Macroscopic healing of esophagitis does not improve esophageal motility

The role of delayed gastric emptying and impaired oesophageal body motility

Delayed gastric emptying in a variable proportion of patients with gastro-oesophageal reflux disease has been observed in most series, however a relationship between delayed gastric emptying and increased gastro-oesophageal reflux has not been convincingly demonstrated. Enhanced postprandial accommodation and delayed emptying of the proximal stomach have been described, but some controversy exists. Impaired primary peristalsis is often present especially in patients with oesophagitis and its prevalence increases with increasing severity of inflammatory mucosal lesions. Patients with gastro-oesophageal reflux disease often have defective triggering of secondary peristalsis independently of presence of oesophagitis. It is presently unclear if impaired oesophageal motility is a primary defect or an irreversible consequence of inflammation. Attempts at pharmacological improvement of impaired oesophageal motility have been so far disappointing. Patients with partially preserved neuromuscular structures need to be identified in order to select them for new prokinetic therapy.

Laparoscopic Nissen fundoplication is a good option in patients with abnormal esophageal motility

BACKGROUND

Patients with gastroesophageal reflux disease (GERD) and abnormal esophageal motility are the most controversial subgroup of surgically treated patients because of potentially increased risk of postoperative dysphagia. Our study aim was to determine if Nissen fundoplication is associated with increased postoperative dysphagia in patients with ineffective esophageal motility.

METHODS

Medical records of all adult (>18 years old) patients who underwent laparoscopic Nissen fundoplication for GERD over 8 years were reviewed retrospectively. Of the 151 patients, 28 (group A) met manometric criteria for abnormal esophageal motility (<30 mmHg mean contractile pressure or <80% peristalsis), whereas 63 (group B) had normal esophageal function. Sixty patients had no manometric data and were therefore excluded from analysis. Follow-up time ranged from 1 month to 5 years. Outcomes (postoperative dysphagia, recurrence of GERD symptoms, free of medications) were compared between groups.

RESULTS

Group A had higher age and American Society of Anesthesiologists (ASA) score (p = 0.016 and 0.020), but this did not correlate with outcome. Two patients (7.1%) in group A and three patients (5.3%) in group B had postoperative dysphagia. When adjusted for follow-up time, there was no significant difference between the groups (p = 0.94). Group B had more cases of recurrent heartburn (10.7% versus 3.6%, p = 0.039), and more patients in this group were back on medications (21.4% versus 7.1%, p < 0.05)

CONCLUSIONS

This retrospective study found equally low rates of dysphagia following Nissen fundoplication regardless of baseline esophageal motility. Preoperative esophageal dysmotility therefore does not seem to be a contraindication for laparoscopic Nissen fundoplication.

The effect of hydrocephalus on lower esophageal sphincter smooth muscle reactivity: experimental study

PURPOSE

The aim of this study was to assess the pharmacophysiological significance of the enteric nervous system for the mechanical responses of lower esophageal sphincter (LES) in infantile rats with kaolin-induced hydrocephalus.

MATERIAL AND METHODS

Hydrocephalus was created in 7-day-old rats by injection of kaolin into the cisterna magna. After 10 days, rats were decapitated. Contractile (KCl, carbachol) and relaxant (isoprenaline, papaverine) responses were determined by using in vitro muscle technique in isolated LES smooth muscle strips.

RESULTS

The receptor-mediated contractile and relaxant response to carbachol and isoprenaline in the LES smooth muscle was impaired in rats with hydrocephalus. There was no significant difference in the KCl and papaverine response in hydrocephalic and sham operated rats.

CONCLUSION

Our findings suggest that hydrocephalus may impair receptor-mediated contractile and relaxant activity of LES smooth muscle leading to gastroesophageal reflux.

Effects of low-power argon plasma coagulation thermoablation of Barrett's epithelium on oesophageal motility

INTRODUCTION

Oesophageal dysmotility contributes to the pathogenesis of Barrett's epithelium (BE) allowing prolonged mucosal contact with injurious refluxate. Argon plasma coagulation (APC) is effective for BE ablation, but it is unknown whether the procedure affects oesophageal motility.

AIM

To assess the effect of low power (30 W) APC therapy on oesophageal motility in patients with BE.

METHODS

Thirty-three patients with at least 4 cm of BE underwent oesophageal manometry before and after APC ablation. All were on proton pump inhibitors. Oesophageal body peristaltic wave duration and amplitude, and lower oesophageal sphincter (LOS) pressure and length were compared before and after treatment.

