Ineffective oesophageal motility: Manometric subsets exhibit different symptom profiles

The American Foregut Society Clinical Practice Committee TIF Working Group, Brewer Gutierrez OI, Choi D, Hejazi R, Samo S, Tran MN, Chang KJ, Ihde G, Bell R, Nguyen NT. American Foregut Society White Paper on Transoral Incisionless Fundoplication

Gastroesophageal reflux disease (GERD) is a chronic disease on a spectrum that has an array of management options ranging from lifestyle changes, acid suppressive therapy to laparoscopic anti-reflux surgery (LARS). Transoral incisionless fundoplication (TIF) is an endoscopic procedure in the management of GERD that re-establishes and augments the gastroesophageal flap valve (GEFV). TIF is appropriate for patients that do not have a hiatal hernia greater than 2 cm. Patients with a hiatal hernia greater than 2 cm have the option to have either a conventional LARS (laparoscopic hiatal hernia repair with complete or partial fundoplication) or a concomitant laparoscopic hiatal hernia repair with TIF, known as concomitant TIF (cTIF). This white paper summarizes the published outcome data for TIF 2.0 and cTIF to date and outline the best practice approaches including patient assessment, selection, and management for TIF and cTIF.

Transoral incisionless fundoplication with EsophyX for gastroesophageal reflux disease: clinical efficacy is maintained up to 10 years

Background  Transoral incisionless fundoplication with EsophyX is reported to be effective in patients with gastroesophageal reflux disease in short-medium term follow-up. Aim  To examine clinical outcomes up to 10 years. Methods  In total, 51 procedures were performed in 50 patients. All entered a yearly clinical follow-up schedule including gastroesophageal reflux disease health-related quality-of-life questionnaires, heartburn and regurgitation scores, and daily proton pump inhibitor consumption. Results  The procedure was successfully performed in 49/50 patients. Severe complications occurred in 2/51 procedures. The remaining 49 patients were re-evaluated at 2 and 3 years, 41 after 5 years, 30 after 7 years, and 14 after 10 years. Eight patients were lost to follow-up between 3 and 5 years. Seven patients who were unresponsive to endoscopic fundoplication underwent surgical fundoplication. The mean scores at 2 years were significantly lower than before the procedure and did not change substantially during the follow-up. The rates of patients who had stopped or halved antisecretive therapy 2, 3, 5, 7, and 10 years after the procedure were 86.7 %, 84.4 %, 73.5 %, 83.3 %, and 91.7 %, respectively. Conclusions  Transoral incisionless fundoplication with EsophyX is an effective therapeutic option for symptomatic gastroesophageal reflux disease patients, with Hill grades I - II or hiatal hernia < 2 cm, who refuse life-long medical therapy or surgery.

Manometric Subtypes of Ineffective Esophageal Motility

Objectives:

Ineffective esophageal motility (IEM) is characterized by well-defined manometric criteria. However, much variation exists within the diagnosis: Some patients exhibit exactly the required five weak swallows to make the diagnosis. Others show consistently ineffective swallows with total absence of any normal swallow. “We hypothesize” there are two different manometric subtypes of IEM; IEM Alternans (IEM-A) and IEM Persistens (IEM-P).

Methods:

A total of 231 IEM patients were identified by high-resolution manometry (HRM). IEM defined by distal contractile integral (DCI) <450 mm Hg/s/cm in ≥50% of test swallows. Abnormal reflux study was defined by excess total number of reflux episodes, abnormal esophageal acid exposure, or positive symptom association.

Results:

A total of 195 (84%) patients had IEM-A and 36 (16%) had IEM-P. A striking gender difference with 34% of IEM-A being males compared to 53% of IEM-P. (P=0.03). Mean age of IEM-P (59.6 years+/−13.1) was greater than IEM-A (55.5 years+/−13.6) (P=0.04). Mean lower esophageal sphincter (LES) resting pressure was significantly lower in IEM-P (20.8 mm Hg+/−1.4) than IEM-A (29 mm Hg+/−1.2) (P=0.002). There was no difference in LES-integrated relaxation pressure (IRP), bolus transit, or manometric presence of hiatal hernia between the two groups. Out of 146, 89 (61%) patients had abnormal reflux study. Esophageal acid exposure in upright position was significantly higher in IEM-P than IEM-A (3.5 vs. 1.7%, P=0.04). Poor gastric acid control on proton pump inhibitor (PPI) was more prevalent among IEM-P patients (58%) than IEM-A (27%) (P=0.007). In subgroup analysis of 41 IEM patients with dysphagia, DCI for liquid swallows was significantly lower in IEM-P (111+/−142 mm Hg/s/cm) compared to IEM-A (421+/−502 mm Hg/s/cm) (P=0.04), lower mean LES resting pressure in IEM-P (16.6+/−9 mm Hg) than IEM-A (31.7+/−18 mm Hg) (P=0.01).

