Sphincter Relaxation Research Articles

BN SO25 - Laparoscopic Management of Achalasia and Iatrogenic Mucosal Perforation in a Patient with Severe Reflux Following Multiple Therapeutic Dilatations

Abstract Background Laparoscopic Heller's cardiomyotomy (LHC) is the gold standard intervention for achalasia. Owing to its well-established complications of reflux symptoms, some surgeons perform an additional fundoplication surgery, although the consensus regarding the clinical benefits of this approach remains unclear.1 A meta-analysis showed that posterior fundoplication has proven to be superior to anterior fundoplication in controlling reflux symptoms.2 Method A gentleman in his 60s reported ongoing severe reflux symptoms following multiple Rigiflex ballon dilatations for achalasia, on manometry and pH studies showed features of pathological acid reflux, incomplete lower oesophageal sphincter relaxation and defective peristalsis. As shown in the video, type 1 sliding hiatus hernia, submucosal fibrosis and peri-oesophagitis were seen intraoperatively. A short cardiomyotomy was performed, which was complicated by iatrogenic oesophageal perforation. Anterior fundoplication with mucosal closure was performed. Results Following the surgery, no leak was observed on the swallow test and the patient reported a massive improvement in reflux symptoms. The addition of fundoplication to LHC in patients with achalasia and reflux symptoms has improved clinical outcomes. Conclusion Concomitant LHC and anti-reflux surgery should be considered in patients presenting with achalasia and gastro-oesophageal reflux symptoms.

Esophageal achalasia presenting as recurrent pneumonia in children: A case series.

Esophageal achalasia (EA) is a rare primary esophageal motility disorder that is considered a rare etiology of dysphagia among infants and children. The proposed primary pathophysiology is related to the loss of ganglion cells in the distal esophageal sphincters, particularly in the Auerbachian muscle layer, which then leads to the dysmotility and failure of lower esophageal sphincter relaxation. Dysphagia, vomiting, poor weight gain, cough, and recurrent aspiration pneumonia are the most common presenting complaints. Herein, we report 3 cases of EA who presented with chronic cough and recurrent aspiration pneumonia. This study reviewed 3 pediatric patients with typical symptoms of EA. All the patients were admitted and referred to the pediatric pulmonology service for evaluation of recurrent pneumonia and suspected aspiration syndrome. All patients underwent a barium esophagogram as a part of the aerodigestive workup of recurrent vomiting, dysphagia, and aspiration pneumonia. Additionally, all the patients underwent workup for other associated congenital anomalies, which included echocardiography, brain magnetic resonance imaging, and an abdominal ultrasound. All patients had EA and presented with recurrent pneumonia. All patients had isolated EA, and none had any evidence of Allgrove syndrome. Pneumatic balloon dilatation was performed for all patients at the same time as the upper gastrointestinal endoscopy. Later, all the patients underwent a laparoscopic Heller myotomy and had no postoperative complications, and their symptoms resolved. EA is a rare condition in children, yet it can be a serious and life-threatening condition if left untreated. Our cases emphasize the significance of considering achalasia in children who experience esophageal dysphagia and recurrent pneumonia. Several pediatric cases have been reported in which respiratory involvement was the primary manifestation of achalasia. These cases highlight the importance of considering gastrointestinal disorders, particularly EA, in the differential diagnosis of children who experience recurrent pneumonia. Early diagnosis and treatment with laparoscopic Heller myotomy can lead to good outcomes for children with achalasia.

