Mean Lower Esophageal Sphincter Research Articles

Clinical outcomes and manometry results of peroral endoscopic myotomy in patients with achalasia: experience in a Latin American referral centre

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

Manometric profile of patients presented with dysphagia – A hospital-based descriptive study

Objectives: The prevalence of dysphagia is 16–22%. Achalasia is characterised by impaired relaxation of the lower oesophageal sphincter (LES) and absent oesophageal peristalsis. Minimally invasive procedures, endoscopic pneumatic balloon dilatation (PD) and peroral endoscopic myotomy (POEM) are treatments of choice. We aimed to assess the manometric profile of patients presented with dysphagia and pre- and post-LES pressure and integrated relaxation pressure (IRP) of patients who underwent PD and POEM. Materials and Methods: One hundred and twenty-nine patients presented with dysphagia underwent high resolution oesophageal manometry (HREM). Manometric parameters: IRP, LES and pattern of motility were noted. According to Chicago classification 4.0, those who are diagnosed with achalasia underwent PD (17) and POEM (15). Statistical analysis was performed using the Statistical Package for the Social Sciences version 28. Pre- and post-procedure values (IRP and basal LES) were compared using the Wilcoxon signed-rank test. Results: Out of 129 patients with dysphagia, 57 had increased IRP and 75 had simultaneous motility. The mean LES pressure and IRP were found to be 28 ± 19.82 and 17 ± 14.04 mmHg, respectively. On analysis, of patients who underwent procedures PD (17) and POEM (15), a statistically significant decrease in IRP was observed in patients with post POEM compared to post PD status (P = 0.005 and 0.017, respectively). Reduced basal LES pressure was observed in patients with post-POEM status compared to post-PD status, which was not statistically significant. Conclusion: About 44% of patients presented with dysphagia were diagnosed with achalasia cardia. POEM procedure was found to be more effective compared to pneumatic dilatation.

Automatic three-dimensional reconstruction of the oesophagus in achalasia patients undergoing POEM: an innovative approach for evaluating treatment outcomes

Background and aimsPeroral endoscopic myotomy (POEM) is a standard treatment option for achalasia patients. Treatment response varies due to factors such as achalasia type, degree of dilatation, pressure and distensibility...

The Impact of Chronic Cannabis Use on Esophageal Motility in Patients Referred for Esophageal Manometry.

Tetrahydrocannabinol, the main psychoactive compound in cannabis, binds with high affinity to the cannabinoid 1 receptor. Small randomized controlled studies using conventional manometry have shown that the cannabinoid 1 receptor can modulate esophageal function, namely transient lower esophageal sphincter relaxation frequency and lower esophageal sphincter tone. The effect of cannabinoids on esophageal motility in patients referred for esophageal manometry has not been fully elucidated using high-resolution esophageal manometry (HREM). We aimed to characterize the clinical effect of chronic cannabis use on esophageal motility utilizing HREM. Patients who underwent HREM from 2009 to 2019 were identified at 4 academic medical centers. The study group consisted of patients with a noted history of chronic cannabis use, a diagnosis of cannabis-related disorder, or a positive urine toxicology screen. Age and gender-matched patients with no history of cannabis use were selected to form the control group. Data on HREM metrics based on the Chicago classification V3, and the prevalence of esophageal motility disorders were compared. Confounding effects of BMI and medications on esophageal motility were adjusted for. Chronic cannabis use was found to be an independent negative predictor of weak swallows (β=-8.02, P =0.0109), but not a predictor of failed swallows ( P =0.6890). The prevalence of ineffective esophageal motility was significantly lower in chronic cannabis users compared with nonusers (OR=0.44, 95% CI 0.19-0.93, P =0.0384). There was no significant difference in the prevalence of other esophageal motility disorders between the 2 cohorts. In patients with dysphagia as their primary indication for HREM, chronic cannabis use was found to be independently associated with increased median integrated relaxation pressure (β=6.638, P =0.0153) and increased mean lower esophageal sphincter resting pressure (β=10.38, P =0.0084). Chronic cannabis use is associated with decreased weak swallows and reduced prevalence of ineffective esophageal motility in patients referred for esophageal manometry. In patients referred for dysphagia, chronic cannabis use is associated with increased integrated relaxation pressure and lower esophageal sphincter resting pressure, though not to levels above the normal range.