RESULTS

In a total of 28 men and five women, with a mean age of 63.4 years (range 39-79) and mean BE length 6.5 cm (range 4-19), macroscopic clearance was achieved in 28 patients. A small statistically significant (P<0.05) increase in peristaltic wave amplitude was seen after APC [mean (SD) mmHg before versus after: 30.4 (15.2) versus 36.2 (20.1) at 13.5 cm, 47.6 (27.1) versus 54.5 (26.8) at 8.5 cm, and 51.2 (35.3) versus 58 (34.4) at 3.5 cm above the LOS]. No changes in either peristaltic wave duration or LOS parameters [mean (SD) pressure 10.6 (5.6) versus 10.3 (4.3) mmHg; length 2.8 (1.3) versus 2.8 (1.0) cm] were observed.

CONCLUSION

APC ablation of BE at a power setting of 30 W does not impair oesophageal motility.

Esophagography predicts favorable outcomes after laparoscopic Nissen fundoplication for patients with esophageal dysmotility

BACKGROUND

We undertook this study to determine if clearance of a food bolus at preoperative esophagography predicts acceptable outcomes after laparoscopic Nissen fundoplication for patients with manometrically abnormal esophageal motility.

STUDY DESIGN

Patients with gastroesophageal reflux disease (GERD) or symptomatic hiatal hernia with evidence of esophageal dysmotility by stationary manometry underwent videoesophagography to document the ability of their esophagus to clear food boluses of varying consistencies. Sixty-six patients were identified who had manometric dysmotility yet were able to clear a food bolus at esophagography, and subsequently underwent laparoscopic Nissen fundoplication. These patients were compared with 100 randomly selected patients with normal motility who underwent laparoscopic Nissen fundoplication. Symptom reduction and satisfaction were assessed through followup. Patients with normal motility were compared with those with manometrically moderate and severe dysmotility.

RESULTS

Preoperative patient demographic data, symptoms, and symptom scores were similar among patients with normal motility and moderate or severe dysmotility. After fundoplication, symptom reduction was notable for all patients regardless of preoperative motility (p < 0.01, paired Student's t-test). There was no notable difference in postoperative symptom scores (p = NS, Kruskal-Wallis ANOVA) or in patient satisfaction (p = NS, chi-square analysis) among patients stratified by esophageal motility.

CONCLUSIONS

Patients with esophageal dysmotility documented by manometry who are able to clear a food bolus at contrast esophagography, have functional results after laparoscopic Nissen fundoplication similar to patients with normal motility. Preoperative esophagography predicts successful outcomes after laparoscopic Nissen fundoplication for patients with manometric esophageal dysmotility.

Nonobstructive dysphagia and recovery of motor disorder after antireflux surgery

BACKGROUND

Changes in motor disorder after Nissen 360 degrees surgery were studied based on clinical signs of preoperative nonobstructive dysphagia.

MATERIALS AND METHODS

Forty-seven patients undergoing Nissen 360 degrees fundoplication for gastroesophageal reflux were studied with pH recording and esophageal manometry before and 1 year after fundoplication. Amplitude of contraction of the distal third of the esophagus (ACDTE) and the presence of primary propulsive waves were studied.

RESULTS

Fourteen patients had clinical signs of preoperative dysphagia. Of these, 50% had an ACDTE lower than 30 mm Hg, and 71.4% nonpropulsive waves (P <0.05). Forty-three percent and 30%, respectively, of patients with dysphagia recovered ACDTE and the presence of primary propulsive waves 1 year after the procedure, as compared with 66.6% (P <0.05) and 81.8% (P <0.01%) of patients without dysphagia.

CONCLUSIONS

A correlation was found between preoperative dysphagia and esophageal motility disorders (P <0.05). One year after fundoplication, recovery was significantly higher in patients without preoperative dysphagia.

The effect of cisapride on oesophageal motility and lower sphincter function in patients with gastro-oesophageal reflux disease

OBJECTIVES

To evaluate the efficiency by which the 5-HT4 agonist cisapride affects important motor functions involved in the control of gastro-oesophageal reflux.

METHOD

Thirty patients with proven gastro-oesophageal reflux disease (endoscopy and 24 h pH-metry) were included in a randomized, double-blind, placebo controlled study with a cross-over design. Cisapride, 20 mg b.i.d., during 4 weeks was compared with placebo. At baseline, as well as after 4 and 8 weeks all patients underwent symptom assessments, sleeve manometry with concomitant oesophageal pH-monitoring and an acid clearance test.

