Pediatric retrograde cricopharyngeal dysfunction diagnosed by high-resolution impedance manometry

OBJECTIVES

The inability to burp, known as retrograde cricopharyngeal dysfunction (R-CPD), was initially described in adults. The proposed clinical diagnostic criteria for R-CPD include belching inability, abdominal bloating and discomfort/nausea, postprandial chest pain, and involuntary noises. Botulinum toxin injection to the cricopharyngeal muscle has been reported to be beneficial. High-resolution esophageal impedance-manometry (HRIM) features in adolescent patients with R-CPD have not been described yet.  The aim of our study was to describe the clinical and HRIM findings of pediatric patients with R-CPD.

METHODS

Clinical and manometric features of five pediatric patients diagnosed with R-CPD were reviewed. HRIM study protocol was modified to include the consumption of carbonated drink to provoke symptoms and distinctive manometric features.

RESULTS

We report five female patients aged 15-20 years who presented with an inability to burp and involuntary throat sounds. HRIM revealed normal upper esophageal sphincter (UES) relaxation during swallowing, but abnormal UES relaxation with concurrent high esophageal impedance reflecting air entrapment and secondary peristalsis following the carbonated drink challenge. Four patients exhibited esophageal motility disorder. All patients reported improvement or resolution of symptoms after botulinum toxin injection to the cricopharyngeus muscle.

CONCLUSIONS

Adolescents with an inability to burp, reflux-like symptoms, bloating, and involuntary throat noises should be assessed for R-CPD by pediatric gastroenterologists with HRIM. The relatively recent recognition of this novel condition is the likely reason for its under- and misdiagnosis in children.

Frequent discrepancies among diagnostic tests for detecting lower esophageal sphincter-related obstruction

BACKGROUND

There are frequent discrepancies among high-resolution manometry (HRM), functional lumen imaging probe (FLIP), and esophagram in identifying lower esophageal sphincter (LES)-related obstruction. We aimed to determine the frequency of those discrepancies and how they influenced clinical treatment/outcomes.

METHODS

We identified patients who had all three tests (HRM, FLIP, and esophagram) and endoscopy performed for evaluation of esophageal symptoms in our Center for Esophageal Diseases. Discrepancies among the tests for the presence of LES obstruction were noted, and the performance of individual tests was compared against a consensus opinion rendered by a panel of esophagologists. Binary logistical regression was performed, and ROC curves were generated for prediction of the consensus clinical diagnosis of LES obstruction.

KEY RESULTS

A total of 126 patients (mean age 57.9 ± 17.0 years; 67% female) met inclusion criteria. All three tests agreed on the presence or absence of LES obstruction in only 72 (57%) patients [no LES obstruction in 57 (45%), LES obstruction in 15 (12%)]. Thirteen patients (10%) had a change in management based on additional findings on FLIP +/- esophagram not seen on HRM with 69% having symptomatic improvement after LES-directed intervention. FLIP was the strongest predictor of a consensus diagnosis of LES obstruction by logistic regression and ROC (OR 23.36, AUC 0.796), followed by HRM (OR 15.41, AUC 0.764).

CONCLUSIONS & INFERENCE

High-resolution manometry, functional lumen imaging probe, and esophagram each have considerable limitations for identifying LES obstruction, and discrepancies among these tests occur frequently. Multimodal testing is often required for adequate evaluation of LES-related obstruction.

Unraveling the Dynamics of Esophageal Motility, Esophagitis Severity, and Age in GERD Patients: A Cross-Sectional Exploration

BACKGROUND

Gastroesophageal reflux disease (GERD) is characterized by prolonged exposure of the esophageal mucosa to gastric content, with esophageal motility playing a pivotal role in its pathophysiology. This study employs a cross-sectional design to investigate the interplay between esophageal motility, the severity of esophagitis, and age in individuals presenting with GERD symptoms.

OBJECTIVE

The primary objective is to assess proximal and distal esophageal contractions in individuals with GERD symptoms, exploring potential correlations with the severity of esophageal lesions and age.

METHODS

A total of 47 patients reporting heartburn and acid regurgitation underwent diagnostic investigations, including esophageal manometry, radiological examinations, and endoscopy. Patients were categorized into groups based on the presence and severity of esophagitis. Esophageal contractions were monitored using a manometric method at various distances from the UES after swallowing 5 mL of water.

RESULTS

Patients with severe esophagitis (SE) exhibited a reduced distal esophageal contraction amplitude compared to those without esophagitis (WE) or with moderate esophagitis (ME). No significant age-related differences were observed in esophageal contractions. Analyses included contraction amplitude, duration, area under the curve (AUC), and propagation time.

CONCLUSION

This study provides insights into the nuanced relationship between esophageal motility, esophagitis severity, and age in GERD patients. The findings highlight the significance of distal esophageal contractions in SE cases, suggesting potential implications for disease progression. Age did not emerge as a significant factor influencing esophageal motility in this patient cohort.

Laparoscopic Approach to Epiphrenic Diverticula Under Endoscopic Assistance: A Technical Report

Introduction: Epiphrenic diverticulum is a rare disease caused by mucosa and submucosa herniation through the muscular layers of the esophageal wall. This study presents a case of a patient with a symptomatic epiphrenic diverticulum treated with surgery under endoscopic assistance. A review of the literature on this unusual condition was conducted, focusing on the pathogenesis, presentation, and surgical challenges. Methods: A 75-year-old woman who underwent an esophagogastroduodenoscopy (EGD) after experiencing worsening dysphagia for food and liquids. The EGD revealed a large epiphrenic diverticulum 36 cm from the upper incisor teeth. The presence of a diverticulum was verified by barium swallow, which revealed a 6 cm diameter epiphrenic diverticulum on the right side of the esophagus. Results: Patient underwent laparoscopic diverticulectomy associated with Heller's myotomy and anterior partial fundoplication. A gastroscope was placed intraoperatively to calibrate the esophagus to prevent stenosis during diverticulectomy, and it was also used to check the integrity of the esophageal wall. The patient tolerated clear liquids on postoperative day 2. Postoperative course was complicated by right pleural effusion and fever managed with antibiotics and pleural drainage. Conclusion: Epiphrenic diverticulectomy in conjunction with management of the underlying motor dysfunction and avoidance of gastroesophageal reflux disease is an effective procedure. Laparoscopy is considered the approach of choice for the majority of patients. Endoscopic assistance during surgery can help the identification of the diverticulum and verify the integrity of the staple line.

Compartmentalized pressurization is a novel prognostic factor for hypercontractile esophagus

BACKGROUND

Hypercontractile esophagus (HE) is a disorder of increased esophageal body contractile strength on high-resolution esophageal manometry (HREM). Compartmentalized pressurization (CP) is a pattern with an isobaric contour of >30 mmHg extending from the contractile front to the lower esophageal sphincter on HREM. The relevance of CP to HE has yet to be explored.

METHODS

A retrospective review was performed on 830 HREM studies of patients to identify HE. HE patients' CP status and symptoms by Eckardt score (ES) were reviewed. Diagnoses were made using Chicago Classification (CC) v4.0.

KEY RESULTS

Forty-seven patients (5.6%) were identified as having HE by CCv3, 30 (3.6%) of which had HE by CCv4. 11/30 HE patients had CP, and 19/30 did not. CP was associated with chronic opioid use (36.4% vs. 5.3% p = 0.047). Presenting ES was greater for HE patients with CP (7 vs. 4). Seven HE patients with CP and 11 without CP were managed medically. ES after medical therapy was higher in HE patients with CP compared to those without CP (9 vs. 0). No HE patients with CP responded to medical therapy. Kaplan-Meier analysis demonstrated significance of this association over time. 83% of all HE patients had all-cause symptom remission.

CONCLUSIONS & INFERENCES

HE patients with CP are associated with a higher presenting ES. HE patients with CP do not respond to medical therapy, while HE patients without CP frequently do respond. CP in HE may have prognostic value in determination of treatment strategy for patients with HE.

MANAGEMENT OF SYMPTOMS RECURRENCE AFTER MYOTOMY FOR ACHALASIA. A PRACTICAL APPROACH

BACKGROUND

Achalasia is an esophageal motility disorder, and myotomy is one of the most used treatment techniques. However, symptom persistence or recurrence occurs in 9 to 20% of cases.

AIMS

This study aims to provide a practical approach for managing the recurrence or persistence of achalasia symptoms after myotomy.

METHODS

A critical review was performed to gather evidence for a rational approach for managing the recurrence or persistence of achalasia symptoms after myotomy.

RESULTS

To properly manage an achalasia patient with significant symptoms after myotomy, such as dysphagia, regurgitation, thoracic pain, and weight loss, it is necessary to classify symptoms, stratify severity, perform appropriate tests, and define a treatment strategy. A systematic differential diagnosis workup is essential to cover the main etiologies of symptoms recurrence or persistence after myotomy. Upper digestive endoscopy and dynamic digital radiography are the main tests that can be applied for investigation. The treatment options include endoscopic dilation, peroral endoscopic myotomy, redo surgery, and esophagectomy, and the decision should be based on the patient's individual characteristics.