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

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

Laparoscopic Heller myotomy versus peroral endoscopic myotomy in children with esophageal achalasia: a systematic review and meta-analysis.

Currently, laparoscopic Heller myotomy (LHM) and peroral endoscopic myotomy (POEM) are the best treatment modalities for esophageal achalasia in children. The purpose of this systematic review and meta-analysis is to compare the efficacy of LHM and POEM. A systematic literature search was performed in PubMed/Medline, Google Scholar and Web of Science for original articles comparing LHM and POEM. All articles were analyzed with respect to operation duration, length of hospital stay, pre- and postoperative Eckardt score (ES), and pre- and postoperative lower esophageal sphincter (LES) pressure. A total of 32 articles, reporting on 800 children, were selected and reviewed. Because of missing diagnostic values of ES and LES in the LHM group, the meta-analysis was limited to the POEM results. According to the random-effects model, the mean ES difference between pre- and post-operation was 4.387 (95% confidence interval [CI] 3.799-4.974), significantly different to zero (z=14.64, P<0.001), while the mean LES pressure difference was 3.63 mmHg mmHg (95%CI 2247-3.879), significantly different to zero (z=7.36, P<0.001). Operation duration was 130.15 min (95%CI 62.59-197.71) for the LHM method and 83.64 min (95%CI 55.14-112.14) for POEM. The pooled estimate of length of hospital stay was 3.4 days (95%CI 2.6-4.44) and it was comparable between the 2 methods. POEM has positive outcomes regarding ES and LES pressure pre- and postoperatively, as well as operation duration, while the length of hospitalization was comparable between POEM and LHM. Well-designed studies are warranted to further clarify differences between the 2 methods.

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.

Comparing Patients Diagnosed With Ineffective Esophageal Motility by the Chicago Classification Version 3.0 and Version 4.0 Criteria.

The Chicago Classification version 4.0 (CCv4.0) of ineffective esophageal motility (IEM) is more stringent than the Chicago Classification version 3.0 (CCv3.0) definition. We aimed to compare the clinical and manometric features of patients meeting CCv4.0 IEM criteria (group 1) versus patients meeting CCv3.0 IEM but not CCv4.0 criteria (group 2). We collected retrospective clinical, manometric, endoscopic, and radiographic data on 174 adults diagnosed with IEM from 2011 to 2019. Complete bolus clearance was defined as evidence of exit of the bolus by impedance measurement at all distal recording sites. Barium studies included barium swallow, modified barium swallow, and barium upper gastrointestinal series studies, and collected data from these reports include abnormal motility and delay in the passage of liquid barium or barium tablet. These data along with other clinical and manometric data were analyzed using comparison and correlation tests. All records were reviewed for repeated studies and the stability of the manometric diagnoses. Most demographic and clinical variables were not different between the groups. A lower mean lower esophageal sphincter pressure was correlated with greater percent of ineffective swallows in group 1 (n = 128) (r = -0.2495, P = 0.0050) and not in group 2. In group 1, increased percent of failed contractions on manometry was associated with increased incomplete bolus clearance (r = 0.3689, P = 0.0001). No such association was observed in group 2. A lower median integrated relaxation pressure was correlated with greater percent of ineffective contractions in group 1 (r = -0.1825, P = 0.0407) and not group 2. Symptom of dysphagia was more prevalent (51.6% versus 69.6%, P = 0.0347) in group 2. Dysphagia was not associated with intrabolus pressure, bolus clearance, barium delay, or weak or failed contractions in either group. In the small number of subjects with repeated studies, a CCv4.0 diagnosis appeared more stable over time. CCv4.0 IEM was associated with worse esophageal function indicated by reduced bolus clearance. Most other features studied did not differ. Symptom presentation cannot predict if patients are likely to have IEM by CCv4.0. Dysphagia was not associated with worse motility, suggesting it may not be primarily dependent on bolus transit.

