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King WW, Yang D, Draganov PV. Esophageal Per-Oral Endoscopic Myotomy (E-POEM): Future Directions and Perspectives. Curr Gastroenterol Rep 2024; 26:241-250. [PMID: 39117966 DOI: 10.1007/s11894-024-00938-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2024] [Indexed: 08/10/2024]
Abstract
PURPOSE OF REVIEW POEM is a mature procedure endorsed by societal guidelines as a first line therapy for achalasia and spastic esophageal disorders. Nonetheless, several questions remain, including expanding indications for POEM, periprocedural evaluation and management, and the optimal POEM technique to enhance clinical success while mitigating risk for reflux. RECENT FINDINGS There is uncertainty regarding several technical aspects of the POEM myotomy; though aggregating evidence supports the use of real-time impedance planimetry to guide the myotomy. While post-POEM reflux remains a concerning long term sequela, there is an increasing focus on the potential role of endoscopic anti-reflux interventions. Lastly, with the widespread adoption of POEM, we continue to witness ongoing efforts to standardize post-procedural care and training in this procedure. POEM is no longer a novel but rather established procedure. Yet, this technique has continued to evolve, with the aim of optimizing treatment success while reducing adverse events and risk for post-procedural reflux.
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Affiliation(s)
- William W King
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, FL, USA
| | - Dennis Yang
- Center for Interventional Endoscopy, AdventHealth, Orlando, FL, USA
| | - Peter V Draganov
- Division of Gastroenterology and Hepatology, University of Florida, PO Box 100214, Gainesville, FL, 32610, USA.
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Dervin H, Sweis R. Incorporating all the evidence: the role of EGJ-CI in GERD diagnosis. Gut 2024:gutjnl-2023-331362. [PMID: 39237128 DOI: 10.1136/gutjnl-2023-331362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 11/02/2023] [Indexed: 09/07/2024]
Affiliation(s)
- Humayra Dervin
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Rami Sweis
- GI Physiology Unit, University College London Hospitals NHS Foundation Trust, London, UK
- University College London, London, UK
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Arndorfer D, Pezzino EC, Pandolfino JE, Halder S, Kahrilas PJ, Carlson DA. Defining lower esophageal sphincter physiomechanical states among esophageal motility disorders using functional lumen imaging probe panometry. Neurogastroenterol Motil 2024:e14906. [PMID: 39223871 DOI: 10.1111/nmo.14906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Revised: 07/19/2024] [Accepted: 08/18/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Functional lumen imaging probe (FLIP) panometry assesses esophageal motility in response to controlled volumetric distension. This study aimed to describe the physiomechanical states of the lower esophageal sphincter (LES) in response to serial filling/emptying regimes for esophageal motility disorders. METHODS Fourty-five patients with absent contractile response on FLIP and diagnoses of normal motility (n = 6), ineffective esophageal motility (IEM; n = 8), scleroderma (SSc; n = 10), or nonspastic achalasia (n = 21) were included, as were 20 patient controls with normal motility on FLIP and manometry. LES diameter and pressure were measured after stepwise FLIP filling at 60 mL, 70 mL, and emptying to 60 mL with relative changes used to define physiomechanical states. KEY RESULTS Passive dilatation after FLIP filling occurred in 63/65 (97%) patients among all diagnoses. After FLIP emptying, passive shortening occurred in 12/14 (86%) normal motility/IEM, 10/10 (100%) SSc, 9/21(43%) achalasia, and 16/20 (80%) controls, with auxotonic relaxation seen in 2/14 (14%) normal motility/IEM, 12/21 (57%) achalasia, and 4/20 (20%) controls. After achalasia treatment (LES myotomy), 21/21 (100%) achalasia had passive shortening after FLIP emptying. CONCLUSIONS & INFERENCES Physiomechanical states of the LES can be determined via response to FLIP filling and emptying regimes. While passive shortening was the general response to FLIP emptying, auxotonic relaxation was observed in achalasia, which was disrupted by LES myotomy. Further investigation is warranted into the clinical impact on diagnosis and treatment of esophageal motility disorders.
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Affiliation(s)
- Daniel Arndorfer
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Elena C Pezzino
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - John E Pandolfino
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Sourav Halder
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Peter J Kahrilas
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Dustin A Carlson
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Angelica B, Tippett M, Lim A, Wong S, Kuo P. Utility of mean nocturnal baseline impedance and post-reflux swallow-induced peristaltic wave index in clinical pH-impedance reflux study. Intern Med J 2024; 54:1523-1530. [PMID: 38530066 DOI: 10.1111/imj.16379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 02/26/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND AND AIMS Analysis of mean nocturnal baseline impedance (MNBI) and post-reflux swallow-induced peristaltic wave index (PSPWi) have been proposed to increase the diagnostic yield of pH-impedance studies in reflux disease. However, routine use of these indices in clinical studies is yet to be established, particularly with PSPWi, which requires laborious manual analysis. Our study aimed to assess the utility of MNBI and PSPWi and their potential for future incorporation into clinical practice. METHODS pH-impedance recordings from consecutive patients referred to the Motility Laboratory at Royal Adelaide Hospital for evaluation of gastro-oesophageal reflux disease (GORD) were prospectively collected and manually analysed. Baseline demographic characteristics, symptoms, acid exposure time (AET), number of reflux episodes, and MNBI and PSPWi were collected. RESULTS Eighty-nine patients were included in the study (age 50 ± 17 years, 35 males). MNBI and PSPWi inversely correlated with AET (R = -0.678, P < 0.0001 and R = -0.460, P < 0.0001 respectively) and with reflux episodes (R = -0.391, P = 0.0002 and R = -0.305, P = 0.0037 respectively). In patients with a negative pH study, but with typical reflux symptoms, 4/30 (13%) had pathologic MNBI and PSPWi. There was a positive correlation between MNBI and PSPWi values (R = 0.525, P < 0.0001). Performing analysis of PSPWi was substantially more laborious than MNBI. CONCLUSION MNBI and PSPWi are both useful adjuncts in the diagnosis of reflux disease, although in our cohort MNBI showed stronger correlation with AET with less time to analyse. The role of these indices remains to be further explored, particularly in patients with inconclusive AET and in those with positive compared to negative symptom association.
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Affiliation(s)
- Bianca Angelica
- Motility Laboratory, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Marcus Tippett
- Motility Laboratory, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Amanda Lim
- Motility Laboratory, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Stephanie Wong
- Motility Laboratory, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Paul Kuo
- Motility Laboratory, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Ellison A, Peller M, Nguyen AD, Carlson DA, Keswani R, Schauer JM, Reddy CA, Souza RF, Spechler SJ, Pandolfino JE, Konda VJA. An endoscopic scoring system for achalasia: the CARS score. Gastrointest Endosc 2024; 100:417-428.e1. [PMID: 38431105 DOI: 10.1016/j.gie.2024.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/29/2024] [Accepted: 02/18/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND AND AIMS The diagnosis of achalasia is associated with an average delay of 2 years. Endoscopic features may prompt an earlier diagnosis. We aimed to develop and test a novel endoscopic score, CARS, for the prediction of achalasia. METHODS Part 1: Twenty endoscopic videos were taken from patients undergoing endoscopy for dysphagia or reflux. A survey with videos and endoscopic criteria options was distributed to 6 esophagologists and 6 general gastroenterologists. Inter-rater reliability (IRR) was measured and logistic regression was used to evaluate predictive performance. Three rounds of review were conducted to select the final score of 4 components. Part 2: A retrospective review was conducted for consecutive patients who had comprehensive esophageal testing. Each patient had a CARS endoscopic score calculated based on findings reported at endoscopy. RESULTS From a video review and analysis of score components, IRR ranged from 0.23 to 0.57 for score components. The final CARS score was selected based on the following 4 components: Contents, Anatomy, Resistance, and Stasis. In a mixed-effects model, the mean score across raters was higher for achalasia compared with nonachalasia subjects (4.44 vs 0.87; P < .01). In part 2 of the study, achalasia patients had a higher mean CARS score compared with those with no or ineffective motility disorder (mean 4.1 vs 1.3; P < .01). CONCLUSIONS We developed a CARS score based on reliability performance in a video-based survey and tested the score in a clinical setting. The CARS score performed well in predicting achalasia.
