br J Surg. 99: 1002-1010.

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Comparison of results from a randomized trial 1 year after laparoscopic Nissen and Toupet fundoplications

The fundoplication of choice for the surgical treatment of gastroesophageal reflux disease (GERD) still is debated. Multichannel intraluminal impedance monitoring (MII) has not been used to compare objective data, and comparative subjective data on laparoscopic Nissen and Toupet fundoplications are scarce. This study randomly allocated 125 patients with documented chronic GERD to either laparoscopic floppy Nissen fundoplication (LNF; n = 62) or laparoscopic Toupet fundoplication (LTF; n = 63). The Gastrointestinal Quality of Life Index (GIQLI), symptom grading, esophageal manometry, and MII data were documented preoperatively and 1 year after surgery. The pre- and postprocedure data were compared. Statistical significance was set at a p value lower than 0.01 (NCT01321294). Both procedures resulted in significantly improved GIQLI and GERD symptoms. Preoperative dysphagia improved in both groups, but the improvement reached significance only in the LTF group. The ability to belch was shown to be significantly more decreased after LNF than after LTF. Gas-bloat and "atypical" extraesophageal symptoms also were decreased after surgery (p < 0.01). However, bowel symptoms were virtually unchanged in both groups. Both procedures resulted in significantly improved lower esophageal sphincter pressures. The improvement was greater in the LNF group than in the LTF group (p < 0.01). The DeMeester score and the numbers of total, acid, proximal, upright, and recumbent reflux episodes decreased in both groups after surgery (p < 0.01). No significant difference between the procedures in terms of MII data was found. Six patients (4.8 %) had to undergo reoperation because of intrathoracic slipping of the wrap. All the patients had undergone LNF. Both procedures proved to be equally effective in improving quality of life and GERD symptoms. However, the reoperation and dysphagia rates were lower and the ability to belch was higher after LTF than after LNF.

Classification of normal and abnormal colonic motility based on cross‐correlations of pancolonic manometry data

Manual analysis of data acquired from manometric studies of colonic motility is laborious, subject to laboratory bias and not specific enough to differentiate all patients from control subjects. Utilizing a cross-correlation technique, we have developed an automated analysis technique that can reliably differentiate the motor patterns of patients with slow transit constipation (STC) from those recorded in healthy controls. Pancolonic manometric data were recorded from 17 patients with STC and 14 healthy controls. The automated analysis involved calculation of an indicator value derived from cross-correlations calculated between adjacent recording sites in a manometric trace. The automated technique was conducted on blinded real data sets (observed) and then to determine the likelihood of positive indicator values occurring by chance, the channel number within each individual data set were randomized (expected) and reanalyzed. In controls, the observed indicator value (3.2 ± 1.4) was significantly greater than that predicted by chance (0.8 ± 1.5; P < 0.0001). In patients, the observed indicator value (-2.7 ± 1.8) did not differ from that predicted by chance (-3.5 ± 1.6; P = 0.1). The indicator value for controls differed significantly from that of patients (P < 0.0001), with all individual patients falling outside of the range of indicator values for controls. Automated analysis of colonic manometry data using cross-correlation separated all patients from controls. This automated technique indicates that the contractile motor patterns in STC patients differ from those recorded in healthy controls. The analytical technique may represent a means for defining subtypes of constipation.

Physiological and pharmacological properties of a modified Brooke ileostomy: justification for retaining the most distal ileum

The traditional Brooke ileostomy removed the last 8-15 cm of the ileum due to concern of occurrence of terminal ileal Crohn's disease, vide infra the ileocolic sphincter was removed. Retaining all the terminal ileum has the potential of retaining the ileocolic sphincter. Our aim was to investigate whether a high-pressure zone existed within the last few centimetres of the ileum and its response to pharmacological stimuli. A balloon manometry catheter was introduced into the stoma of 16 patients who had formation of an end ileostomy (ileocolic sphincter retained, ICS). Recordings were made at 1 cm intervals from the meatus in order to identify the maximum intra-luminal resting and intra-abdominal pressure. At the point of maximum resting pressure, the response to phenylephrine (10% gel) and glyceryl trinitrate (GTN) (0.2% paste) was recorded. Results were recorded using an Ohmeda Oestiva 5 manometry system (in millimeter of mercury) and data were analysed using ANOVA. Results were compared with 13 historical controls (ileocolic sphincter removed). There was no significant difference in resting intra-abdominal pressure between the two groups (historical controls 8.5 ± 3.0 mmHg; ICS 9.0 ± 3.2 mmHg), p = NS. The maximum resting intra-luminal pressure in ICS patients exceeded historical controls 16 ± 2.9 vs 10.0 ± 2.5 mmHg, p < 0.001. In ICS patients, phenylephrine increased the resting pressure to 26.0 ± 3.5 mmHg, p < 0.001. In historical controls, the pressure remained unchanged, 12 ± 4.7 mmHg, p = NS. Subsequent addition of GTN to both groups lowered maximum intra-luminal pressure to pre-study values, 10 ± 4.2 mmHg (ICS) and 7 ± 3.5 mmHg (controls), p = NS. Retention of the ileocolic sphincter in a modified Brooke ileostomy preserves a physiological high-pressure zone, the properties of which can be modified by pharmacological agents.