Esophageal Manometry and pHmetry Profile in Obese Patients Selected for Bariatric Surgery

Background: Obesity is a highly prevalent disease and risk factor for gastroesophageal reflux disease (GERD) which could predispose to esophageal motility disorders. Few studies exist regarding manometric and phmetric findings in patients with obesity who are candidates to bariatric surgery. The objective was to describe the preoperative profile of patients with obesity selected for bariatric surgery. Methods: Retrospective analysis of 338 patients with obesity, subjected to 24 hour-pHmetry with impedance and manometry prior to bariatric surgery between 2006 and 2021. Descriptive and analytical statistics were used for analysis. Results: The mean age and body mass index was 41.94 ± 0.70 years and 38.75 ± 0.37 kg/m2, respectively. GERD symptoms were present in 43.3% (139/321). A 24-hour pHmetry analysis showed a pathologic DeMeester index in 46.7% of patients, of which 64.3% (63/98) were symptomatic. Impedance was abnormal in 53.4%, of which 67% (73/109) were symptomatic. Manometry registered dysmotility in 22.7% (69/304) of patients, a mean lower esophageal sphincter (LES) pressure of 11.93 ± 0.43 mmHg and hypotensive LES in 38.5%. Mean gastric pressure was 9.79 ± 0.33 mmHg after deglutition and only 11.4% (34/299) presented abnormal gastroesophageal gradients. Conclusions: There is a high prevalence of dysmotility and GERD in candidates to bariatric surgery with obesity. Esophageal 24 hour-pHmetry with impedance and manometry should be considered within preoperative tests as pathologic results could guide appropriate procedure selection, at least in symptomatic patients.

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

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

The Impact of Magnetic Sphincter Augmentation (MSA) on Esophagogastric Junction (EGJ) and Esophageal Body Physiology and Manometric Characteristics.

To evaluate the impact of MSA on lower esophageal sphincter (LES) and esophageal body using high resolution impedance manometry. MSA is an effective treatment in patients with gastroesophageal reflux disease, but there is limited data on its impact on esophageal functional physiology. Patients who underwent MSA were approached 1-year after surgery for objective foregut testing consists of upper endoscopy, esophagram, high resolution impedance manometry, and esophageal pH-monitoring. Postoperative data were then compared to the preoperative measurements. A total of 100 patients were included in this study. At a mean follow up of 14.9(10.1) months, 72% had normalization of esophageal acid exposure. MSA resulted in an increase in mean LES resting pressure [29.3(12.9) vs 25(12.3), P < 0.001]. This was also true for LES overall length [2.9(0.6) vs 2.6(0.6), P = 0.02] and intra-abdominal length [1.2(0.7) vs 0.8(0.8), P < 0.001]. Outflow resistance at the EGJ increased after MSA as demonstrated by elevation in intrabolus pressure (19.6 vs 13.5 mmHg, P < 0.001) and integrated relaxation pressure (13.5 vs 7.2, P < 0.001). MSA was also associated with an increase in distal esophageal body contraction amplitude [103.8(45.4) vs 94.1(39.1), P = 0.015] and distal contractile integral [2647.1(2064.4) vs 2099.7(1656.1), P < 0.001]. The percent peristalsis and incomplete bolus clearance remained unchanged ( P = 0.47 and 0.08, respectively). MSA results in improvement in the LES manometric characteristics. Although the device results in an increased outflow resistance at the EGJ, the compensatory increase in the force of esophageal contraction will result in unaltered esophageal peristaltic progression and bolus clearance.

Comparison of Treatment Response in Different Types of Achalasia: A Long-Term Study.

BACKGROUND Three manometric patterns are seen in high-resolution manometry (HRM). Response to treatment has been reported to be different in these subtypes. We aimed to investigate the frequency and response to treatment in subtypes of achalasia. METHODS 306 patients between 15 to 60 years old, naïve to treatment with idiopathic achalasia (IA) were evaluated prospectively in a cohort study for 8 years. The patients were treated with pneumatic balloon dilation (PBD), and evaluated before and one month after PBD with Achalasia Symptom Score (ASS) and timed barium esophagogram (TBE) and then every 6 months with ASS. The primary study outcome was defined as a reduction in ASS (equal to or less than 4) and a reduction greater than 80% in the volume of barium in TBE at 1 month after PBD compared with baseline values. RESULTS According to HRM, 57 were classified as type I (18.62%), 223 as type II (72.9%), and 26 as type III (8.5%). The mean lower esophageal sphincter (LES) residual pressures before treatment were 34.05 ± 31.55, 32.99 ± 17.90, and 37.47 ± 14.07 mmHg in types I, II, and III, respectively (p = 0.18). The mean ASS values before treatment were 12.23, 11.50, and 11.50, for types I, II, and III, respectively (p = 0.29). The ASS dropped to 2.50 in type I, 2.40 in type II, and 2.12 in type III at 1 month after treatment (p = 0.83). Eventually, at the end of follow-up, 24 patients with type I (83%), 82 patients with type II (67%), and five patients with type III (83%) showed sustained good responses (p = 0.528). CONCLUSION Manometric subtypes of achalasia did not have an important role in clinical success in the long term. Achalasia has no definite cure, but with current treatment modalities, palliation of symptoms is possible in over 90% of patients.