Conclusions:

There are two distinct manometric IEM subtypes; IEM-P with an older male predominance, more advanced reflux disease, weaker LES, and worse response to PPI; likely a more advanced manifestation than IEM-A. However, the question if there are different etiologies underlying the two subtypes remains to be answered.

Surgical techniques to prevent reflux esophagitis in proximal gastrectomy reconstructed by esophagogastrostomy with preservation of the lower esophageal sphincter, pyloric and celiac branches of the vagal nerve, and reconstruction of the new His angle for early proximal gastric cancer

PURPOSE

This article describes the surgical techniques to prevent reflux esophagitis (RE) after proximal gastrectomy reconstructed by esophagogastrostomy (PGE) preservation of the lower esophageal sphincter (LES) and both pyloric and celiac branches of the vagal nerve (PCVN), and reconstruction of the new His angle (HA) for early proximal gastric cancer (PGC).

METHODS

Twenty patients after PGE were divided into 2 groups (group A: 10 patients without preserved LES and PCVN for advanced PGC; group B: 10 patients with preserved LES and PCNV and the addition of a new HA for early PGC). A postoperative interview on gastroesophageal reflux disease (GERD) and satisfaction with this procedure and the collection of endoscopic findings for RE and stasis of the remnant stomach (SRS) were conducted 1 year after PGE in groups A and B.

RESULTS

The rates of proton pump inhibitor administration and the symptoms of GERD, RE and SRS in group A were significantly higher than those in group B (p = 0.0433, p = 0.0190, p = 0.0253, p = 0.0190, respectively). Seven out of 10 patients in group A voiced dissatisfaction. Patients in group B were significantly more satisfied with this procedure than those in group A (p = 0.0010).

CONCLUSION

This method is useful for preventing postoperative GERD including RE in early PGC patients.

Significance of the lower esophageal sphincter preservation in preventing alkaline reflux esophagitis in patients after total gastrectomy reconstructed by Roux-en-Y for gastric cancer

To clarify the significance of the lower esophageal sphincter (LES) for prevention of alkaline reflux esophagitis (ARE) after total gastrectomy reconstructed by Roux-en-Y (TGRY) for gastric cancer, we investigated LES function and lower esophageal pH in TGRY patients with or without LES preservation. A total of 51 patients 5 years after TGRY were divided into groups A (26 patients without preserved LES) and B (25 patients with preserved LES) and compared with 22 control participants (group C). Manometric study and ambulatory 24-hour esophageal pH monitoring were performed on all patients. Symptomatic and endoscopic AREs in group A were significantly higher than those in group B (P < 0.05). The length of LES and maximum LES pressure in group A were significantly shorter and lower, respectively, than in groups B and C (P < 0.01). The length of LES and maximum LES pressure in patients with symptomatic ARE were significantly shorter and lower, respectively, than in patients without symptomatic ARE (P < 0.01). Percentages of time with pH >7 and pH >8 within 24 hours in group A were significantly higher than those in groups B and C (P < 0.01). Preservation of the LES may be necessary to prevent ARE after TGRY.

Long-term efficacy of transoral incisionless fundoplication with Esophyx (Tif 2.0) and factors affecting outcomes in GERD patients followed for up to 6 years: a prospective single-center study

BACKGROUND

Transoral incisionless fundoplication (TIF) with the EsophyX™ device creates an antireflux valve with good functional results in patients with gastro-esophageal reflux disease (GERD). The aim of this study was to assess the long-term effect of TIF 2.0 on pathological reflux and symptoms in GERD patients with daily dependence on proton pump inhibitors (PPI).

METHODS

Fifty patients underwent TIF. All underwent GERD-HRQL and GERD-QUAL questionnaires, upper GI endoscopy, esophageal manometry, and 24-h pH-impedance before and 6, 12, and 24 months after TIF, and subsequent yearly clinical re-evaluation.

RESULTS

Patients were followed for up to six years (mean 52.7 ± 19.7 months). In all, 83.7, 79.6, 87.8, and 84.4% of patients stopped or halved the PPI therapy 6, 12, 24, and 36 months after TIF. Three-year figure remained stable up to 6 years. Symptom scores off PPI were significantly lower at 6, 12, 24, and 36 months. At 6 months, Hill's grade I of the newly created valve persisted in all pre-procedure Hill's grade I patients, in 66.7% of grade II and 58.3% of grade III. This figure remained substantially unchanged at 12 and 24 months, too. Impedance monitoring indicated significantly fewer total and acid refluxes after treatment (p = 0.01). Factors predicting good outcomes were pre-procedure Hill's grade I-II, no hiatal hernia or hernia ≤2 cm (p = 0.03), absence of ineffective esophageal motility (p < 0.0001), and number of fasteners deployed (p = 0.01).