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Affiliation(s)
- Ashton Ellison
- Division of Gastroenterology, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott and White Research Institute, Dallas, Texas.
| | - Matthew Peller
- Division of Gastroenterology and Hepatology, Kenneth C. Griffin Esophageal Center, Northwestern Medicine, Northwestern University, Chicago, Illinois
| | - Anh D Nguyen
- Division of Gastroenterology, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott and White Research Institute, Dallas, Texas
| | - Dustin A Carlson
- Division of Gastroenterology and Hepatology, Kenneth C. Griffin Esophageal Center, Northwestern Medicine, Northwestern University, Chicago, Illinois
| | - Rajesh Keswani
- Division of Gastroenterology and Hepatology, Kenneth C. Griffin Esophageal Center, Northwestern Medicine, Northwestern University, Chicago, Illinois
| | - Jacob M Schauer
- Department of Preventive Medicine, Division of Biostatistics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Chanakyaram A Reddy
- Division of Gastroenterology, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott and White Research Institute, Dallas, Texas
| | - Rhonda F Souza
- Division of Gastroenterology, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott and White Research Institute, Dallas, Texas
| | - Stuart J Spechler
- Division of Gastroenterology, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott and White Research Institute, Dallas, Texas
| | - John E Pandolfino
- Division of Gastroenterology and Hepatology, Kenneth C. Griffin Esophageal Center, Northwestern Medicine, Northwestern University, Chicago, Illinois
| | - Vani J A Konda
- Division of Gastroenterology, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott and White Research Institute, Dallas, Texas
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De Ponthaud C, Voron T, Paye F. Laparoscopic floppy Nissen fundoplication with valve calibration: a safe and efficient procedure. Surg Today 2024; 54:1041-1050. [PMID: 38589734 DOI: 10.1007/s00595-024-02817-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 01/14/2024] [Indexed: 04/10/2024]
Abstract
PURPOSES A floppy Nissen fundoplication with valve calibration (FNF-VC) performed by laparotomy has been described, to reduce postoperative dysphagia and gas bloating after 360°-fundoplication. As laparoscopy is the gold standard for fundoplication, this study reports the first results of a modified FNF-VC adapted for laparoscopy (LFNF). METHODS Seventy-two consecutive patients, who underwent LFNF for refractory GERD between 2012 and 2021, were included. Postoperative outcomes and quality of life (QoL) by GERSS, GERD-HRQL, and GIQLI scores before and after surgery were assessed. RESULTS The main symptoms were pyrosis (81%), regurgitation (39%), Ear-Nose-Throat symptoms (22%), and thoracic pain (24%). Hiatal hernia was present in 85% (n = 61) of the patients. There was no postoperative mortality, and the severe postoperative morbidity rate (Dindo-Clavien ≥ III) was 6%. After a median follow-up of 3.6 years, only 8% of patients were still taking proton-pump inhibitors. Long-term residual dysphagia was noted in 15% of the patients, but none required reoperation or interventional endoscopic procedures. QoL improved, with a significant reduction in GERSS and GERD-HRQL scores and a postoperative GIQLI of 101.75 (75-117.5). CONCLUSION This series reports the safety and efficacy of an FNF-VC adapted for laparoscopy to treat GERD with a limited rate of residual dysphagia.
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Affiliation(s)
- Charles De Ponthaud
- Department of Digestive and Hepato-Pancreato-Biliary Surgery, Hôpital Saint Antoine, Assistance Publique Hôpitaux de Paris, 184 Rue du Faubourg Saint Antoine, 75012, Paris, France
- Sorbonne University, Paris, France
| | - Thibault Voron
- Department of Digestive and Hepato-Pancreato-Biliary Surgery, Hôpital Saint Antoine, Assistance Publique Hôpitaux de Paris, 184 Rue du Faubourg Saint Antoine, 75012, Paris, France
- Sorbonne University, Paris, France
| | - François Paye
- Department of Digestive and Hepato-Pancreato-Biliary Surgery, Hôpital Saint Antoine, Assistance Publique Hôpitaux de Paris, 184 Rue du Faubourg Saint Antoine, 75012, Paris, France.
- Sorbonne University, Paris, France.
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Biermann M, Obineme C, Godiers M, Kundu S, Jain AS. The functional lumen imaging probe contractile response pattern is the best predictor of botulinum toxin response in esophagogastric junction outflow obstruction. Neurogastroenterol Motil 2024; 36:e14859. [PMID: 38988105 PMCID: PMC11321917 DOI: 10.1111/nmo.14859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 04/12/2024] [Accepted: 06/26/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND Esophagogastric junction outflow obstruction (EGJOO) is a heterogenous disorder in which the correct management strategy is unclear. We assessed whether functional lumen imaging probe (FLIP) topography data could select EGJOO, which would benefit from lower esophageal sphincter Botulinum toxin (Botox) injection. METHODS This was a single-center prospective study of adult patients meeting Chicago Classification (CC) v3.0 criteria for EGJOO. We assessed differences in pretreatment physiologic measurements on high-resolution manometry (HRM) and FLIP and other relevant clinical variables in predicting Botox response (>50% in BEDQ at 2 months). KEY RESULTS Sixty-nine patients were included (ages 33-90, 73.9% female). Of these, 42 (61%) were Botox responders. Majority of physiologic measures on HRM and FLIP and esophageal emptying were not different based on Botox response. However, a spastic-reactive (SR) FLIP contractile response (CR) pattern predicted a Botox response with OR 25.6 (CI 2.9-229.6) when compared to antegrade FLIP CR; and OR for impaired-disordered/absent CR was 22.5 (CI 2.5-206.7). Logistic regression model using backward elimination (p value = 0.0001, AUC 0.79) showed that a SRCR or IDCR/absent response and the upright IRP predicted Botox response. Response rates in tiered diagnostic groups were: (i) CCv3.0 EGJOO (60.9%), (ii) CCv4.0 EGJOO (73.1%), (iii) CCv4.0 + FLIP REO (80%), (iv) CCv4.0, FLIP REO, and abnormal FLIP CR (84.2%), and (v) CCv4.0, FLIP REO, and SR FLIP CR (90%). CONCLUSIONS AND INFERENCES FLIP helps identify patients with EGJOO who are likely to response to LES Botox therapy. An abnormal FLIP contractile response pattern is the single-most important predictor of a Botox response.
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Affiliation(s)
- Maya Biermann
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Chuma Obineme
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Marie Godiers
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Suprateek Kundu
- Department of Medicine, Data Analytics and Biostatistics Core, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Anand S Jain
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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Kamboj AK, Katzka DA, Vela MF, Yadlapati R, Ravi K. A practical approach to ineffective esophageal motility. Neurogastroenterol Motil 2024; 36:e14839. [PMID: 38837280 PMCID: PMC11321916 DOI: 10.1111/nmo.14839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 05/15/2024] [Accepted: 05/22/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND AND PURPOSE Ineffective esophageal motility (IEM) is the most frequently diagnosed esophageal motility abnormality and characterized by diminished esophageal peristaltic vigor and frequent weak, absent, and/or fragmented peristalsis on high-resolution esophageal manometry. Despite its commonplace occurrence, this condition can often provoke uncertainty for both patients and clinicians. Although the diagnostic criteria used to define this condition has generally become more stringent over time, it is unclear whether the updated criteria result in a more precise clinical diagnosis. While IEM is often implicated with symptoms of dysphagia and gastroesophageal reflux disease, the strength of these associations remains unclear. In this review, we share a practical approach to IEM highlighting its definition and evolution over time, commonly associated clinical symptoms, and important management and treatment considerations. We also share the significance of this condition in patients undergoing evaluation for anti-reflux surgery and consideration for lung transplantation.
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Affiliation(s)
- Amrit K. Kamboj
- Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - David A. Katzka
- Department of Digestive and Liver Diseases, Columbia University, New York, NY
| | - Marcelo F. Vela
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ
| | - Rena Yadlapati
- Division of Gastroenterology and Hepatology, University of California San Diego, San Diego, CA
| | - Karthik Ravi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
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Renard D, Clavier T, Gourcerol G, Desprez C. Impact of anesthesia drugs on digestive motility measurements in humans: A systematic review. Neurogastroenterol Motil 2024; 36:e14855. [PMID: 38934423 DOI: 10.1111/nmo.14855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 06/13/2024] [Accepted: 06/14/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND AND PURPOSE Measurement of gastro-intestinal motility is increasingly performed under general anesthesia during endoscopic or surgical procedures. The aim of the present study was to review the impact of different anesthetic agents on digestive motility measurements in humans. METHODS This systematic review was performed using the Medline-Pubmed and Web of Science databases. All articles published until October 2023 were screened by identification of key words. Studies were reviewed if patients had an assessment of digestive motility using conventional perfused manometry, high-resolution manometry, electronic barostat or functional lumen impedance planimetry with the use of inhaled or intravenous anesthetic anesthetic agents (propofol, ketamine, halogens, nitrous oxide, opioids, and neuromuscular blockades). RESULTS Four hundred and eighty-eight unique citations were identified, of which 42 studies met the inclusion criteria and were included in the present review. The impact of anesthetics was mostly studied in patients who underwent esophageal manometry. There was a heterogeneity in both the dose and timing of administration of anesthetics among the studies. Remifentanil analgesia was the most studied anesthetic drug in the literature, showing a decrease in both distal latency and lower esophageal sphincter pressure after its administration, but the impact on Chicago classification was not studied. Inhaled anesthetics administration elicited a decrease in lower esophageal sphincter pressure, but contradictory findings were shown on esophageal motility following propofol or neuromuscular blocking agents administration. CONCLUSION Studies of the impact of anesthetics on digestive motility remain scarce in the literature, although some agents have been reported to profoundly affect gastro-intestinal motility.
