Nonspecific Esophageal Motility Disorder Research Articles

Demographic and clinical characteristics of patients with nonspecific esophageal motility disorder

Aim: Although nonspecific esophageal motility disorder(NEMD) is the most common diagnosis in manometry, unlike other primary esophageal disorders, it is the least known and least studied disorder in the literature. Studies with a small number of patient groups have been reported in the literature. The aim of this study is to share the demographic and clinical characteristics of the single center high-volume NEMD patients we have followed up. 
 Material and Method: The study was carried out retrospectively by examining the motility records of 391 patients diagnosed with NEMD in the motility laboratory of the gastroenterology clinic of our hospital. 20-year motility laboratory records between 1991 and 2019 were reviewed. 
 Results: The mean age of 391 patients diagnosed with NEMD was 49.08±14.4 (18-90). 213 (54.5%) of them were female, and 178 (45.5%) of them were male. The primary symptom was reflux in 56.8% (222/391) of the patients, and dysphagia in 43.2% (169/391). While there was no esophagitis in 78.2% of the patients who had endoscopy, esophagitis was found in 21.8% of them. Pathological reflux was detected in 73.5% of the patients whose 24-hour pH was measured. In the repeated manometry results of patients due to increased complaints in their follow-up whose initial manometry findings were compatible with NEMD, 18 patients were diagnosed with achalasia, 5 patients with nutcracker esophagus, and 4 patients with diffuse esophageal spasm (DES). 
 Conclusion: The majority of patients with NEMD are associated with reflux. Patients with NEMD who do not have endoscopic and radiological organic disorders should be re-evaluated with manometry and further examinations if their complaints persist.

Assessment of Esophageal High-Resolution Impedance Manometry in Patients with Nonobstructive Dysphagia.

Background High-resolution impedance manometry (HRIM) can calculate the bolus motion parameters and the ratio of complete esophageal transit besides the conventional esophageal dynamic parameters; therefore, we could better manage the patients with nonobstructive dysphagia (NOD) clinically. Aim To analyze the HRIM parameter results of NOD patients and evaluate the characteristics of their esophageal motility and transit function. Methods In total, 58 NOD patients were assessed and the clinical diagnoses were determined. HRIM was performed, and both conventional high-resolution manometry and esophageal transit parameters were analyzed. Results In 58 NOD patients, 28 patients had achalasia, 3 esophagogastric junction outflow obstruction, and 20 nonspecific esophageal motility disorders, and 7 were normal. Impedance results demonstrated that all the patients with achalasia exhibited incomplete esophageal transit (ICET), three patients with esophagogastric junction outflow obstruction showed ICET, and the average bolus transit time (BTT) was 6.6 ± 1.2 sec. In 20 nonspecific esophageal motility disorders, 13 patients with gastroenterologly reflux disease (GERD) presented ineffective esophageal motility and fragmented peristalsis, and 65.0% swallows had exhibited ICET. However, 49.1% swallows of 7 nonspecific esophageal motility disorder patients with non-GERD had exhibited ICET. The average BTT in 13 GERD patients was longer than that in the non-GERD patients (8.1 ± 1.1 sec versus 5.5 ± 0.3 sec, P < 0.05). And in the seven patients with normal esophagus function, 3.5% swallows showed ICET and BTT was 5.6 ± 0.3 sec. Conclusion Achalasia was the most common esophageal dysmotility in NOD patients, followed by nonspecific esophageal motility disorders. The clinical diagnoses of NOD were mostly achalasia and GERD. Impedance assessments showed that all achalasia cases exhibited ICET, and other esophageal motility abnormalities that represented ICET were associated with contraction break and ineffective swallow. Compared to non-GERD patients, BTT was significantly prolonged in patients with GERD.