CONCLUSIONS

TIF by the EsophyX achieved lasting elimination of daily dependence on PPI in 75-80% of patients for up to 6 years. TIF seems an effective therapy for selected symptomatic GERD patients.

Can different subsets of ineffective esophageal motility influence the outcome of nissen fundoplication?

BACKGROUND

Ineffective esophageal motility (IEM) in patients with gastroesophageal reflux disease includes three different subsets that may affect symptom profiles. Our aim was to assess symptoms and functional outcome in patients with erosive esophagitis according to different subsets of IEM, before and after Nissen fundoplication (NF).

METHODOLOGY

A retrospective study with prospective follow-up of 72 patients with reflux esophagitis and IEM in whom open NF was performed. Based on principal manometric esophageal body motility disorder, patients were divided in three groups: predominantly low-amplitude (LAC, N = 38), non-propulsive (NPC, N = 18), and simultaneous low-amplitude esophageal contractions (SC, N = 16). Patients underwent symptomatic questionnaire and stationary esophageal manometry before and 6 months, 1 year, and 3 years after surgery.

RESULTS

Preoperatively, patients in NPC and SC groups had higher mean scores of dysphagia, without statistical significance as opposed to the LAC group (p = 0.239). Postoperative dysphagia occurred in 36 patients, without statistical significance between groups regarding dysphagia grades (p = 0.390). A longer duration of postoperative dysphagia was noted in the SC group (p < 0.05). Improvement of nadir values of contraction amplitudes in distal esophagus occurred postoperatively in all groups, significantly higher in LAC (p < 0.001).

CONCLUSION

Three years after NF, successful symptomatic and functional outcome was achieved in analyzed groups of patients with erosive esophagitis regardless of IEM subtype.

Gastroesophageal reflux symptoms in typical and atypical GERD: roles of gastroesophageal acid refluxes and esophageal motility

BACKGROUND/AIM

To determine the roles of gastroesophageal acid reflux (GER) and esophageal dysmotility on typical and atypical GERD symptoms.

METHODS

Two hundred thirty-six patients (159 females, age 47 ± 14 years) with typical and atypical GERD symptom(s) for > 3 months underwent standard water perfused esophageal manometry (EM) and 24 h esophageal pH studies during off therapy.

RESULTS

Eighty seven and 93 patients had positive lower esophageal pH tests and abnormal EM, respectively. Patients with positive lower esophageal pH test were significantly older (50 ± 13 vs 45 ± 13 years, P < 0.005) and had higher prevalence of acid regurgitation symptoms than patients with negative test (56/87 vs 72/149, P < 0.05). Patients with positive upper esophageal pH test (n = 67) also had significantly higher prevalence of acid regurgitation symptoms (43/67 vs 74/152, P < 0.05). Prevalence of other upper gastrointestinal and respiratory symptoms were similar between patients with positive and negative upper and lower pH test. Patients with abnormal EM were significantly older (49 ± 14 vs 45 ± 13 years, P < 0.05) and had higher prevalence of chronic cough than patients with normal EM(30/93 vs 26/143, P < 0.05). In patients with positive pH tests, the prevalence of dysphagia, chronic cough, and hoarseness of voice were significantly higher in patients with abnormal than those with normal EM (18/31 vs 18/56, P < 0.05; 12/31 vs 6/56, P < 0.005 and 19/31 vs 18/56, P < 0.01, respectively). Whereas in patients with negative lower pH tests, only the prevalence of heartburn was significantly lower in patients with normal than those with abnormal EM (26/87 vs 30/62, P < 0.05).

CONCLUSIONS

Acid regurgitation but not heartburn was associated with GER. Esophageal dysmotility had no significant effect on acid regurgitation symptom but associated with chronic cough, hoarseness of voice, and dysphagia only in patients with abnormal esophageal acid exposure.

Habitual rapid food intake and ineffective esophageal motility

AIM: To study non-cardiac chest pain (NCCP) in relation to ineffective esophageal motility (IEM) and rapid food intake.

METHODS: NCCP patients with a self-reported habit of fast eating underwent esophageal manometry for the diagnosis of IEM. Telephone interviews identified eating habits of additional IEM patients. Comparison of manometric features was done among IEM patients with and without the habit of rapid food intake and healthy controls. A case study investigated the effect of 6-mo gum chewing on restoration of esophageal motility in an IEM patient. The Valsalva maneuver was performed in IEM patients and healthy controls to assess the compliance of the esophagus in response to abdominal pressure increase.

