Assessment of the rapid pullthrough technique in oesophageal manometry

Yield pressure, anatomy of the cardia and gastro-oesophageal reflux

The yield pressure at which the cardia opens in response to gastric distension was measured in 155 subjects with and without gastro-oesophageal reflux (GOR) and after Nissen fundoplication. Yield pressure was measured by endoscopy or during oesophageal manometry. The median pressure was significantly lower in subjects with GOR than in those without (P < 0.0001). After successful Nissen fundoplication this pressure increased to supranormal values (P < 0.0001). There was a close relationship between yield pressure and the presence and size of hiatus hernia and also between yield pressure and the valvular appearance of the cardia at endoscopy. There was a significant correlation between yield pressure and oesophageal acid exposure. However, no relationship was observed between yield pressure and lower oesophageal sphincter pressure or intra-abdominal length. These results suggest that yield pressure is useful for assessment of the competence of the cardia, particularly after antireflux surgery. The competence of the cardia is greatly influenced by its anatomical structure.

Manometric patterns using esophageal body and lower sphincter characteristics. Findings in 1013 patients

In order to determine the actual spectrum of abnormal esophageal motility, manometric patterns in 1013 consecutive tracings were established using a classification method that employs esophageal body and lower esophageal sphincter (LES) characteristics. Peristaltic performance and contraction wave parameters were measured in the esophageal body; basal pressure and relaxation were included for the LES. Nine hundred thirty (92%) of the tracings could be completely classified, and 33 different patterns were observed (915 occurring at a rate greater than 1%). Abnormalities were most common in contraction wave parameters (661 tracings, 65%), and least common in LES relaxation (105 tracings, 10%). Patterns most typical of achalasia and diffuse esophageal spasm were found in 6.4% and 5.0% of tracings, respectively. Statistical analysis of the patterns demonstrated that significant bidirectional predictive associations between categories were restricted to features representing pathology-based motor disorders (ie, achalasia and "scleroderma-esophagus"). This systematic classification method is capable of recognizing and cataloging common findings of motor dysfunction in the esophageal body and LES as well as uncommon patterns representing traditional motility disorders. Our findings provide reference data for clinical esophageal manometry.

Recurrent reflux and wrap disruption after Nissen fundoplication: detection, incidence and timing

One hundred and twenty-five patients with refractory gastro-oesophageal reflux disease underwent floppy Nissen fundoplication. Median follow-up was 52 months, and included endoscopy, manometry and prolonged pH recordings in all cases in addition to clinical assessment. Using objective criteria, 12 patients (9.6 per cent) developed recurrent reflux. In nine of these patients, endoscopy had suggested that the Nissen fundoplication had disrupted; wrap disruption was confirmed in seven patients who underwent reoperation. The median time to endoscopic recognition of wrap disruption was 7 months (range 3-10 months). In contrast, of 115 patients with endoscopic evidence of an intact fundoplication, only 3 (2.6 per cent) had recurrent reflux. Endoscopy allowed reliable differentiation between those with and without reflux control after operation (P less than 0.001). These results suggest that recurrent reflux after Nissen fundoplication is due to wrap disruption. This phenomenon occurs within the first postoperative year and can be recognized by informed endoscopic assessment.

Oesophageal manometry and pH recording does not predict the bad results of Nissen fundoplication

A prospective study of the value of preoperative oesophageal manometry in selecting patients for gastro-oesophageal reflux surgery has been performed. One hundred and twenty-six consecutive patients had a floppy Nissen fundoplication with a median follow-up period of 48 months (range 21-96 months). Reflux was controlled in 116 patients (92.1 per cent). One hundred and five patients (83.3 per cent) had a clinically satisfactory result (Visick grades 1 and 2). Poor results were largely due to recurrent reflux, technical failure or the irritable bowel syndrome. An unsatisfactory result was not more likely in those with upright reflux, an oesophageal motility disorder or a competent cardia as defined by manometry. Preoperative oesophageal studies, other than those required to make an accurate diagnosis, were found to have no value in deciding the suitability of patients for surgical correction of gastro-oesophageal reflux.

Esophageal motility in cirrhotics with and without esophageal varices

Esophageal manometry was performed in 45 cirrhotics with varices, in 15 cirrhotics without varices, and in 20 normal subjects, to define the effect of varices on esophageal motility. Cirrhotics with varices showed a decreased amplitude of motor waves in the lower half of the esophagus (p less than 0.01), an increased duration of primary peristaltic waves along the entire length of the esophagus (upper esophagus, p less than 0.05; lower esophagus, p less than 0.01), and an increased peak-to-peak speed of primary peristaltic waves (p less than 0.01). Resting lower esophageal sphincter pressure and duration of sphincter relaxation were similar in patients and controls. The above-mentioned abnormalities might be due to the mechanical effect of the presence of varices.

The lower oesophageal sphincter after floppy Nissen fundoplication

The pressure and intra-abdominal length of the lower oesophageal sphincter (LOS) were measured by oesophageal manometry before and after floppy Nissen fundoplication (FNP) for intractable gastrooesophageal reflux. Control of reflux was assessed by 24 h pH recording and endoscopy. It was complete in 67 cases (84.8 per cent) in this non-consecutive series. In the group as a whole LOS pressure increased significantly after FNP, but the intra-abdominal length did not. LOS pressure decreased in 21 cases of whom 16 (76.2 per cent) still had perfect reflux control. Likewise, intra-abdominal length decreased in 41 cases of whom 36 (87.8 per cent) had good reflux control. There was no evidence of a compensatory increase in length to account for reflux control when LOS pressure decreased. When a length-pressure diagram was plotted for the postoperative measurements no clear separation of those with persistent reflux could be seen. These results suggest that the measured changes in LOS pressure and length following FNP are an artefact of surgery rather than the means by which the operation controls gastro-oesophageal reflux.

Oesophageal manometry. A comparison of hydraulic and syringe catheter infusion systems using a simple hydrostatic bench model

A simple hydrostatic bench model is described which can be used to validate oesophageal intraluminal manometry measurements. Conventional syringe pump infusion was compared with the hydraulic capillary infusion system using this model. Accurate recording of pressure changes was achieved on the low compliance hydraulic system at infusion rates of 1 X 10(-8) m3 s-1 (0.6 ml min-1). To achieve comparable accuracy with syringe pump infusion, undesirably rapid infusion rates of 10.35 X 10(-8) m3 s-1 (6.2 ml min-1) were required. We believe that the hydrostatic bench model is a useful tool for checking the accuracy of infused catheter systems.