The Contribution of High-Resolution versus Conventional Esophageal Manometry to the Assessment of Esophageal Motor Disorders in Patients With Non-Cardiac Chest Pain (NCCP)

Introduction: NCCP is defined as recurring, angina-like, retrosternal chest pain of non-cardiac origin. It has been estimated that up to 30% of the non-GERD related NCCP patients demonstrate an esophageal motor disorder using conventional manometry (CM). Thus, the aim of the study was to determine if high resolution esophageal manometry (HREM), which has become the standard of care, improved the diagnosis of esophageal motor disorders, as compared with CM, in patients with NCCP. Methods: We evaluated 300 consecutive non-GERD related NCCP patients who underwent either HREM or CM. A total of 150 patients had CM and the other 150 patients HREM. The Chicago 3 classification and the Castell and Spechler classification were used to determine the esophageal motor disorder of patients undergoing HREM and CM, respectively. Results: In both HREM and CM groups, a normal esophageal motility study was the most frequent finding (47% vs. 36%, respectively). In patients who underwent CM, the most commonly demonstrated esophageal motility disorder was hypotensive lower esophageal sphincter. Hypotensive LES was a significantly more common finding in patients undergoing CM versus HREM (27.3% vs. 4.7%, p<0.001). Other less common motility disorders seen in the CM group were nonspecific esophageal motility disorders (NEMD) (12%), nutcracker esophagus (9.3%), ineffective esophageal motility (IEM) (6.7%), achalasia (2.7%), distal esophageal spasm (DES) (5.3%), and absent contractility (0.67%). In general, hypertensive motility disorders, like DES and nutcracker esophagus, were less common than hypotensive motility disorders (15% vs. 35%, p=0.9) in NCCP patients. There was no significant difference in the number of hypertensive or hypotensive motility disorders diagnosed with CM versus those diagnosed with HREM. In the HREM group, IEM was the most commonly diagnosed motility abnormality. The likelihood of finding an IEM was significantly more common in the HREM group as compared with the CM group (25% vs. 7%, p<0.001). Other motility abnormalities that were less commonly diagnosed with HREM included: achalasia (7.3%), esophagogastric junction outflow obstruction (4%), absent contractility (4%), jackhammer/nutcracker esophagus (3.3%), DES (2.7%) and NEMD (1.3%). Conclusion: HREM did not improve the percentage and type of esophageal motor disorders diagnosed in NCCP patients as compared with CM. This is likely due to limitations of Chicago 3 classification. Normal esophageal motility remains the most common finding.

Clinical utility of oesophageal manometry in evaluation of chest pain and dysphagia at tertiary centre

Background: Manometry is the gold standard test for diagnosis esophageal motility disorders. Disordered esophageal motor function is a common cause of symptom as particularly dysphagia, chest pain, and those associated with gastroesophageal reflux. Manometric studies are used in the evaluation of patients with symptoms suggestive of esophageal origin such as dysphagia, odynophagia, heartburn, and unexplained chest pain. Motor function can be assessed by a variety of recording techniques including radiology, scintigraphy manometer, and most recently intraluminal electrical impedance monitoring. Some of these are complementary. The gold standard, however, for the assessment of motor disorders remains manometry. Hypertensive LES, ineffective esophageal motility and nonspecific esophageal motility disorder are effectively diagnosed. Manometric measurement of esophageal pressure is the most direct method for assessment of motor function. Methods: A prospective study done in department of surgery, Vijaya Nagara Institute of Medical Sciences, Bellary, Karnataka, India, between December 2010 to May 2012. Study included 30 patients of age 18-80 years were evaluated by oesophageal manometry who presented with non-cardiac chest pain and dysphagia. Results: Manometric evaluation of patients presenting with non-cardiac chest pain and dysphagia revealed, hypotensive LES was most common constituting 39.6% of cases followed by, hypertensive LES (16.5%), achalasia (13.2%), ineffective esophageal motility (13.2%), nonspecific esophageal motility disorder (9.9%), nutcracker and diffuse esophageal spasm (3.3%). Conclusions: Oesophageal manometry helps in identifying different motility disorder and delineates the treatment plan based on the recordings.

Progression of Jackhammer Esophagus to Type II Achalasia.