An innovative electrical neurostimulation approach to mimic reflexive urination control in spinal cord injury models

Neurogenic lower urinary tract dysfunction (NLUTD) is a frequent consequence of spinal cord injury (SCI), leading to symptoms that significantly impact quality of life. Although many life-saving techniques are available, current treatment strategies for managing NLUTD still exhibit limitations and drawbacks. Here, we introduce a new electrical neuromodulation strategy involving electrical stimulation of the major pelvic ganglion (MPG) to initiate bladder contraction, in conjunction with innovative programmable (IPG) electrical stimulation on the pudendal nerve (PN) to induce external urethral sphincter (EUS) relaxation in freely moving or anesthetized SCI mice. Furthermore, we conducted the void spot assay, and cystometry coupled with EUS electromyography (EMG) recordings to evaluate voiding function, and monitor bladder pressure and EUS activity. Our findings demonstrate that our novel electrical neuromodulation approach effectively triggers coordinated bladder muscle contraction and EUS relaxation, effectively counteracting SCI-induced NLUTD. Additionally, this electrical neuromodulation method enhances voiding efficiency, closely resembling natural reflexive urination in SCI mice. Thus, our study offers a promising electrical neurostimulation approach aimed at restoring physiological coordination and potentially offering personalized treatment for improving voiding efficiency in individuals with SCI-associated NLUTD.

Delayed diagnosis and treatment of achalasia: a case report

BackgroundAchalasia is characterized as an esophageal motility disorder with incomplete relaxation of the lower esophageal sphincter. Achalasia can be associated with abnormal peristalsis and symptoms of dysphagia, acid reflux, and chest pain. The exact pathophysiology of achalasia remains unclear, but it is hypothesized to be due to degeneration of the myenteric plexus.Case presentationIn this case, a 46-year-old Hispanic man presented to the emergency room with a 12-year history of progressive discomfort with swallowing solids and liquids. Due to many years of incomplete follow-up care and lack of understanding of the course of his disease, this patient’s symptoms escalated to complete intolerance of oral intake and significant weight loss. He was diagnosed with achalasia during his hospital stay and treated successfully with laparoscopic Heller myotomy.ConclusionsThis case discussion illustrates the importance of follow-up care and patient education so that diagnosis and treatment of achalasia are not delayed.

Functional Disorders of the Biliary Tract and Cholelithiasis: Analysis of a Possible Relationship

Aim: Diagnostic criteria for functional disorders of the biliary tract are presented in the materials of the Rome IV consensus, as well as expert councils of Russian and foreign specialists. Episodes of functional biliary pain are caused by a violation of bile outflow through the cystic duct and sphincter of Oddi. It has been suggested that there is a “biliary continuum” in which in some patients’ biliary dysfunction is transformed into cholelithiasis. Key points. Lithogenic bile is considered as the pathophysiological basis for the development of biliary dyskinesia and cholelithiasis. Lithogenic bile provokes inflammation of low grades in the mucous membrane of the biliary tract, decreased contractility of the gallbladder and impaired relaxation of the biliary sphincters, impaired physiological response to cholecystokinin. Changes in motility of the biliary tract may be associated with the influence of hydrophobic bile salts and impaired eicosanoid metabolism. Hyperplasia of the epithelium and muscle layer, hypersecretion of mucin and cholesterol precipitation further impair the outflow of bile. Experimental data and some clinical observations indicate the possibility of transformation of biliary dysfunction into cholelithiasis. Dysfunction of the sphincter of Oddi is one of the possible consequences of cholecystectomy and, in fact, acts as a variant of postcholecystectomy syndrome. The basis for the treatment of biliary dysfunctions are antispasmodics of different classes, which can be combined with ursodeoxycholic acid. The biliary tract-selective antispasmodic hymecromone has shown high effectiveness in relieving biliary pain, which also has a moderate choleretic effect and the ability to prevent the crystallization of cholesterol in bile and can be used both for functional diseases and for cholelithiasis. The domestic drug hymecromone “Odecromone” entered the pharmaceutical market. Conclusion. There is no doubt that the relevance of further study of the patterns of development of biliary dysfunctions and GI is obvious. The study of this problem will contribute to the development of effective preventive approaches, including in the field of nutraceuticals.

