Primary Motility Disorder Research Articles

When is parenteral nutrition indicated in the hospitalized, acutely ill patient?

The current review discusses current practices regarding appropriate indications for parenteral nutrition in acutely ill hospitalized patients. We address-specific indications for parenteral nutrition in the perioperative period, and in inflammatory bowel disease, oncology, hepatobiliary, critical care and end-stage renal disease patients. Acutely ill hospitalized patients can develop intestinal failure requiring parenteral nutrition. Recent studies have provided insight into the main indications. The most common indications for inpatient parenteral nutrition include postsurgical complications, including prolonged ileus, sepsis, fistula and leaks, and bowel obstruction, predominantly malignant. Severe or complicated inflammatory bowel disease and cancer treatment-related mucosal enteropathies (mucositis, enterocolitis, gut graft-versus-host disease) are the next commonest indications. Less frequent indications are primary motility disorders and inability to secure enteral access for enteral nutrition. Gastrointestinal failure of the intensive care patient is a separate entity resulting from multiple mechanisms, including an enteropathy and dysmotility. Despite the wider availability of nutrition support teams, use of parenteral nutrition is not without risk. The risks and benefits of parenteral nutrition in the acute setting need to be carefully considered even when it is indicated.

Pseudocyst presenting as pseudoachalasia

Achalasia cardia is a primary motility disorder of esophagus which is due to loss of ganglion cells in myentric plexus, etiology of which is unknown. The condition causes dysphagia due to failure of relaxation of lower esophageal sphincter. Pseudoachalasia is a similar disorder which occurs usually due to adenocarcinoma of the cardia and also due benign tumors at this level. We present a rare case of pseudocyst of pancreas extending into mediastinum which mimics as pseudoachalasia.

364 Shorter Esophageal Length Is Associated With Increased Proximal Reflux and Symptom Severity in Patients Presenting With Laryngopharyngeal Reflux (LPR) Symptoms

INTRODUCTION: Laryngopharyngeal reflux (LPR) is a heterogeneous condition with various underlying pathologies. The effect of esophageal anatomy on LPR is unclear. Shorter distance between lower esophageal sphincter (LES) and upper esophageal sphincter (UES) may allow refluxate to more easily reach the pharynx. We aimed to examine the effect of esophageal length on reflux parameters and symptoms. METHODS: 115 consecutive patients (64% female, mean age 53.9 yrs) with suspected LPR referred for high-resolution manometry (HRM) and combined hypopharyngeal-esophageal multichannel intraluminal impedance-pH testing (HEMII-pH) at a tertiary center in 3/2018-5/2019 were enrolled. Validated symptom surveys were prospectively collected at time of testing, including Reflux Symptom Index (RSI) and 12-item short-form health survey (SF-12) for health-related quality of life (HRQOL). Esophageal length was measured from the distal margin of UES to the proximal margin of LES on HRM. Univariate analyses were performed with Pearson correlation or Student’s t-test. Generalized linear regression was used for multivariate analysis. RESULTS: Mean esophageal length on HRM was 20.4 cm (SD = 2.2). Esophageal length was significantly shorter among patients with a hiatal hernia ≥2 cm (19.2 cm vs 20.6 cm, P = 0.01), but did not correlate with any primary motility disorder per Chicago classification v3.0. Shorter esophageal length was significantly associated with higher acid exposure time and proximal reflux events on impedance, with a trend toward more total reflux events (Table 1). Esophageal length was also shorter among patients with pharyngeal reflux events on HEMII-pH compared to those without (20.0 cm vs 20.9 cm, P = 0.04). Even after controlling for hiatal hernia size, esophageal length remained independently predictive of reflux severity and pharyngeal reflux events. There was a correlation between shorter esophageal length and more severe symptoms on the heartburn/chest pain/indigestion subscore of RSI, but not total RSI or throat symptom subscores (Table 2). Shorter esophageal length was associated with lower physical health scores on SF-12 for HRQOL (Figure 1). CONCLUSION: Shorter esophageal length is independently associated with increased reflux severity, proximal reflux, and pharyngeal reflux, even after controlling for hiatal hernia size. It also correlates with more severe typical reflux symptoms and physical HRQOL. Decreased esophageal length may play a role in the pathophysiology of reflux in patients with LPR symptoms.