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Affiliation(s)
- Domitille Renard
- Department of Anesthesiology, Critical Care and Perioperative Medicine, Rouen University Hospital, Rouen, France
| | - Thomas Clavier
- Department of Anesthesiology, Critical Care and Perioperative Medicine, Rouen University Hospital, Rouen, France
- INSERM EnVI UMR Unit 1096, Rouen University Hospital, Rouen, France
| | - Guillaume Gourcerol
- Digestive Physiology Department, CHU Rouen, Rouen, France
- Nutrition, Brain and Gut Laboratory, INSERM Unit 1073, Rouen University Hospital, Rouen, France
| | - Charlotte Desprez
- Digestive Physiology Department, CHU Rouen, Rouen, France
- Nutrition, Brain and Gut Laboratory, INSERM Unit 1073, Rouen University Hospital, Rouen, France
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Idalsoaga F, Díaz LA, Ayares G, Cabrera D, Chahuan J, Monrroy H, Halawi H, Arrese M, Arab JP. Review article: Oesophageal disorders in chronic liver disease. Aliment Pharmacol Ther 2024; 60:715-726. [PMID: 39082463 DOI: 10.1111/apt.18193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 07/03/2024] [Accepted: 07/20/2024] [Indexed: 08/29/2024]
Abstract
BACKGROUND Oesophageal disorders and chronic liver disease are common worldwide and significantly impact quality of life. The intricate link between these conditions, including how oesophageal disorders like GERD, Barrett's oesophagus and oesophageal cancer affect and are affected by chronic liver disease, remains poorly understood. AIMS To review the relationship between oesophageal disorders and chronic liver disease, evaluating epidemiology, pathophysiology and therapeutic factors. METHODS We reviewed the literature on the relationship between oesophageal disorders and chronic liver disease, including cirrhosis, using the PubMed database RESULTS: Oesophageal disorders such as gastroesophageal reflux disease, Barrett's oesophagus, oesophageal cancer, oesophageal motor disorders and oesophageal candidiasis are prevalent among individuals with cirrhosis, exacerbating the burden of liver disease. These diseases have a multifaceted symptomatology and pathogenic basis, posing a significant challenge in cirrhotic patients that necessitates careful diagnosis and management. Additionally, therapies frequently used for these diseases, such as proton pump inhibitors, require careful consideration in cirrhotic patients due to potential adverse effects and altered pharmacokinetics. Managing oesophageal disorders in cirrhotic patients requires a cautious approach due to possible interactions with medications and the risk of adverse effects. Furthermore, symptoms associated with these conditions are often exacerbated by common interventions in patients with cirrhosis, such as band ligation for oesophageal varices. CONCLUSIONS Oesophageal disorders are common in cirrhosis and increase the disease burden. These conditions require careful management due to complex symptoms and treatment risks. Proton pump inhibitors and other therapies must be used cautiously, as cirrhosis interventions can worsen symptoms.
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Affiliation(s)
- Francisco Idalsoaga
- Departamento De Gastroenterología, Escuela De Medicina, Pontificia Universidad Católica De Chile, Santiago, Chile
| | - Luis Antonio Díaz
- Departamento De Gastroenterología, Escuela De Medicina, Pontificia Universidad Católica De Chile, Santiago, Chile
| | - Gustavo Ayares
- Departamento De Gastroenterología, Escuela De Medicina, Pontificia Universidad Católica De Chile, Santiago, Chile
| | - Daniel Cabrera
- Faculty of Medicine, Universidad de los Andes, Santiago, Chile
- Centro de Estudios e Investigación en Salud y Sociedad, Escuela de Medicina, Facultad de Ciencias Médicas, Universidad Bernardo O Higgins, Santiago, Chile
| | - Javier Chahuan
- Departamento De Gastroenterología, Escuela De Medicina, Pontificia Universidad Católica De Chile, Santiago, Chile
| | - Hugo Monrroy
- Departamento De Gastroenterología, Escuela De Medicina, Pontificia Universidad Católica De Chile, Santiago, Chile
| | - Houssam Halawi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Marco Arrese
- Departamento De Gastroenterología, Escuela De Medicina, Pontificia Universidad Católica De Chile, Santiago, Chile
| | - Juan Pablo Arab
- Departamento De Gastroenterología, Escuela De Medicina, Pontificia Universidad Católica De Chile, Santiago, Chile
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
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Gundling F, Schad CM. ["Tailored therapy" in a 36 year old female patient with persistent dysphagia]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:1369-1370. [PMID: 39250960 DOI: 10.1055/a-2309-5915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Affiliation(s)
- Felix Gundling
- Medizinische Klinik II: Gastroenterologie, Gastroenterologische Onkologie, Hepatologie, Diabetologie, Stoffwechsel, Infektiologie, Klinikum am Bruderwald der Sozialstiftung Bamberg, Buger Str. 80, 96049 Bamberg
| | - Christopher Moritz Schad
- Medizinische Klinik II: Gastroenterologie, Gastroenterologische Onkologie, Hepatologie, Diabetologie, Stoffwechsel, Infektiologie, Klinikum am Bruderwald der Sozialstiftung Bamberg, Buger Str. 80, 96049 Bamberg
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Pasta A, Facchini C, Calabrese F, Bodini G, De Bortoli N, Furnari M, Mari A, Savarino EV, Savarino V, Visaggi P, Zentilin P, Giannini EG, Marabotto E. Esophageal motor disorders across ages: A retrospective multicentric analysis. J Am Geriatr Soc 2024; 72:2782-2791. [PMID: 38975863 DOI: 10.1111/jgs.19068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 06/02/2024] [Accepted: 06/11/2024] [Indexed: 07/09/2024]
Abstract
BACKGROUND Age-related changes in the gastrointestinal system are common and may be influenced by physiological aging processes. To date, a comprehensive analysis of esophageal motor disorders in patients belonging to various age groups has not been adequately reported. METHODS We conducted a retrospective assessment of high-resolution manometry (HRM) studies in a multicenter setting. HRM parameters were evaluated according to the Chicago Classification version 4.0. Epidemiological, demographic, clinical data, and main manometric parameters, were collected at the time of the examination. Age groups were categorized as early adulthood (<35 years), early middle-age (35-49 years), late middle-age (50-64 years), and late adulthood (≥65 years). RESULTS Overall, 1341 patients (632, 47.0% male) were included with a median age of 55 years. Late adulthood patients reported more frequently dysphagia (35.2%) than early adulthood patients (24.0%, p = 0.035), early middle-age patients (21.0%, p < 0.0001), and late middle-aged patients (22.7%, p < 0.0001). Esophagogastric junction outflow obstruction was more prevalent in late adulthood (16.7%) than in early adulthood (6.1%, p = 0.003), and in early middle-age (8.1%, p = 0.001). Patients with normal esophageal motility were significantly younger (52.0 years) than patients with hypercontractile esophagus (61.5 years), type III achalasia (59.6 years), esophagogastric junction outflow obstruction (59.4 years), absent contractility (57.2 years), and distal esophageal spasm (57.0 years), in multivariate model (p < 0.0001). CONCLUSION The rate of esophageal motor disorders is higher in older patients, in particular esophagogastric junction outflow obstruction and hypercontractile esophagus. Future prospective studies are necessary to confirm our results and to find tailored strategies to improve clinical outcomes.
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Affiliation(s)
- Andrea Pasta
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Chiara Facchini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Francesco Calabrese
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Giorgia Bodini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Nicola De Bortoli
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Manuele Furnari
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Amir Mari
- Gastroenterology Unit, Nazareth EMMS Hospital, Nazareth, Israel
- The Azrieli Faculty of Medicine, Bar Ilan University, Ramat Gan, Israel
| | - Edoardo V Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
- Gastroenterology Unit, Azienda Ospedale Università di Padua, Padua, Italy
| | - Vincenzo Savarino
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Pierfrancesco Visaggi
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Patrizia Zentilin
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Edoardo G Giannini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Elisa Marabotto
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
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Costantini A, Costantini M, Provenzano L, Capovilla G, Nicoletti L, Forattini F, Vittori A, Nezi G, Santangelo M, Moletta L, Valmasoni M, Salvador R. Complementary pneumatic dilations are an effective and safe treatment when laparoscopic myotomy fails: A 30-year experience at a single tertiary center. J Gastrointest Surg 2024; 28:1533-1539. [PMID: 39232590 DOI: 10.1016/j.gassur.2024.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 06/02/2024] [Accepted: 06/13/2024] [Indexed: 09/06/2024]
Abstract
BACKGROUND In the last 3 decades, laparoscopic Heller myotomy (LHM) has represented the treatment of choice for esophageal achalasia, solving symptoms in most patients. Little is known about the fate of patients relapsing after LHM or their treatment. In this study, we aimed at evaluating the results of complementary pneumatic dilations (CPDs) after ineffective LHM. METHODS We evaluated the patients who underwent LHM with Dor fundoplication (LHD) from 1992 to 2022 and were submitted to CPD for persistent or recurrent symptoms. The patients were followed clinically and with manometry, barium swallow, and endoscopy when necessary. An Eckardt score (ES) of > 3 was used as threshold for failure. RESULTS Of 1420 patients undergoing LHD, 120 (8.4%) were considered failures and were offered CPD. Ten patients refused further treatment; in 5 CPD was not indicated for severe esophagitis; 1 patient had surgery for a misshaped fundoplication and 1 patient developed cancer 2 years after LHD; that leaves 103 patients who underwent a median 2 CPDs (IQR, 1-3), at a median of 15 (IQR, 8-36) months after surgery, with 3.0- to 4.0-cm Rigiflex dilator (Boston Scientific, Massachusetts, USA). No perforations were recorded. Only 6 patients were lost to follow-up. Thus, 97 were followed for a median of 37 months (IQR, 6-112) after the last CPD: 70 (72%) were asymptomatic, whereas 27 (28%) had significant persistent dysphagia (ES > 3). The only differences between the 2 groups were the ES after surgery (P < .01) and the number of required CPD. Overall, the combination of LHD + CPD provided a satisfactory outcome in 96.5% of the patients. CONCLUSION CPDs represent an effective and safe option to treat patients after a failed LHD: when the postsurgery ES consistently remains high and the number of CPDs required to control symptoms exceeds 2, this may suggest the need for further invasive treatments.