The level of impaired esophageal bolus transit measured by multichannel intraluminal impedance: Cross-sectional study

BackgroundEsophageal motility disorders (EMDs) are often diagnosed manometrically, yet the underlying pathology is not always clear. Esophageal function testing (EFT), which incorporates manometry and multichannel intraluminal impedance (MII), is considered a useful tool in the assessment of EMDs. ObjectiveThis study aims to assess the most likely level of impaired bolus transit within the esophagus which may help further localize and characterize EMDs. MethodsIn a retrospective study design, we reviewed consecutive EFTs over a period of 12 months. Data included diagnosis, presenting symptoms, and EFT results of liquid and viscous swallows. Each patient underwent 10 liquid and 10 viscous swallows, and bolus transit is measured at 5, 10, 15 and 20 cm above the gastroesophageal junction (GEJ). We recorded the initial level of impaired bolus transit for each swallow. ResultsA total of 2358 swallows in 118 patients was included for analysis. Of these, 837 swallows (35.5%) were incompletely transmitted. The proportions of impaired bolus transit were 39%, 41%, 15.6%, 4.4% at 20 cm, 15 cm, 10 cm, and 5 cm above the GEJ, respectively. The common symptoms at presentation were dysphagia (47%), heartburn (44%), chest pain (24.6%) and regurgitation (18%). The mean lower esophageal sphincter (LES) pressure was 24 ± 13.9 mmHg whereas the mean contraction amplitude was 84 ± 46.6 mmHg. ConclusionIn patients with abnormal esophageal clearance, the most likely levels of impaired bolus transit are 15 and 20 cm above the GEJ. These levels of the esophagus should be a focus of attention in future studies evaluating the pathophysiology of esophageal dysmotility.

A233 AGING AND ESOPHAGEAL MOTILITY: A HIGH-RESOLUTION MANOMETRY STUDY

Abstract Background Studies have found possible physiologic changes to esophageal motility with aging that are not currently taken into account in routine high-definition esophageal manometry (HDEM) interpretation. Aims We aimed to quantify the relationship between these physiologic changes and aging to improve HDEM interpretation. Methods We conducted a retrospective analysis of medical records for all patients who underwent HDEM at a tertiary hospital center between January 2015 and December 2019. Inclusion criteria were patients ≥18 years with normal HDEM. Exclusion criteria were abnormal HDEM; abnormal upper digestive endoscopy or imagery. Outcomes were median integrated relaxation pressure (IRP); mean lower esophageal sphincter (LES) pressure; mean distal contractal integral (DCI); mean distal latency (DL); mean peristaltic break (PB) according to the v3.0 Chicago classification criteria. Data was extracted from electronic patient medical records into a database for analysis. Effect of age on outcomes was examined through univariate and multivariate linear regression analysis. Results We identified 1917 patients with HDEM and included 790 patients with normal exams [mean age 55.8 yrs (IQR 46 – 66), 64% female]. Indications for HDEM included dysphagia (41.3%); gastroesophageal reflux disease (29.2%); chest pain (11.0%); other (13.3%). There was a statistically significant relationship between age and IRP [Coef=0.08 (95%CI 0.05 – 0.1), p&amp;lt;0.001, R^2=0.04] as well as DCI [Coef=10.9 (95%CI 4.1 – 17.8), p=0.002, R^2=0.01] and DL [Coef=-0.01 (95%CI -0.02 – -0.002), p=0.01, R^2=0.008]. No statistically significant relationship was found between age and LES pressure [Coef=0.03 (95%CI -0.01 – 0.08), p=0.16] or PB [Coef=0.007 (95%CI -0.002 – 0.016), p=0.14]. Multivariate analysis showed statistically significant relationships between IRP and age (p&amp;lt;0.001), BMI (p=0.001), NSAID use (p=0.034), and female sex (p=0.048). Conclusions We found that IRP, DCI, and DL are significantly correlated with the normal aging process. Modifications could therefore be considered for normal diagnostic cutoffs for both age extremes to prevent over or under-diagnosis of motility disorders. Funding Agencies None

ANATOMIC DAMAGE OF THE LOWER ESOPHAGEAL SPHINCTER AFTER SUBTOTAL GASTRECTOMY.