926 POEM Is a Safe and Effective Treatment for Achalasia: A Large Single Center Experience

INTRODUCTION: Achalasia is a primary motility disorder characterized by aperistalsis and failure of lower esophageal sphincter relaxation. Traditionally, treatment modalities have consisted of drug therapy, botulinum toxin injections, laparoscopic Heller myotomy, and balloon pneumatic dilatation. However, in the past several years, the novel technique peroral endoscopic myotomy (POEM) has gained popularity, as prior studies have suggested that it offers excellent short-term outcomes. In this study, we analyze the efficacy of POEM with a focus on both short-term and long-term outcomes. METHODS: This retrospective study utilized collected data at our tertiary referral center. A total of 71 patients underwent POEM. 18 patients were lost to follow-up post-procedure. 47 patients were included in the short-term assessment, defined as less than 6 months removed from the procedure, while 15 patients were included in the long-term assessment, defined as greater than or equal to 6 months removed from the procedure. Eckhardt score was assessed before POEM and afterwards for short-term follow-up and long-term follow-up. RESULTS: Mean age was 56.5 years old. 54% of patients were female. Mean short term follow-up time was 2.96 months. Mean long-term follow-up time was 13.0 (8-27) months. The mean pre-POEM Eckhardt score was 7.6. The mean short-term post-POEM Eckhardt score was 1.2 (P < 0.001) while the mean long-term post-POEM Eckhardt score was 1.8 (P < 0.001). There was no significant difference between short-term and long-term Eckhardt scores. Additionally, there were no adverse outcomes or effects in any of the 65 POEM cases. CONCLUSION: This study was one of the largest single-center studies that examining the efficacy and safety of POEM . Eckhardt scores decreased significantly after POEM, remained significantly decreased at longer-term follow-up, and there were no adverse outcomes. In short, this study supports that POEM is a safe, effective, and durable option for the treatment of achalasia.

Esophageal dysmotility: An intrinsic feature of megacystis, microcolon, hypoperistalsis syndrome (MMIHS)

ObjectivesMegacystis–microcolon–hypoperistalsis syndrome (MMIHS) also called Berdon's Syndrome, is a smooth muscle myopathy that results in an enlarged bladder, microcolon, and small bowel hypoperistalsis. In our series of six patients with this disorder, all had disordered swallowing. Therefore, we prospectively characterized esophageal structure and function in all. MethodsDiagnoses had been established by contrast radiography, small bowel manometry, and urodynamic studies. To investigate the esophagus, we endoscoped and biopsied the esophagus of each patient on multiple occasions. All patients also underwent water soluble contrast esophagography and esophageal manometry. ResultsUpon careful questioning, all patients had swallowing dysfunction, and the majority of their enteral intake was via gastrostomy or gastrojejunostomy. All took some oral alimentation, but eating was slow and none could aliment themselves completely by the oral route, receiving 50% or less of their calories by mouth. Four had megaesophagus whereas the esophagus of the two youngest was of normal caliber. All had eosinophilic esophagitis and/or esophageal Candidiasis from time to time, but successful treatment of these findings failed to improve their symptoms. Manometry revealed normal lower esophageal sphincter (LES) resting tone and normal LES relaxation, but for all, peristalsis was absent in the esophageal body. ConclusionsThis series expands the spectrum of findings in MMIHS, to include a primary motility disorder of the esophageal body. As patients age, the esophageal caliber appears to increase. Successful treatment of neither esophageal eosinophilia nor Candidiasis is effective in ameliorating the motility disorder. If our findings are confirmed in more patients with MMIHS, this disorder should be renamed, megacystis–microcolon–intestinal-and esophageal hypoperistalsis syndrome. Type of studyPrognosis study, Level IV (case series).

Pediatric Intestinal Failure: The Key Outcomes for the First 100 Patients Treated in a National Tertiary Referral Center During 1984-2017.