CONCLUSIONS

A good clinical evaluation and the use of proper tests jointly with a rational assessment, are essential for the management of symptoms recurrence or persistence after achalasia myotomy.

Per-Oral Endoscopic Myotomy-Induced Gastroesophageal Reflux Disease and Review of the Efficacy of Proton Pump Inhibitors as a Management Strategy: Review of the Literature

Per-oral endoscopic myotomy (POEM) is a minimally invasive procedure that is very effective in the treatment of achalasia, a rare esophageal motility disorder. POEM has become the first-line treatment for achalasia, with high success rates reported in the literature. However, a known complication of POEM is gastroesophageal reflux disease (GERD). The exact cause and risk factors of post-POEM GERD are not fully understood; however, a number of factors have played a role in its development. The management of post-POEM GERD is mainly by conservative measures, such as lifestyle changes and medications, like proton pump inhibitors (PPI), which are often the first-line method of treatment. However, surgical procedures, such as fundoplication, may be necessary in some patients. This literature review will discuss the effectiveness of the use of PPIs as a management strategy for post-POEM GERD, the factors that lead to PPI-resistant GERD, and other management strategies utilized in these cases.

Relaxation of the lower esophageal sphincter in response to reduced volume distension during FLIP Panometry

BACKGROUND

The esophageal response to stepwise distension during the functional lumen imaging probe (FLIP) Panometry study often parallels high-resolution manometry (HRM) motility diagnoses. This study aimed to describe the changes in FLIP metrics during FLIP emptying, that is, reduced volume distension.

METHODS

Adult patients who completed FLIP and HRM for esophageal motility evaluation were included. Esophagogastric junction (EGJ) opening parameters were assessed during stepwise FLIP filling to volumes of 60 mL ("filling 60 mL"), then 70 mL, and then back to 60 mL ("emptying 60 mL"). HRM studies were analyzed per Chicago classification version 4.0 (CCv4.0).

KEY RESULTS

Among 265 patients included, HRM/CCv4.0 diagnoses included achalasia in 80 patients (30%), normal motility in 70 (26%), and ineffective esophageal motility (IEM) in 43 (16%). EGJ-distensibility index (DI) and EGJ diameter were greater during emptying 60 mL than filling 60 mL in achalasia, normal motility, and IEM (p values <0.002). If applying the emptying 60 mL EGJ-DI (vs. filling 60 mL EGJ-DI), EGJ opening classification changed from reduced EGJ opening to borderline EGJ opening in 31% of achalasia patients and in 2% of patients with normal motility or IEM. EGJ opening classification was unchanged in 69% achalasia and 96% of normal motility/IEM.

CONCLUSIONS AND INFERENCES

This study suggests that isotonic or auxotonic relaxation of the lower esophageal sphincter occurs with reduced volume distension in patients with achalasia and normal motility. The study also supports the importance of utilizing a standardized FLIP motility study protocol (i.e., controlled, stepwise filling to 50 mL, 60 mL, then 70 mL) to provide reliable and generalizable FLIP metrics to facilitate diagnosis of esophageal motility disorders.

Assessment of the Physical Invasiveness of Peroral Endoscopic Myotomy during the Perioperative Period Based on Changes in Energy Metabolism

A novel treatment method for achalasia of the esophagus and related disorders is known as peroral endoscopic myotomy (POEM). This study aimed to calculate the resting energy expenditure (REE) and evaluated the degree of physical invasiveness based on metabolic changes during the perioperative period of POEM. Fifty-eight patients who underwent POEM were prospectively enrolled; REE, body weight (BW), and basal energy expenditure were measured on the day of POEM, postoperative day 1 (POD 1), and three days after POEM (POD 3). The median REE/BW increased from 19.6 kcal/kg on the day of POEM to 24.5 kcal/kg on POD 1. On POD 3, it remained elevated at 20.9 kcal/kg. The stress factor on POD 1 was 1.20. Among the factors, including the Eckardt score, operation time, and the length of myotomy, the length of myotomy was associated with changes in REE/BW. During the perioperative period of POEM, the level of variation in energy expenditure was lower than that of esophageal cancer surgeries performed under general anesthesia. However, because the length of myotomy is a factor affecting changes in energy expenditure, careful perioperative management is desirable for patients with longer myotomy lengths.

Major mixed motility disorders: An important subset of esophagogastric junction outflow obstruction

BACKGROUND

Esophagogastric junction outflow obstruction (EGJOO) is an esophageal motility disorder characterized by a lack of relaxation of the esophagogastric junction (EGJ), with preserved esophageal body peristalsis. We propose new terminology for the coexistence of EGJOO with hypercontractile esophagus and distal esophageal spasm as a major mixed motility disorder (MMMD), and normal peristalsis or a minor disorder of peristalsis such as ineffective esophageal motility with EGJOO as isolated or ineffective EGJOO (IEGJOO).

METHODS

We reviewed prior diagnoses of EGJOO, stratified diagnoses as IEGJOO or MMMD, and compared their symptomatic presentations, high-resolution manometry (HRM) and endoluminal functional lumen imaging probe (EndoFLIP) metrics, and treatment responses at 2-6 months of follow-up.

RESULTS

Out of a total of 821 patients, 142 met CCv3 criteria for EGJOO. Twenty-two were confirmed by CCv4 and EndoFLIP as having EGJOO and were clinically managed. Thirteen had MMMD, and nine had IEGJOO. Groups had no difference in demographic data or presenting symptoms by Eckardt score (ES). HRM showed MMMD had greater distal contractile integral, frequency of hypercontractile swallows, and frequency of spastic swallows, and greater DI by EndoFLIP. Patients with MMMD showed greater reduction in symptoms after LES-directed intervention when measured by ES compared with IEGJOO (7.2 vs. 4.0).

CONCLUSION

Patients with MMMD and IEGJOO present similarly. Detectable differences in HRM portend different responses to endoscopic therapy. Because patients with MMMD have greater short-term prognosis, they should be considered a different diagnostic classification to guide therapy.

Technical success in performing esophageal high-resolution manometry: a review of competency recommendations, predictors of failure, and alternative techniques

Esophageal high-resolution manometry (HRM) is the gold standard for diagnosing esophageal motility disorders. As this is performed without sedation, it may be poorly tolerated by patients. Additionally, advancing the catheter tip until the stomach may also be difficult, especially if there is a disease affecting the esophagus or esophagogastric junction which may lead to coiling of the catheter. Currently, there are no guidelines as to who can perform HRM. An expert opinion has recommended minimum numbers of cases for the operator to perform in order to obtain and maintain competency. Several studies have reported on the rates of flawed HRM studies with approximately 20% being imperfect, including about 3% with critical flaws. The presence of a large hiatal hernia and achalasia have been identified as predictors of technical failure. Studies with minor flaws are usually still interpretable and clinically useful. Reports have also described several techniques for sedation-assisted placement of the HRM catheter, and this appears to be a promising alternative in cases of failed HRM, especially as sedation does not appear to significantly affect HRM measurements. An algorithm on how to proceed after a technically imperfect HRM study is proposed. Further research in this field is warranted including confirmation of the recommended competency numbers, assessing for quality measures in performing HRM such as technical success rate, identifying additional predictors of technical failure, standardization of the terminology, and qualifying the benefit of sedation-assisted HRM.

Benefit of extending the protocol for high resolution manometry according to the version 4.0 of the Chicago criteria. A multicenter study

BACKGROUND

The last version of the Chicago Criteria for high resolution esophageal manometry proposes an expanded protocol including complementary maneuvers to improve the diagnostic yield of the exploration. Our aim was to determine the diagnostic gain of the CCv4.0 protocol compared to the CCv3.0 protocol.

METHODS

All manometry recordings performed in 4 reference centers during the first 10 months after the implementation of the new protocol were retrospectively reviewed. The time spent to complete the protocol was measured, and the changes in diagnosis resulting from the new CCv4.0 were compared to CCv3.0.

KEY RESULTS

From a total of 756 HRM performed, 606 studies could be properly analyzed. The duration of the studies was 18.3 ± 4.3 min. From these, 11.3 ± 3.4 min were spent to complete the CCv3.0 protocol, and 7.4 ± 3.6 min were spent for the remaining maneuvers. A discordant diagnosis between CCv3.0 and CCv4.0 was obtained in 12% of patients: 32% of patients with ineffective esophageal motility turned to normal motility; 24% of patients with esophagogastric junction outlet obstruction (EGJOO) turned to a non-obstructive disorder; and 1% of patients with an apparently normal EGJ relaxation, turned to an obstructive disorder. EGJOO according to CCv4.0 was more prevalent in patients referred for dysphagia (11%) than those referred for GERD (4%; p = 0.003).