ABSTRACT - BACKGROUND:Dysfunction of the lower esophageal sphincter (LES), gastroesophageal reflux disease, and erosive esophagitis in patients undergoing subtotal gastrectomy are commonly recognized occurrences, but until now the causes remain unclear.AIM: The hypothesis of this study is that subtotal gastrectomy provokes changes on the LES resting pressure and its competence, due to the anatomical damage of it, given that the oblique “Sling” fibers, one of the muscular components of the LES, are transected during this surgical procedure.METHODS: Seven adult mongrel dogs (18-30 kg) were anesthetized and admitted for transection of the proximal stomach. Later, the proximal gastric remnant was closed by a suture. Intraoperatively, slow pull-through LES manometries were performed on each dog, under basal conditions (with the intact stomach), and in the closed proximal gastric remnant. The mean of these measurements is presented, with each dog serving as its control.RESULTS: The mean LES pressure (LESP) measured in the proximal gastric remnant, compared with the LESP in the intact stomach, was decreased in five dogs, increased in one dog, and remained unchanged in other dogs.CONCLUSION: The upper transverse transection of the stomach and closing the stomach remnant by suture provoke changes in the LESP. We suggested that these changes in the LESP are secondary to transecting the oblique “Sling” fibers of the LES, one of its muscular components. The suture and closing of the proximal gastric remnant reanchor these fibers with more, less, or the same tension, whether or not modifying the LESP.

Magnet-assist endoscopic augmentation of the lower esophageal sphincter for treatment of gastroesophageal reflux disease: cadaveric and survival studies in a porcine model (with video).

Augmentation of the lower esophageal sphincter (LES) is the primary goal of both surgical and endoscopic therapies for gastroesophageal reflux disease (GERD). The feasibility, efficacy, safety, and reversibility of a newly developed endotherapy for GERD using intraluminal magnets referred to as a magnet closure device (MCD) were evaluated. This study involved nine cadaveric and six survival pigs. The MCD consisted of a ring neodymium magnet attached to a 2-0 polypropylene suture and suture anchor. The MCD was deployed onto the esophageal wall at the region of the LES using an endoscopic suturing device. Two to three MCDs were placed on opposing walls to induce closure of the esophageal lumen. LES pressures were measured using high-resolution manometry at the index procedure (baseline and immediately post-MCD placement) and at survival endoscopy. Endoscopic removal of the devices was performed followed by necropsy at week 2. MCDs were successfully deployed in all cadaveric (n = 22) and survival animals (n = 12). In cadavers, 20/22 (91%) sutures were full-thickness with no adjacent organ injury. In survival animals, mean LES pressure increased from 8.4mmHg (baseline) to 32.4mmHg immediately post-procedure (p < 0.01). No clinically significant adverse events occurred. Repeat endoscopy at two weeks showed intact MCDs in 4/6 (67%) animals with significant increase in median LES pressure (n = 4, 24.0mmHg versus 7.4mmHg [baseline], p < 0.05). Endoscopic removal of MCDs was successfully achieved. Endoscopic augmentation of the LES using a new MCD was feasible, safe and reversible with significantly increased LES pressures recorded. Future studies are needed to enhance durability. These preliminary results on a reversible technique are promising and may represent an attractive alternative to endoluminal GERD therapy.

The role of intraoperative endoscopic guidance during laparoscopic repair of esophageal achalasia