Pediatric-onset intestinal failure (IF) remains a severe illness with life-threatening consequences. In this study, we analyzed a single center's outcomes of IF over 3 decades. All children with IF who required parenteral nutrition (PN) >2 months or small-intestinal resection ≥50% managed since 1984 were included for retrospective outcome analyses. In total, 100 patients with median PN duration of 1.2 (interquartile range, 0.4-3.5) years were identified. Causes of IF were short bowel syndrome (SBS; n = 78), primary intestinal motility disorders (n = 14), and congenital intestinopathies (n = 8). Patients with SBS had median 40 (25-60) cm of small bowel remaining. Overall, Kaplan-Meier 5- and 10-year weaning-off estimates were 67% (95% CI, 57-77) and 73% (95% CI, 63-84), respectively. Weaning off PN was predicted by remaining bowel anatomy, multidisciplinary treatment era, and absence of immune deficiency. Catheter-related bloodstream infections decreased from 1.4 to 0.6/1000 PN days (P = .0003) with systematic use of taurolidine locks. None had progressive liver disease. Thirty-one percent of patients with SBS underwent autologous intestinal reconstructive surgery. Five patients received and 2 were listed for isolated intestinal transplantation. Eight patients died, and overall 15-year survival rate estimate was 91% (95% CI, 85-98). Despite reassuring rates of survival and weaning off PN, long-term PN failed in 14% of patients solely because of catheter complications in the recent era. Achievement of enteral autonomy in those with the shortest remaining small bowel and functional cause of IF remains challenging.

Intestinal failure as a significant risk factor for renal impairment in children.

Although impaired renal function has been a frequent finding among adults with intestinal failure (IF), the data on children is scarce. The aim of this study was to assess renal function in pediatric-onset IF. Medical records of 70 patients (38 boys) with pediatric-onset IF due to either short bowel syndrome (n=59) or primary motility disorder (n=11) and a history of parenteral nutrition (PN) dependency for ≥1mo were evaluated. Renal function at the most recent follow-up was studied using plasma creatinine, cystatin C, and urea concentrations and estimated glomerular filtration rate (eGFR). At a median age of 5.7y and after PN duration of 3.2y, 20 patients (29%) had decreased eGFR and higher cystatin C and urea concentrations. Patients with decreased renal function had significantly longer duration of PN (3.2 versus 0.9y; P=0.030) and shorter percentage of age-adjusted small bowel length remaining (22 versus 32%; P=0.041) compared with patients with preserved renal function. No other predisposing factors for decreased eGFR were identified. Patients with pediatric-onset IF are at significant risk for impaired renal function, which is associated with the duration of PN and the length of the remaining small bowel. In the present study, no other predisposing factors for decreased eGFR were found. Further studies using measured GFR are needed.

Diagnostic outcome of contrast videofluoroscopic swallowing studies in 216 dysphagic dogs.

Determining the anatomic and functional origin for dysphagia is critical for development of an appropriate therapeutic plan and determination of the prognosis. The purpose of this retrospective study was to report the quantitative and qualitative outcome of contrast videofluoroscopic swallowing studies in a large cohort of dysphagic dogs presenting to a tertiary veterinary care hospital. The videofluoroscopic swallowing studies were reviewed to generate values for pharyngeal constriction ratio, timing of swallowing events (maximum pharyngeal contraction, opening of upper esophageal sphincter, closing of upper esophageal sphincter, and reopening of epiglottis), type of esophageal peristalsis generated, and esophageal transit time. One or more anatomic locations for origin of dysphagia were assigned (pharyngeal, cricopharyngeal, esophageal (primary motility disorder), other esophageal (stricture, vascular ring anomaly, mass), lower esophageal sphincter/hiatus. Sixty-one of 216 studies (28%) were deemed unremarkable. Twenty-seven of 216 dogs (13%) had pharyngeal dysphagia, 17/216 dogs (8%) had cricopharyngeal dysphagia, 98/216 dogs (45%) had dysphagia secondary to esophageal dysmotility, 19/216 dogs (9%) had dysphagia secondary to focal esophageal disorders, and 97/216 dogs (45%) had dysphagia of lower esophageal sphincter/hiatus origin. Multiple abnormalities were present in 82/216 (38%) dogs. Elevated pharyngeal constriction ratio was associated with pharyngeal, cricopharyngeal, and esophageal motility disorders, delayed upper esophageal sphincter opening was associated with cricopharyngeal disorders, a lower percentage of primary esophageal peristaltic waves was associated with cricopharyngeal, pharyngeal, or primary esophageal motility disorders. In conclusion, videofluoroscopic swallowing studies was pivotal in the diagnosis of dysphagia with 155/216 (72%) dogs receiving a final diagnosis.

Waist to hip ratio is a better predictor of esophageal acid exposure than body mass index.