Comprehensive Approaches to the Treatment of Esophageal Achalasia

Introduction and purpose Achalasia is the most prevalent primary esophageal motility disorder, marked by improper relaxation of the lower esophageal sphincter (LES), increased resting pressure in the LES, and a lack of peristalsis in the esophagus. Symptoms include difficulty swallowing (dysphagia), regurgitation, chest pain, and weight loss. Due to the nonspecific nature of these symptoms, diagnosis can be delayed by several years. Since the underlying cause of achalasia is still unknown, treatment options focus on alleviating symptoms by targeting the lower esophageal sphincter. Materials and methods This paper is based on a literature review sourced from PubMed, using the following keywords: achalasia, POEM, laparoscopic cardiomyotomy, pneumatic dilation, and botulinum toxin injection. Results Various treatment options are available for achalasia, each offering unique features and results. The main approaches include Peroral Endoscopic Myotomy (POEM), Laparoscopic Myotomy (LM), Botulinum Toxin Injection, and Pneumatic Dilation (PD). Conclusion Each treatment differs in its level of invasiveness, duration of symptom relief, risk of complications, and the likelihood of requiring additional interventions. The selection of the most suitable option is influenced by individual patient factors, such as the type and severity of achalasia, overall health, and personal preference

Effectiveness of 0.3 % nifedipine gel combined with 2.0 % lidocaine and BTA 80 U in treatment of chronic anal fissure. Pilot randomized study. Preliminary results

AIM: to improve the results of chronic anal fissure treatment. PATIENTS AND METHODS: the study included 22 patients randomized by random numbers generation method into 2 groups. Eleven patients were included in main group and were treated with 0.3 % nifedipine + 2.0 % lidocaine gel, 11 patients of the control group received injections of botulinum toxin A into the internal anal sphincter at a dose of 80 U (BTA 80). RESULTS: by day 30, there was a decrease of maximal resting pressure in anal canal (MRPAC) in both the main and control groups [p = 0.015 and p = 0.004, respectively] and the average resting pressure in anal canal (ARPAC) [p = 0.01 and p = 0.02, respectively]. There was no difference between the groups in pain severity both after stool and during the day (p = 0.5 and p = 0.6, respectively). On day 60, the defect was epithelized in 6/11 (54.6 %) patients of the study group and in 9/11 (81.8 %) patients of the BTA 80 group [p = 0.36], respectively. The reason of treatment failure in 4/11 (36.4 %) patients of the main group and 2/11 (18.2 %) patients of the control group was a preserved internal sphincter spasm. It was found that these patients used a lower amount of the drug product — 2.2 (1.8; 2.5) mg/day compared to 2.4 (1.9; 2.7) mg/day in other patients. On the day 30 after surgical treatment, complaints about gas incontinence were registered in 1/11 (9.1 %) patients of the main group and 1/11 (9.1 %) patients of the control group [p = 1]. Such a complication as external hemorrhoid thrombosis occurred only in 1/11 (9.1 %) patients in the BTA 80 group [p = 0.87]. CONCLUSION: the study results show that gel containing 0.3 % nifedipine and 2 % lidocaine produces an effect on the tone of the internal sphincter comparable to BTA. However, the lack of accurate dosage of the drug product and/or low patient compliance reduce the effectiveness of treatment and make the use of BTA preferable for medical relaxation of the internal sphincter.