Purpose The aim was to assess the advantage of using intraoperative endoscopic guidance during laparoscopic repair of esophageal achalasia. Materials and methods This was a retrospective study conducted at Ain Shams Specialized Hospitals that included 84 patients. A total of 42 patients had Heller cardiomyotomy procedure with dor fundoplication and another 42 patients had the same procedure with intraoperative endoscopic guidance. Results Preoperative symptoms included dysphagia in 80 (95%) patients, regurgitation and vomiting in 60 (71.5%) patients, heartburn in 56 (66%) patients, and postprandial chest pain in 40 (49%) patients. Weight loss occurred in 42 (50%) patients. Overall, 72 (85%) patients had tried 2–3 pneumatic dilation. Mean lower esophageal sphincter pressure preoperatively was 33 and was 13.3 mmHg postoperatively (4.1–28.4). The operative time was 45±20 min in the endoscopic group and was 40±10 in the nonendoscopic guidance. Overall, 5 patients of the nonendoscopic group had perforation and one case of bleeding. Postoperatively, dysphagia was seen in one (2.25%) patient of the endoscopic group and four (9.5%) patients of the nonendoscopic group. Postprandial heart pain was seen in two (4.6%) patients of the endoscopic group and four (9.2%) patients of the nonendoscopic group. Moreover, 2 (4.6%) patients of the endoscopic group and four (9.5%) patients of the nonendoscopic group had postoperative regurgitation. Weight regain was seen in 19 (90%) patients of the endoscopic group and 17 (80%) patients of the patients of nonendoscopic group after 12-month follow-up. Conclusion Heller cardiomyotomy with endoscopic guidance is very important not only as a guide to ensure adequate myotomy but also to limit the extent of the myotomy, thereby minimizing the postoperative reflux symptoms.

S0421 Lower Esophageal Sphincter Pressures Are Significantly Reduced in Patients With a Hiatal Hernia but No Major Abnormality on Esophageal Manometry

INTRODUCTION: A hiatal hernia (HH) eliminates the normal alignment of the lower esophageal sphincter (LES) and crural diaphragm (CD), separating the two components of the esophago-gastric junction high pressure zone (EGJHPZ). This separation may affect parameters measured during high resolution esophageal manometry (HREM), including measurements of resting lower esophageal sphincter (LES) pressure. The effect of a HH on LES relaxation, as measured by integrated relaxation pressure (IRP), is less well studied. The aim of this study was to determine how a HH affects HREM parameters. METHODS: HREM performed at a large referral-based motility center between 2013 and 2019 were reviewed. Patients with any major/minor peristaltic disorder based on Chicago Classification version 3.0 (CC3), or where the catheter did not traverse the LES, were excluded. Key manometric parameters including LES resting pressure and IRP, distal contractile integral (DCI), contractile front velocity (CFV), distal latency (DL) and esophageal length were collected. Patients were further subdivided into 3 groups according to HH size on HREM for analysis: no HH, HH 0.1–1.9cm, and HH ≥ 2 cm. RESULTS: A total of 1330 HREM reports were reviewed, with 479 studies not showing a CC3 abnormality. These patients had no HH (189, 39.5%), HH 0.1–1.9 cm (172, 35.9%), and HH ≥ 2 cm (118, 24.6%) (Figure 1). Analysis demonstrated that the presence of a HH was associated with a significantly lower mean LES resting pressure, IRP, and DCI (all P-values < 0.02, Table 2). Esophageal length was consistently shorter in HH patients (P < 0.01). For all 3 parameters, values decreased as HH size increased. There was no statistical difference between groups with respect to CFV or DL. CONCLUSION: In patients without a CC3 peristaltic abnormality, HH patients show significant decreases in LES resting pressure, IRP, and esophageal length. Separating the CD from the EGJHPZ may be partially responsible for the drop in pressures. However, HREM analysis software is supposed to isolate the LES from any CD contribution. Additional investigation is necessary to determine whether and what HH-related changes to the LES itself are contributing to this significant difference, and if they affect related conditions such as gastro-esophageal reflux. Shorter esophageal length may impact the success of a HH repair. Further studies exploring the outcomes of different surgical approaches in varying esophageal lengths are warranted.Figure 1.: Study Flow Diagram.Table 1.: Baseline Demographic CharacteristicsTable 2.: High Resolution Esophageal Manometry Findings

Quantitative assessment of crural closure for laparoscopic anti-reflux surgeries: A novel technique to reduce post-operative dysphagia.