RESULTS

Despite adequate plasma levels cisapride had no significant effect on swallow induced peristaltic amplitude, duration, propagation speed, the elicitation of secondary peristalsis nor on acid clearance. Neither the basal tone of the lower oesophageal sphincter nor the number of transient lower oesophageal sphincter relaxations induced by gas distension of the stomach was affected by the administered dose of cisapride.

CONCLUSION

Although cisapride has been alleged to improve symptoms as well as the oesophagitis in patients with gastro-oesophageal reflux disease, we found the compound (20 mg b.i.d.) devoid of effects on important motor mechanisms involved in the pathogenesis of the disease.

Overview of the mechanisms of gastroesophageal reflux

Reflux of acidic gastric contents through the esophagogastric junction into the esophageal lumen occurs in everyone nearly every day. The esophagogastric junction is composed of several structural components that contribute to its function as the primary antireflux barrier. Only when 1 or more of these components fail does reflux esophagitis develop. The initial focus of this review is on transient lower esophageal sphincter relaxations, a vagally mediated reflex arc that accounts for almost all reflux events in healthy individuals and the majority of reflux events in those with reflux esophagitis. The association of erosive esophagitis with low or absent (incompetent) lower esophageal sphincter (LES) pressure and anatomic disruptions of the esophagogastric junction, such as hiatal hernia, are also important, especially with respect to whether the LES dysfunction and hernia are the cause or the consequence of erosive disease.

Pathogenesis of gastroesophageal reflux and Barrett esophagus

Barrett esophagus is a metaplastic condition that affects the lower esophagus and is a complication of gastroesophageal reflux disease (GERD). Under normal circumstances, the reflux of gastric contents into the esophagus is prevented by a complex barrier at the esophagogastric junction. Dysfunction of the lower esophageal sphincter and the presence of a hiatal hernia lead to failure of this barrier. Esophageal mucosal damage results from the chronic exposure of the esophageal mucosa to gastroduodenal contents and the lack of an effective mucosal defense. This article is an overview of the dysfunction of the esophagogastric junction that leads to GERD. The role of the contents of the reflux and that of Helicobacter pylori infection in the pathogenesis of Barrett esophagus are also summarized.

Pathogenesis of gastroesophageal reflux and Barrett esophagus

Barrett esophagus is a metaplastic condition that affects the lower esophagus and is a complication of gastroesophageal reflux disease (GERD). Under normal circumstances, the reflux of gastric contents into the esophagus is prevented by a complex barrier at the esophagogastric junction. Dysfunction of the lower esophageal sphincter and the presence of a hiatal hernia lead to failure of this barrier. Esophageal mucosal damage results from the chronic exposure of the esophageal mucosa to gastroduodenal contents and the lack of an effective mucosal defense. This article is an overview of the dysfunction of the esophagogastric junction that leads to GERD. The role of the contents of the reflux and that of Helicobacter pylori infection in the pathogenesis of Barrett esophagus are also summarized.

Complete fundoplication is not associated with increased dysphagia in patients with abnormal esophageal motility

Abnormal esophageal motility is a relative contraindication to complete (360-degree) fundoplication because of a purported risk of postoperative dysphagia. Partial fundoplication, however, may be associated with increased postoperative esophageal acid exposure. Our aim was to determine if complete fundoplication is associated with increased postoperative dysphagia in patients with abnormal esophageal motor function. Medical records of 140 patients (79 females; mean age 48 +/- 1.1 years) who underwent fundoplication for gastroesophageal reflux disease (GERD) were reviewed retrospectively to document demographic data, symptoms, and diagnostic test results. Of the 126 patients who underwent complete fundoplication, 25 met manometric criteria for abnormal esophageal motility (#30 mm Hg mean distal esophageal body pressure or #80% peristalsis), 68 had normal esophageal function, and 33 had incomplete manometric data and were therefore excluded from analysis. Of the 11 patients who underwent partial fundoplication, eight met criteria for abnormal esophageal motility, two had normal esophageal function, and one had incomplete data and was therefore excluded. After a median follow-up of 2 years (range 0.5 to 5 years), patients were asked to report heartburn, difficulty swallowing, and overall satisfaction using a standardized scoring scale. Complete responses were obtained in 72%. Sixty-five patients who underwent complete fundoplication and had manometric data available responded (46 normal manometry; 19 abnormal manometry). Outcomes were compared using the Mann-Whitney U test. After complete fundoplication, similar postoperative heartburn, swallowing, and overall satisfaction were reported by patients with normal and abnormal esophageal motility. Likewise, similar outcomes were reported after partial fundoplication. This retrospective study found equally low dysphagia rates regardless of baseline esophageal motility; therefore a randomized trial comparing complete versus partial fundoplication in patients with abnormal esophageal motility is warranted.