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Affiliation(s)
- Andrea Costantini
- Department of Surgical, Gastroenterological and Oncological Sciences, Unit of Surgery 1, University of Padua, Padua, Italy
| | - Mario Costantini
- Department of Surgical, Gastroenterological and Oncological Sciences, Unit of Surgery 1, University of Padua, Padua, Italy
| | - Luca Provenzano
- Department of Surgical, Gastroenterological and Oncological Sciences, Unit of Surgery 1, University of Padua, Padua, Italy
| | - Giovanni Capovilla
- Department of Surgical, Gastroenterological and Oncological Sciences, Unit of Surgery 1, University of Padua, Padua, Italy
| | - Loredana Nicoletti
- Department of Surgical, Gastroenterological and Oncological Sciences, Unit of Surgery 1, University of Padua, Padua, Italy
| | - Francesca Forattini
- Department of Surgical, Gastroenterological and Oncological Sciences, Unit of Surgery 1, University of Padua, Padua, Italy
| | - Arianna Vittori
- Department of Surgical, Gastroenterological and Oncological Sciences, Unit of Surgery 1, University of Padua, Padua, Italy
| | - Giulia Nezi
- Department of Surgical, Gastroenterological and Oncological Sciences, Unit of Surgery 1, University of Padua, Padua, Italy
| | - Matteo Santangelo
- Department of Surgical, Gastroenterological and Oncological Sciences, Unit of Surgery 1, University of Padua, Padua, Italy
| | - Lucia Moletta
- Department of Surgical, Gastroenterological and Oncological Sciences, Unit of Surgery 1, University of Padua, Padua, Italy
| | - Michele Valmasoni
- Department of Surgical, Gastroenterological and Oncological Sciences, Unit of Surgery 1, University of Padua, Padua, Italy
| | - Renato Salvador
- Department of Surgical, Gastroenterological and Oncological Sciences, Unit of Surgery 1, University of Padua, Padua, Italy.
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14
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Mikulski MF, Ashcroft C, Morley TJ, Provenza C, Desilets DJ, Romanelli JR. The effect of per-oral endoscopic myotomy by achalasia subtype as measured by impedance planimetry. Surg Endosc 2024; 38:5331-5337. [PMID: 39026005 DOI: 10.1007/s00464-024-11051-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Accepted: 07/06/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Achalasia is an esophageal motility disorder with three subtypes based on manometry that can treated with per-oral endoscopic myotomy (POEM). With the advent of impedance planimetry (EndoFLIP®), we hypothesized the three achalasia subtypes would have different pre-POEM EndoFLIP® diameter and distensibility index (DI) measurements but would be similar after POEM. METHODS A single-institution, retrospective review of consecutive POEM cases by a single surgeon-endoscopist team from 04/07/2017 to 08/28/2023. Patients with a diagnosis of achalasia were stratified into type 1, 2, or 3 based on pre-POEM manometry. Patient characteristics, Eckardt scores, and pre-and-post-POEM diameter and DI were compared by subtype with descriptive, univariate, and multivariable linear regression statistics. RESULTS Sixty-four patients met inclusion criteria, of whom 9(14.1%) had Type 1, 36(56.3%) had Type 2, and 19(29.7%) had Type 3. There were no differences between Types with respect to median pre-POEM Eckardt scores (9[IQR:7-9) vs. 8[IQR:6-9] vs. 7[IQR:5-8], p = 0.148), median post-POEM Eckardt scores (0[IQR:0-1] vs. 0[IQR:0-0] vs. 0[IQR0-0.5], p = 0.112). EndoFLIP® data revealed variation in median pre-POEM diameter and DI between Subtypes (6.9[IQR:6-8.5] vs. 5.5[IQR:5-6.8] vs. 5[IQR:5-6.1], p = 0.025 and 1.8[IQR:1.3-3.2] vs. 0.9[IQR:0.6-1.6] vs. 0.6[IQR:0.5-0.8], p = 0.003, respectively), but not in the change in diameter or DI post-POEM (5.1[IQR:4.3-5.9] vs. 5.1[IQR:4.1-7.1] vs. 5.9[IQR:5-6.4], p = 0.217 and 3.9[IQR:2.5-4.7] vs. 3.4[IQR:2.4-4.7] vs. 2.7[IQR:2.3-3.7], p = 0.461, respectively). However, after adjusting for potentially confounding factors, pre- or post-POEM diameter and DI did not demonstrate statistically significant differences among subtypes. CONCLUSIONS Achalasia subtypes did not demonstrate different pre-POEM diameters or DI as measured by EndoFLIP® nor are there differences after POEM completion. While achalasia subtypes may have slightly different pathophysiology based on manometry findings, similar pre- and post-POEM impedance planimetry findings, along with similar Eckardt scores, support the use of POEM in the treatment of any achalasia subtype.
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Affiliation(s)
- Matthew F Mikulski
- Department of Surgery, Chan Medical School - Baystate Medical Center, University of Massachusetts, 759 Chestnut Street, Springfield, MA, 01199, USA.
| | - Craig Ashcroft
- Department of Surgery, Chan Medical School - Baystate Medical Center, University of Massachusetts, 759 Chestnut Street, Springfield, MA, 01199, USA
| | - Timothy J Morley
- Department of Surgery, Saint Francis Hospital and Medical Center, Hartford, CT, USA
| | - Christina Provenza
- Department of Surgery, Chan Medical School - Baystate Medical Center, University of Massachusetts, 759 Chestnut Street, Springfield, MA, 01199, USA
| | - David J Desilets
- Department of Gastroenterology, University of Massachusetts Chan Medical School - Baystate Medical Center, Springfield, MA, USA
| | - John R Romanelli
- Department of Surgery, Chan Medical School - Baystate Medical Center, University of Massachusetts, 759 Chestnut Street, Springfield, MA, 01199, USA
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Vespa E, Barchi A, Mandarino FV, Fasulo E, Fratto MC, Passaretti S, Azzolini F, Savarino EV, Danese S. Standard length of peroral endoscopic myotomy (POEM) for achalasia: a systematic review and meta-analysis. Dis Esophagus 2024:doae069. [PMID: 39214522 DOI: 10.1093/dote/doae069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 07/11/2024] [Accepted: 08/08/2024] [Indexed: 09/04/2024]
Abstract
Peroral endoscopic myotomy (POEM) is an established treatment for achalasia, yet there is still a lack of technical standardization. No clear definition of 'long', 'standard', or 'short' POEM exists to date. We conducted a systematic review with meta-analysis to analyze current POEM length standards. We included studies reporting technical details of POEM, in which no definite or comparative myotomy length was intentionally adopted (standard myotomy). The primary outcome was the pooled mean total myotomy length. Sub-group analyses were performed to explore heterogeneity across studies. From the initial 7172 records, 31 studies with 3023 patients were included. Pooled mean of total myotomy length was 10.39 cm (95% CI 10.06-10.71; I2 99.3%). Pooled mean of esophageal and gastric myotomy length, provided by 17 studies, was 7.11 cm (95% CI 6.51-7.71; I2 99.8%) and 2.81 cm (95% CI 2.41-3-22; I2 99.8%), respectively. On subgroup analysis for achalasia subtypes, pooled mean length in non-spastic achalasia (type I and II) was 10.17 cm (95% CI 9.91-10.43; I2 94.2%), while in type III it was 14.02 cm (95% CI 10.59-17.44; I2 98.9%). Pooled mean myotomy length for studies conducted between 2014-2020 was 10.53 cm (95% CI, 10.22-10.84; I2 99.1%) and 9.74 cm (95% CI, 7.95-11.54; I2 99.7%) in 2021-2022. Myotomy length during a 'standard' POEM is 10.4 cm, remaining over 10 cm in non-spastic achalasia. The high heterogeneity across studies confirms that the POEM technique needs further standardization. We found no significant time trend towards adopting short POEM, despite recent evidence supporting its use.
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Affiliation(s)
- Edoardo Vespa
- Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Alberto Barchi
- Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Francesco Vito Mandarino
- Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Ernesto Fasulo
- Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Maria Caterina Fratto
- Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Sandro Passaretti
- Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Francesco Azzolini
- Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Edoardo Vincenzo Savarino
- Department of Surgery, Oncology, and Gastroenterology, University of Padua, Padua, Italy
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, Azienda Ospedale Università di Padova, Padua, Italy
| | - Silvio Danese
- Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
- Faculty of Medicine, Department of Gastroenterology and Endoscopy, Università Vita-Salute San Raffaele, Milan, Italy
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Ren XF, Yu ZH, Song WX, Meng QG, Chen X. Diagnostic and therapeutic strategies for achalasia of the cardia. Shijie Huaren Xiaohua Zazhi 2024; 32:545-555. [DOI: 10.11569/wcjd.v32.i8.545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Revised: 07/12/2024] [Accepted: 07/19/2024] [Indexed: 09/01/2024] Open
Abstract
The diagnosis of achalasia of the cardidia (AC) is primarily based on clinical symptoms, esophagographic findings, esophagodynamic examination, and upper gastrointestinal endoscopic findings. High resolution manometry is considered the gold standard for diagnosis. With the advan-cement of new technologies, the diagnostic methods for AC have become more diverse, and three-dimensional modeling may facilitate early detection of AC. The use of endoscopic functional intracavity imaging probe can enhance diagnostic accuracy. Common treatment options include endoscopic balloon dilation, laparoscopic Heller myotomy, and peroral endoscopic myotomy (POEM). POEM has emerged as the most widely utilized therapeutic approach currently, significantly improving the clinical success rate in treating AC. This article provides a comprehensive review on recent research progress in the diagnosis and treatment of AC.