It has been suggested that patients with certain motility disorders may progress overtime to develop achalasia. We describe a 66 year-old woman who presented with dysphagia for solids and liquids for a period of 18 months. Her initial workup showed normal endoscopy and non-specific esophageal motility disorder on conventional manometry. Six months later, due to persistence of symptoms, the patient underwent a high resolution esophageal manometry (HREM) demonstrating jackhammer esophagus. The patient was treated with a high dose proton pump inhibitor but without resolution of her symptoms. During the last year, the patient reported repeated episodes of food regurgitation and a significant weight loss. A repeat HREM revealed type II achalasia. Multiple case reports, and only a few prospective studies have demonstrated progression from certain esophageal motility disorders to achalasia. However, this report is the first to describe a case of jackhammer esophagus progressing to type II achalasia.

Sa1321 The Incidence of Nonspecific Esophageal Motility Disorders (NEMD) in Persons With Spinal Cord Injury Compared to Able-Bodied Controls

G A A b st ra ct s be demonstrated on barium esophagram (BE) based on retrograde propulsion of barium, disorganized peristalsis, and repetitive lumen-obliterating contractions. However, it is unclear whether BE findings of spasm are equivalent to HRM criteria for DES, or if these radiographic findings are different entities. Aims: The aims of our study were: (1) To determine the HRM correlates of radiographic spasm, and (2) To compare the diagnostic yield of the Chicago Classification versus conventional manometric criteria for patients with BE spasm. Methods: We performed a retrospective review of all adult patients referred to a single tertiarycare center for HRM between 11/1/2011 and 10/31/2012. Manometric and radiographic information was collected. When spasm was identified on BE, each HRM was re-reviewed to assign a diagnosis by both the conventional and Chicago classification. For those patients with severe spasm on BE, the two classifications were directly compared to determine whether there was concordance. Results: 409 HRM were performed during the 1-year study period. 218 (53%) also obtained a BE. 102/218 (47%) had radiographic spasm; graded by the radiologist as mild (12), moderate (10), severe (25), or unclassified severity (55). Table 1 describes all 102 patients by the Chicago and conventional criteria. The conventional classification labeled more cases as DES than the Chicago classification, whereas the latter were more often considered normal. However, Table 2 describes how the diagnostic schemes were employed for severe cases of spasm (n=25). Though conventional diagnoses of DES were reclassified to other hypercontractile / spastic disorders by Chicago classification, there was no case where the conventional criteria diagnosed spasm and the Chicago classification failed to identify a hypercontractile state. Conclusions: The presence of radiographic spasm is associated with a wide spectrum of HRM abnormalitites, including achalasia, EGJ outflow obstruction, hypercontractile disorders and hypocontractile disorders, and is not specific for a HRM diagnosis of DES. Though fewer cases of DES were diagnosed using the Chicago Criteria as compared to conventional classification, these cases were reclassified to other hypercontractile groups by Chicago nomenclature, and not missed. Ultimately, outcome studies are warranted to determine the natural history of different manometric subtypes identified in the context of radiographic spasm. Table 1: The Chicago and conventional classifications for 102 adults with radiographic evidence of spasm

Diffuse Esophageal Spasm in Children Referred for Manometry

Diffuse esophageal spasm (DES) causes chest pain and/or dysphagia in adults. We reviewed charts of 278 subjects 0 to 18 years of age after esophageal manometry to describe the frequency and characteristics of DES in children. Patient diagnoses included normal motility (61%), nonspecific esophageal motility disorder (20%), DES (13%, n=36), and achalasia (4%). Of patients with DES, the most common chief complaint was food refusal in subjects younger than 5 years (14/24, 58%) and chest pain in subjects older than 5 years (4/12, 33%). Comorbid medical conditions, often multiple, existed in 33 subjects. DES should be considered when young children present with food refusal.