CONCLUSIONS AND INFERENCES

Prolongation of the time spent to complete the CCv4.0 protocol leads to a change in the diagnosis of 12% of patients. Clinically relevant changes are mainly related to the evaluation of EGJOO.

Usefulness of Endoscopy for the Detection and Diagnosis of Primary Esophageal Motility Disorders and Diseases Relating to Abnormal Esophageal Motility

Esophagogastroduodenoscopy (EGD) is performed to rule out organic diseases in the diagnosis of esophageal motility disorders (EMDs). Abnormal endoscopic findings can be observed during EGD, which indicate the presence of EMDs. Several endoscopic findings at both the esophagogastric junction and esophageal body that are related to EMDs have been reported. Gastroesophageal reflux disease (GERD) and eosinophilic esophagitis (EoE) could be detected during EGD, and these diseases are often associated with abnormal esophageal motility. Image-enhanced endoscopy (IEE) could improve the detection of these diseases during EGD. Although no report has been published previously on the potential usefulness of IEE in the endoscopic diagnosis of EMDs, IEE can be used to detect disorders that can be associated with abnormal esophageal motility.

Peroral endoscopic myotomy for the treatment of achalasia in the Unified Healthcare System (SUS): results of a short-term

INTRODUCTION

achalasia is a chronic disease. Since there is no curative treatment, diagnosed patients have pharmacological and/or surgical techniques available, aimed at minimizing the condition. POEM appears as a promising new type of palliative treatment with good rates of symptom improvement.

OBJECTIVE

evaluate the profile of POEM at the Clinical Hospital of the Federal University of Pernambuco (HC - UFPE) and correlate it with the world scenario.

METHODS

data collection was performed retrospectively from September 2017 to October 2019 with all patients undergoing POEM at the HC - UFPE. Sociodemographic, clinical, and hospital variables were evaluated before and three months after the procedure.

RESULTS

of 27 patients (52.41 ± 19.24 years old) who underwent the procedure, 66.7% had idiopathic etiology and 33.3% had etiology secondary to Chagas disease. 48% patients underwent previous procedures, of which seven used some type of medication for symptom control, two underwent pneumatic endoscopic dilation, and four underwent Heller cardiomyotomy with partial fundoplication. 62.5% of the evaluated patients had type II achalasia before the procedure. Seven (25.9%) patients presented the following adverse events: four presented bleeding, two pneumoperitoneum, and one both complications, all being treated conservatively. The Eckardt score reduced from 8.37 ± 1.45 to 0.85 ± 1.06 (p-value <0.001).

CONCLUSION

clinical improvement of symptoms and the patient profile followed the worldwide trend, with emphasis on the etiology secondary to Chagas disease, endemic in Brazil. Gastroesophageal reflux remains the main post-operative symptom.

From Chicago classification v3.0 to v4.0: Diagnostic changes and clinical implications

BACKGROUND

The Chicago Classification (CC) used to define esophageal motility disorders in high-resolution manometry (HRM) has evolved over time. Our aim was to compare the frequency of motility disorders diagnosed with the last two versions (CCv3.0 and CCv4.0) and to evaluate symptoms severity according to the diagnoses.

METHODS

From June to December 2020, patients who underwent esophageal HRM with swallows in supine and sitting positions were included. HRM studies were retrospectively analyzed using CCv3.0 and CCv4.0. Symptoms severity and quality of life were assessed with validated standardized questionnaires.

KEY RESULTS

Among the 130 patients included (73 women, mean age 52 years), motility disorder diagnoses remained unchanged in 102 patients (78%) with both CC. The 3 patients with esophago-gastric junction outflow obstruction (EGJOO) with CCv3.0 were EGJOO, ineffective esophageal motility (IEM) and normal with CCv4.0. Twenty-four out of 63 IEM diagnosed with the CCv3.0 (38%) turned into normal motility with the CCv4.0. Whatever the CC used, brief esophageal dysphagia questionnaire score was significantly higher in patients with EGJ relaxation disorders compared to those with IEM (25 (0-34) vs 0 (0-19), p = 0.01). Gastro-Esophageal Reflux disease questionnaire (GERD-Q) score was higher in patients with IEM with both CC compared to those who turned to normal with CCv4.0.

CONCLUSIONS AND INFERENCES

While motility disorders diagnoses remained mainly unchanged with both CC, IEM was less frequent with CCv4.0 compared to CCv3.0. The higher GERD-Q score in IEM patients with CCv4.0 suggests that CCv4.0 might identify IEM more likely associated with GERD.

First Robotic Roux-en-Y Gastric Bypass for the Treatment of Refractory Gastroesophageal Reflux Disease in a Patient With Systemic Sclerosis

Systemic sclerosis (SSc) is an immune-mediated disease that results in fibrosis of the skin and internal organs. Refractory gastroesophageal reflux disease (GERD) associated with severe esophageal dysmotility is common in SSc patients, and surgical treatment with usual anti-reflux procedures such as fundoplications is associated with dismal symptomatic relief and postoperative dysphagia. We report the first robotic short-limb Roux-en-Y gastric bypass (RYGB) with a short Roux limb for the treatment of GERD in a patient with SSc with intense esophageal dysmotility. The operative time was two hours. The procedure and postoperative course were uneventful. The patient presented complete relief of gastroesophageal reflux symptoms and no postoperative dysphagia in a two-year follow-up. Therefore, short-limb RYGB is a safe and very effective alternative for the treatment of severe GERD in patients with SSc. The robotic surgical platform may have some advantages compared to conventional laparoscopy.

Integrated Relaxation Pressure (IRP) Distinguishes between Reflux-Predominant and Dysphagia-Predominant Phenotypes of Esophageal "Absent Contractility"

Background: Patients with absent contractility (AC) often suffer from either reflux or dysphagia. It remains unclear what factors determine which phenotype patients present with. We sought to evaluate if high-resolution manometry metrics, especially integrated relaxation pressure (IRP), could explain this. Methods: Cases of AC from three medical centers were reviewed for demographic, clinical, and manometric data. Cases with an IRP between 10−15 mmHg or subsequent diagnosis of achalasia were excluded. Results: 69 subjects were included (mean age 56.1; 71% female). A total of 41 (59.4%) were reflux-predominant. The reflux-predominant group was younger (51.1 vs. 63.5, p = 0.002) and had lower median LES basal pressures (7.5 vs. 12.5 mmHg, p = 0.014) and IRP values (1.5 vs. 5.6 mmHg, p < 0.001) compared to the dysphagia group. When divided into tertiles, the trend in symptoms between LES basal pressure tertiles was not significant. However, the trend for IRP was significant (p < 0.001). For example, in the lowest IRP tertile, 91.3% of subjects were reflux-predominant compared to only 26.1% in the highest tertile, while the dysphagia-predominant group increased from 8.7% to 73.9%. In a regression model controlling for age and using IRP tertile 1 as the reference, having an IRP in tertile 2 increased the likelihood of having dysphagia-predominant disease by 7, while being in tertile 3 increased the likelihood by 22. Conclusions: IRP helps distinguish between the reflux-predominant and dysphagia-predominant phenotypes of AC. This may have therapeutic clinical consequences as procedures such as fundoplication to tighten the LES may benefit patients with reflux and a low IRP, while procedures like peroral endoscopic myotomy (POEM) to disrupt the LES may benefit patients with dysphagia and a relatively high IRP.

The prevalence of gastroesophageal reflux disease in named manometric patterns of dysmotility according to the Chicago Classification 4.0

Esophageal motility disorders (EMD) may be considered primary disorders only in the absence of gastroesophageal reflux disease (GERD). If GERD is present, treatment should be directed toward correction of the abnormal reflux. The actual prevalence of GERD in manometric dysmotility patterns according to the new Chicago Classification 4.0 (CC4) is still elusive. This study aims to evaluate the prevalence of GERD in patients with esophageal motility disorders according to the CC4. We reviewed 400 consecutive patients that underwent esophageal manometry and pH monitoring. Esophageal motility was classified according to the CC4 and GERD + was defined by a DeMeester score > 14.7. Normal motility or unclassified dysmotility was present in 290 (73%) patients, with GERD+ in 184 of them (63%). There were a total of 110 patients (27%) with named esophageal motility disorders, with GERD+ in 67 (61%). The incidence of ineffective esophageal motility was 59% (n = 65) with 69% GERD +, diffuse esophageal spasm was 40% (n = 44) with 48% GERD +, and hypercontractile esophagus was 0.01% (n = 1) with 100% GERD +. There was no correlation between the presence of GERD and the number of non-peristaltic swallows. Our results show that: (i) manometry only is not enough to select patients' treatment as >60% of patients with named esophageal motility disorders have GERD; (ii) there was no correlation between the presence of GERD and the number of non-peristaltic swallows.