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Affiliation(s)
- Xiang-Feng Ren
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Zi-Han Yu
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Wen-Xuan Song
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Qing-Guo Meng
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Xin Chen
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin 300052, China
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Latorre-Rodríguez AR, Mittal SK, Simmonds H, Kim P, Bremner RM. pHoenix score: development and validation of a novel approach to decrease the number of inconclusive GERD diagnoses. Surg Endosc 2024:10.1007/s00464-024-11105-1. [PMID: 39192040 DOI: 10.1007/s00464-024-11105-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 07/15/2024] [Indexed: 08/29/2024]
Abstract
BACKGROUND The Johnson-DeMeester composite score (DMS) is the historical gold standard for diagnosing gastroesophageal reflux disease (GERD). The Lyon Consensus outlines criteria for diagnosing GERD by pH monitoring, defining normal acid exposure time (AET) as < 4% and pathological as > 6%, presenting diagnostic uncertainty from 4 to 6%. We aimed to (i) calculate the proportion of borderline studies defined by total AET alone that are reclassified as normal or pathological by the DMS, (ii) determine the importance of supine AET for reclassification, and (iii) propose a new classification system using a composite score that considers positional changes. METHODS This single-center, retrospective, observational study analyzed data from patients with an overall total AET from 2 to 6% on 48-h pH monitoring (Bravo pH capsule). Preselected predictors (supine and upright AET) were included in a model to create a composite score (i.e., pHoenix score) using the regression coefficients. The model was internally validated, and discriminative ability was tested against the DMS and compared to the total AET. RESULTS We identified 114 patients (80 [70.2%] women; median age, 55 years). Using the total AET, 26 (22.8%) were classified as normal and 88 (77.2%) as borderline; however, using the DMS, 45 (39.5%) were classified as normal and 69 (60.5%) as pathological. The new pHoenix score demonstrated strong discriminative ability (AUC: 0.957 [95% CI 0.917, 0.998]) with high sensitivity and specificity (lower threshold, 94.4% and 79.2%; upper threshold, 87 and 95.8%). Compared to the total AET alone, the pHoenix score significantly decreased the proportion of inconclusive cases (77.2% vs. 13.2%, p < 0.001). CONCLUSION Total AET has low sensitivity to identify pathological reflux as it disregards supine versus upright reflux. The pHoenix score improves the distinction between normal and pathological cases and reduces ambiguity, offering an alternative approach to diagnosing GERD that addresses the limitations of using total AET alone or the DMS.
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Affiliation(s)
- Andrés R Latorre-Rodríguez
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Road, Phoenix, AZ, 85013, USA
- Grupo de Investigación Clínica, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario. Bogotá D.C., Bogotá, Colombia
| | - Sumeet K Mittal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Road, Phoenix, AZ, 85013, USA.
- Creighton University School of Medicine, Phoenix Health Sciences Campus, Phoenix, AZ, USA.
| | - Hailey Simmonds
- School of Molecular Sciences, Arizona State University, Tempe, AZ, USA
| | - Peter Kim
- Creighton University School of Medicine, Phoenix Health Sciences Campus, Phoenix, AZ, USA
| | - Ross M Bremner
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Road, Phoenix, AZ, 85013, USA
- Creighton University School of Medicine, Phoenix Health Sciences Campus, Phoenix, AZ, USA
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18
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Ueha R, Koyama M, Seto A, Sato T, Goto T, Orimo K, Mitsui J, Yamasoba T. Esophageal Dysmotility in Multiple System Atrophy: A Retrospective Cross-Sectional Study. J Clin Med 2024; 13:5026. [PMID: 39274241 DOI: 10.3390/jcm13175026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2024] [Revised: 08/21/2024] [Accepted: 08/23/2024] [Indexed: 09/16/2024] Open
Abstract
Background/Objective: Multiple system atrophy (MSA) is often associated with dysphagia and esophageal dysmotility (ED). However, ED in patients with MSA is poorly understood. To assess the relationship between ED, dysphagia, and other clinical findings in such patients and investigate the details of ED in MSA using high-resolution manometry (HRM). Methods: Patients from The University of Tokyo Hospital with MSA who underwent swallowing examinations, esophagography, and HRM between 2017 and 2022 were enrolled. A retrospective chart review of patients' backgrounds, swallowing function, and esophageal motility was performed. ED was evaluated using the Chicago Classification version 4.0. Results: Seventy-four patients with MSA were identified. The median age was 64 years, 48 patients (65%) were male, and the cerebellar variant type was predominant (69%). Abnormal upper esophageal sphincter (UES) resting pressure was observed in 34 patients (46%) and intraesophageal stasis in 65 (88%). High-severity MSA was a risk factor for developing dysphagia, vocal fold movement impairment, and abnormal UES function (p < 0.05). However, no overt clinical risk factors for ED were identified. Various types of ED were detected using HRM, and ineffective esophageal motility was the most frequent disorder. Conclusions: ED is a common occurrence in patients with MSA. Although a high-severity MSA may be a risk factor for developing dysphagia and vocal fold motion impairment, ED can occur regardless of clinical severity. Since ED is rarely detected based on subjective symptoms, careful evaluation of esophageal motility by esophagography or HRM is warranted in patients with MSA.
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Affiliation(s)
- Rumi Ueha
- Swallowing Center, The University of Tokyo Hospital, Tokyo 113-8655, Japan
- Department of Otolaryngology and Head and Neck Surgery, Faculty of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Misaki Koyama
- Department of Otolaryngology and Head and Neck Surgery, Faculty of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Akiko Seto
- Department of Neurology, Faculty of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Taku Sato
- Department of Otolaryngology and Head and Neck Surgery, Faculty of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Takao Goto
- Department of Otolaryngology and Head and Neck Surgery, Faculty of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Kenta Orimo
- Department of Neurology, Faculty of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Jun Mitsui
- Department of Neurology, Faculty of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Tatsuya Yamasoba
- Department of Otolaryngology and Head and Neck Surgery, Faculty of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
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Nabi Z, Basha J, Inavolu P, Goud R, Veligatla V, Tummuru SP, Cheripelli N, Arutla M, Ramchandani M, Darisetty S, Nageshwar Reddy D. Comprehensive analysis of nutritional parameters in patients with idiopathic achalasia: A prospective study in India. Indian J Gastroenterol 2024:10.1007/s12664-024-01664-5. [PMID: 39158832 DOI: 10.1007/s12664-024-01664-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Accepted: 07/29/2024] [Indexed: 08/20/2024]
Abstract
BACKGROUND AND AIM Achalasia cardia, a primary motility disorder of the esophagus, poses significant malnutrition risks. This study aims at comprehensively assessing the nutritional status in untreated achalasia patients, contrasting it with functional gastrointestinal disorders (FGIDs) cases and impact of per-oral endoscopic myotomy (POEM) on nutrition at one-year. METHODS We conducted a prospective study, including consecutive achalasia cases, from December 2021 to April 2022 at a tertiary care centre. Biochemical parameters, anthropometry, subjective global assessment (SGA) and malnutrition universal screening tool were used for nutritional assessment. Cases diagnosed with FGIDs served as controls. RESULTS As many as 118 cases (41.2 ± 13.9 years, 61% males) with achalasia and 200 controls (43.4 ± 11.9 years, 69% males) were included in the study. Sub-types of achalasia included type I (16.9%), II (76.3%) and III (6.8%). Overall, 38.1% and 6.8% cases were moderately and severely malnourished, respectively. As compared to controls, cases with achalasia had lower pre-albumin (19.4 vs. 25.2; p = 0.001), serum calcium (p = 0.012), vitamin D (p = 0.001), serum iron (p = 0.001), triceps fold thickness (p = 0.002) and hand-grip strength (p = 0.001). On univariate analysis, type-I achalasia, body mass index, % weight loss, lower esophageal sphincter pressures and Eckardt scores were predictors of malnourishment (SGA). On multivariate analysis, type of achalasia, mid arm circumference and low body mass index were significant predictors of malnourishment in cases with achalasia. There was significant improvement in the nutritional status after POEM at one-year follow-up. CONCLUSION Achalasia patients demonstrate a notably higher risk of malnutrition compared to individuals with FGIDs. Nutritional status significantly improves after POEM. (NCT05161923).
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Affiliation(s)
- Zaheer Nabi
- Asian Institute of Gastroenterology, 6-3-661, Hyderabad, 500 082, India.
| | - Jahangeer Basha
- Asian Institute of Gastroenterology, 6-3-661, Hyderabad, 500 082, India
| | - Pradev Inavolu
- Asian Institute of Gastroenterology, 6-3-661, Hyderabad, 500 082, India
| | - Rajesh Goud
- Asian Institute of Gastroenterology, 6-3-661, Hyderabad, 500 082, India
| | | | | | | | - Madhulika Arutla
- Department of Clinical Nutrition, Asian Institute of Gastroenterology, Hyderabad 500 082, India
| | - Mohan Ramchandani
- Asian Institute of Gastroenterology, 6-3-661, Hyderabad, 500 082, India
| | | | - D Nageshwar Reddy
- Asian Institute of Gastroenterology, 6-3-661, Hyderabad, 500 082, India
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Aurino L, Pesce M, Rurgo S, Puoti MG, Polese B, Capuano M, Palomba G, Aprea G, Seguella L, Esposito G, Palenca I, Efficie E, Sarnelli G. Clinical and nutritional correlates associated with weight changes in achalasia patients and the impact of laparoscopic Heller myotomy. Dig Liver Dis 2024:S1590-8658(24)00891-0. [PMID: 39147673 DOI: 10.1016/j.dld.2024.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2024] [Revised: 07/23/2024] [Accepted: 07/28/2024] [Indexed: 08/17/2024]
Abstract
BACKGROUND Achalasia is characterized by symptoms of esophageal obstruction, preventing food consumption. However, weight loss is observed only in a subset of patients, and data from literature is conflicting. AIMS Our study aimed at evaluating predictors of weight loss in achalasia patients and at verifying the impact of treatment on nutritional status. METHODS 123 achalasia patients, eligible for laparoscopic Heller myotomy, were studied. Demographic, clinical and nutritional data (calorie intake and macronutrient composition) were recorded at baseline and one-year post-treatment. Significant weight loss/gain was considered for variation of 10 % of body weight at baseline and post-treatment, respectively. RESULTS 57.7 % of patients reported weight loss at presentation. These subjects had shorter disease duration, worse symptoms, lower BMI and consumed fewer calories than patients without weight loss. Post-treatment, we observed a considerable improvement in Eckardt score and BMI values. Almost 50 % of the population reported significant weight gain, particularly in individuals with weight loss at baseline. Caloric intake also rose significantly, positively affecting BMI categories. CONCLUSION We showed that achalasia-induced weight loss is associated with symptoms' severity and disease duration. Conversely, over 50 % of treated patients were in the overweight/obese category, highlighting the need for individualized nutritional interventions in achalasia patients.