Secondary oesophageal peristalsis in gastro-oesophageal reflux disease

BACKGROUND AND AIMS

To evaluate the status of secondary oesophageal peristalsis in gastro-oesophageal reflux disease (GORD) and the effect of healing of oesophagitis on these abnormalities.

METHODS

Twenty-one patients diagnosed with GORD and 10 control subjects in the same age group were studied. Primary peristalsis was elicited by 10 5 mL water boluses and secondary peristalsis by 10 20 mL boluses of air injected 15 cm above the lower oesophageal sphincter.

RESULTS

The pattern of primary peristalsis was normal in a significantly lower number of patients compared with control subjects, six patients (28.6%) versus seven controls (70%), (P<0.05). Similarly, the number of subjects with a normal pattern of secondary peristalsis was also lower in the patient group (zero vs three; P<0.05). A normal primary peristaltic response occurred with 71 (33.8%) of the 210 water boluses in the patients and 73 (73%) of the 100 water boluses in the control subjects, respectively (P<0.001). A normal secondary peristaltic response was seen with 15 (7.1%) of 210 air boluses in patients and 32 (32%) of 100 air boluses in the control subjects (P<0.001). The amplitude of secondary peristaltic waves and the duration of contraction (mean+/-SEM) were significantly lower in patients compared with the control subjects (43.5+/-4.7 vs 89.0+/-13.1 and 3.4+/-0.8 vs 3.9+/-0.3, respectively; P=<0.05). In the 13 patients in whom repeat evaluation was performed after healing of oesophagitis, there was no significant change in the number of patients with normal peristaltic response, number of normal responses to air and water boluses, or amplitude, duration and velocity of peristalsis.

CONCLUSION

Significant abnormalities of secondary oesophageal peristalsis occur in patients with GORD and these are not reversed by healing of oesophagitis.

Motility abnormalities in gastroesophageal reflux disease

Esophageal dysmotility occurs in association with GERD; however, the cause of these motility abnormalities is not known. It is also not clear whether injury results from the presence of acid itself, inflammatory change or fibrosisin the esophageal wall. It is also unclear if reversal of these abnormalities takes place, and if so, to what degree. There are, however, a subset of patients who seem to have improvement with effective medical or surgical therapy, parodoxically, the same patients in whom a fundoplication, particularly a complete wrap, would lead to severe postoperative dysphagia secondary to preoperative dysmotility. What does all this mean for the individual patient? It is likely that most will not have any important change in esophageal motility abnormalities with standard medical or surgical therapy. Fundoplication might be safely performed in patients with minimal motility abnormalities, but those with severe abnormalities should be approached with caution. The conservative approach is to perform a partial fundoplication (Toupet) in those with ineffective motility (> 30% low-amplitude or nontransmitted contractions). It is hoped that future investigations will aid in understanding the pathogenesis of these abnormalities and how they can be used more precisely to guide antireflux therapy.

Intrasphincteric botulinum toxin versus pneumatic dilatation for achalasia: a cost minimization analysis

BACKGROUND

Pneumatic dilatation or intrasphincteric botulinum toxin injection provide effective symptom relief for patients with achalasia. Although intrasphincteric botulinum toxin injection is simple and safe, its efficacy may be short-lived. Pneumatic dilatation lasts longer, but esophageal perforation is a risk. We compared treatment costs for pneumatic dilatation and intrasphincteric botulinum toxin injection using a decision analysis model to determine whether the practical advantages of intrasphincteric botulinum toxin injection outweigh the economic impact of the need for frequent re-treatment.

METHODS

Probability estimates for intrasphincteric botulinum toxin injection were derived from published reports. Probability estimates for the pneumatic dilatation strategy were obtained by retrospective review of our 10-year experience using the Rigiflex dilator. Direct, "third-party payer" costs were determined in Canadian dollars.

RESULTS

Intrasphincteric botulinum toxin injection was significantly more costly at $5033 compared with $3608 for the pneumatic dilatation strategy, yielding an incremental cost of $1425 over the 10-year period considered. Sensitivity analysis showed that pneumatic dilatation is less expensive across all probable ranges of costs and probability estimates. The intrasphincteric botulinum toxin injection strategy is less costly if life-expectancy is less than 2 years.

