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Herbella FAM, Patti MG. Chicago classification version 4.0© from surgeons' point of view. Neurogastroenterol Motil 2021; 33:e14090. [PMID: 33506552 DOI: 10.1111/nmo.14090] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 01/12/2021] [Indexed: 12/06/2022]
Affiliation(s)
| | - Marco G Patti
- Department of Surgery, Federal University of São Paulo, São Paulo, Brazil
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Herbella FAM, Del Grande LM, Schlottmann F, Patti MG. Changes in the Treatment of Primary Esophageal Motility Disorders Imposed by the New Classification for Esophageal Motility Disorders on High Resolution Manometry (Chicago Classification 4.0). Adv Ther 2021; 38:2017-26. [PMID: 33772739 DOI: 10.1007/s12325-021-01714-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 03/16/2021] [Indexed: 12/21/2022]
Abstract
The Chicago Classification is the most used classification for primary esophageal motility disorders (PEMD). This classification was recently updated to the 4.0 version. This opinion piece focuses on the possible implications for the treatment of PMED determined by the new classification. Chicago Classification 4.0 included two new concepts for the diagnosis of achalasia: (1) type III achalasia diagnosis demands 100% absent peristalsis defined as either failed peristalsis or spasm; (2) “inconclusive diagnosis of achalasia” was added as a possibility. Both may decrease unnecessary treatment. Esophagogastric junction outflow obstruction, distal esophageal spasm, and hypercontractile esophagus were only considered clinically significant when correlated to supportive testing and relevant clinical symptoms and in the absence of gastroesophageal reflux disease. This may decrease the surge of treatment, especially peroral endoscopic myotomy, based solely on manometric diagnosis.
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Abstract
OBJECTIVE To evaluate dysphagia and manometric changes in the upper oesophageal sphincter in patients with unilateral vocal fold paralysis. METHODS Thirty patients with unilateral vocal fold paralysis due to vagal nerve paralysis scheduled for evaluation were enrolled in the study group; 24 healthy subjects were included in the control group. Upper oesophageal sphincter basal and residual pressure, relaxation time, and pharyngeal pressure values were evaluated by manometry. All patients completed the Turkish Eating Assessment Tool 10 questionnaire, the MD Anderson dysphagia questionnaire and the reflux symptom index form. RESULTS Swallowing assessment questionnaires and reflux symptom index results were significantly higher in the study group. Upper oesophageal sphincter basal and relaxation pressures were lower in the study group. Upper oesophageal sphincter relaxation time was shorter in the study group, but pressure values recorded from the pharynx were higher. CONCLUSION Upper oesophageal sphincter manometric pressure was lower in patients with unilateral vocal fold paralysis. A hypotonic sphincter likely contributes to dysphagia and aspiration.
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Silva RMBD, Herbella FAM, Gualberto D. NORMATIVE VALUES FOR A NEW WATER-PERFUSED HIGH RESOLUTION MANOMETRY SYSTEM. Arq Gastroenterol 2018; 55Suppl 1:30-34. [PMID: 30088532 DOI: 10.1590/s0004-2803.201800000-40] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 04/03/2018] [Indexed: 01/24/2023]
Abstract
BACKGROUND Esophageal manometry is the most reliable method to evaluate esophageal motility. High resolution manometry (HRM) provides topographic contour colored plots (Clouse Plots) with simultaneous analysis from the pharynx to the stomach. Both solid state and water-perfused systems are available. OBJECTIVE This study aims to determinate the normative data for a new water-perfused HRM. METHODS HRM was made in 32 healthy volunteers after 8 hours fasting. HRM system used consisted of a 24-channel water-perfused catheter (Multiplex, Alacer Biomedica, São Paulo, Brazil). The reusable catheter is made of polyvinyl chloride (PVC) with 4.7 mm of diameter. Side holes connected to pressure transducers are spaced 2 cm for the analysis from the pharynx to the lower esophageal sphincter (LES). Holes are spaced 5 mm and 120° in a spiral disposition in the LES area. The sensors encompass 34 cm in total. Upper esophageal sphincter (UES) parameters studied were basal and relaxation pressures. Esophageal body parameters were distal contractile integral (DCI), distal latency (DL) and break. LES parameters studied were basal pressure, integrated residual pressure (IRP), total and abdominal length. Variables are expressed as mean ± standard deviation, median (interquartile range) and percentiles 5-95th. RESULTS All volunteers (17 males, aged 22-62 years) completed the study and tolerated the HRM procedure well. Percentiles 5-95th range were calculated: Upper Esophageal Sphincter (UES) basal pressure 16.7-184.37 (mmHg), DL: 6.2-9.1 (s), DCI: 82.72-3836.61 (mmHg.s.cm), break: <7.19 (cm), LES basal pressure: 4.89-37.16 (mmHg), IRP: 0.55-15.45 (mmHg). CONCLUSION The performance and normative values obtained for this low-cost water-perfused HRM seems to be adequate for clinical use.