Surgical treatment for nonspecific esophageal motility disorders

Nonspecific esophageal motility disorder (NEMD) is a vague category that includes patients with poorly defined contraction abnormalities observed during esophageal manometry. This study investigated the therapeutic effects of the video-assisted thoracoscopic surgery (VATS) approach using long myotomy and fundopexy for NEMD. The VATS approach using myotomy and fundopexy was performed for 4 patients of NEMD between 2005 and 2008. A total of 4 patients with NEMD that underwent treatment at our institution were analyzed retrospectively. The patients included 2 males and 2 females with a median age of 48 years (range 21-74 years). The median duration of NEMD symptoms was 58 months (range 4-108 months). Dysphagia was a primary symptom in all patients. Chest pain was a primary symptom in 3 of 4 patients (75 %). Treatment with medication was attempted before the operation. The median operative time was 344.5 min (range 210-476 min). The median time before starting oral feeding was 2.5 days (range 2-22 days). All patients achieved a significant improvement of their previous condition. The VATS approach using myotomy and fundopexy for NEMD is a good treatment in cases resistant to medication and balloon dilation.

The Evolution of Achalasia

Esophageal motility abnormalities have been described as existing in a spectrum which includes achalasia, distal esophageal spasm, nutcracker esophagus and possibly other less distinct motility findings. There has been much questioning and controversy relevant to whether these different manometric features evolve from one to another and thus form a changing spectrum amongst themselves. Most clear in the reported literature extending back into the 1960s are reports of esophageal spasm ‘‘evolving’’ into more typical achalasia over time [1]. What has never been established, however, is whether a less clear form of motility defect can be identified that will predictably evolve into classic achalasia. It is intuitive, however, that the patient with a normal esophagus when exposed to the etiologic agent for achalasia (currently unknown) would show a progression (evolution?) of manometric changes over time. The term non-specific esophageal motility disorder (NEMD) was introduced into the literature in an attempt to establish a category for abnormal motility that did not quite fit the classic definitions for achalasia, spasm and nutcracker esophagus. Since it was described to include all motility abnormalities that fail to fit more classic definitions, the potential for a broad and truly non-specific group of findings was established. Thus, NEMD became a wastebasket for potential motility changes not otherwise well described. In the mid 1990s, when we surveyed a group of some 60 patients diagnosed with NEMD, we recognized that essentially 100% of them actually had been placed in this category based on the findings of increased numbers of low amplitude ‘‘ineffective’’ peristaltic waves as described in 1988 by the manofluoroscopic studies of Kahrilas et al. [2]. We suggested that the term ‘‘ineffective esophageal motility’’ (IEM) was a more meaningful descriptor for this ill-defined manometric entity and that it would better define the motility findings previously called ‘‘non-specific’’ [3]. In this issue of Digestive Diseases and Sciences, Muller et al. [4] suggest that patients previously diagnosed with NEMD had a high likelihood of evolving to classic achalasia. This may well be true, however, there are aspects of their report that one must consider before accepting this as a fact. Included in these are questions whether the initial manometric diagnosis was correct or did a number of these patients initially have findings that would actually be consistent with a diagnosis of achalasia? This is particularly pertinent when one recognizes the fact that the so called ‘‘classic’’ manometric findings of achalasia, a hypertensive resting LES with poor relaxation and the absence of peristalsis, may only all be found in less than one-third of otherwise typical cases [5]. The suggestion that approximately 50% of NEMD patients might evolve into typical achalasia seems exceedingly high, but would certainly be expected if the initial interpretation was incorrect and the diagnosis was actually a form of achalasia. Furthermore, if the 15 achalasia cases described by Muller et al. are based on the original 76 NEMD patients, then the incidence of achalasia falls to 19%. This raises the second important question involving these data. Since only 28 of the original 76 patients had a repeat manometry, it is quite likely that a serious selection bias is in play here. My guess would be that many of these actually were patients with early achalasia when their initial studies were performed and they were self-selected based on the continuing progression D. O. Castell (&) Department of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC 29425-2900, USA e-mail: castell@musc.edu