Geriatric patients with esophageal motility disorders benefit more from minimally invasive peroral endoscopic myotomy: a multicenter study in Japan

Geriatric patients with existing studies on the safety and efficacy of peroral endoscopic myotomy (POEM) for achalasia involve small sample sizes and single institutions. However, multi-center, large-scale data analyses are lacking. The study aimed to clarify the characteristics of geriatric patients with esophageal motility disorders (EMDs) and determine the procedure-related outcomes and clinical course following POEM. This cohort study included 2,735 patients with EMDs who were treated at seven Japanese facilities between 2010 and 2019. The patients' characteristics and post-POEM clinical courses were compared between the geriatric (age ≥ 75 years; n = 321) and non-geriatric (age < 75 years; n = 2,414) groups. Compared with the non-geriatric group, the geriatric group had higher American Society of Anesthesiologists physical status scores; more recurrent cases; lower incidence of chest pain; and higher incidence of type III achalasia, distal esophageal spasm, and Jackhammer esophagus. Furthermore, the incidence of sigmoid esophagus was higher, although esophageal dilation was not severe in this group. POEM was safe and effective for geriatric patients with treatment-naïve and recurrent EMDs. Furthermore, compared with the non-geriatric group, the geriatric group had lower post-POEM Eckardt scores, fewer complaints of refractory chest pain, and a lower incidence rate of post-POEM reflux esophagitis. Geriatric patients are characterized by worse clinical conditions, more spastic disorders, and greater disease progression of EMDs, which are also the indications for minimally invasive POEM. POEM is more beneficial in geriatric patients as it has lowering symptom scores and incidence rates of reflux esophagitis.

Nasal trumpet harmoniously improves tolerance to high-resolution impedance manometry catheter placement

Background.

High-resolution impedance manometry (HRiM) is the gold-standard test to accurately diagnose esophageal dysmotility and a component of 24-hour pH testing for gastroesophageal reflux disease (GERD). Most commonly, HRiM is performed without sedation in a motility laboratory setting. Occasionally, patients are unable to complete this test due to poor tolerance, inability to traverse the nasopharynx, or inability to navigate through a hypertonic LES or large hiatal hernia. We report our two-center experience utilizing a nasopharyngeal airway (nasal trumpet) to facilitate insertion of the manometry catheter among patients who failed initial placement through the nasopharynx.

Methods.

We used size 24 French nasal trumpets in patients who had failed typical insertion of HRiM catheters during the index unsedated procedure. Topical anesthetic was applied transnasally followed by nasal trumpet insertion. The manometry catheter was introduced through the nasal trumpet, circumventing anatomical barriers to placement.

Results.

We successfully completed HRiM studies in 8 such consecutive patients. Indications for procedure included dysphagia and GERD. Each patient tolerated nasal trumpet use, and there were no complications.

Conclusion.

The addition of the nasal trumpets to the motility lab toolbox can assist with challenging motility catheter placement. This device is inexpensive, widely available, and reduces procedure failure rates due to nasopharyngeal barriers to successful placement.

Esophageal Motility Disorders in the Natural History of Acid-Dependent Causes of Dysphagia and Their Influence on Patients' Quality of Life-A Prospective Cohort Study

Background: Esophageal dysmotility may be the cause or a secondary effect of gastric acid-dependent diseases: erosive reflux disease (ERD), Schatzki ring (SR) and eosinophilic esophagitis (EoE). Methods: This study aims to compare concomitant dysphagia with ERD, SR and EoE, considering manometric patterns, their role in the natural history and their impact on assessing quality of life. Fifty-eight patients with dysphagia underwent high-resolution manometry and esophago-gastro-duodenoscopy (EGD) with an assessment of SR, ERD and sampling for EoE, completed a questionnaire with the Eating Assessment Tool (EAT-10) and the Gastrointestinal Quality of Life Index. Based on endoscopic images and the histopathological criterion of EoE (≥15 eosinophils/high-power field), patients were assigned to groups with ERD, EoE, SR and with normal endoscopic and histopathological images. In the data analysis, p ≤ 0.05 was considered statistically significant. This trial was registered with ClinicalTrials.gov (no. NCT04803162). Results: Both EoE, SR and ERD correlate with ineffective motility. In ERD, normal peristalsis precedes the development of the disease, unlike EoE, which develops later and leads to absent contractility. The development of SR is associated with disorders of the upper esophageal sphincter (UES). In the group with SR and ERD, UES insufficiency significantly reduces the quality of life. Patients with normal esophagus in EGD scored the lowest quality of life and those with SR had the most severe dysphagia. Conclusion: The esophageal motility disorders co-occurring with endoscopic and histological anomalies do not significantly affect the severity of dysphagia, however, in the case of patients with ERD and SR and concomitant UES insufficiency, this motor dysfunction has a significant impact on the reduction in the patients’ quality of life. Although no specific esophageal motility pattern typical of EoE, ERD and SR has been identified, comparative assessment of manometric features may have a potential role in differential diagnosis.

Dysphagia lusoria: utility of high-resolution impedance manometry to identify true disease

Dysphagia lusoria is a rare cause of dysphagia due to impingement of the esophagus by an aberrant right subclavian artery. Although most remain asymptomatic, this aberrant vessel can lead to progressive dysphagia in childhood or even later in life as a result of arteriosclerotic burden and attenuation of esophageal compliance that led to esophageal compression. We present a 56-year-old man with a 3-year history of progressively worsening dysphagia to solids and liquids and globus sensation. Videofluoroscopic swallowing study (modified barium esophagram) and barium esophagram showed delayed barium tablet transit in the upper esophagus and focal smooth narrowing of the upper esophagus caused by external compression, respectively. Computed tomography imaging demonstrated external compression of proximal esophagus from an aberrant right subclavian artery with high atherosclerotic burden. In addition, high-resolution impedance manometry (HRiM) revealed a striking high-pressure pulsatile vascular band in the proximal esophagus (108 mmHg) associated with poor bolus transit, demonstrating the utility of HRiM in strengthening the diagnoses of true dysphagia lusoria.

Multicenter Evaluation with Eckardt Score of Laparoscopic Management with Heller Myotomy and Dor Fundoplication for Esophageal Achalasia in a Pediatric Population in Colombia

Background: Esophageal achalasia is a rare, chronic, and progressive neurodegenerative motility disorder that is characterized by a lack of relaxation of the lower esophageal sphincter. Laparoscopic Heller myotomy (LHM) is the ideal in our population. Multiple surgical and medical treatments have been raised. However, there has been a need to expand studies and generate a clear algorithm for an ideal therapeutic algorithm. Methods: Clinical record was retrospectively analyzed of patients who underwent LHM and Dor fundoplication evaluated with Eckardt score, at four Colombian medical centers between February 2008 and December 2018. Results: There were a total of 21 patients (12 males and 9 females, ages 8 months to 16 years). The time from onset of symptoms to surgery was between 5 months and 14 years. One patient had esophageal mucosa perforation, 2 patients were converted to open surgery, and 1 patient had a postoperative fistula. All patients were discharged 3 to 9 days postoperatively, at which time they tolerated normal oral feeding. During follow-up, all the patients had an improvement in nutritional status and a greater functional recovery; 4 had reflux and 1 had reflux-like symptoms. Conclusion: LHM with Dor-type fundoplication maintains the effectiveness of open surgery with low postoperative morbidity and mortality and good functional results according to Eckardt score evaluation.

Comparison of the safety and efficacy of peroral endoscopic myotomy between octogenarians and non-octogenarians

OBJECTIVES

This study compared the safety and efficacy of peroral endoscopic myotomy for esophageal motility disorders between octogenarians and non-octogenarians.

METHODS

This retrospective observational study recruited 321 patients (28 octogenarians and 293 non-octogenarians) who underwent peroral endoscopic myotomy from two institutions. Clinical success (postoperative Eckardt score ≤ 3), technical success (completion of gastric and esophageal myotomy), and perioperative adverse events were compared between octogenarians and non-octogenarians. Perioperative adverse events were classified into major and minor adverse events based on the International Peroral Endoscopic Myotomy Survey criteria and were subdivided into technical and non-technical adverse events according to the presence of a direct causal relationship with the procedure.

RESULTS

There were no significant differences in the rates of clinical success 1 year after treatment (100% vs. 97.3%, P = 0.64) and technical success (100% vs. 99.7%, P = 0.91) between octogenarians and non-octogenarians. Octogenarians had a higher incidence of perioperative adverse events (28.6% vs. 10.2%, P = 0.00097), particularly major adverse events (25.0% vs. 3.0%, P < 0.0001). There were no significant differences in the incidence of minor adverse events (7.1% vs. 7.9%, P = 0.67). Although there was no difference in the incidence of technical adverse events (10.7% vs. 9.2%, P = 0.74), octogenarians had a significantly higher incidence of non-technical adverse events (17.9% vs. 1.0%, P = 0.0002).

CONCLUSIONS

There were no significant differences in short-term clinical success and technical success between octogenarians and non-octogenarians. However, octogenarians showed a significantly higher incidence of perioperative adverse events, particularly in major adverse events and non-technical adverse events. Peroral endoscopic myotomy for octogenarians should be carefully applied.