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Affiliation(s)
- Laura Aurino
- Department of Clinical Medicine and Surgery, 'Federico II' University of Naples, Naples, Italy, Via Pansini 5, 80131, Naples, Italy.
| | - Marcella Pesce
- Department of Clinical Medicine and Surgery, 'Federico II' University of Naples, Naples, Italy, Via Pansini 5, 80131, Naples, Italy.
| | - Sara Rurgo
- Department of Clinical Medicine and Surgery, 'Federico II' University of Naples, Naples, Italy, Via Pansini 5, 80131, Naples, Italy.
| | - Maria Giovanna Puoti
- Department of Pediatric Gastroenterology and Hepatology, Santobono-Pausilipon Children's Hospital, Via Mario Fiore, 6, 80129, Naples, Italy.
| | - Barbara Polese
- Department of Clinical Medicine and Surgery, 'Federico II' University of Naples, Naples, Italy, Via Pansini 5, 80131, Naples, Italy.
| | - Marianna Capuano
- Department of Clinical Medicine and Surgery, 'Federico II' University of Naples, Naples, Italy, Via Pansini 5, 80131, Naples, Italy.
| | - Giuseppe Palomba
- Department of Clinical Medicine and Surgery, 'Federico II' University of Naples, Naples, Italy, Via Pansini 5, 80131, Naples, Italy.
| | - Giovanni Aprea
- Department of Clinical Medicine and Surgery, 'Federico II' University of Naples, Naples, Italy, Via Pansini 5, 80131, Naples, Italy.
| | - Luisa Seguella
- Department of Physiology and Pharmacology "V. Erspamer", Sapienza University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy.
| | - Giuseppe Esposito
- Department of Physiology and Pharmacology "V. Erspamer", Sapienza University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy.
| | - Irene Palenca
- Department of Physiology and Pharmacology "V. Erspamer", Sapienza University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy.
| | - Eleonora Efficie
- Department of Clinical Medicine and Surgery, 'Federico II' University of Naples, Naples, Italy, Via Pansini 5, 80131, Naples, Italy.
| | - Giovanni Sarnelli
- Department of Clinical Medicine and Surgery, 'Federico II' University of Naples, Naples, Italy, Via Pansini 5, 80131, Naples, Italy.
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Tong MH, Zhang MJ, Wang LX, Zhang ZF, Duan ZJ. Incorporating body mass index into esophageal manometry metrics and mean nocturnal baseline impedance for the evaluation of gastro-esophageal reflux disease. Sci Rep 2024; 14:18269. [PMID: 39107491 PMCID: PMC11303378 DOI: 10.1038/s41598-024-69253-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Accepted: 08/02/2024] [Indexed: 08/10/2024] Open
Abstract
This study aims to enhance the effectiveness of high resolution manometry (HRM) and pH-impedance monitoring metrics in distinguishing between gastro-esophageal reflux disease (GERD) and non-GERD. A retrospective propensity score matching (PSM) study was conducted on 643 patients with GERD symptoms. PSM matched 134 GERD patients with 134 non-GERD controls. Body mass index (BMI), intra-esophageal pressure (IEP) and intra-gastric pressure (IGP) were significantly higher in the GERD group compared to the non-GERD group. BMI was correlated with IEP and IGP positively. IGP was positively correlated with esophagogastric (EGJ) pressure (EGJ-P) in participants with EGJ type 1 and 2, but not in participants with EGJ type 3. BMI was correlated with distal MNBI negatively. Logistic regression showed BMI as an independent risk factor for GERD. Receiver operating characteristic curve (ROC) and decision curve analysis (DCA) showed that BMI adjusted EGJ contractile integral (EGJ-CI) and BMI adjusted MNBI were superior to the corresponding original ones in predicting GERD susceptibility. According to the findings, BMI and IGP are the main factors contributing to the development of GERD. BMI affects IEP through the adaptive response of EGJ-P to IGP. Incorporating BMI into the calculations of EGJ-CI and MNBI can improve their ability in predicting GERD susceptibility.
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Affiliation(s)
- Meng-Han Tong
- Department of Gastroenterology, The First Affiliated Hospital of Dalian Medical University, Dalian, 116000, Liaoning, China
| | - Ming-Jie Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Dalian Medical University, Dalian, 116000, Liaoning, China
| | - Li-Xia Wang
- Department of Gastroenterology, The First Affiliated Hospital of Dalian Medical University, Dalian, 116000, Liaoning, China
| | - Zhi-Feng Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Dalian Medical University, Dalian, 116000, Liaoning, China.
| | - Zhi-Jun Duan
- Department of Gastroenterology, The First Affiliated Hospital of Dalian Medical University, Dalian, 116000, Liaoning, China
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do Carmo GC, de Assis Mota G, da Silva Castro Perdoná G, de Oliveira RB. Integrated Relaxation Pressure and Its Diagnostic Ability May Vary According to the Conditions Used for HREM Recording. Dysphagia 2024; 39:746-756. [PMID: 38182941 DOI: 10.1007/s00455-023-10655-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 12/04/2023] [Indexed: 01/07/2024]
Abstract
Integrated Residual Pressure (IRP) measured under conditions alternative to supine single swallows may provide clinically useful information regarding EGJ relaxation. This study aimed to compare IRP values obtained under different situations and explore their potential clinical utility. We analyzed and compared the values of IRP obtained from healthy volunteers and patients with suspected achalasia during supine single swallows (Ssup-IRP), sitting single swallows (Ssit-IRP), supine multiple rapid swallows (Msup-IRP), and sitting multiple rapid swallows (Msit-IRP). We analyzed the HREM recordings of 40 healthy volunteers and 53 patients with suspected achalasia. The four metrics were significantly different from each other in healthy volunteers (Ssup-IRP > Msup-IRP > Ssit-IRP > Msit-IRP) and their corresponding 95th percentiles were substantially distinct (Ssup-IRP: 25.3 mmHg, Ssit-IRP: 20.9 mmHg, Msup-IRP: 15.9 mmHg, and Msit-IRP: 11.9 mm Hg, respectively). Complete agreement among the four metrics in predicting abnormal IRP was found in 39 of the 47 patients with suspected achalasia who completed the protocol. Optimal cutoffs derived from ROC curve analysis demonstrated ≥ 0.95 specificities for detection of impaired EGJ relaxation among patients with suspected achalasia. Among the eight patients with suspected achalasia with normal Ssup-IRP, five demonstrated abnormal Msit-IRP and four abnormal Ssit-IRP. Significant differences of IRP exist depending on the measurement situation, indicating that correct interpretation of IRP values requires specific cutoffs for each situation.The sensitivities of Ssit-IRP and Msit-IRP in detecting defective EGJ relaxation appear to be slightly higher than that of Ssup-IRP.
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Affiliation(s)
- Gardenia Costa do Carmo
- Department of Medicine, Medical School of Ribeirão Preto, University of São Paulo, 3900, Bandeirantes Avenue, Monte Alegre, Ribeirão Preto, São Paulo, 14049-900, Brazil
| | - Gustavo de Assis Mota
- Department of Medicine, Medical School of Ribeirão Preto, University of São Paulo, 3900, Bandeirantes Avenue, Monte Alegre, Ribeirão Preto, São Paulo, 14049-900, Brazil
| | - Gleici da Silva Castro Perdoná
- Department of Medicine, Medical School of Ribeirão Preto, University of São Paulo, 3900, Bandeirantes Avenue, Monte Alegre, Ribeirão Preto, São Paulo, 14049-900, Brazil
| | - Ricardo Brandt de Oliveira
- Department of Medicine, Medical School of Ribeirão Preto, University of São Paulo, 3900, Bandeirantes Avenue, Monte Alegre, Ribeirão Preto, São Paulo, 14049-900, Brazil.
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Halder S, Yamasaki J, Liu X, Carlson DA, Kou W, Kahrilas PJ, Pandolfino JE, Patankar NA. Enhancing Chicago Classification diagnoses with functional lumen imaging probe-mechanics (FLIP-MECH). Neurogastroenterol Motil 2024; 36:e14841. [PMID: 38852150 PMCID: PMC11246220 DOI: 10.1111/nmo.14841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 04/11/2024] [Accepted: 05/25/2024] [Indexed: 06/11/2024]
Abstract
BACKGROUND Esophageal motility disorders can be diagnosed by either high-resolution manometry (HRM) or the functional lumen imaging probe (FLIP) but there is no systematic approach to synergize the measurements of these modalities or to improve the diagnostic metrics that have been developed to analyze them. This work aimed to devise a formal approach to bridge the gap between diagnoses inferred from HRM and FLIP measurements using deep learning and mechanics. METHODS The "mechanical health" of the esophagus was analyzed in 740 subjects including a spectrum of motility disorder patients and normal subjects. The mechanical health was quantified through a set of parameters including wall stiffness, active relaxation, and contraction pattern. These parameters were used by a variational autoencoder to generate a parameter space called virtual disease landscape (VDL). Finally, probabilities were assigned to each point (subject) on the VDL through linear discriminant analysis (LDA), which in turn was used to compare with FLIP and HRM diagnoses. RESULTS Subjects clustered into different regions of the VDL with their location relative to each other (and normal) defined by the type and severity of dysfunction. The two major categories that separated best on the VDL were subjects with normal esophagogastric junction (EGJ) opening and those with EGJ obstruction. Both HRM and FLIP diagnoses correlated well within these two groups. CONCLUSION Mechanics-based parameters effectively estimated esophageal health using FLIP measurements to position subjects in a 3-D VDL that segregated subjects in good alignment with motility diagnoses gleaned from HRM and FLIP studies.