RESULTS: Although most patients diagnosed with NCCP do not exhibit IEM, remarkably, all 12 NCCP patients who were self-reporting fast eaters with a main complaint of chest pain (75.0%) had contraction amplitudes in the mid and distal esophagus that were significantly lower compared with healthy controls [(23.45 mmHg (95%CI: 14.06-32.85) vs 58.80 mmHg (95%CI: 42.56-75.04), P < 0.01 and 28.29 mmHg (95%CI: 21.77-34.81) vs 50.75 mmHg (95%CI: 38.44-63.05), P < 0.01, respectively)]. In 7 normal-eating IEM patients with a main complaint of sensation of obstruction (42.9%), the mid amplitude was smaller than in the controls [30.09 mmHg (95%CI: 19.48-40.70) vs 58.80 mmHg (95%CI: 42.56-75.04), P < 0.05]. There was no statistically significant difference in manometric features between the fast-eating and normal-eating groups. One NCCP patient who self-reported fast eating and was subsequently diagnosed with IEM did not improve with proton-pump inhibition but restored swallow-induced contractions upon 6-mo gum-chewing. The Valsalva maneuver caused a markedly reduced pressure rise in the mid and proximal esophagus in the IEM patients.

CONCLUSION: Habitual rapid food intake may lead to IEM. A prospective study is needed to validate this hypothesis. Gum-chewing might strengthen weakened esophageal muscles.

Heterogeneity in oesophageal dysfunction among patients with different reflux symptoms

BACKGROUND AND AIM

Ineffective oesophageal motility (IOM) often occurs in patients with gastro-oesophageal reflux disease. We aimed to examine the hypothesis of whether the presence of IOM differs between patients with gastro-oesophageal reflux disease with different symptom profiles.

METHODS

Eligible patients were subclassified according to their predominant symptom of heartburn (HB) or acid regurgitation (AR). All patients underwent combined multichannel intraluminal impedance and oesophageal manometry. IOM was further graded according to the presence of oesophageal transit abnormalities.

RESULTS

Fourteen healthy individuals, 16 HB patients and 24 AR patients participated in this study. The percentage of swallows with complete bolus transit was lower in AR than in HB patients during liquid and viscous swallowing (P<0.05). Abnormal bolus transit occurred more frequently in AR patients than in HB patients with liquid swallows (P<0.001) and viscous swallows (P<0.05). IOM occurred more frequently in AR patients than in HB patients (42.7 vs. 12.5%, P=0.049). In patients with IOM, severe functional abnormality was more frequently found in AR patients than in HB patients (P<0.05).

CONCLUSION

This study suggests a potential link between oesophageal body dysfunction and individual reflux symptom. Patients with a predominant symptom of AR are characterized by greater IOM and defective bolus clearance.

Transoral incisionless fundoplication (TIF 2.0) with EsophyX for gastroesophageal reflux disease: long-term results and findings affecting outcome

INTRODUCTION

Transoral incisionless fundoplication (TIF) with the EsophyX(™) device is reported to be effective for creating a continent gastroesophageal valve and for good functional results, as measured by pH impedance in patients with gastroesophageal reflux disease (GERD). The aim of this study is to assess the long-term effect of TIF in patients with symptomatic GERD.

PATIENTS AND METHODS

TIF 2.0 fundoplication was done in 42 consecutive patients. All were studied with GERD-HRQL and GERD-QUAL questionnaires, upper gastrointestinal (GI) endoscopy, esophageal manometry, and 24 h pH impedance before and at 6, 12, and 24 months after TIF.

RESULTS

In all, 35 patients completed 6-month follow-up; 21 (60.0%) completely stopped proton pump inhibitor (PPI) therapy, 6 (17.1%) more than halved it, and 8 (22.9%) continued with the same dose as before the procedure. There were 26 patients with complete 24-month follow-up; 11 (42.3%) completely stopped PPI therapy, 7 (26.9%) more than halved it, and 8 (30.8%) were taking the same dose as before the procedure. Hiatal hernia and ineffective esophageal motility seemed to raise the risk of recurrence of symptoms (p = 0.02 and p < 0.001, respectively). The number of fasteners deployed during TIF was the only factor predictive of successful outcome (p = 0.018).

CONCLUSIONS

TIF using the EsophyX device allowed withdrawal or reduction of PPI in about 77% of patients at 6-month follow-up and about 69% at 24 months. Larger number of fasteners deployed during TIF was predictive of positive outcome; pre-TIF ineffective esophageal motility and hiatal hernia raised the risk of recurrence of GERD symptoms, but were not significant from a prospective point of view.