793. MODIFIED HELLER DOR FOR ACHALASIA

Abstract Introduction Achalasia is an esophageal disorder that involves a failure in the relaxation of the lower esophageal sphincter, which leads to dysphagia and other symptoms. The objective of the present study is to report the surgical technique performed in a patient with achalasia, in which the Heller myotomy technique was performed together with Dor fundoplication. Method The technique performed was a modified Heller-Dor with long myotomy Surgical intervention began with the introduction of the trocars plus pneumoperitoneum, a narrow of distal esohagus and enlargement of the diaphragmatic crura, mas found. Continuing with dissection of the esophageal hiatus with ultrasonic forceps, release of phreno-esophageal membrane. The esophagus was elongated in the mediastinum and brought 7 centimeters to the abdomen. After that, there was approximation of the diaphragmatic crura with 1 point of Ethibond 2-0. Following the dissection of the eophagogastric junction and identification of the posterior and anterior vagus nerve, releasing the “fat pad” for correct identification of the esophagogastric junction. So, the myotomy in the esophagus 6 centimeters above the cardia and 3 centimeters below, was performed. Follow, the gastric fundus was sutured to the anterior border of the esophagus and left diaphragmatic pillar with 2-0 Ethibond, until the esophagus gastric junction in running suture. The anterior suture, covering the myotomy the edge of the muscular layer of the esophagus as the same way. Conclusion Finally, with regard to the treatment of achalasia, Heller cardiomyotomy plus Dor fundoplication, has been shown to be efficient for improvement of dysphagia symptoms and to avoid symptoms related to emergence of reflux after myotomy. https://drive.google.com/file/d/176L7Jo0tFMylWvhsgtscESHHFbOONl4A/view?usp=sharing

378. LAPAROSCOPIC PRIMARY CLOSURE OF ESOPHAGEAL RUPTURE CAUSED BY BALLOON DILATATION FOR ACHALASIA AND HELLER'S MYOTOMY WITH DOR FUNDOPLICATION

Abstract Background Achalasia is a Primary motor disorder of the esophagus cased by Insufficient lower esophageal sphincter relaxation and loss of esophageal peristalsis. Major clinical presentations are Dysphagia, regurgitation, and occasional chest pain with or without weight loss. One of most commonly performed conservative treatment is pneumatic dilatation and its most serious complication is esophageal perforation. In this presentation we will introduce a case of esophageal perforation caused by pneumatic dilatation for esophageal achalasia treated with laparoscopic primary closure of perforation and simultaneous Heller’s myotomy with Dor Fundoplication. Methods Esophageal perforation occurred during endoscopic pneumatic dilatation occurred in 61-year-old female patient with achalasia. Initially endoscopic clipping was performed but the patient showed leukocytosis, tachycardia and decreased oxygen saturation with dyspnea. Chest CT showed intraabdominal and mediastinal free air and defect in distal esophagus. Then the patient was referred for surgery. During laparoscopic exploration, 3cm mucosal and 6cm muscle tearing at distal esophagus 2cm proximal to the esophagogastric junction at 3 o’clock direction. After removal of endoscopic clips, primary closure of esophageal rupture in 2-layed method and simultaneous Heller’s Myotomy with Dor fundoplication at 12 o’clock direction was performed. Results The patient showed rapid recovery from septic condition. Nasogastric tube was removed 4 days after surgery. Upper GI series checked with gastrografin 5 days after surgery showed no leakage and no delayed passage in distal esophagus. Chest tube and abdominal drain were removed and the patient was discharged 10 days after surgery. There was no dysphagia and reflux during follow-up afterwards. Conclusion Primary closure for esophageal rupture occurred during balloon dilatation for achalasia and simultaneous Heller’s myotomy with Dor fundoplication by approaching the esophagus from a different direction were successfully performed reducing not only the risk of fulminant sepsis but also the burden of the surgery for achalasia that would be needed to be performed later.

Long-term Outcomes of Periurethral Sphincter Botulinum Toxin in Female Chronic Urinary Retention.