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Affiliation(s)
- Sourav Halder
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Jun Yamasaki
- Department of Mechanical Engineering, McCormick School of Engineering, Northwestern University, Evanston, Illinois, USA
| | - Xinyi Liu
- Department of Engineering Sciences and Applied Mathematics, McCormick School of Engineering, Northwestern University, Evanston, Illinois, USA
| | - Dustin A Carlson
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Wenjun Kou
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Peter J Kahrilas
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - John E Pandolfino
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Neelesh A Patankar
- Department of Mechanical Engineering, McCormick School of Engineering, Northwestern University, Evanston, Illinois, USA
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24
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Leopold A, Wu A, Xie G. Nasopharyngeal airway assistance improves esophageal intubation rates of high-resolution esophageal manometry catheters. Neurogastroenterol Motil 2024; 36:e14824. [PMID: 38775182 PMCID: PMC11246217 DOI: 10.1111/nmo.14824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 04/17/2024] [Accepted: 05/09/2024] [Indexed: 07/14/2024]
Abstract
BACKGROUND High-resolution esophageal manometry (HREM) is the gold standard test for esophageal motility disorders. Nasopharyngeal airway-assisted insertion of the HREM catheter is a suggested salvage technique for failure from the inability to pass the catheter through the upper esophageal sphincter (UES). It has not been demonstrated that the nasopharyngeal airway improves procedural success rate. METHODS Patients undergoing HREM between March 2019 and March 2023 were evaluated. Chart review was conducted for patient factors and procedural success rates before and after use of nasopharyngeal airway. Patients from March 2019 to May 2021 did not have nasopharyngeal airway available and were compared to patients from May 2021 to March 2023 who had the nasopharyngeal airway available. KEY RESULTS In total, 523 HREM studies were conducted; 234 occurred prior to nasopharyngeal airway availability, and 289 occurred with nasopharyngeal airway availability. There was no difference in HREM catheter UES intubation rates between periods when a nasopharyngeal airway attempt was considered procedural failure (85% vs. 85%, p = 0.9). Nasopharyngeal airway use after UES intubation failure lead to improved UES intubation rates (94% vs. 85%, p < 0.01). Thirty-six patients that failed HREM catheter UES intubation had the procedure reattempted with a nasopharyngeal airway, 30 (83%) of which were successful. The nasopharyngeal airway assisted catheter UES intubation for failures attributed to nasal pain and hypersensitivity, gagging, coughing, and pharyngeal coiling. CONCLUSIONS & INFERENCES Utilization of the nasopharyngeal airway increased rates of UES intubation. When HREM catheter placement through the UES fails, placement of a nasopharyngeal airway can be trialed to overcome patient procedural intolerance.
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Affiliation(s)
- Andrew Leopold
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Angela Wu
- Department of Internal Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Guofeng Xie
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Division of Gastroenterology & Hepatology, VA Maryland Healthcare System, Baltimore, Maryland, USA
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Soliman H, Wuestenberghs F, Desprez C, Leroi AM, Melchior C, Gourcerol G. Alterations in gastrointestinal motility assessed by high-resolution antroduodenal manometry in patients with severe disorders of gut-brain interaction. Am J Physiol Gastrointest Liver Physiol 2024; 327:G306-G315. [PMID: 38860287 DOI: 10.1152/ajpgi.00039.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 05/28/2024] [Accepted: 06/07/2024] [Indexed: 06/12/2024]
Abstract
Data are limited regarding gastrointestinal motility disturbance in disorders of gut-brain interaction (DGBI). This study aimed to characterize antroduodenal motor alterations in patients with high-resolution antroduodenal manometry (HR-ADM). HR-ADM was performed in patients with severe DGBI and compared with healthy volunteers (HV). HR-ADM used a commercially available probe composed of 36 electronic sensors spaced 1 cm apart and positioned across the pylorus. Antral and duodenal motor high-resolution profiles were analyzed, based on the frequency, amplitude, and contractile integral/sensor (CI/s) calculated for each phase of the migrating motor complex (MMC). Eighteen HV and 64 patients were investigated, 10 with irritable bowel syndrome (IBS), 24 with functional dyspepsia (FD), 15 with overlap IBS-FD, and 15 with other DGBI. Compared with HV, patients had a lower frequency of phase II duodenal contractions (27 vs. 51 per hour; P = 0.002) and a lower duodenal phase II contraction amplitude (70 vs. 100 mmHg; P = 0.01), resulting in a lower CI/s of phase II (833 vs. 1,901 mmHg·cm·s; P < 0.001) in the duodenum. In addition, the frequency of phase II propagated antroduodenal contractions was lower (5 vs. 11 per hour; P < 0.001) in patients compared with HV. Interestingly, the antral CI/s of phase III was decreased in FD patients but not in IBS patients. Patients with severe DGBI display alterations in antral and intestinal motility assessed by commercially available HR-ADM. Whether these alterations may explain symptom profiles in such patients remains to be confirmed (NCT04918329 and NCT01519180).NEW & NOTEWORTHY Gastrointestinal dysmotility has been assessed poorly in disorders of gut-brain interaction (DGBI), especially with high-resolution antroduodenal manometry. Plots of DGBI patients showed lower duodenal contractions during phase II regarding amplitude, frequency, and contractile integral/sensor (CI/s) compared with healthy volunteers. A lower frequency of propagated antroduodenal contractions was also reported. Finally, antral CI/s was lower in patients with functional dyspepsia during phase III. Further studies are needed to assess the clinical significance of these alterations.
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Affiliation(s)
- Heithem Soliman
- Department of Physiology, "Nutrition, inflammation and microbiota-gut-brain axis", Université Rouen Normandie, INSERM, CHU Rouen, Rouen, France
- Department of Gastroenterology, Hôpital Louis Mourier, AP-HP Nord, Université de Paris-Cité, Colombes, France
| | - Fabien Wuestenberghs
- Department of Physiology, "Nutrition, inflammation and microbiota-gut-brain axis", Université Rouen Normandie, INSERM, CHU Rouen, Rouen, France
- Department of Gastroenterology, Hôpital Avicenne, AP-HP, Sorbonne Paris Nord University, Bobigny, France
| | - Charlotte Desprez
- Department of Physiology, "Nutrition, inflammation and microbiota-gut-brain axis", Université Rouen Normandie, INSERM, CHU Rouen, Rouen, France
| | - Anne-Marie Leroi
- Department of Physiology, "Nutrition, inflammation and microbiota-gut-brain axis", CHU Rouen, Université Rouen Normandie, INSERM, ADEN UMR1073, CIC-CRB 1404, Rouen, France
| | - Chloé Melchior
- Department of Gastroenterology, "Nutrition, inflammation and microbiota-gut-brain axis", Université Rouen Normandie, INSERM, ADEN UMR1073, CHU Rouen, CIC-CRB 1404, Rouen, France
| | - Guillaume Gourcerol
- Department of Physiology, "Nutrition, inflammation and microbiota-gut-brain axis", CHU Rouen, Université Rouen Normandie, INSERM, ADEN UMR1073, CIC-CRB 1404, Rouen, France
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26
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Palones E, Plaza V, Gonzalez-Quereda L, Segarra-Casas A, Querol L, Bertoletti F, Rodriguez MJ, Gallano P, Crespo-Lessmann A. Chronic Cough and Cerebellar Ataxia With Neuropathy and Bilateral Vestibular Areflexia Syndrome (CANVAS): Screening for Mutations in Replication Factor C Subunit 1 (RFC1). Arch Bronconeumol 2024; 60:468-474. [PMID: 38755058 DOI: 10.1016/j.arbres.2024.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 04/05/2024] [Accepted: 04/27/2024] [Indexed: 05/18/2024]
Abstract
INTRODUCTION A common complaint in patients is chronic cough (CC), which may be refractory (RCC) or unexplained (UCC). Recent studies point, as a possible cause of CC, to the hereditary cerebellar ataxia with neuropathy and bilateral vestibular areflexia syndrome (CANVAS), with an estimated carrier prevalence of 1 in 20000. AIM In patients with CC, determine the prevalence of the biallelic (AAGGG)exp mutation in replication factor C subunit 1 (RFC1) responsible for CANVAS, test the usefulness of the Rydel-Seiffer fork test, and evaluate patient quality of life (QoL). METHODS Clinical and functional data were collected for the 33 included patients undergoing CC studies in our specialized unit. Performed were an etiological study of CC following European Respiratory Society recommendations, a genetic study of RFC1 mutations, and Rydel-Seiffer fork testing to detect possible peripheral vibratory sensitivity impairment. Administered to evaluate QoL were 4 questionnaires. RESULTS Prevalence of biallelic (AAGGG)exp in RFC1 was 6.1% (n=2) overall, increasing to 7.1% in the RCC subgroup, and to 33.3% in the Rydel-Seiffer fork altered results subgroup. Prevalence of monoallelic (AAGGG)exp in RFC1 was 18.2% (n=6) overall, rising to 50.0% (n=2) in the UCC subgroup. CONCLUSION Genetic screening for (AAGGG)exp in RFC1, and also use of the Rydel-Seiffer fork test, should be considered in specialized CC consultations for patients with RCC and UCC. Detecting possible CANVAS symptoms in CC studies would identify candidates for early genetic screening, of interest in reducing the disease burden for patients and health systems alike.