Clinical and Manometric Course of Nonspecific Esophageal Motility Disorders

The evolution of nonspecific esophageal motility disorders remains unclear. The aim of this study was to investigate whether nonspecific esophageal motility disorders progress into specific motility disorders and whether such progression is predictable. Seventy-six symptomatic patients (49 males, 27 females, mean age 57 ± 16 years) with newly diagnosed nonspecific esophageal motility disorders were prospectively registered and followed-up. Follow-up visits, with structured interviews and manometric re-evaluation, were recommended biannually and whenever symptoms exacerbated. Forty-three patients were followed for up to 4 years, symptoms worsened in 30% of patients, resolved in 26%, improved in 14% and were unchanged in 30%. Twenty-eight patients agreed to undergo manometric re-evaluation. Fifteen (53.6%) of these patients showed a progression to achalasia. The remaining patients continued to display features of nonspecific esophageal motility disorders (32%) or had normal motility (11%). The only significant association could be determined between age and progression to achalasia reaching nearly 100% in patients' ≤46 years of age. In contrast, none of the patients' ≥68 years progressed. More than half of the patients in our cohort with nonspecific esophageal motility disorders showed a transition into achalasia. Neither manometric nor clinical findings predicted the progression of nonspecific esophageal motility disorders. However, young patients were more likely to progress to achalasia.

Have Referral Patterns to Esophageal Laboratories Changed Over Time? A Study of Esophageal Manometry in 2008 Compared to 1987

Purpose: Compare distribution of specific esophageal motility abnormalities and reason for referral to a tertiary esophageal function laboratory in 2008 compared to twenty years ago. Methods: A retrospective review was conducted of patients referred to our esophageal function laboratory from July 2003 to June 2008 (Group A). The primary symptom for referral was identified. The distribution of motility findings, were compared to a prior study conducted by the senior author in 1987 (Group B). Patients were grouped into 3 categories based on primary symptom; dysphagia, noncardiac chest pain, and other (e.g. globus, cough, heartburn, etc.), the latter of which was not included in the final analysis as this was not reported in 1987. The manometric diagnosis for each patient was classified as Normal, Achalasia, Distal esophageal spasm (DES), hypocontractile motility disorder (Ineffective Esophageal Motility [IEM] and/or low LES pressure) and hypercontractile motility disorder (nutcracker and/or high LES pressure). These results were then compared to the data obtained from a large review published by Katz et al (Annals Int Med, 1987) of 1161 patients with noncardiac chest pain or dysphagia and similar manometric classifications. In 1987, patients with hypocontractile motility disorders were labeled as Nonspecific esophageal motility disorder. By today's criteria, they are sufficiently similar to be so classified. Statistics: Chi-Square test to compare groups A to B. A p-value <0.05 is statistically significant. Results: 1263 studies reviewed; other (N=490), dysphagia and chest pain (see Table).TableConclusion: Reason for referral for esophageal function testing has substantially changed dramatically compared to 1980s. Dysphagia (and other) symptoms predominate over chest pain. There is a significant increase in the number of abnormal studies and distribution of motility abnormalities likely reflective of the change in referral pattern.

Nonspecific esophageal motility disorders may be an early stage of a specific disorder, particularly achalasia

The clinical significance of nonspecific esophageal motility disorder (NEMD) is unclear. Our aim was to investigate the natural history of NEMD. All manometries performed at Meir Hospital from 1997 to 2004 and diagnosed as NEMD were reviewed. Manometric criteria for NEMD included either low-amplitude peristalsis, nonprogression of peristalsis, prolonged retrograde or triple-peaked waves, or incomplete relaxation of the lower sphincter. Patients determined to have NEMD were contacted and asked to complete a questionnaire and undergo a second manometry. NEMD had been diagnosed in 137 patients. Upon review of manometry results, 65 patients were eligible for the study (36 men and 29 women). The other 72 patients did not have NEMD when we reviewed their manometry tracing, applying strict criteria as specified in Table 1. The average age was 64 +/- 16 years (range 24-83 years). The average follow-up period was 7 +/- 2 years. All 65 patients were symptomatic at their initial prestudy visit. By the second visit, symptoms had resolved in 33 (51%) patients and improved in 13 (19%). Dysphagia, chest pain, and food regurgitation had improved, whereas heartburn and respiratory symptoms had not. Of 37 patients with triple-peaked waves, only 11 (30%) had improved clinically. Of the 65 study patients, 17 (26%) had a second manometry during the study, which was normal in 2 (12%), unchanged in 11 (69%), and revealed achalasia in 4 (23%), representing 6% of all study patients. NEMD is generally a benign disorder that improves clinically in most cases. Nevertheless, in about 6% of patients, NEMD may evolve into achalasia.