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Affiliation(s)
| | - Fernando A M Herbella
- Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Cirurgia, São Paulo, SP, Brasil
| | - Daniel Gualberto
- Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Cirurgia, São Paulo, SP, Brasil
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Valezi AC, Herbella FA, Mali-Junior J, Menezes MDA, Liberatti M, Sato RO. PREOPERATIVE MANOMETRY FOR THE SELECTION OF OBESE PEOPLE CANDIDATE TO SLEEVE GASTRECTOMY. Arq Bras Cir Dig 2018; 30:222-224. [PMID: 29019566 PMCID: PMC5630218 DOI: 10.1590/0102-6720201700030013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 06/20/2017] [Indexed: 12/12/2022]
Abstract
Background: Sleeve gastrectomy may alter esophageal motility and lower esophageal sphincter pressure. Aim: To detect manometric changings in the esophagus and lower esophageal sphincter before and after sleeve gastrectomy in order to select patients who could develop postoperative esophageal motilitity disorders and lower esophageal sphincter pressure modifications. Methods: Seventy-three patients were selected. All were submitted to manometry before the operation and one year after. The variables analyzed were: resting pressure of the lower esophageal sphincter, contraction wave amplitude, duration of contraction waves, and esophageal peristalsis. Data were compared before and after surgery and to the healthy and non-obese control group. Exclusion criteria were: previous gastric surgery, reflux symptoms or endoscopic findings of reflux or hiatal hernia, diabetes and use of medications that could affect esophageal or lower esophageal sphincter motility. Results: 49% of the patients presented preoperative manometric alterations: lower esophageal sphincter hypertonia in 47%, lower esophageal sphincter hypotonia in 22% and increase in contraction wave amplitude in 31%. One year after surgery, manometry was altered in 85% of patients: lower esophageal sphincter hypertonia in 11%, lower esophageal sphincter hypotonia in 52%, increase in contraction wave amplitude in 27% and 10% with alteration in esophageal peristalsis. Comparing the results between the preoperative and postoperative periods, was found statistical significance for the variables of the lower esophageal sphincter, amplitude of contraction waves and peristalsis. Conclusion: Manometry in the preoperative period of sleeve gastrectomy is not an exam to select candidates to this technique.