Dysphagia lusoria: A vascular etiology?

Dysphagia lusoria is difficulty swallowing as a result of extrinsic esophageal compression by an aberrant right subclavian artery (ARSA). We present the case of a 59‐year‐old patient with ARSA and history of chronic dysphagia. Vascular decompressive surgery was performed, but it failed to resolve his symptoms. Esophageal manometry indicated concomitant esophageal gastric junction outflow obstruction in the setting of a small hiatal hernia. Our case highlights the diagnostic dilemma surrounding dysphagia lusoria and identification of cases that should undergo surgical repair. Based on a thorough review of the literature and our case, we propose a complete foregut workup for possible other causes as potential etiologies of dysphagia prior to surgical treatment of dysphagia lusoria.

DUAL-POEM for associated esophageal and gastric motility disorders: case series of endoscopic cardiomyotomy and endoscopic pyloromyotomy

Background: Per-oral esophageal myotomy endoscopic (E-POEM) has clearly proved safety and efficiency in the treatment of esophageal spastic disorders. Recent studies on endoscopic pyloromyotomy (G-POEM) suggest good efficiency and safety in the treatment of gastroparesis. In recent literature, some reports showed both esophageal motility disorders and gastroparesis.Methods: We report the case of four patients with esophageal and gastric motility disorders who were successfully treated with DUAL POEM (E-POEM and G-POEM) in two separate procedures.Results: Clinical improvement was reported in all patients with a decrease of the Eckardt score for esophageal motility disorders and a decrease of the GCSI score for gastroparesis. No adverse events occurred after any procedure. These reported cases suggest that is possible to perform an E-POEM and a G-POEM in the same patient in two distinct procedures.Conclusions: DUAL POEM seems to be faisable in patient with esophageal motility disorders associated with gastroparesis. The possibility of the concomitant occurrence of esophageal and gastric motility disorders could lead to change in practices with an overall assessment including gastric empting scintigraphy, high resolution manometry and pH-impedancemetry for patients with digestive motility disorders.

High-resolution manometry in diagnostics and evaluation of therapy effectiveness in patients with eosinophilic esophagitis - underestimated breakthrough or dead end?

Eosinophilic esophagitis (EoE) is a chronic disease with non-specific symptoms, among which dysphagia is a prevailing one. The observed increase of EoE rate, its chronic and recurrent character, as well as invasive follow-up examination (periodical panendoscopy with specimen collection for histopathology), compel optimization of both the diagnostics algorithm and disease monitoring through searching for new, unique methods and tools so far not applied, including high-resolution manometry (HRM). Mentioned investigations result from advances in comprehension of disease pathogenesis, in which it is suggested that development of a chronic inflammatory reaction of the esophageal wall may lead to consecutive fibrosis and motility disorders. In research published to date one manometric pattern characteristic for EoE was not obtained, whereas the obtained inconsistent and at times contradictory results do not correlate either with symptoms exacerbation or endoscopic scan. Numerous constraints of discussed studies as well as current knowledge in disease etiopathology and esophagus biomechanics prompt further investigation of HRM significance in diagnostics and therapy monitoring of patients with EoE.

Changes in high-resolution manometric diagnosis over time: implications for clinical decision-making

Although High resolution esophageal manometry (HRM) is the gold standard to assess esophageal motility, little is known about the stability of the manometric diagnosis over time and its implications for management. To assess the stability and usefulness of repeat HRM in patients presenting with esophageal symptoms over time we performed this retrospective study of patients with esophageal symptoms. Medical records, questionnaires, and HRM tracing were independently reviewed using the Chicago classification. The primary objective was to assess the stability of the manometric diagnosis over time; secondary objective was its change (positive or negative). At least one repeat study was performed in 86 patients (36% women, ages 20-86, with mild to moderate symptoms), while 26 had a third procedure. Mean intervals between studies were 15 ± 1.6 months (for baseline v. first study) and 13 ± 0.8 months (for second to third study). Of the 27 patients initially with a normal study, 11 changed (five had esophago-gastric junction outflow obstruction [EGJOO], two diffuse esophageal spasm [DES], one jackhammer esophagus [JE], and three ineffective esophageal motility [IEM] [41% change]). Of the 24 patients with initial EGJOO, only nine retained it (65.2% change). Of nine patients with initial DES, four changed (44.4% change). Similarly, different diagnosis was seen in 7 of 24 initial IEM patients (22.7% change). Only one patient had achalasia initially and this remained stable. Additional changes were noted on a third HRM. Fluidity in the HRM diagnosis over time questions its validity at any timepoint and raises doubts about the need for intervention.

Gastrointestinal tract involvement in mixed connective tissue disease (Sharp syndrome)

Mixed connective tissue diseases (MCTD) is a very rare autoimmune disease connecting clinical signs of systemic lupus, systemic sclerosis, polymyositis and rheumatoid arthritis. Clinical manifestations are very diverse. In some patients, the digestive tract is affected in varying degrees. The esophagus is affected most often, and patients are complaining of dysphagia. Morphologically, this disorder is similar to the injure in systemic scleroderma. In this case, we describe a unique case of a severe damage of digestive tract manifested by esophageal motility disorders, cachectization, ascites, and repeated ileus conditions.

Difficult peroral endoscopic myotomy: definition and management strategies

Introduction: Peroral endoscopic myotomy (POEM) has been established as an alternative endoscopic method for the treatment of achalasia, and several studies have confirmed its relatively long-term efficacy. Although most of the POEM procedures can be smoothly completed, technical difficulties do arise during the treatment of some patients, which may lead to prolonged procedure duration, increased procedure-related complications, or even aborted POEM.Area covered: In the present review, we provide a comprehensive review of difficult POEM, focusing on its definition, risk factors, and intraoperative management strategies. The present review is expected to provide tips for not so experienced operators who perform POEM.Expert commentary: Submucosal fibrosis and sigmoid-type esophagus are associated with difficult POEM. Sometimes, the following may also be associated with difficult POEM: previous endoscopic or surgical treatments, spastic esophageal disorders (type III achalasia, distal esophageal spasm, and hypercontractile esophagus), achalasia with diverticulum or situs inversus. For operators who begin to perform POEM, I suggest an exclusion of patients with severe submucosal fibrosis or sigmoid-type esophagus, and begin to perform POEM for these patients when they have completed at least 50 cases of 'easy POEM' and the proposed management strategies may be helpful.

Surgical treatment of Killian-Jamieson diverticulum: A case report and literature review

This study describes a patient with symptomatic Killian-Jamieson, a rare entity, successfully treated by cervical approach with diverticulum resection and esophagomyotomy.

Botulinum toxin for the treatment of hypercontractile esophagus: Results of a double-blind randomized sham-controlled study

INTRODUCTION

Botulinum toxin injection is known to be efficient to treat achalasia. We conducted a randomized trial in order to evaluate its efficacy to treat symptomatic hypercontractile esophageal disorders as characterized by esophageal high-resolution manometry.

METHODS

Patients with significant dysphagia and/or thoracic pain related to an hypercontractile esophageal motility disorder as defined by the Chicago Classification were randomized to receive an injection of botulinum toxin (100 U in 10 points in the distal part of the esophageal wall) or a sham procedure. Symptoms were assessed at 3 months with the Eckardt score. Patients could receive a first or second botulinum toxin injection 1 month later if symptoms persisted.

RESULTS

Twenty-three patients (13 women, mean age 60 years) were included: 13 received botulinum toxin injection, and 10 a sham procedure. The improvement of symptoms at 3 months was significant compared to baseline, but similar in the active treatment and sham procedure arms. However, there was no change in quality of life scores. Seventeen patients received a second injection at 4 months. There was a significant trend toward improvement of symptoms up to the end of follow-up at 12 months, without a significant relationship with the administration of botulinum toxin.

DISCUSSION

Botulinum toxin injection is not superior to a sham procedure to improve symptoms related to hypercontractile esophageal disorders, suggesting an important placebo effect in for this type of disease. This observation must be taken into account when evaluating more aggressive therapies such as endoscopic myotomy (clinicaltrials.gov: NCT01955174).