Obesity and gastroesophageal reflux disease (GERD) are major health problems showing an inconstant relationship in the literature. Therefore, anthropometric parameters which are predictive and can simply be assessed at first patient presentation may lead to a better patient selection for ambulatory reflux monitoring. We aimed to examine the association of body mass index (BMI) and waist to hip ratio (WHR) with gastroesophageal reflux activity during 24hour-pH-impedance monitoring. Seven hundred and seventy-one patients with GERD symptoms underwent 24hour-pH-impedance monitoring and high resolution manometry off proton pump inhibitors. Patients with known primary motility disorders of the esophagus and pre-existing endoscopic or operative procedure on esophagus or stomach were excluded from the study. Reflux parameters and anthropometric and demographic data from our prospectively gathered database were analyzed. We performed univariate and multivariate regression analysis to evaluate the associations of BMI and WHR with reflux parameters measured with 24hour-pH-impedance monitoring. WHR showed a significantly stronger association with esophageal acid exposure than BMI (P<.001). Our data show that 6.9% of the percentage of endoluminal pH<4 in the distal esophagus is attributable to WHR. Furthermore, an association of WHR with impaired esophageal acid clearance was observed. Additionally, we observed an inverse relationship between lower esophageal sphincter integrity (P=.05) and esophageal acid exposure. WHR is a better predictor for esophageal acid exposure than BMI. Biomechanical and metabolic mechanisms of central fat distribution may influence reflux parameters in 24hour pH impedance monitoring, which may affect patient selection for ambulatory reflux monitoring.

Peroral Endoscopic Myotomy (POEM) for Achalasia

Achalasia, a primary motility disorder of the esophagus, is the result of improper relaxation of the lower esophageal sphincter and has an incidence ranging from 1 to 6 in 100,000. Impaired transit of food and liquid from the esophagus to the stomach results in symptoms of dysphagia, regurgitation, retrosternal fullness/pain, and weight loss. Symptoms can be managed with a range of medical or procedural therapy. However, the best results are obtained from surgical management with myotomy. Per oral endoscopic myotomy (POEM) has emerged as a less invasive manner through which to perform a myotomy and provides relief of dysphagia comparable to laparoscopic Heller myotomy – the current standard of surgical therapy for achalasia.

Long-term outcome of peroral endoscopic myotomy for esophageal achalasia in patients with previous Heller myotomy.

Peroral endoscopic myotomy (POEM) is an emerging procedure in the treatment of esophageal achalasia, a primary motility disorder. However, the long-term outcome of POEM in patients, who have previously undergone a Heller myotomy, is unknown. Using a local database, we identified patients with esophageal achalasia, who underwent POEM. We compared patients with a previous Heller myotomy to those, who had received none or only non-surgical therapy prior to the POEM procedure. We conducted follow-up examinations at 3, 12, and 24months following the procedure. We included 66 consecutive patients undergoing POEM for achalasia, of which 14 (21.2%) had undergone a prior Heller myotomy. In both groups, the preoperative Eckardt score was 7. Postoperatively, the non-Heller group experienced a more pronounced symptom relief at both 3-, 12-, and 24-month follow-up compared with the Heller group, and there was a tendency for the effect of POEM to reduce over time. We suggest that there isa correlation between preoperative measurements of gastroesophageal sphincterpressures and the chance of a successful POEM. POEM has a place in the treatment of esophageal achalasia in patients with a prior Heller myotomy and persistent symptoms as it is a safe procedure with acceptable long-term results.

How to Effectively Use High-Resolution Esophageal Manometry

How to Effectively Use High-Resolution Esophageal Manometry

Update on the endoscopic treatments for achalasia.

Achalasia is the most common primary motility disorder of the esophagus and presents as dysphagia to solids and liquids. It is characterized by impaired deglutitive relaxation of the lower esophageal sphincter. High-resolution manometry allows for definitive diagnosis and classification of achalasia, with type II being the most responsive to therapy. Since no cure for achalasia exists, early diagnosis and treatment of the disease is critical to prevent end-stage disease. The central tenant of diagnosis is to first rule out mechanical obstruction due to stricture or malignancy, which is often accomplished by endoscopic and fluoroscopic examination. Therapeutic options include pneumatic dilation (PD), surgical myotomy, and endoscopic injection of botulinum toxin injection. Heller myotomy and PD are more efficacious than pharmacologic therapies and should be considered first-line treatment options. Per oral endoscopic myotomy (POEM) is a minimally-invasive endoscopic therapy that might be as effective as surgical myotomy when performed by a trained and experienced endoscopist, although long-term data are lacking. Overall, therapy should be individualized to each patient’s clinical situation and based upon his or her risk tolerance, operative candidacy, and life expectancy. In instances of therapeutic failure or symptom recurrence re-treatment is possible and can include PD or POEM of the wall opposite the site of prior myotomy. Patients undergoing therapy for achalasia require counseling, as the goal of therapy is to improve swallowing and prevent late manifestations of the disease rather than to restore normal swallowing, which is unfortunately impossible.