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Affiliation(s)
- Antonio Carlos Valezi
- Digestive System Surgery, Department of Surgery, State University of Londrina, Londrina, PR, Brazil
| | | | - Jorge Mali-Junior
- Digestive System Surgery, Department of Surgery, State University of Londrina, Londrina, PR, Brazil
| | | | - Mário Liberatti
- Digestive System Surgery, Department of Surgery, State University of Londrina, Londrina, PR, Brazil
| | - Rafael Onuki Sato
- Digestive System Surgery, Department of Surgery, State University of Londrina, Londrina, PR, Brazil
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Akinsiku O, Yamasaki T, Brunner S, Ganocy S, Fass R. High resolution vs conventional esophageal manometry in the assessment of esophageal motor disorders in patients with non-cardiac chest pain. Neurogastroenterol Motil 2018; 30:e13282. [PMID: 29286206 DOI: 10.1111/nmo.13282] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 12/04/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND High-resolution esophageal manometry (HREM) has become a leading tool in the assessment of esophageal motor disorders, replacing conventional manometry. However, there is limited data about the contribution of HREM as compared with conventional manometry to the assessment of esophageal motor disorders in patients with non-cardiac chest pain (NCCP). The aim of the study was to compare the distribution of esophageal motor disorders in patients with NCCP using HREM as compared with conventional manometry and to determine if HREM improved diagnosis of these disorders. METHODS In this study, we included 300 consecutive patients with NCCP who underwent either HREM or conventional manometry over a period of 10 years. A total of 150 patients had conventional manometry and the other 150 patients HREM. The Chicago 3.0 classification and the Castell and Spechler classification were used to determine the esophageal motor disorder of NCCP patients undergoing HREM and conventional manometry, respectively. KEY RESULTS In both HREM and the conventional manometry groups, normal esophageal motility was the most frequent finding (47% and 36%; respectively, P = .054). Hypotensive lower esophageal sphincter was the most common motility disorder identified by conventional manometry (27.3%), while ineffective esophageal motility was the most common esophageal motor disorder identified by HREM (25.3%). CONCLUSIONS & INFERENCES There is a discrepancy in the type of esophageal motor disorders identified by HREM as compared with conventional manometry in NCCP patients. Hypotensive motility disorders are the most commonly diagnosed by both manometric techniques.
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Affiliation(s)
- O Akinsiku
- The Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH, USA
| | - T Yamasaki
- The Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH, USA
| | - S Brunner
- The Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH, USA
| | - S Ganocy
- The Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH, USA
| | - R Fass
- The Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH, USA
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Abstract
Esophageal achalasia is a primary esophageal motility disorder characterized by the absence of esophageal peristalsis and failure of the lower esophageal sphincter to relax in response to swallowing. These abnormalities lead to impaired emptying of food from the esophagus into the stomach with resulting food stasis. Most patients experience severe dysphagia, and regurgitation can lead to aspiration and respiratory problems. Consequently, the quality of life of patients affected by achalasia is severely impacted. A thorough evaluation with upper endoscopy, barium swallow, and esophageal manometry is mandatory to establish the diagnosis and plan the optimal treatment. In selected patients, an ambulatory pH monitoring is recommended to distinguish between gastroesophageal reflux disease and achalasia.
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Affiliation(s)
- Francisco Schlottmann
- Department of Medicine and Surgery, University of North Carolina, Chapel Hill, North Carolina and
| | - Rafael M. L. Neto
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Fernando A. M. Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Marco G. Patti
- Department of Medicine and Surgery, University of North Carolina, Chapel Hill, North Carolina and
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Schlottmann F, Herbella F, Allaix ME, Patti MG. Modern management of esophageal achalasia: From pathophysiology to treatment. Curr Probl Surg 2018; 55:10-37. [DOI: 10.1067/j.cpsurg.2018.01.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Schlottmann F, Herbella FA, Patti MG. Understanding the Chicago Classification: From Tracings to Patients. J Neurogastroenterol Motil 2017; 23:487-494. [PMID: 28866876 PMCID: PMC5628980 DOI: 10.5056/jnm17026] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 04/26/2017] [Accepted: 06/09/2017] [Indexed: 01/29/2023] Open
Abstract
Current parameters of the Chicago classification include assessment of the esophageal body (contraction vigour and peristalsis), lower esophageal sphincter relaxation pressure, and intra-bolus pressure pattern. Esophageal disorders include achalasia, esophagogastric junction outflow obstruction, major disorders of peristalsis, and minor disorders of peristalsis. Sub-classification of achalasia in types I, II, and III seems to be useful to predict outcomes and choose the optimal treatment approach. The real clinical significance of other new parameters and disorders is still under investigation.