Outcomes of Treatment for Achalasia Depend on Manometric Subtype

Patients with achalasia are treated with either pneumatic dilation (PD) or laparoscopic Heller myotomy (LHM), which have comparable rates of success. We evaluated whether manometric subtype was associated with response to treatment in a large population of patients treated with either PD or LHM (the European achalasia trial). Esophageal pretreatment manometry data were collected from 176 patients who participated in the European achalasia trial. Symptoms (weight loss, dysphagia, retrosternal pain, and regurgitation) were assessed using the Eckardt score; treatment was considered successful if the Eckardt score was 3 or less. Manometric tracings were classified according to the 3 Chicago subtypes. Forty-four patients had achalasia type I (25%), 114 patients had achalasia type II (65%), and 18 patients had achalasia type III (10%). After a minimum follow-up period of 2 years, success rates were significantly higher among patients with type II achalasia (96%) than type I achalasia (81%; P < .01, log-rank test) or type III achalasia (66%; P < .001, log-rank test). The success rate of PD was significantly higher than that of LHM for patients with type II achalasia (100% vs 93%; P < .05), but LHM had a higher success rate than PD for patients with type III achalasia (86% vs 40%; P = .12, difference was not statistically significant because of the small number of patients). For type I achalasia, LHM and PD had similar rates of success (81% vs 85%; P = .84). A higher percentage of patients with type II achalasia (based on manometric tracings) are treated successfully with PD or LHM than patients with types I and III achalasia. Success rates in type II are high for both treatment groups but significantly higher in the PD group. Patients with type III can probably best be treated by LHM. Trialregister.nl number NTR37; ISRCTN56304564.

Impaired Esophageal Bolus Transit in Patients with Gastroesophageal Reflux Disease and Abnormal Esophageal Acid Exposure

Background/AimsWe assessed the bolus transit and motility characteristics in gastroesophageal reflux disease (GERD) patients with abnormal esophageal pH monitoring.MethodsWe retrospectively reviewed the combined impedance-esophageal manometry data from consecutive patients who had abnormal acid exposure during 24-hour esophageal pH monitoring. We compared these data to the results from functional heartburn (FH) and asymptomatic volunteers.ResultsThe data from 33 GERD patients (mean age of 51 years, 18 males), 14 FH patients (mean age of 51 years, one male), and 20 asymptomatic volunteers (mean age of 27 years, nine males) were analyzed. Ineffective esophageal motility was diagnosed in 10% of the volunteers, 21% of the FH patients, and 15% of the GERD patients. Ineffective contraction was more frequent in GERD and FH patients than in volunteers (16% and 20% vs 6%, respectively; p<0.05). Additionally, 10% of the volunteers, 21% of the FH patients and 36% of the GERD patients had an abnormal bolus transit. Complete bolus transit was less frequent, and bolus transit was slower in GERD patients than in volunteers for liquid (70% vs 85%) and viscous swallows (57% vs 73%). A longer acid clearance time was associated with abnormal bolus transit in the GERD group.ConclusionsPatients with GERD have mild peristaltic dysfunction and incomplete and slower esophageal bolus transit. These conditions predispose them to prolonged acid contact with the esophagus.