Functional Gallbladder Dyskinesia and Pathological Finding of Gallbladder Microlithiasis: Which Came First — The Chicken or the Egg?

Introduction: Functional gallbladder (GB) dyskinesia is a debilitating disorder. We have previously shown that a significant number of subjects with chronic dyspepsia and a negative gastrointestinal (GI) work up had functional GB dyskinesia, which is characterized by a low GB ejection fraction (GBEF). Functional GB dyskinesia is thought to be due to metabolic disorders such as bile supersaturated with cholesterol or as a result of a primary motility disorder. However, the definitive etiology remains unclear. We examined the association of GB dyskinesia and blood dyscrasia, hypercholesterolemia, obesity, diabetes mellitus, and pathological findings of microlithiasis in subjects who underwent cholecystectomy. Methods: We retrospectively studied 129 subjects whose symptoms could not be explained by findings on abdominal ultrasound and computed tomography scan, upper and lower GI endoscopy. We excluded subjects with incomplete data, radiological findings of cholelithiasis/choledocholithiasis, previous sphincterotomy, any biliary surgery, and ongoing prokinetic medications. Pathology specimens were studied in those patients diagnosed with GB dyskinesia (low GBEF). Statistical analysis was performed using chi-square for categorical variables and t-test for continuous variables with age-, gender-, and ethnicity-adjusted odds ratios. Unconditional logistic regression model was used to estimate 95% confidence intervals (CI). SAS 9.3 software was used to perform the statistical analysis. Results are shown as mean (range). Results: One hundred twenty nine subjects were included. Seventy two percent (93/129) were female and fifty three percent (69/129) were African American. Mean age of the subjects was 54 (range 15-96). Fifty two percent (68/129) of subjects were diagnosed with GB dyskinesia. Of these, 24% (16/68) had chronic cholecystitis, and 3% (2/68) had microlithiasis found in pathological specimens. On multivariate analysis, the presence of blood dyscrasias (p=0.60), hypercholesterolemia (p=0.60), and diabetes mellitus (p=0.70) were not statistically significant. No correlation was found among age, gender, ethnicity, BMI, and GB dyskinesia. Conclusion: Metabolic disorders such as blood dyscrasia, hypercholesterolemia, and diabetes mellitus were not associated with GB dyskinesia. However, we found that subjects with GB dyskinesia had chronic cholecystitis and microlithiasis, which was not detected by imaging studies. Larger studies are warranted to validate these findings.

Refined Multidisciplinary Protocol-Based Approach to Short Bowel Syndrome Improves Outcomes.

Management of short bowel syndrome (SBS) has significantly evolved recently. We present our single-center, 25-year experience focusing on the implementation of a refined multidisciplinary SBS care protocol. This is a retrospective review of the patients with SBS treated at our tertiary center from 1988 to 2014, with either <25% short bowel remaining or duration of parenteral nutrition (PN) >3 months. Patients with primary intestinal motility disorders were excluded. Clinical characteristics, including intestinal anatomy, markers of cholestasis, and catheter-related infections (CRIs), were analyzed. The implementation of a refined modern uniform management protocol in 2009 divided the cohort into 2 subgroups, whose outcomes are compared. Forty-eight patients with SBS were identified (median gestational age 33 weeks). Of them, 22 were born between 2009 and 2014. The main causes of SBS were necrotizing enterocolitis (46%) and midgut volvulus (23%). Median remaining small bowel length was 36 cm. The overall survival was 23 of 26 (88%) before 2009 and 21 of 22 (95%) thereafter, whereas none were transplanted. Duration of PN shortened from a median of 15 to 6 months (P = 0.0015) in the latter cohort, whereas frequency of autologous intestinal reconstruction surgery (31%) remained unchanged. Frequency of neonatal cholestasis was similar in both groups (75%), but cleared in all after 2009. Before 2009, 2 patients died of progressive cholestatic liver failure. The CRI rates decreased from 1.7 to 0.7 per 1000 catheter-days between 2000-2008 and 2009-2014, respectively (P = 0.0178). Uniform refined multidisciplinary approach decreased the duration of PN and CRI rates with high transplant-free survival and avoidance of liver failure, although the frequency of transient neonatal cholestasis remained unchanged.