Nonneurogenic chronic urinary retention is an uncommon problem in young female individuals, and a well characterised causes is Fowler syndrome (primary disorder of urethral sphincter relaxation). Intermittent catheterisation is often challenging, and gold standard treatment sacral neuromodulation is not widely available. Urethral sphincter botulinum toxin injection has been shown to be effective cross-sectionally, however little is known about long-term outcomes. Female individuals presenting with urinary retention due to Fowler syndrome were reviewed retrospectively from a single tertiary referral centre over an 11-year period (2010-2021). One hundred units of onabotulinum toxin A (BoTX-A) was injected into the striated urethral sphincter in a divided dose by the periurethral approach. Efficacy and side effects were assessed 4 weeks after injection. Thirty-three female individuals with a mean age of 40.1±14.1 years received 165 unique urethral sphincter BoTX-A injections over 11 years. Nineteen individuals (57.6%) presented in acute urinary retention, and 28 (84.8%) were reliant on catheterisation. Twenty-one individuals (64%) responded to BoTX-A injections and had a significantly raised baseline maximum urethral closure pressure (MUCP), compared to nonresponders (114.6 cm H2O, P=0.012). Side effects were reported following 19 injections (11.5%) however, were mild and transient. Fifteen individuals received more than 1 botulinum toxin injection (median, 3 injections), with a median interval of 112 days (interquartile range) and efficacy persisted following repeat injections and no safety concerns were seen. Sphincter botulinum toxin through the periurethral approach is safe and effective following repeat injections, and offers a low-cost, minimally invasive alternative to managing female chronic urinary retention due to Fowler syndrome, particularly when there was a high baseline MUCP.

EndoFLIP Use in De Novo and Revisional Foregut Surgery

AbstractEndoFLIP technology, utilizing impedance planimetry, has revolutionized the assessment of gastrointestinal sphincters by providing real-time measurements of cross-sectional area and pressure to calculate distensibility. This review explores its application in de novo and revisional foregut surgeries. Preoperatively, EndoFLIP has demonstrated efficacy in evaluating gastroesophageal reflux disease, hiatal hernia, and esophageal motility disorders, including achalasia, by distinguishing motility patterns and identifying sphincter incompetence. In gastroparesis, EndoFLIP's measurement of pyloric distensibility correlates with gastric emptying and symptom severity, guiding therapeutic decisions for pyloric interventions. Intraoperatively, EndoFLIP optimizes surgical outcomes in antireflux procedures, such as fundoplication and hiatal hernia repairs, by balancing effective reflux control with minimizing postoperative complications like dysphagia and gas bloat. For esophageal myotomy, including Heller myotomy and per oral endoscopic myotomy, EndoFLIP ensures adequate sphincter relaxation, reducing reflux risks. Additionally, during endoscopic pyloromyotomy for gastroparesis, EndoFLIP predicts clinical success by assessing postprocedural distensibility. While promising, further research is essential to establish standardized intraoperative protocols and ideal measurement targets, enhancing the reproducibility and accuracy of EndoFLIP applications. Overall, EndoFLIP offers a significant advancement in foregut surgery, improving diagnostic precision and therapeutic outcomes.

Regurgitation, eructation, and supragastric belch: retrograde esophageal motility, disorders, and treatment.

This review describes pathologic conditions of retrograde flow into the esophagus along with recent therapeutic advances and treatment options. The esophagus facilitates anterograde and retrograde movement of contents, the latter of which is mediated by transient lower esophageal sphincter relaxations (TLESRs). Gastroesophageal reflux disease (GERD) often includes esophageal-specific symptoms such as heartburn or regurgitation. Volume regurgitation responds less frequently to acid suppression with proton pump inhibitors (PPIs) than heartburn, given its relationship with incompetence of the esophagogastric junction (EGJ) and increased frequency of TLESRs. Therefore, although the refluxate pH can be altered with PPIs, the frequency of reflux episodes is generally not reduced and surgical and endoscopic treatments may be favored. Other instances of abnormal retrograde esophageal flow respond better to medical therapy, or lifestyle interventions. Compared to gastric belching because of increased stomach distension, supragastric belching is caused by intake of air from pharynx into the esophagus followed by rapid expulsion of air. These conditions can be distinguished on esophageal tests such as high-resolution manometry and are likely to respond to behavioral modifications. Retrograde flow into the esophagus can be a normal occurrence, but diagnostic testing to distinguish causes can guide appropriate intervention.