Background:Long-term dysphagia is a known complication of laparoscopic anti-reflux surgery (LARS). Of the several factors, inadequate hiatal closure is one of the major reasons for its occurrence. The aim of this study is to develop a technique for the quantitative assessment of crural closure during LARS to reduce dysphagia.Materials and Methods:It is an analysis of prospectively collected data of 109 patients who underwent LARS at a tertiary healthcare centre in India. To identify the adequacy of hiatal closure intraoperatively, a 7 French Fogarty catheter was used, and its balloon was inflated with 1 cc air at the repaired hiatus. This inflated balloon in the repaired hiatus following cruroplasty gives an accurate quantitative assessment of the adequate closure and adequate space for food bolus to pass without causing mechanical obstruction after hiatus repair. Pre- and post-operative 12 months’ DeMeester scores and lower oesophageal sphincter (LES) pressures were calculated.Results:The patients had a significant reduction in DeMeester scores postoperatively from a mean of 68.5–12.3 (P < 0.0001). None of the patients had long-term dysphagia or the need for long-term proton-pump inhibitors. The mean LES pressures on post-operative manometry showed increase to 15.1 mmHg from a mean of 6.4 mmHg, which was statistically significant (P = 0.0001). None of the patients had a recurrence of hiatus hernia.Conclusion:Quantitative assessment of adequacy for crural closure during LARS using a 7 French Fogarty catheter balloon is a novel technique which may decrease the incidence of post-operative dysphagia or intrathoracic wrap migration or recurrence of hiatus hernia.

Sa1262 A LARGE SINGLE-CENTER STUDY ON THE CLINICAL OUTCOMES OF PER-ORAL ENDOSCOPIC MYOTOMY FOR SIGMOID TYPE 2 ACHALASIA

Per-oral endoscopic myotomy (POEM) has been recognized as a safe and effective minimally-invasive endoscopic treatment for achalasia. Good clinical outcomes have been reported on the application of POEM in straight type achalasia. On the other hand, results of POEM in sigmoid type achalasia, especially sigmoid type 2, are limited. This study aims to report the clinical outcomes of POEM for sigmoid type 2 achalasia. A single-center retrospective study was conducted. A prospectively collected database of 2000 patients who underwent POEM in Showa University between September 2008 to June 2019 has been reviewed. Patients who were diagnosed as sigmoid type 2 achalasia and underwent POEM were included in this study. Sigmoid type 2 achalasia was defined as an enormously dilated and tortuous esophagus in barium esophagram and double esophageal lumen in some CT slices. The primary outcome was the success rate, defined as an Eckardt Symptom Score(ESS) of less than 3 without additional treatments such as balloon dilation or redo POEM. The secondary outcomes were integrated relaxation pressure(IRP), mean lower esophageal sphincter(LES) pressure, and GERD after POEM. Patient’s characteristics: A total of 108 patients (age: 58.4±14.7 y/o, 51 females(47%), BMI: 21.7±4.6kg/m2) were included. Based on Chicago Classification, the type of achalasia seen were as follows: Type I/II/III= 28/8/1, and there were 71 unidentified cases due to the difficulty of inserting catheters. Diameter of esophagus was 48.1±17.5mm. Duration of symptoms was 17.4(7.7-29)years. ESS was 5(3-7). As pre-treatment, 49 patients had balloon dilation, Hellor-Dor in 8 patients, and Heller myotomy in 2 patients. Procedure-related parameters: Operation time was 95.9±32.1min. Myotomy length was 7(5-9)cm at the esophageal side, and 3(2-3)cm at the gastric side. Post-operative hospital stay was 4(4-5) days. The following complications were noted: mucosal perforation in 3 patients, submucosal hematoma or bleeding in 3 patients. Treatment outcomes: Success rate after 2 months was 89.1%(82/92). Pre- and 2-months post-POEM ESS were 5.0±2.5 and 1.1±1.0 (p<0.0001), respectively. Pre- and 2-months post-POEM IRP were 15.7±9.9 and 8.6±5.5 mmHg (p=0.0012), respectively. Pre- and 2-months post-POEM mean LES pressure were 19.9±13.9 and 14.6±7.7 mmHg (p=0.066), respectively. GERD 2-months post-POEM were as follows: Grade(N/A/B/C/D=37/29/13/7/1). Patients with GERD symptoms were 11.3%(10/88). PPI usage rate was 16.1%(13/81). Success rate after 1 year was 87.8%(43/49). Since good results of the short- and mid-term success rate and significant improvement of ESS and IRP value were achieved, POEM shows to be an effective procedure for sigmoid type 2 achalasia. Long-term results are expected in future studies.CT slice showing double esophageal lumenView Large Image Figure ViewerDownload Hi-res image Download (PPT)