Autologous intestinal reconstruction surgery as part of comprehensive management of intestinal failure.

Pediatric intestinal failure (IF) remains to be associated with significant morbidity and mortality, the most frequent underlying etiologies being short bowel syndrome (SBS), and primary motility disorders. Management aims to assure growth and development, while preventing complications and facilitating weaning off parenteral support (PS) by fully utilizing adaptation potential of the remaining gut. Probability of survival and weaning off PS is improved by coordinated multidisciplinary intestinal rehabilitation combining individualized physiological enteral and parenteral nutrition (PN), meticulous central line care and medical management with carefully planned surgical care. Increasing evidence suggests that autologous intestinal reconstruction (AIR) surgery is effective treatment for selected short bowel patients. Bowel lengthening procedures normalize pathological adaptation-associated short bowel dilatation with potential to support intestinal absorption and liver function by various mechanisms. Although reversed small intestinal segment, designed to prolong accelerated intestinal transit, improves absorption in adult SBS, its feasibility in children remains unclear. Controlled bowel obstruction to induce dilatation followed by bowel lengthening aims to gain extra length in patients with the shortest duodenojejunal remnant. Reduced PS requirement limits the extent of complications, improving prognosis and quality of life. The great majority of children with SBS can be weaned from PS while prognosis of intractable primary motility disorders remains poor without intestinal transplantation, which serves as a salvage therapy for life-threatening complications such as liver failure, central vein thrombosis or recurrent bloodstream infections.

Surgical rehabilitation of short and dysmotile intestine in children and adults

Aims. This is a descriptive study aiming to compare outcomes of intestinal rehabilitation surgery among pediatric and adult intestinal failure (IF) patients with either primary intestinal motility disorders or short bowel syndrome (SBS) treated by our nationwide program. Methods. Medical records of IF patients (n = 31, 71% children) having undergone autologous intestinal reconstructions (AIR) (n = 25), intestinal transplantation (ITx) (n = 5), or being listed for ITx (n = 2) between 1994 and 2014 were reviewed. Results. At surgery, median age was 3.4 (interquartile range, 1.0–22.1) in SBS (n = 22) and 16.5 (3.2–26.7) years in dysmotility patients (n = 9) who received median 60% and 83% of energy requirement parenterally, respectively. Median small bowel length was shorter in SBS than dysmotility patients (34 versus 157 cm, p < 0.001). Following AIR, none of the dysmotility patients achieved permanent intestinal autonomy, whereas 68% of SBS patients weaned off parenteral nutrition (PN) (p = 0.022) and none required listing for ITx. Five dysmotility patients who underwent ITx achieved intestinal autonomy. Regarding both AIR and ITx procedures, no significant difference in PN weaning was observed between the two subgroups. At last follow-up, 3.3 (0.6–8.0) years postoperatively, median plasma bilirubin was 6 (4–16) µmol/l, while liver biopsy showed fibrosis (Metavir stage 1–2) in 50% and cholestasis in 8%. Proportion of PN energy requirement had reduced significantly (p = 0.043) among PN-dependent SBS (n = 7) but not among dysmotility patients (n = 5). Overall survival was 90%. Conclusion. AIR surgery was beneficial among selected SBS patients, whereas in intestinal dysmotility disorders, permanent PN weaning was only achieved by ITx.

Laparoscopic Heller myotomy for achalasia: does the age of the patient affect the outcome?

Esophageal achalasia is the most common primary motility disorder of the esophageal body and lower esophageal sphincter. The optimal management strategy for elderly patients with achalasia remains inconclusive, however elderly patients are still more likely to be recommended for endoscopic treatments rather than LHM, due to a perception of increased surgical risk in these patients. Advantages of surgical myotomy in the elderly over pneumatic dilation are: 1. the risk of mucosal perforation during surgery is better controlled than after endoscopic balloon dilatation and 2. the greater efficacy for the surgical approach where only one procedure is routinely required whereas pneumatic dilation often requires repeat treatment to achieve long-term relief of symptoms.