Myotomy-First Approach to Epiphrenic Esophageal Diverticula

Introduction: Epiphrenic esophageal diverticula are typically treated with concurrent cardiomyotomy and diverticulectomy. However, resection of these diverticula can be technically difficult and associated with significant morbidity with a staple line leak rate ranging up to 27%. For this reason, and because the diverticulum is secondary to a primary esophageal motility disorder such as achalasia, we decided to adopt a laparoscopic myotomy-first strategy, reserving the diverticulectomy for patients with persistent or recurrent symptoms. Methods: From 2004 to 2018, 22 patients with epiphrenic diverticula were treated by laparoscopic Heller myotomy and partial fundoplication alone, with the plan to add the diverticulectomy as a second stage if needed. There were 13 women and 9 women, with a mean age of 68 years. Results: Patients had been symptomatic for an average of 36 months. The most common presenting symptom was dysphagia (91%), followed by regurgitation (77%). More than half of the diverticula were solitary and on the right side. Esogphagoscopy ruled out cancer. Esophageal manometry (18 patients) showed achalasia in 14 patients, nutcracker esophagus in 3 patients, and nonspecific motility disorder in 1 patient. There were no perioperative complications, and average length of stay was 2.5 days. At a mean follow-up of 68 months, dysphagia resolved in 77% and regurgitation in 86% of patients. Three patients had persistent symptoms: 2 patients underwent a transthoracic diverticulectomy (1 patient with resolution of symptoms and 1 patient with no improvement). Another patient had per oral endoscopic myotomy, but his dysphagia persisted. Conclusions: The laparoscopic myotomy-first approach reduces risk and unnecessary surgery. A laparoscopic Heller myotomy and partial fundoplication provide excellent resolution of symptoms for most, whereasonly a few will need a staged resection of the diverticulum.

Acid exposure in patients with gastroesophageal reflux disease is associated with esophageal dysmotility

OBJECTIVE

To explore the correlation between reflux disease and abnormal esophageal motility in patients with gastroesophageal reflux disease (GERD).

METHODS

Participants (patients with GERD and controls) who underwent 24-h impedance-pH monitoring (MII-pH monitoring) and high-resolution manometry between January 2012 and February 2017 were retrospectively studied. The patients were divided into two groups (acid reflux and nonacid reflux) based on their MII-pH monitoring data. Reflux episodes, endoscopic findings, and esophageal dynamic parameters were assessed and compared.

RESULTS

A total of 142 patients were included (acid reflux [n = 58], nonacid reflux [n = 60], control group [n = 24]). There were more patients with esophagitis and more severe esophageal mucosal injury in the acid reflux group than in the nonacid reflux group. The acid reflux group had reduced lower esophageal sphincter (LES) basal pressure, shorter LES length, lower esophageal pressure and distal contractile integral index than the nonacid reflux group. Patients in the acid reflux group had more large breaks and a higher incidence of type II and III esophagogastric junction morphology than those in the nonacid reflux group. Acid exposure time, the incidence of long-term acid reflux, recumbent acid reflux, and the incidence of acid and nonacid reflux had a significant negative correlation with esophageal body motility or LES function.

CONCLUSION

This study suggests that an increase in esophageal acid exposure is correlated with an increase in esophageal dysmotility in patients with GERD.

Gender, medication use and other factors associated with esophageal motility disorders in non-obstructive dysphagia

Background

High-resolution esophageal manometry (HREM) is the diagnostic test of choice for evaluation of non-obstructive dysphagia. Studies regarding the predictors of esophageal dysmotility are limited. Therefore, our aim was to study the prevalence of and factors associated with esophageal motility disorders in patients with non-obstructive dysphagia.

Methods

We performed a retrospective review of all patients with non-obstructive dysphagia who underwent HREM in a tertiary center between 1 January 2014 and 31 December 2015. After obtaining IRB approval (16-051), clinical records were scrutinized for demographic data, symptoms, medication use, upper endoscopic findings and esophageal pH findings. HREM plots were classified per Chicago Classification version 3.0. Primary outcome was prevalence of esophageal motility disorders; secondary outcomes assessed predictive factors.

Results

In total, 155 patients with non-obstructive dysphagia (55 ± 16 years old, 72% female) were identified. HREM diagnosis was normal in 49% followed by ineffective esophageal motility in 20%, absent contractility in 7.1%, achalasia type II in 5.8%, outflow obstruction in 5.2%, jackhammer esophagus in 4.5%, distal esophageal spasm in 3.9%, fragment peristalsis in 1.9%, achalasia type I in 1.9%, and achalasia type III in 0.6%. Men were five times more likely to have achalasia than women [odds ratio (OR) 5.3, 95% confidence interval (CI): 2.0-14.2; P = 0.001]. Patients with erosive esophagitis (OR 2.9, 95% CI: 1.1-7.7; P = 0.027) or using calcium channel blockers (OR 3.0, 95% CI: 1.2-7.4; P = 0.015) were three times more likely to have hypomotility disorders.

Conclusion

From this study, we concluded that HREM diagnosis per Chicago Classification version 3.0 was normal in 49% of patients with non-obstructive dysphagia. Male gender, erosive esophagitis and use of calcium channel blockers were predictive of esophageal motility disorders.

Factors predictive of gastroesophageal reflux disease and esophageal motility disorders in patients with non-cardiac chest pain

BACKGROUND

Patients with non-cardiac chest pain (NCCP) are referred for esophageal motility testing and pH monitoring since gastroesophageal reflux disease (GERD) and esophageal motility disorders are frequently encountered in these patients. Our aim was to determine the prevalence and distribution of these disorders and to identify predictors of abnormal esophageal function testing.

METHODS

We performed a retrospective study of NCCP patients who presented after a negative cardiac evaluation and underwent esophageal manometry, esophageal pH monitoring and upper endoscopy from January 2010 to January 2017.

KEY RESULTS

In a total of 177 patients, esophageal motility disorders were diagnosed in 31% and GERD in 35% of the patients. The most common diagnoses were ineffective esophageal motility (IEM) in 14.1%, jackhammer esophagus in 6.8%, diffuse esophageal spasm in 5.1% and achalasia in 2.3% patients. Older age [for every 5-year increment, odds ratio (OR) 1.2 (95% confidence intervals (CI) 1.00-1.3) p = .047] and dysphagia [OR 3.8 (95% CI, 1.9-7.5) p < .001] were predictors of esophageal motility disorders. Older age [for every 5-year increment, OR 1.2 (95% CI, 1.01-1.3) p = .032] was predictive of GERD. Abnormal esophageal testing was associated with male gender [OR 2.2 (95% CI, 1.04-4.6) p = .039], older age [for every 5-year increment, OR 1.2 (95% CI, 1.03-1.3) p = .016] and Caucasian race [OR 3.1 (95% CI, 1.1-8.7) p < .029].

CONCLUSIONS

Approximately two thirds of patients presenting with NCCP have GERD or esophageal motility disorders. Esophageal function testing in NCCP should be considered in older patients, men, Caucasians and those presenting with dysphagia.

Esophageal provocation tests: Are they useful to improve diagnostic yield of high resolution manometry?

High resolution manometry (HRM) is the gold standard to diagnose esophageal motility disorders but has some limitations. The inclusion of provocative tests might enhance the diagnostic yield of HRM. These tests are easy to perform and to add to the regular manometry protocol. Multiple rapid swallows (MRS; 5 2-mL swallows) is useful to assess the contractile reserve and deglutitive inhibition. The optimal number of MRS to perform might be 3 as suggested by Mauro et al. in this issue of Neurogastroenterology & Motility. The absence of contractile reserve might be associated with gastro-esophageal reflux disease and with an increased risk of post fundoplication dysphagia. Single viscous and solid swallows might enhance the detection of esophageal motility disorders but are not significantly associated with symptom occurrence. Test meal has the advantage to represent a real-life scenario and is promising to depict significant motility findings responsible for esophageal symptoms. Post-prandial recording might also be of interest to diagnose rumination and belching disorders. The best indication of rapid drink challenge test (free drinking of 200 mL) is currently the diagnosis of esophago-gastric junction obstruction. Finally, abdominal compression might be an option to evaluate response of esophageal peristalsis in a context of outflow resistance as proposed by Brink et al. in this issue. These provocative maneuvers appear to provide a complementary role in the evaluation of esophageal motility but require prospective studies to determine the validity of the findings and whether they will lead to changes in clinical practice.

Focal achalasia - case report and review of the literature

Esophageal achalasia is a primary smooth muscle motility disorder specified by aperistalsis of the tubular esophagus in combination with a poorly relaxing and occasionally hypertensive lower esophageal sphincter (LES). These changes occur secondary to the destruction of the neural network coordinating esophageal peristalsis and LES relaxation (plexus myentericus). There are limited data on segmental involvement of the esophagus in adults.

We report on the case of a 54-year-old man who presented initially with complete aperistalsis limited to the distal esophagus. After a primary good response to BoTox-infiltration of the distal esophagus the patient relapsed two years later. The manometric recordings documented now a progression of the disease with a poorly relaxing hypertensive lower esophageal sphincter and complete aperistalsis of the tubular esophagus (type III achalasia according to the Chicago 3.0 classification system).

This paper also reviews diagnostic findings (including high resolution manometry, CT scan, barium esophagram, upper endoscopy and upper endoscopic ultrasound data) in patients with achalasia and summarizes the therapeutic options (including pneumatic balloon dilatation, botulinum toxin injection, surgical or endoscopic myotomy).