Gastroesophageal Reflux Disease: New Insights and Treatment Approaches.

Gastroesophageal reflux disease (GERD) remains a significant global health concern, with increasing prevalence and a substantial impact on quality of life. This narrative review explores recent advances in our understanding of GERD pathophysiology, diagnosis, and management. The complex interplay of factors contributing to GERD, including lower esophageal sphincter dysfunction, transient sphincter relaxations, and esophageal motility disorders, is discussed. Emerging diagnostic techniques, such as high-resolution manometry and impedance-pH monitoring, have enhanced our ability to accurately identify and characterize GERD. The review highlights the evolving landscape of GERD treatment, from conventional approaches like lifestyle modifications and proton pump inhibitors to novel strategies including potassium-competitive acid blockers, endoscopic therapies, and minimally invasive surgical techniques. The potential role of the microbiome in GERD pathogenesis and as a therapeutic target is examined. The concept of personalized medicine in GERD management is explored, considering genetic factors, biomarkers, and individual patient profiles. Complications of GERD, including erosive esophagitis, Barrett's esophagus, and esophageal adenocarcinoma, are reviewed, emphasizing the importance of early detection and appropriate management. The economic burden and impact on the quality of due to GERD are also addressed. This comprehensive review underscores the multifaceted nature of GERD and the need for a personalized, multidisciplinary approach to its management. It highlights ongoing research efforts and emerging therapies that promise to improve outcomes for GERD patients, while also identifying areas requiring further investigation to optimize diagnosis and treatment strategies.

Manometric Abnormalities in Patients With and Without Chronic Cough

PurposeThis study examines the relationship between chronic cough and vagal hypersensitivity by measuring baseline esophageal motility, with interest in the upper esophageal sphincter (UES). Materials and methodsPatients undergoing workup for dysphagia were assigned to a chronic cough or control group based on self-reported symptoms. Differences in demographics, medical comorbidities, and high resolution esophageal manometry findings were obtained retrospectively. Results62.5% of our cohort had chronic cough (30/48). There were no significant differences between the two groups with respect to sex, age, and race/ethnicity. Laryngopharyngeal reflux (LPR) was the only statistically significant predictor of CC (OR 74.04, p = 0.010). Cough patients had upper esophageal sphincter relaxation duration (734 ms) significantly longer than the non-cough patients (582 ms; p = 0.03), though both groups had similar upper esophageal mean basal pressure, mean residual pressure, relaxation time-to-nadir, and recovery time. No significant difference was found in the median intrabolus pressure and UES motility mean peak pressure between groups. ConclusionSubtle differences in high-resolution manometry between patients with and without cough suggest, in line with previous studies, baseline alterations of upper esophageal function may manifest in patients with chronic cough through an undetermined mechanism that may include underlying vagal hypersensitivity. These findings encourage further manometric study examining the relationship between UES dysfunction and chronic cough.

Severe Dysphagia in a Patient with Wallenberg Syndrome and Killian Jamieson Diverticulum: A Case Report

Lateral medullary syndrome (Wallenberg syndrome) and Killian Jamieson diverticulum are both conditions known to cause dysphagia. Here, we present the first reported case of severe dysphagia due to Wallenberg syndrome and a Killian Jamieson diverticulum discovered incidentally during videofluoroscopic swallowing study. A 66-year-old male previously diagnosed with Wallenberg syndrome was referred to our hospital due to severe dysphagia. Pre-operative work-up revealed decreased left-sided pharyngeal contraction, left vocal fold paralysis, impaired laryngeal elevation, and poor upper esophageal sphincter relaxation during swallowing. Furthermore, on videofluoroscopic swallowing study, an incidental finding of a contrast-filled outpouching of the esophagus on the left, below the level of the cricopharyngeus, indicated the presence of a pharyngoesophageal diverticulum. The patient underwent bilateral cricopharyngeal myotomy with diverticulectomy, laryngeal suspension surgery, and tracheostoma revision. The diagnosis of a Killian Jamieson diverticulum was confirmed based on intra-operative findings, as the diverticular pouch was indeed seen to be located below the cricopharyngeal muscle. For patients with severe dysphagia that does not improve with swallowing rehabilitation, swallowing improvement surgery is an option. It aims to improve pre-operatively identified dysfunctional sites in the swallowing mechanism. It is important to always consider pharyngoesophageal diverticula as a possible cause of dysphagia so as not to miss the diagnosis. In this patient’s case, diverticulectomy was necessary to ensure the best possible outcomes in terms of improving his dysphagia.