Diagnosis of chest pain with foregut symptoms in Chinese patients

To evaluate the diagnosis of chest pain with foregut symptoms in Chinese patients. Esophageal manometric studies, 24-h introesophageal pH monitoring and 24-h electrocardiograms (Holter electrocardiography) were performed in 61 patients with chest pain. Thirty-nine patients were diagnosed with non-specific esophageal motility disorders (29 patients with abnormal gastroesophageal reflux and eight patients with myocardial ischemia). Five patients had diffuse spasm of the esophagus plus abnormal gastroesophageal reflux (two patients had concomitant myocardial ischemia), and one patient was diagnosed with nutcracker esophagus. The esophageal manometric studies, 24-h intra-esophageal pH monitoring and Holter electrocardiography are significant for the differential diagnosis of chest pain, particularly in patients with foregut symptoms. In cases of esophageal motility disorders, pathological gastroesophageal reflux may be a major cause of chest pain with non-specific esophageal motility disorders. Spasm of the esophageal smooth muscle might affect the heart-coronary smooth muscle, leading to myocardial ischemia.

Achalasia and Nonachalasia Esophageal Motility Disorders

Dysphagia and chest pain often occur in adults, and most patients with persistent symptoms initially undergo evaluation to rule out reflux esophagitis, esophageal cancer, and cardiovascular disease. When the findings of these evaluations are normal, esophageal manometry is performed. Esophageal motility disorders, which include achalasia, diffuse esophageal spasm, nutcracker esophagus, hypertensive lower esophageal sphincter, and nonspecific esophageal motility disorder, are often identified in these patients. In our series, 78% of patients with nonobstructive dysphagia or unexplained (noncardiac) chest pain or both have an esophageal motility disorder (achalasia, 44%; diffuse esophageal spasm, 5%; nutcracker esophagus, 2%; and nonspecific esophageal motility disorder, 27%). Therefore, in patients who present with dysphagia or chest pain or both, an esophageal motility disorder should be suspected.

Is esophageal dysphagia in the extreme elderly (≥80 years) different to dysphagia younger adults? A clinical motility service audit

Dysphagia in elderly patients has major effects on nutrition and quality of life. Although aging itself is associated with changes in esophageal motility, the impact of this on symptoms such as dysphagia is unclear. Data in the extreme elderly are also limited. Symptoms and manometric diagnoses from 23 consecutive older patients (older dysphagia [OD]) >or=80 reporting esophageal dysphagia (12 female, mean age 83 (range 80-93) were compared with those from 23 gender matched younger patients (young dysphagia [YD]) also with dysphagia (mean age 35, range [17-46]). More older patients reported dysphagia as their primary symptom (OD 22/23 vs YD 14/23, P = 0.005). Overall, dysphagia was most common for solids only (OD 16/23 vs YD 15/23) and rare for liquids only (OD 1/23 vs YD 3/23). Dysphagia for both liquids and solids was more frequent in older patients (OD 6/23 vs YD 1/23, P < 0.05). Fewer older patients reported heartburn (OD 3/23 vs YD 14/23, P = 0.001). Manometric diagnoses were generally similar between OD and YD patients with the most common diagnoses being 'nonspecific esophageal motility disorder' (nine each) and 'ineffective peristalsis' (OD = 6, YD = 7). There was a trend for diagnoses related to lower esophageal sphincter failure to be more frequent in younger subjects (OD 1 vs YD 7, P = 0.053). Despite differences in symptom patterns, broad manometric diagnoses in the extreme elderly with dysphagia are similar to younger dysphagia patients. Further studies are required to determine whether this relates to insensitivity in recording or reporting of esophageal manometry (or perceptual differences associated with aging).