Trends in diagnoses after implementation of the Chicago classification for esophageal motility disorders (V3.0) for high-resolution manometry studies

To determine trends in the diagnostic distribution of esophageal motility disorders after implementation of the Chicago Classification Version 3.0 (CC V3.0) for interpretation of high-resolution manometry (HRM) studies compared to non-Chicago Classification criteria. Retrospective trends analysis of patients with an HRM study conducted at a single center from January 1, 2013 to September 30, 2015. The implementation of the CC V3.0 for manometry interpretation occurred in September 2014. Patient charts were manually reviewed for data collection including demographics and HRM diagnoses. The prevalence and relative risks (RR) of CC V3.0 diagnostic categories (i.e. normal, indeterminate, achalasia, and EGJ outflow obstruction [EJGOO], and major and minor motility disorders) were calculated before and after CC V3.0 implementation. Four hundred sixty-five HRM studies were included in the study including 268 before and 179 after CC V3.0 implementation. The mean ± SD age was 54 ± 15.4 years and 59.8% were female (n = 278). The percentage with indeterminate diagnosis decreased from 35.3% before CC V3.0 implementation to 16.8% after implementation (adjusted RR 0.5, 95%CI 0.30-0.70, p < 0.001). The percentage with a major motility disorders decreased from 13.9% to 7.3% (adjusted RR 0.5, 95%CI 0.2-1.0, p < 0.001). The percentage with EJGOO and minor diagnoses increased from 1.4% to 14.5% and 11.9% to 22.9%, respectively. The percentage with achalasia and normal diagnosis did not change over the study period. Implementation of CCV3.0 was associated with changes in the distribution of esophageal motility diagnoses in clinical practice. The percentage of indeterminate and major diagnosis decreased and EGJOO and minor diagnoses increased. The decrease in the number of indeterminate studies suggests that the CC V3.0 may clarify the criteria for the interpreting physician. The increase in studies with a diagnosis of EGJ outflow obstruction may reflect the heterogeneity of disorders with clinically relevant outflow obstruction.

Treatments for achalasia in 2017: how to choose among them

PURPOSE OF REVIEW

To review recent advances in achalasia diagnostics and therapeutics.

RECENT FINDINGS

The cardinal feature of achalasia, impaired lower esophageal sphincter (LES) relaxation, can occur in association with varied patterns of esophageal contractility. The Chicago Classification distinguishes among these as follows: without contractility (type I), with panesophageal pressurization (type II), with premature (spastic) distal esophageal contractions (type III), or even with preserved peristalsis [esophagogastric junction (EGJ) outlet obstruction]. Physiological testing also reveals achalasia-like syndromes that also benefit from achalasia therapies. Coincident with this has been the development of peroral endoscopic myotomy (POEM), an endoscopic technique for performing an esophageal myotomy. Hence, the option now exists to either selectively ablate the LES (pneumatic dilation, laparoscopic Heller myotomy, or POEM) or to ablate the sphincter and create a myotomy along some or the entire adjacent smooth muscle esophagus (POEM). Each achalasia syndrome has unique treatment considerations; type II achalasia responds well to all therapies, whereas type III responds best to POEM.

SUMMARY

Emerging data support the concept that optimal management of achalasia is phenotype-specific, guided by high-resolution manometry, and, in some instance, functional luminal imaging probe studies. This opinion article reviews the varied characteristic and treatment considerations of achalasia syndromes as currently understood.

Primary Esophageal Motility Disorders: Beyond Achalasia

The best-defined primary esophageal motor disorder is achalasia. However, symptoms such as dysphagia, regurgitation and chest pain can be caused by other esophageal motility disorders. The Chicago classification introduced new manometric parameters and better defined esophageal motility disorders. Motility disorders beyond achalasia with the current classification are: esophagogastric junction outflow obstruction, major disorders of peristalsis (distal esophageal spasm, hypercontractile esophagus, absent contractility) and minor disorders of peristalsis (ineffective esophageal motility, fragmented peristalsis). The aim of this study was to review the current diagnosis and management of esophageal motility disorders other than achalasia.

Complications of botulinum toxin injections for treatment of esophageal motility disorders†

In achalasia and spastic esophageal motility disorders, botulinum toxin (botox) injection is considered an effective and low-risk procedure for short-term symptom relief. It is mainly offered to medically high-risk patients. However, no analysis of risks of botox injections has been performed. To determine the incidence and risk factors of procedure-related complications after esophageal botox injections, we analyzed the records of all patients undergoing botox injection therapy for esophageal motility disorders at four university hospitals in Europe and North America between 2008 and 2014. Complications were assigned grades according to the Clavien-Dindo classification. In 386 patients, 661 botox treatments were performed. Main indications were achalasia (51%) and distal esophageal spasm (DES) (30%). In total, 52 (7.9%) mild complications (Clavien-Dindo grade I) were reported by 48 patients, the majority consisting of chest pain or heartburn (29 procedures) or epigastric pain (5 procedures). No ulceration, perforation, pneumothorax, or abscess were reported. One patient died after developing acute mediastinitis (Clavien-Dindo grade V) following injections in the body of the esophagus. In univariate logistic regression, younger age was associated with an increased risk of complications (OR 1.43, 95%CI 1.03-1.96). Treatment for DES, injections into the esophageal body, more injections per procedure, more previous treatments and larger amount of injected botulinum toxin were no risk factors for complications. Esophageal botox injection seems particularly appropriate for high-risk patients due to low complication rate. However, it should not be considered completely safe, as it is associated with rare side effects that cannot be predicted.

Prolonged measurement improves the assessment of the barrier function of the esophago-gastric junction by high-resolution manometry

BACKGROUND

Etiology of gastro-esophageal reflux disease (GERD) is multifactorial, but incompetence of the esophago-gastric junction (EGJ) appears to be of crucial importance. Established manometric parameters for assessment of EGJ barrier function are sub-optimal, potentially because they reflect only a very brief (up to 30 seconds), not necessarily representative period. This prospective, case-control study tested the performance of novel, high-resolution manometry (HRM) parameters of EGJ function in the assessment of GERD.

METHODS

Patients with reflux symptoms and healthy controls (HC) underwent standard HRM and 24-hour pH±impedance measurements. EGJ morphology, lower esophageal sphincter pressure integral (LES-PI), EGJ contractile integral (EGJ-CI) were compared with total-EGJ-CI, a novel parameter summarizing EGJ barrier function during the entire HRM protocol. Esophageal acid exposure ≥4.2%/24 h (A-Reflux-pos) or ≥73 reflux episodes in 24 hours (V-Reflux-pos) were considered pathological.

KEY RESULTS

Sixty five HC and 452 patients completed HRM, 380 (84%) patients underwent ambulatory reflux-monitoring. LES-PI, EGJ-CI and total-EGJ-CI correlated with EGJ morphology subtypes (all P<.00001). Only total-EGJ-CI was consistently lower in A-Reflux-pos and V-Reflux-pos subjects compared with HC and patients without GERD. Total-EGJ-CI was also the single best parameter for prediction of pathological reflux (optimal cut-off 47 mmHg cm, AUC 0.746, P<.0001). This cut-off value, approximately 1 SD below the mean normal value, showed modest sensitivity 54% and positive predictive value 46%, but good specificity 85% and negative predictive value 89% for GERD diagnosis.

CONCLUSION & INFERENCES

Total EGJ-CI, a new metric that summarizes EGJ contractility over time, allows an improved assessment of EGJ barrier function. Pathological reflux is unlikely if this metric is within the upper two-thirds of the normal range.

Rapid Drink Challenge in high-resolution manometry: an adjunctive test for detection of esophageal motility disorders

BACKGROUND/AIMS

The Chicago Classification for diagnosis of esophageal motility disorders by high-resolution manometry (HRM) is based on single water swallows (SWS). Emerging data suggest that a "Rapid Drink Challenge" (RDC) increases sensitivity for motility disorders. This study establishes normal values and diagnostic thresholds for RDC in clinical practice.

METHODS

Two cohort studies were performed in patients with dysphagia or reflux symptoms (development and validation sets). Healthy subjects and patient controls provided reference values. Ten SWS and two 200-mL RDC were performed. Primary diagnosis for SWS was established by the Chicago Classification. Abnormal RDC was defined by impaired esophagogastric junction (EGJ) function (elevated integrated relaxation pressure during RDC [IRP-RDC]); incomplete inhibition of contractility during and ineffective contraction after RDC. Diagnostic thresholds identified in the development set were prospectively tested in the validation set.

RESULTS

Normal values were determined in healthy (n=95; age 37.8 ± 12) and patient controls (n=44; age 46.4 ± 15). Development and validation sets included 178 (54 ± 17 years) and 226 (53 ± 16 years) patients, respectively. Integrated relaxation pressure during RDC was higher for SWS than RDC in all groups (overall P<.001), except achalasia. Rapid Drink Challenge suppressed contractility, except in achalasia type III, spasm, and hypercontractile motility disorders (P<.001). An effective after-contraction was present more often in health than disease (P<.001). Optimal diagnostic thresholds identified in the development set (IRP-RDC ≥12 mmHg achalasia, IRP-RDC ≥ 8mmHg "all cause" EGJ dysfunction), were confirmed in the validation set (both, sensitivity ~85%, specificity >95%).