Peroral Endoscopic Myotomy (POEM) for Esophageal Primary Motility Disorders: Analysis of 100 Consecutive Patients

IntroductionPeroral endoscopic myotomy (POEM) is a flexible endoscopic approach to the lower esophageal sphincter (LES) providing access for a myotomy to relieve dysphagia. The technique has been adopted worldwide due to reports of excellent short-term clinical outcomes. We report on a consecutive patient cohort with clinical and objective outcomes representing the establishment of a POEM program within a busy esophageal surgical practice. MethodsComprehensive data was collected prospectively on all patients undergoing POEM from October 2010 to November 2013 at a single institution. Patients were classified based on high-resolution manometry (HRM). Operative data and immediate outcomes were reviewed. Symptom scores, HRM, and timed barium swallow (TBS) were performed prior to the procedure. Patients were asked to undergo routine postoperative testing 6–12 months after surgery with the addition of standard 24-h pH to the preoperative protocol. Morbidity was defined as requiring additional procedures or prolonged hospital stay >2 days. ResultsOne hundred POEM patients were included in the final analysis. The mean age was 58 years (18–83 years). Primary presenting symptoms included dysphagia 81, chest pain 10, and regurgitation 9. The mean follow-up was 16 months. HRM diagnoses were 75 achalasia (30 type I, 43 type II, 2 type III), 12 nutcracker esophagus, 5 diffuse esophageal spasm (DES), and 8 isolated hypertensive non-relaxing LES.The mean operative time was 128 min. The median hospital length of stay (LOS) was 1 day. The overall morbidity was 6 %; all were treated endoscopically or with conservative management without further sequelae (three had intra-tunnel leak diagnosed on routine esophagram and one developed a postoperative intra-tunnel hemorrhage, one developed Ogilvie’s, and one required prolonged intubation for CO2 retention).The average LES resting/residual pressure significantly decreased (44.3/22.2 to 19.6/11.7 in millimeters of mercury). Esophageal emptying improved from 40 to 90 % on TBS with 93 % patients demonstrating >90 % emptying at 1 min. Of the achalasia patients, 36 % (17/47) showed some return of normal peristalsis (≥70 % peristalsis) on post-op HRM.Abnormal acid exposure was present on postoperative testing in 38 % (26/68). Of these, 14 were asymptomatic. No reflux patient required additional antireflux procedure.Eckardt scores decreased from 6 to 1. Dysphagia was improved or eradicated in 97 % with a complete resolution accomplished in 89 %. Complete dysphagia relief was better for achalasia patients (46/47 patients; 97.8 %) vs. non-achalasia patients (17/24; 70.8 %). Of those with preoperative chest pain, 91.5 % reported complete relief.Four patients have refractory dysphagia. Two non-achalasia patients underwent subsequent laparoscopic Heller myotomy and two are improved following serial endoscopic dilatations. ConclusionThis study represents the largest POEM series to date that includes objective data. Despite reflux in one/three of patients, POEM provides excellent relief of dysphagia (97 %) and chest pain (91.5 %) for patients with esophageal spastic disorders with acceptable procedural morbidity.

Chronische Motilitätsstörungen des oberen Gastrointestinaltrakts im Alter

Primary motility disorders of the upper gastrointestinal (GI) tract result from an impairment of the motor function of the esophagus, stomach, and duodenum by malfunction of the enteric nervous system or degeneration of the gastrointestinal muscle layer. Other forms of upper GI motility disorders occur secondary to underlying systemic diseases. The exact pathophysiology of the disturbances within the enteric nervous system of the upper GI tract is not yet clearly understood. For motility disorders resulting from systemic diseases the lack of knowledge with respect to the underlying pathomechanism is even greater. The term functional dyspepsia summarizes some symptoms of the upper abdomen, suggesting a disorder of upper GI motility or perception; however, this link to disturbed physiology has never been convincingly demonstrated. This overview describes therapeutic options for motility disorders of the upper GI tract regarding medicinal, endoscopic and surgical targets. The efficacy of medicinal therapy of upper GI motility disorders is low due to the lack of understanding of the pathophysiology. Therefore, endoscopic and other interventional therapies have to be applied also in the elderly patient group. The restrictions for metoclopramide published by the European Medicines Agency (EMA) in July 2013 have limited the armentarium of medicinal therapy of chronic motility disorders of the upper GI tract.