Exploratory study on the impact of intraesophageal pressure on quality of life in patients following total gastrectomy: a retrospective cohort study

BackgroundThe usefulness of high-resolution impedance manometry (HRIM) in patients who underwent total gastrectomy with Roux-en-Y (R-Y) anastomosis has never been well validated. This study aimed to investigate whether intraesophageal pressure affects quality of life in patients who underwent total gastrectomy with R-Y anastomosis.MethodsThe participants comprised 12 patients who underwent total gastrectomy for gastric cancer between October 2014 and July 2022 and underwent a postsurgical HRIM examination. The association between the HRIM data and Postgastrectomy Syndrome Assessment Scale-37 (PGSAS-37) questionnaires was analyzed.ResultsEsophageal body motility was normal in almost all patients. The anastomosis shape (circular stapler and overlap method with linear stapler) did not influence intraesophageal pressure. The integrated relaxation pressure and lower esophageal sphincter (LES) residual pressure during swallowing-induced relaxation were involved in “diarrhea subscale” scores (p = 0.0244 and p = 0.0244, respectively). The average maximum intrabolus pressure was not involved in postgastrectomy symptom. The contractile front velocity correlated with the “indigestion subscale,” “diarrhea subscale,” and “constipation subscale” (p = 0.0408, p = 0.0143, and p = 0.0060, respectively). The distal latency, i.e., the time from upper esophageal sphincter relaxation to contractile deceleration, was also associated with the “abdominal pain subscale” (p = 0.0399). LES pressure and esophageal body motility affected patients’ quality of life after total gastrectomy.ConclusionsHRIM for the evaluation of intraesophageal pressure is useful for the functional assessment of esophagojejunostomy with the R-Y reconstruction after total gastrectomy.

Correlation of Balloon Pressure Used for Pneumatic Dilatation in Achalasia with Manometric Findings and Factors Associated With the Need for Repeat Procedure.

Achalasia is a chronic and rare disorder of esophageal motility. It is characterized by spastic or absent esophageal contractions and impairment of relaxation of the lower esophageal sphincter. Treatment modalities include smooth muscle-relaxing medications, botulinum toxin injections to lower the esophageal sphincter, pneumatic dilatation, and surgical interventions. Pneumatic dilatation is deemed to be an effective treatment option and is the most widely used non-surgical intervention. We designed this prospective study to look for any possible correlation between balloon pressure used in pneumatic dilatation, manometric findings, and patient characteristics. And to find any possible association between the need for repeat pneumatic dilatations and factors like gender, age, duration of symptoms, Eckardt score, daily retrosternal pain, manometric findings, and balloon pressures. Thirty-one patients with confirmed achalasia were enrolled in the study. All of these patients underwent pneumatic dilatation. Pearson's correlation coefficient was found to be 0.234 (p-value 0.23) between the required balloon pressure and integrated relaxation pressure (IRP). Six of these patients required repeat pneumatic dilatations. No statistically significant association was noted between the need for repeat intervention and gender, age over 40, age under 20, Eckardt score over 10, daily chest pain, duration of symptoms over two years, and IRP over 30 mmHg. In conclusion, it could be said that pneumatic dilatation does not carry a 100% success rate, and repeat sessions are needed in many of the patients with achalasia. So, long-term follow-up is crucial. Managing expectations and making a realistic plan with proper informational care is important at the beginning of treatment.