Correlation of Rectal Balloon Expulsion Test Between Seated and Supine Position

Purpose: Defecatory disorders are diagnosed by rectal balloon expulsion (BE) and anorectal manometry, which are traditionally evaluated in the seated and left lateral (LL) positions respectively. This may explain the observed limited correlation between rectoanal gradient (manometry) and balloon expulsion. Hence, our aims were to compare manometry with BE in the LL and seated positions. Methods: Sixty-two healthy women and 158 women with Rome II criteria for chronic constipation were included in the study. Balloon expulsion was assessed in seated (time needed to expel the balloon: normal - ≤60 s, abnormal - >60 s) and left lateral (additional traction weight needed to expel the balloon: normal - ≤100 g, abnormal - >100 g) positions. Based on BE, patients were classified into four groups: normal in both positions, abnormal in left lateral position only, abnormal in seated position only and abnormal in both positions. Anorectal pressures (rest, squeeze, and simulated evacuation (SE)) were measured by high resolution manometry (HRM). Demographic, manometry and clinical data was compared using chi-square and t-tests. Multivariable logistic regression was used to assess predictors of balloon expulsion in both positions. Results: BE performed in seated and left lateral positions was concordant in 173 subjects (normal in both positions - 141, abnormal in both positions - 32), and discordant in 47 subjects (abnormal only in left lateral position - 30, abnormal only in seated position - 17). There was modest agreement (κ=0.43 [95% CI 0.30-0.57]) between seated and left lateral BE. Age, BMI, anal resting and squeeze pressure, length of anal sphincter and squeeze duration were not significantly different among groups (Table). However, compared to subjects with normal BE in both positions, anal relaxation during simulated evacuation (SE) was lower, anal pressure during SE was higher, and the rectoanal gradient during SE was more negative in the 3 other categories; these variables were all associated (p ≤ 0.0004) with group status. High anal pressure during SE (OR1.02, 95% CI 1.00-1.04) and high rectal sensory threshold for desire to defecate (OR1.01, 95% CI 1.00-1.02) were associated with increased risk of abnormal BE in both positions, whereas high rectal pressure during SE (OR 0.96, 95% CI 0.93 - 0.98) was associated with lower risk.Table: [1720] Comparison of Symptoms and Anorectal Parameters among GroupsConclusion: This case-control study demonstrates modest agreement between rectal balloon expulsion in the left lateral and seated positions. In addition to abnormal seated BE, which is considered indicative of pelvic floor dysfunction, HRM findings suggest that even some patients with abnormal BE in the left lateral position have pelvic floor dysfunction.

The Chicago classification for achalasia in a French multicentric cohort

BackgroundAchalasia is divided into 3 subtypes using the Chicago classification for high-resolution manometry. Aim of this study was to apply this classification to a multicentric French cohort of achalasia and to compare clinical and manometric characteristics between the 3 subtypes. MethodsOesophageal symptoms were collected in a retrospective study of patients diagnosed with achalasia on high-resolution manometry. Manometry data were analyzed with oesophago–gastric junction resting and relaxation pressures, and upper oesophageal sphincter resting pressure. Achalasia was classified according to the Chicago classification. ResultsFrom 2007 to August 2011, achalasia was diagnosed in 169 patients, 14% classified as type I, 70% as type II and 16% as type III. Type III patients were older than types I and II (62 years vs. 52, p=0.03). Ninety five percent of patients complained of dysphagia, 16% of chest pain (no difference between the 3 subtypes); 50% of type I patients presented regurgitations compared to 33% of type II and 22% of type III (p=0.10). Oesophago–gastric junction and upper oesophageal sphincter pressures did not differ between the 3 groups. ConclusionType II was the more prevalent subtype of achalasia in this French multicentre cohort. The older age of patients with type III achalasia suggests a different pathophysiology.

Laparoscopic Nissen versus Toupet fundoplication: objective and subjective results of a prospective randomized trial