CONCLUSIONS

Rapid Drink Challenge contributes clinically relevant information to routine HRM studies, especially in patients with EGJ dysfunction.

Dysmotility in Esophageal Atresia: Pathophysiology, Characterization, and Treatment

Esophageal dysmotility is almost universal after esophageal atresia (EA) repair and is mainly related to the developmental anomaly of the esophagus. Esophageal dysmotility is involved in the pathophysiology of numerous symptoms and comorbidities associated with EA such as gastroesophageal reflux disease, aspiration and respiratory complications, and symptoms of dysphagia and feeding disorders. High-resolution esophageal manometry (HREM) has facilitated the characterization of the dysmotility, but there is an incomplete correlation between symptoms and manometrical patterns. Impedance coupled to HREM should help to predict the clinical outcome and therefore personalize patient management. Nowadays, the management of esophageal dysmotility in patients with EA is essentially based on treatment of associated inflammation related to peptic or eosinophilic esophagitis.

Anatomic abnormalities are common potential explanations of manometric esophagogastric junction outflow obstruction

BACKGROUND

Esophagogastric junction outflow obstruction (EGJOO) is an esophageal motility diagnosis associated with a myriad of conditions. The frequency of EGJOO attributed to anatomic causes compared to idiopathic causes is uncertain. Our study aims to identify the frequency of EGJOO and to compare these two groups.

METHODS

We conducted a case-control study of high-resolution manometry (HRM) studies with a diagnosis of EGJOO performed at a single academic center. EGJOO cases were classified as anatomic (if any potential anatomic cause was identified) or idiopathic. Clinical and manometric characteristics of idiopathic EGJOO were compared with anatomic EGJOO cases.

KEY RESULTS

Criteria for EGJOO were met in 11% of HRM studies. Ancillary studies revealed 21/32 EGJOO cases had potential anatomic causes with a hiatal hernia noted in 15/21 cases of anatomic EGJOO. Idiopathic EGJOO cases met Chicago Classification criteria for hypercontractile esophagus with greater frequency than anatomic cases (p = 0.01). The mean distal contractile integral was significantly greater for idiopathic cases compared to anatomic cases (p = 0.003). Treatments used for EGJOO were varied and usually successful in alleviating symptoms. Patients with anatomic EGJOO related to a hiatal hernia who underwent an antireflux operation did not develop dysphagia postoperatively.

CONCLUSIONS & INFERENCES

EGJOO is a frequently encountered manometric diagnosis, commonly associated with anatomic abnormalities potentially explaining the EGJOO. These findings support current recommendations to pursue ancillary diagnostics to investigate cases of unexplained EGJOO. Cases of idiopathic EGJOO are more likely to have hypercontractility on HRM, possibly suggesting a primary esophageal motility disorder.

Functional Esophageal Disorders

Functional esophageal disorders consist of a disease category that present with esophageal symptoms (heartburn, chest pain, dysphagia, globus) not explained by mechanical obstruction (stricture, tumor, eosinophilic esophagitis), major motor disorders (achalasia, EGJ outflow obstruction, absent contractility, distal esophageal spasm, jackhammer esophagus), or gastroesophageal reflux disease (GERD). While mechanisms responsible are unclear, it is theorized that visceral hypersensitivity and hypervigilance play an important role in symptom generation, in the context of normal or borderline function. Treatments directed at improving borderline motor dysfunction or reducing reflux burden to sub-normal levels have limited success in symptom improvement. In contrast, strategies focused on modulating peripheral triggering and central perception are mechanistically viable and clinically meaningful. However, outcome data from these treatment options are limited. Future research needs to focus on understanding mechanisms underlying visceral hypersensitivity and hypervigilance so that appropriate targets and therapies can be developed.

The Chicago Classification of esophageal motility disorders, v3.0

BACKGROUND

The Chicago Classification (CC) of esophageal motility disorders, utilizing an algorithmic scheme to analyze clinical high-resolution manometry (HRM) studies, has gained acceptance worldwide.

METHODS

This 2014 update, CC v3.0, developed by the International HRM Working Group, incorporated the extensive clinical experience and interval publications since the prior (2011) version.

KEY RESULTS

Chicago Classification v3.0 utilizes a hierarchical approach, sequentially prioritizing: (i) disorders of esophagogastric junction (EGJ) outflow (achalasia subtypes I-III and EGJ outflow obstruction), (ii) major disorders of peristalsis (absent contractility, distal esophageal spasm, hypercontractile esophagus), and (iii) minor disorders of peristalsis characterized by impaired bolus transit. EGJ morphology, characterized by the degree of overlap between the lower esophageal sphincter and the crural diaphragm and baseline EGJ contractility are also part of CC v3.0. Compared to the previous CC version, the key metrics of interpretation, the integrated relaxation pressure (IRP), the distal contractile integral (DCI), and the distal latency (DL) remain unchanged, albeit with much more emphasis on DCI for defining both hypo- and hypercontractility. New in CC v3.0 are: (i) the evaluation of the EGJ at rest defined in terms of morphology and contractility, (ii) 'fragmented' contractions (large breaks in the 20-mmHg isobaric contour), (iii) ineffective esophageal motility (IEM), and (iv) several minor adjustments in nomenclature and defining criteria. Absent in CC v3.0 are contractile front velocity and small breaks in the 20-mmHg isobaric contour as defining characteristics.

CONCLUSIONS & INFERENCES

Chicago Classification v3.0 is an updated analysis scheme for clinical esophageal HRM recordings developed by the International HRM Working Group.

Esophageal mucosal resection versus esophagectomy: a comparative study of surgical results in patients with advanced megaesophagus

BACKGROUND

The surgical treatment of advanced megaesophagus has no consensus, being esophagectomy the more commonly used method. Since it has high morbimortality--inconvenient for benign disease -, in recent years an alternative has been introduced: the esophageal mucosal resection.

AIM

To compare early and late results of the two techniques evaluating the operative time, length of ICU stay; postoperative hospitalization; total hospitalization; intra- and postoperative complication rates; mortality; and long-term results.

METHODS

Were evaluated retrospectively 40 charts, 23 esophagectomies and 17 mucosectomies. In assessing postoperative results, interviews were conducted by using a specific questionnaire.

RESULTS

Comparing the means of esophagectomy and mucosal resection, respectively, the data were: 1) surgical time--310.2 min and 279.7 min (p > 0.05); 2) length of stay in ICU--5 days and 2.53 days (p <0.05); 3) total time of hospitalization--24.25 days and 20.76 days (p> 0.05); 4) length of hospital stay after surgery--19.05 days and 14.94 days (p> 0.05); 5) presence of intraoperative complications--65% and 18% (p <0.05); 6) the presence of postoperative complications - 65% and 35% (p> 0.05). In the assessment of late postoperative score (range 0-10) esophagectomy (n = 5) obtained 8.8 points and 8.8 points also got mucosal resection (n = 5).

CONCLUSIONS

Esophageal mucosal resection proved to be good alternative for surgical treatment of megaesophagus. It was advantageous in the immediate postoperative period by presenting a lower average time in operation, the total hospitalization, ICU staying and complications rate. In the late postoperative period, the result was excellent and good in both operations.

Epiphrenic diverticula mini-invasive surgery: a challenge for expert surgeons--personal experience and review of the literature

BACKGROUND AND AIMS

While in the past, thoracotomy represented the traditional surgical approach for the treatment of epiphrenic diverticula, actually mini-invasive approach seems to be the preferred treatment as many series have been published in the recent years. This article describes the authors' experience with the laparoscopic approach for performing diverticulectomy, myotomy, and Nissen-Rossetti fundoplication.

MATERIAL AND METHODS

From 1994 to 2010, 21 patients (10 men and 11 women), mean age 58.5 years (range 45-74 years), with symptomatic epiphrenic diverticulum underwent laparoscopic diverticulectomy, myotomy and Nissen-Rossetti fundoplication.

RESULTS

The mean operative time was 135 min (range = 105-190 min). Mean hospital stay was 14.2 days (range = 7-25 days). In 5 patients (23.8%), a partial suture staple line leak was observed. Conservative treatment achieved leak resolution in all the cases. One patient (4.8%) died of a myocardial infarction in the postoperative period. After a mean clinical follow-up period of 78 months (range = 6-192 months), excellent or good outcome was referred with no dysphagia in 16 patients (80%) and only mild occasional dysphagia in 4 patients (20%).

CONCLUSIONS

Surgical treatment of epiphrenic diverticula remains a challenging procedure also by mini-invasive approach, with major morbidity and mortality rates. For this reason, indications must be restricted only to selected and symptomatic patients in specialized centers.