Secondary Achalasia and Other Esophageal Motility Disorders After Laparoscopic Nissen Fundoplication for Gastroesophageal Reflux Disease

The purpose of our investigation was to determine the frequency of secondary achalasia and other esophageal motility disorders revealed on barium studies after laparoscopic Nissen fundoplication and to present the clinical and radiographic findings in these patients. Esophageal dysmotility was found in nine (7%) of 138 patients after laparoscopic Nissen fundoplication, including secondary achalasia in three (33%), diffuse esophageal spasm (DES) in two (22%), and a nonspecific esophageal motility disorder in four (44%). Our findings suggest that patients who undergo laparoscopic Nissen fundoplication for gastroesophageal reflux disease are at risk for the development of esophageal motility disorders, including secondary achalasia and DES. Careful evaluation of esophageal motility on postoperative barium studies may help to identify esophageal dysmotility and to differentiate this finding from structural complications of the wrap as a cause of refractory symptoms in these patients.

Esophageal motility disorders in the morbidly obese population

Most studies investigating esophageal motility among the morbidly obese have focused on the relationship between lower esophageal sphincter (LES) pressure and gastroesophageal reflux disease (GERD). Very few studies in the literature have examined motility disorders among the morbidly obese population in general outside the context of GERD. This study aimed to determine the prevalence of esophageal motility disorders in obese patients selected for bariatric surgery. A total of 116 obese patients (81 women and 35 men) selected for laparoscopic gastric banding underwent manometric evaluation of their esophagus from January to March 2003. Tracings were retrospectively reviewed for the end points of LES resting pressure, LES relaxation, and esophageal peristalsis. The study patients had a body mass index (BMI) of 42.9 kg/m2, and a mean age of 48.6 years. The following abnormal manometric findings were demonstrated in 41% of the patients: nonspecific esophageal motility disorders (23%), nutcracker esophagus (peristaltic amplitude >180 mmHg) (11%), isolated hypertensive LES pressure (>35 mmHg) (3%), isolated hypotensive LES pressure (<12 mmHg) (3%), diffuse esophageal spasm (1%), and achalasia (1%). Only one patient with abnormal esophageal motility reported noncardiac chest pain. Despite a high prevalence of esophageal dysmotility in our morbidly obese study population, there was a conspicuous absence of symptoms. Although the patients in this study were not directly questioned with regard to esophageal symptoms, several studies in the literature support our conclusion.

Preoperative esophageal manometry and outcome of laparoscopic adjustable silicone gastric banding

Laparoscopic adjustable silicone gastric banding (LASGB) for morbid obesity has been reported to provide long-term weight loss with a low risk of operative complications. Nevertheless, esophageal dilation leading to achalasia-like and reflux symptoms is a feared complication of LASGB. This study evaluates the clinical benefit of routine preoperative esophageal manometry in predicting outcome after LASGB in morbidly obese patients. A review of prospectively collected data on 77 patients who underwent routine esophageal manometry prior to LASGB for morbid obesity from February 2001 to September 2003 was performed. Aberrant motility, abnormal lower esophageal sphincter (LES) pressures, and other nonspecific esophageal motility disorders noted on preoperative esophageal manometry defined patients of the abnormal manometry group. Outcome differences in weight loss, emesis, band complications, and gastroesophageal reflux disease (GERD) resolution or improvement were compared between patients of the abnormal and normal manometry groups after LASGB. Analysis of variance (ANOVA) and chi-square tests were performed to determine the significance of these outcomes. Of the patients tested, 14 had abnormal esophageal manometry results, whereas 63 had normal manometry results before LASGB. There was no significant difference in percent excess weight loss (%EWL) at 6 and 12 months between the groups after gastric banding. Severe postoperative emesis occurred more frequently in patients with abnormal manometry results than in those with normal manometry results. There were two band-related complications, both of which occurred in patients of the normal manometry group. Preoperative esophageal manometry does not predict weight loss or GERD outcomes after LASGB in morbidly obese patients. Postoperative emesis was more common in patients with abnormal manometry findings, but such symptoms were manageable and did not lead to poor weight loss or to band removal or increased band-related complications.