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Affiliation(s)
- Francisco Schlottmann
- Department of Surgery and Center for Esophageal Diseases, University of North Carolina, Chapel Hill, NC, USA
| | - Fernando A Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Marco G Patti
- Department of Surgery and Center for Esophageal Diseases, University of North Carolina, Chapel Hill, NC, USA
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Pinna BR, Herbella FAM, de Biase N, Vaiano TCG, Patti MG. High-Resolution Manometry Evaluation of Pressures at the Pharyngo-upper Esophageal Area in Patients with Oropharyngeal Dysphagia Due to Vagal Paralysis. Dysphagia 2017; 32:657-662. [PMID: 28528491 DOI: 10.1007/s00455-017-9811-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 05/11/2017] [Indexed: 01/08/2023]
Abstract
The motility of the pharynx, upper esophageal sphincter (UES), and proximal esophagus in patients with oropharyngeal dysphagia is still not entirely understood. High-resolution manometry (HRM) was recently added to the armamentarium for the study of this area. This study aims to describe HRM findings in patients with vagal paralysis. Sixteen patients (mean age 54 years, 69% females) with oropharyngeal dysphagia due to unilateral vagal paralysis were prospectively studied. All patients underwent HRM. Motility of the UES and at the topography of the velopharynx and epiglottis were recorded. (1) UES relaxation is compromised in a minority of patients, (2) epiglottis pressure does not follow a specific pattern, (3) vellum is hypotonic in half of the patients, (4) dysphagia is related to a low pharyngeal pressure, not to a flow obstruction at the level of the UES, and (5) aspiration is related to low pressures at the level of the UES and epiglottis and higher pressures at the level of the vellum. Pharyngeal motility is significantly impaired in patients with oropharyngeal dysphagia and unilateral vagal paralysis. In half of the cases, UES resting pressure is preserved due to unilateral innervation and relaxation is normal in most patients. Dysphagia therapy in these patients must be directed toward improvement in the oropharyngeal motility not at the UES.
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Affiliation(s)
- Bruno Rezende Pinna
- Department of Ear, Nose and Throat, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Fernando A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Rua Diogo de Faria 1087 cj 301, Sao Paulo, SP, 04037-003, Brazil.
| | - Noemi de Biase
- Department of Ear, Nose and Throat, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Thays C G Vaiano
- Speech-Language Pathology and Audiology Department, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Marco G Patti
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
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Herbella FAM, Colleoni R, Bot L, Vicentine FPP, Patti MG. High-resolution Manometry Findings in Patients After Sclerotherapy for Esophageal Varices. J Neurogastroenterol Motil 2016; 22:226-30. [PMID: 26554823 PMCID: PMC4819860 DOI: 10.5056/jnm15132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 10/07/2015] [Accepted: 11/02/2015] [Indexed: 02/02/2023] Open
Abstract
Background/Aims Endoscopic therapy for esophageal varices may lead to esophageal dysmotility. High-resolution manometry is probably the more adequate tool to measure esophageal motility in these patients. This study aimed to evaluate esophageal motility using high resolution manometry following eradication of esophageal varices by endoscopic sclerotherapy. Methods We studied 21 patients (11 women, age 52 [45–59] years). All patients underwent eradication of esophageal varices with endoscopic sclerotherapy and subsequent high resolution manometry. Results A significant percentage of defective lower esophageal sphincter (basal pressure 14.3 [8.0–20.0] mmHg; 43% hypertonic) and hypocontractility (distal esophageal amplitude 50 [31–64] mmHg; proximal esophageal amplitude 40 [31–61] mmHg; distal contractile integral 617 [403–920] mmHg · sec · cm; 48% ineffective) was noticed. Lower sphincter basal pressure and esophageal amplitude correlated inversely with the number of sessions (P < 0.001). No manometric parameter correlated with symptoms or interval between last endoscopy and manometry. Conclusions Esophageal motility after endoscopic sclerotherapy is characterized by: (1) defective lower sphincter and (2) defective and hypotensive peristalsis. Esophageal dysmotility is associated to an increased number of endoscopic sessions, but manometric parameters do not predict symptoms.
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Affiliation(s)
- Fernando A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, São Paulo, Brazil
| | - Ramiro Colleoni
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, São Paulo, Brazil
| | - Luiz Bot
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, São Paulo, Brazil
| | - Fernando P P Vicentine
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, São Paulo, Brazil
| | - Marco G Patti
- Department of Surgery, University of Chicago, Chicago, USA
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