CONCLUSIONS

Intrasphincteric botulinum toxin injection is more costly than pneumatic dilatation for the treatment of achalasia. The added expense of frequent re-treatment with intrasphincteric botulinum toxin injection outweighs the potential economic benefits of the safety of the procedure, unless life-expectancy is 2 years or less.

Five-year audit of ambulatory 24-hour esophageal pH-manometry in clinical practice

BACKGROUND

Esophageal function testing was developed to aid diagnosis in patients with negative endoscopy. Although combined 24-h esophageal pH-manometry is now commercially available, its routine clinical effectiveness has not yet been studied.

METHODS

From 1992 to 1996 we evaluated 303 consecutive patients who were first-time referrals to our unit for 24-h esophageal pH-manometry. The referral indications were gastroesophageal reflux disease, 47.2%; dysphagia, 18.5%; non-cardiac chest pain, 14.9%; connective tissue disease, 13.2%; and symptomatic patients after antireflux surgery, 6.3%.

RESULTS

Overall, esophageal function testing altered the diagnosis of 44% of the patients, confirmed it in 38%, and specifically changed the management of 66%. The final clinical 'diagnosis' was reflux disease, 54% (32% with non-specific esophageal motility disorder); connective tissue disease, 9.9%; achalasia, 9.6%; other specific esophageal motility disorders, 3.3%; non-specific esophageal motility disorders, 6.9%; and normal, 16.2%. The cost per testing was estimated to be US$305 and per change in management US$465.

CONCLUSION

Combined 24-h pH-manometry has been shown to be a useful and cost-effective test for the management of selected patients in whom the primary investigation was insufficient.

The effect of healing oesophagitis on oesophageal motor function as determined by oesophageal scintigraphy and ambulatory oesophageal motility/pH monitoring

BACKGROUND

Oesophagitis has been shown by standard manometry to be associated with impaired oesophageal motility, but it remains unclear if this abnormality improves with healing of oesophagitis.

AIM

To determine if healing of oesophagitis improves oesophageal motility using solid bolus oesophageal transit scintigraphy and combined ambulatory oesophageal motility/pH monitoring.

METHODS

Patients with grade II-III oesophagitis underwent ambulatory motility/pH monitoring (using a Konigsberg catheter with four pressure transducers at 5 cm intervals) and solid bolus scintigraphy before and after treatment with omeprazole 20 mg b.d. for 8-14 weeks.

RESULTS

Three (11%) of the 28 patients failed to heal. Initial scintigraphy was abnormal in 18 (67%) of 27 patients (one refused scintigraphy). Twenty-three of the 25 healed patients had repeat studies showing no significant change in the number which were abnormal (16 (64%), P = 1.0) or the overall oesophageal transit time (P = 0.65). Due to intolerance of the technique, only 11 patients had ambulatory motility/pH performed both before and after healing, giving the study 90% power to detect a 5 mmHg increase in peristaltic amplitude. No significant improvement was seen in any motility or pH parameter after healing of oesophagitis.

CONCLUSION

Analysis of oesophageal motility showed no improvement in peristaltic activity after healing of oesophagitis, suggesting that the abnormal motility is either a primary disorder or an irreversible consequence of mucosal damage.

The effect of mosapride, a novel prokinetic, on acid reflux variables in patients with gastro-oesophageal reflux disease

BACKGROUND

Mosapride is a novel prokinetic agent facilitating acetylcholine release from the enteric cholinergic neurones through a selective 5-HT4 receptor agonistic action. It is also active through its main metabolite M1, which is a 5-HT3 antagonist. The importance of motor dysfunction in the pathogenesis of gastro-oesophageal reflux disease (GERD) makes it interesting to examine the effect of mosapride on oesophageal acid exposure.

METHODS

The effect of mosapride on oesophageal 24-h acid reflux variables was studied in 21 patients with GERD symptoms and a pre-entry total acid exposure time (pH < 4) of more than 5%. Ambulatory pH monitoring was performed after treatment with 40 mg mosapride citrate or placebo q.d.s. for 2 days in random order, using a double-blind crossover technique, with a washout period of at least 5 days.

RESULTS

Mosapride was significantly more effective than placebo in decreasing the total number of reflux episodes, the total number of reflux episodes lasting more than 5 min and the total time, as well as the amount of day time, of intra-oesophageal pH below 4. Consequently, mosapride also significantly improved total acid clearance time.

CONCLUSION

Mosapride 40 mg q.d.s. is effective in decreasing acid reflux in the oesophagus in patients with GERD and therefore has the potential to be effective in the treatment of this disease.