The Incidence of Gastro-Esophageal Disease for the Patients with Typical Chest Pain and a Normal Coronary Angiogram

BackgroundAlthough patients may present with typical chest pain and exhibit ischemic changes on the cardiac stress test, they are frequently found to have a normal coronary angiogram. Thus, we wanted to determine which procedures should be performed in order to make an adequate diagnosis of the cause of chest pain.Methods121 patients (males: 42, 34.7%) who had a normal coronary angiogram with typical chest pain were included in this study. All the patients underwent upper endoscopy, Bernstein's test and esophageal manometry.ResultsAmong the 121 patients, clinically stable angina was noted in 107 (88.4%). Stress testing was done in 82 (67.8%); it was positive in 52 (63.4%). Endoscopic findings were erosive gastritis in 18 (14.8%), gastric ulcer in 4 (3.3%), duodenal ulcer in 5 (4.1%), and reflux esophagitis in 16 (13.2%). Positive results were observed on Berstein's test for 68 patients (56.2%); 59 (86.8%) of them had non-erosive reflux disease. On the esophageal manometry, 35 (28.9%) of these patients had motility disorders. Nutcracker esophagus was observed in 27 patients (22.3%), nonspecific esophageal motility disorder was observed in 5 (4.1%), and hypertensive lower esophageal sphincter was observed in 3 (2.5%). Among the 52 patients with positive cardiac stress testing and a negative coronary angiogram (this clinically corresponded to microvascular angina), 46 patients (85.1%) showed abnormal findings on the gastro-esophageal studies.ConclusionsIn our study, 85.1% of the patients with microvascular angina revealed positive results of gastric or esophageal disease. In spite of any existing evidence of microvascular angina or cardiac syndrome X, it would be more advisable to perform gastro-esophageal studies to adequately manage chest pain.

Cause and treatment of epiphrenic diverticula

Background Epiphrenic diverticula of the esophagus are often associated with a concomitant esophageal motor disorder, which is thought to be the cause of the diverticulum and some of the patient’s symptoms. At one time diverticula were best removed via a left thoracotomy, but now the operation can be performed laparoscopically in most cases. We hypothesized that: (1) a motor disorder is the underlying cause of the diverticulum; and (2) optimal treatment consists of laparoscopic resection of the diverticulum, a Heller myotomy, and Dor fundoplication. Methods We performed a retrospective review of a prospectively collected database from a university hospital tertiary care center. Between June 1994 and December 2002, we evaluated 21 patients with epiphrenic diverticula. An associated motility disorder of the esophagus was found in 81% of patients (achalasia, 9%; diffuse esophageal spasm, 24%; nonspecific esophageal motility disorder, 24%; nutcracker esophagus, 24%). Seven (33%) of these patients, all with esophageal dysmotility, were referred for treatment. The laparoscopic operation entailed resection of the diverticulum (using an endoscopic stapler), a Heller myotomy, and a Dor fundoplication. Results All operations were completed laparoscopically. The postoperative course of 6 patients was uneventful and they left the hospital after 72 ± 21 hours. In 1 patient an acute paraesophageal hernia developed, which was repaired on the second postoperative day. Late follow-up (median 57 months) showed that all 7 patients were asymptomatic. Conclusions These data support the conclusions that: (1) a primary esophageal motility disorder is the underlying cause of most epiphrenic diverticula; and (2) laparoscopic treatment is successful and should be the method of choice. The diverticular neck can be exposed satisfactorily from the abdomen; a stapler inserted from this angle is better orientated to transect the neck than one inserted through a thoracoscopic approach. Furthermore, the myotomy and fundoplication are much more easily performed from the abdomen than from alternative approaches.