Although symptom outcomes following laparoscopic fundoplication have been adequately evaluated in the past, comparative subjective data of laparoscopic Nissen and Toupet fundoplications are scarce. Multichannel intraluminal impedance monitoring (MII) has not been used so far for comparison of objective data. One hundred patients with documented chronic gastroesophageal reflux disease (GERD) were randomly allocated to either floppy Nissen fundoplication (group I, n = 50) or Toupet fundoplication (group II, n = 50). Gastrointestinal Quality of Life Index (GIQLI), symptom grading, esophageal manometry, and MII data were documented preoperatively and 3 months after surgery. Subjective and objective outcome data were compared to those of healthy individuals. Symptom intensity was significantly more severe and GIQLI showed impairment in the examined patient population compared to healthy controls. Both procedures resulted in a significant improvement in GIQLI and GERD symptoms (p < 0.01). Dysphagia improved significantly only in group II, while cough, asthma, and distortion of taste improved significantly in both groups. Hoarseness symptoms showed some degree of improvement in both groups but reached statistical significance only in group I. Postoperatively, bowel symptoms partly increased and the ability to belch decreased in both groups (p < 0.05). Comparison of postoperative GIQLI and symptom scores showed no significant difference between the two groups, except for the ability to belch, which was more impaired after Nissen fundoplication. Both procedures resulted in a significant improvement in lower esophageal sphincter (LES) pressure; however, the improvement was greater in group I than in group II. MII data showed more reflux control after Nissen, but the differences between the procedures were not significant. Both procedures equally improve quality of life and GERD symptoms. Bowel symptoms may increase after both procedures at the 3-month follow-up. Manometry and MII data favor Nissen fundoplication, but dysphagia and the inability to belch are more common compared to Toupet fundoplication.

Influence of the esophageal hiatus size on the lower esophageal sphincter, on reflux activity and on symptomatology

Hiatal hernia is an underlying factor contributing to gastroesophageal reflux disease (GERD). However, it remains elusive whether the size of the esophageal hiatus has a de facto influence on the lower esophageal sphincter (LES), on the intensity of patient reflux, on GERD symptoms and on the quality of life (QoL). One hundred patients with documented chronic GERD underwent laparoscopic fundoplication. QoL was evaluated before surgery using the Gastrointestinal Quality of Life Index (GIQLI). Additionally, GERD symptoms and nonspecific gastrointestinal symptoms were documented using a standardized questionnaire (score 0-224). The size of the esophageal hiatus was measured during surgery by calculating the hiatal surface area (HSA). Correlation analysis between the preoperative QoL, GERD symptoms, esophageal manometry, multichannel intraluminal impedance monitoring data and HSA size was performed, in order to investigate whether the HSA has an influence on the patients'symptoms, GIQLI, manometry and multichannel intraluminal impedance monitoring data. Statistical significance was set at a P-value of 0.05. The HSA sizes ranged from 1.51cm(2) to 16.09cm(2) (mean 4.14cm(2) ). The preoperative GIQLI ranged from 15 points to 133 points (mean 94.37 points). Symptom scores ranged from 2 points to 192 points (mean 49.84 points). No significant influence of the HSA on GIQLI or preoperative symptoms was recorded. HSA size had a significant negative effect on LES pressure. Additionally, there was a significant positive correlation between HSA size and number of refluxes in supine position. For the rest of the evaluated data, including DeMeester score, total number of refluxes, refluxes in upright position, acid reflux events, proximal reflux events, LES length and body motility, no significant correlation was found. Although patients subjectively are not significantly affected by the size of the hiatus, it has significant effects on the LES pressure and on gastroesopageal reflux in supine position.

Effectiveness of Biofeedback Therapy in the Treatment of Anterior Resection Syndrome After Rectal Cancer Surgery

Although anterior resection syndrome commonly occurs after anal sphincter-saving surgery, no standard treatment option is currently available. The aim of the present study was to evaluate the clinical effectiveness of biofeedback in patients with anterior resection syndrome after sphincter-saving surgery for rectal cancer. This study was a retrospective review of data collected during the course of treatment. Patients were treated at a teaching hospital (Asan Medical Center) in Seoul, Korea, from January 2003 through December 2008. Patients who received biofeedback therapy for anterior resection syndrome after rectal cancer surgery were included. The Cleveland Clinic Florida fecal incontinence score, number of bowel movements per day, a visual analog scale for assessing patient satisfaction, and anorectal manometry were used to assess outcome of biofeedback treatment. : After biofeedback therapy, significant improvements were observed in fecal incontinence score (P < .001), number of bowel movements (P < .001), and anorectal manometry data (maximum resting pressure, P = .010; maximum squeeze pressure, P = .006; rectal capacity, P = .003). Compared with patients who started biofeedback treatment less than 18 months after surgery, those who started biofeedback at 18 months or longer after surgery showed greater improvements in fecal incontinence score (P = .032). Only patients with fecal incontinence as the primary symptom showed significant improvements in all variables, including fecal incontinence score, P < .001; defecation frequency, P < .001; and anorectal manometry (maximum resting pressure, P = .027; maximum squeeze pressure, P = .021; rectal capacity, P = .004). Patients who received radiation therapy in addition to surgery reported a significantly higher satisfaction score than those receiving surgery alone (P = .041). This is a nonrandomized retrospective study. Anorectal manometry was not regularly performed in all patients. Biofeedback therapy produced significant clinical benefits for patients with severe fecal incontinence and may be an effective treatment for patients with anterior resection syndrome after surgery for rectal cancer.