Gastroesophageal reflux disease after laparoscopic sleeve gastrectomy

Background. GastroEsophageal Reflux Disease (GERD) is a common problem among obese and overweight people, including as a complication of bariatric surgery, Laparoscopic Sleeve Gastrectomy (LSG). Aim. To conduct a retrospective analysis of the frequency of GERD in patients with morbid obesity after laparoscopic sleeve gastrectomy. Materials and Methods. In this retrospective study, data from 152 patients who underwent LSG were analyzed. All patients were diagnosed with morbid obesity and were deemed suitable for surgery. The minimum follow-up period was twelve months. All patients were assessed preoperatively for the severity of GERD using 24-hour pH monitoring, and upper gastrointestinal tract examination via FibroGastroDuodenoScopy (FGDS) to identify signs of reflux disease, esophagitis and Barrett's esophagus and GERD-HRQL (Health-Related Quality of Life) questionnaire. Results. During the study, out of 152 patients without GERD (DeMeester Index (DMI) was 6.87±3.38), 23 (15.1%) of them within 12 months after LSG developed de novo GERD (DMI 9.12±8.87, p=0.04). In four patients with de novo GERD, esophagitis grade A was detected. The pathomechanism of GERD following LSG was multifactorial, caused by a combination of anatomical, physiological, and physical factors. Contributing factors included the shape of the sleeve, damage to the lower esophageal sphincter, and esophageal motility disorders. Conclusions. LSG is effective in promoting weight loss, but poses a significant risk of developing GERD. Our study found a 15.1% incidence of GERD after LRH, which is lower than other studies, probably due to the routine use of 24-hour pH monitoring to identify patients with asymptomatic GERD. Anatomical changes due to LSG, in particular resection of the gastric fundus and dissection in the area of the angle of His, increase the temporary relaxation of the lower esophageal sphincter, contributing to the development of GERD. Keywords: bariatric surgery, morbid obesity, GERD.

Gastroesophageal reflux disease after laparoscopic sleeve gastrectomy

Background. GastroEsophageal Reflux Disease (GERD) is a common problem among obese and overweight people, including as a complication of bariatric surgery, Laparoscopic Sleeve Gastrectomy (LSG). Aim. To conduct a retrospective analysis of the frequency of GERD in patients with morbid obesity after laparoscopic sleeve gastrectomy. Materials and Methods. In this retrospective study, data from 152 patients who underwent LSG were analyzed. All patients were diagnosed with morbid obesity and were deemed suitable for surgery. The minimum follow-up period was twelve months. All patients were assessed preoperatively for the severity of GERD using 24-hour pH monitoring, and upper gastrointestinal tract examination via FibroGastroDuodenoScopy (FGDS) to identify signs of reflux disease, esophagitis and Barrett's esophagus and GERD-HRQL (Health-Related Quality of Life) questionnaire. Results. During the study, out of 152 patients without GERD (DeMeester Index (DMI) was 6.87±3.38), 23 (15.1%) of them within 12 months after LSG developed de novo GERD (DMI 9.12±8.87, p=0.04). In four patients with de novo GERD, esophagitis grade A was detected. The pathomechanism of GERD following LSG was multifactorial, caused by a combination of anatomical, physiological, and physical factors. Contributing factors included the shape of the sleeve, damage to the lower esophageal sphincter, and esophageal motility disorders. Conclusions. LSG is effective in promoting weight loss, but poses a significant risk of developing GERD. Our study found a 15.1% incidence of GERD after LRH, which is lower than other studies, probably due to the routine use of 24-hour pH monitoring to identify patients with asymptomatic GERD. Anatomical changes due to LSG, in particular resection of the gastric fundus and dissection in the area of the angle of His, increase the temporary relaxation of the lower esophageal sphincter, contributing to the development of GERD. Keywords: bariatric surgery, morbid obesity, GERD.

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.