Esophageal motor abnormalities in eosinophilic esophagitis identified by high‐resolution manometry

Esophageal motility abnormalities, as measured by conventional manometry (CM), are non-specific in the majority of patients with eosinophilic esophagitis (EoE). Moreover, the study of CM is limited by poor interobserver agreement. The aims of the present study were: (i) to assess the esophageal patterns in EoE by a topographic analysis of high-resolution manometry (HRM) data; and (ii) to establish a relationship between motility abnormalities and symptoms of EoE, such as dysphagia and bolus impaction. All adult patients with EoE diagnosed according to histological criteria, and controls with gastroesophageal reflux disease symptoms and dysphagia, were included. HRM was done in EoE patients and controls. For the analysis of data, the Chicago classification was followed. HRM was performed in 21 patients with EoE, as well as in 21 controls. Of the 21 patients with EoE, 10 (48%) showed pan-esophageal pressurization, six (28%) showed peristaltic dysfunction, and in five cases (24%), HRM was normal. There was no pan-esophageal pressurization in controls. Nine of 10 patients with pan-esophageal pressurization required endoscopic bolus removal (P < 0.05); none had obstructive endoscopy findings. The most frequent esophageal motor abnormality measured by HRM was a pan-esophageal pressurization. Bolus impaction in patients with EoE was associated with pan-esophageal pressurization.

Robotic-assisted Heller myotomy for esophageal achalasia: feasibility, technique, and short-term outcomes.

Laparoscopic Heller myotomy is the standard surgical treatment for esophageal achalasia. The incidence of esophageal perforation is about 5-10%. Robotic-assisted Heller myotomy (RAHM) offers results at least as good as those from laparoscopic procedures, additionally yielding fewer intraoperative complications. The aim of this study was to demonstrate the safety and feasibility of RAHM and its value in the treatment of esophageal achalasia. We analyzed demographics, preoperative symptoms, esophagograms, esophageal manometry, intraoperative and postoperative data of all the patients who underwent RAHM for achalasia at three institutions: 36 women and 37 men, mean age 45±16 (13-87) years. Dysphagia was present in 100% of patients. Thirty-three patients (45%) had had previous endoscopic treatment: 23 patients had pneumatic dilation, four patients had Botox injections, and six patients had both. Surgical time averaged 119min (range of 62-211); blood loss averaged 23ml; no mucosal perforations were observed; length of hospitalization was 1.5days; there were no deaths. At 12months, 96% of patients had relief of their dysphagia. In conclusion, RAHM is safe and effective since there were no intraoperative esophageal perforations and relief of symptoms was achieved in 96% of the patients.

Anatomical registration and three-dimensional visualization of low and high-resolution pan-colonic manometry recordings.

Colonic propagating sequences (PS) are important for the movement of colonic content and defecation, and aberrant PS patterning has been associated with slow transit constipation. However, because these motor patterns are typically recorded over long periods (24 h +), the visualization of PS spatiotemporal patterning is difficult. Here, we develop a novel method for displaying pan-colonic motility patterns. A 3D mesh representing the geometry of the human colon was created as follows: (i) Human colon images from the Visible Human Dataset were digitized to create a 3D data cloud, and (ii) A surface mesh was fitted to the cloud using a least-squares minimization technique. Colonic manometry catheters were placed in the ascending colon of healthy controls and patients with slow transit constipation (STC), with the aid of a colonoscope. The colonic manometry data were interpolated and mapped to the model according to the following anatomical landmarks: cecum, hepatic flexure, splenic flexure, sigmoid-descending junction, and anus. These 3D images clearly and intuitively communicate characteristics of normal and abnormal colonic motility. Specifically we have shown the reduced amplitude of the antegrade propagating pressure waves (PPW) throughout the colon and reduced frequency of PPWs at the mid-colon in patients with STC. A novel method for the 3D visualization of PS is presented, providing an intuitive method for representing a large volume of physiological data. These techniques can be used to display frequency, amplitude or velocity data, and will help to convey regions of abnormally in patient populations.