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Affiliation(s)
- Esther Palones
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain; Department of Respiratory Medicine, Institut de Recerca Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.
| | - Vicente Plaza
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain; Department of Respiratory Medicine, Institut de Recerca Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Lidia Gonzalez-Quereda
- Genetics and Microbiology Department, Universitat Autònoma de Barcelona, Barcelona, Spain; Genetics Department, Institut de Recerca Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Alba Segarra-Casas
- Genetics and Microbiology Department, Universitat Autònoma de Barcelona, Barcelona, Spain; Genetics Department, Institut de Recerca Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Luis Querol
- Neuromuscular Disease Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Federico Bertoletti
- Department of Digestive Pathology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - María José Rodriguez
- Genetics Department, Institut de Recerca Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Pía Gallano
- Genetics and Microbiology Department, Universitat Autònoma de Barcelona, Barcelona, Spain; Genetics Department, Institut de Recerca Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Networked Biomedical Research Centre for Rare Diseases (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
| | - Astrid Crespo-Lessmann
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain; Department of Respiratory Medicine, Institut de Recerca Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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Baroud S, Kerbage A, Patel A, Horton A, Sims A, Patel D, Mehta K, Kapil N, Kavitt R, Rangan V, Yu Y, Shibli F, Song G, Fass R. Ineffective esophageal motility is associated with diabetes mellitus end organ complications. Neurogastroenterol Motil 2024; 36:e14826. [PMID: 38873936 DOI: 10.1111/nmo.14826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 04/24/2024] [Accepted: 05/15/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Diabetes Mellitus (DM) is known to induce a wide range of harmful effects on several organs, notably leading to ineffective esophageal motility (IEM). However, the relationship between DM and IEM is not fully elucidated. We aimed to determine the relationship between DM and IEM and to evaluate the impact of DM's end organ complications on IEM severity. METHODS A multicenter cohort study of consecutive patients undergoing high-resolution esophageal manometry (HREM) was performed. We reviewed medical records of patients diagnosed with IEM using HREM, encompassing data on demographics, DM history, antidiabetic and other medications as well as comorbidities. KEY RESULTS Two hundred and forty six subjects met the inclusion criteria. There was no significant difference in any of the HREM parameters between diabetics and nondiabetics. Out of 246 patients, 92 were diabetics. Diabetics with neuropathy presented a significantly lower distal contractile integral (DCI) value compared to those without neuropathy (248.2 ± 226.7 mmHg·cm·sec vs. 375.6 ± 232.4 mmHg·cm·sec; p = 0.02) Similarly, the DCI was lower in diabetics with retinopathy compared to those without retinopathy (199.9 ± 123.1 mmHg·cm·sec vs. 335.4 ± 251.7 mmHg·cm·sec; p = 0.041). Additionally, a significant difference was observed in DCI values among DM patients with ≥2 comorbidities compared to those without comorbidities (224.8 ± 161.0 mmHg·cm·sec vs. 394.2 ± 243.6 mmHg·cm·sec; p = 0.025). Around 12.6% of the variation in DCI could be explained by its linear relationship with hemoglobin A1c (HbA1c), with a regression coefficient (β) of -55.3. CONCLUSION & INFERENCES DM is significantly associated with IEM in patients with neuropathy, retinopathy, or multiple comorbidities. These results are pivotal for tailoring patient-specific management approaches.
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Affiliation(s)
- Serge Baroud
- Division of Gastroenterology and Hepatology, Metro Health Medical Center, The Esophageal and Swallowing Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Anthony Kerbage
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Amit Patel
- Duke University School of Medicine and the Durham Veterans Affairs Medical Center, Durham, North Carolina, USA
| | - Anthony Horton
- Duke University School of Medicine and the Durham Veterans Affairs Medical Center, Durham, North Carolina, USA
| | - Ariel Sims
- The University of Chicago Medicine, Chicago, Illinois, USA
| | - Dhyanesh Patel
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kurren Mehta
- Duke University School of Medicine and the Durham Veterans Affairs Medical Center, Durham, North Carolina, USA
| | - Neil Kapil
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robert Kavitt
- The University of Chicago Medicine, Chicago, Illinois, USA
| | - Vikram Rangan
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Yue Yu
- Division of Life Sciences and Medicine, Department of Gastroenterology, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, Anhui, China
| | - Fahmi Shibli
- Division of Gastroenterology and Hepatology, Metro Health Medical Center, The Esophageal and Swallowing Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Gengqing Song
- Division of Gastroenterology and Hepatology, Metro Health Medical Center, The Esophageal and Swallowing Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Ronnie Fass
- Division of Gastroenterology and Hepatology, Metro Health Medical Center, The Esophageal and Swallowing Center, Case Western Reserve University, Cleveland, Ohio, USA
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Richmond M, DeVore EK, Song PC. Esophageal Dysphagia in Adults: When It Sticks. Otolaryngol Clin North Am 2024; 57:569-579. [PMID: 38604886 DOI: 10.1016/j.otc.2024.02.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
Esophageal dysphagia is a common yet difficult to diagnose condition. This article underscores the role of detailed patient history and physical examinations, including prompt endoscopic evaluation, for accurate differentiation between esophageal and oropharyngeal dysphagia. The authors discuss the heightened importance of early intervention in certain patient groups, such as elderly individuals and patients with head and neck cancer, to mitigate the risk of malnutrition and infection. The authors delve into etiologic factors highlighting the complexity of clinical presentations and the significance of tailored management strategies.
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Affiliation(s)
- Miller Richmond
- Georgetown School of Medicine, 3900 Reservoir Road, NW, Washington, DC 20057, USA
| | - Elliana Kirsh DeVore
- Department of Otolaryngology, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA; Division of Laryngology, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, USA
| | - Phillip C Song
- Department of Otolaryngology, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA; Division of Laryngology, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, USA.
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Nawaz N, Saleh H, Koop AH. 57-Year-Old Woman With Chest Pressure. Mayo Clin Proc 2024; 99:1317-1322. [PMID: 38912988 DOI: 10.1016/j.mayocp.2023.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 10/06/2023] [Accepted: 10/10/2023] [Indexed: 06/25/2024]
Affiliation(s)
- Nanjiba Nawaz
- Preliminary Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Jacksonville, FL
| | - Hasan Saleh
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Jacksonville, FL
| | - Andree H Koop
- Advisor to residents and Consultant in Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL.
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Losada Galván I, García M, Hasslocher-Moreno AM, Ortiga A, Sanz S, Molina I, Gascón J, Pinazo MJ. How do we classify organ involvement in Chagas disease? A systematic review of organ involvement since 1909, Highlighting the urgent need for a universal classification system in Chronic Chagas disease. PLoS Negl Trop Dis 2024; 18:e0012367. [PMID: 39102443 PMCID: PMC11326633 DOI: 10.1371/journal.pntd.0012367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 08/15/2024] [Accepted: 07/12/2024] [Indexed: 08/07/2024] Open
Abstract
Chagas disease (CD) is recognized as one of the 20 neglected tropical diseases by the World Health Organization (WHO), posing a significant global health challenge. The objective of this work was to conduct a systematic methodology review to explore the different classifications used to describe the presence and degree of organ involvement in patients with CD since the disease's description in 1909. We searched relevant electronic medical databases from their inception dates to July 2023. We also delved into historical variations and revisions of each classification, the necessary diagnostic methods, their prognostic value, and their uptake. Our study underscores the conspicuous absence of a universally accepted CD classification system for cardiac and digestive involvement, both in the context of clinical trials and within current clinical guidelines. This endeavour will facilitate cross-population comparisons if clinical manifestations and complementary test results are available for each patient, constituting a pivotal stride toward identifying precise prognoses and establishing a minimum data set requisite for a fitting CD classification, tailored to the test availability in both endemic and non-endemic regions.
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Affiliation(s)
- Irene Losada Galván
- ISGlobal, Barcelona, Spain
- Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), Barcelona, Spain
- Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | | | | | - Sergi Sanz
- ISGlobal, Barcelona, Spain
- Department of Basic Clinical Practice, Faculty of Medicine, University of Barcelona
- CIBER Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Spain
| | - Israel Molina
- International Health Unit Vall d'Hebron-Drassanes, Infectious Diseases Department, Vall d'Hebron University Hospital, PROSICS Barcelona, Barcelona, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III (CIBERINFEC, ISCIII), Spain
| | - Joaquim Gascón
- ISGlobal, Barcelona, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III (CIBERINFEC, ISCIII), Spain
| | - Maria-Jesus Pinazo
- Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), Barcelona, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III (CIBERINFEC, ISCIII), Spain
- Drugs for Neglected Diseases initiative, Rio de Janeiro, Brasil
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Yousef A, Krause A, Yadlapati R, Sharma P, Weissbrod PA. Upper Esophageal Sphincter and Esophageal Motility Pathology on Manometry in Retrograde Cricopharyngeal Dysfunction. Otolaryngol Head Neck Surg 2024; 171:478-485. [PMID: 38587015 DOI: 10.1002/ohn.735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 02/13/2024] [Accepted: 02/29/2024] [Indexed: 04/09/2024]
Abstract
OBJECTIVE There exists a paucity of data regarding the mechanism and manometric findings in retrograde cricopharyngeal dysfunction (RCPD). In this study, we aimed to compare esophageal physiologic findings between patients with RCPD compared to an asymptomatic cohort. STUDY DESIGN Case-control study. SETTING Tertiary Care Center. METHODS Esophageal high-resolution impedance manometry was completed preoperatively in patients diagnosed with RCPD. Manometric data were compared between the RCPD and asymptomatic cohorts. A 2:1 age-sex-matched asymptomatic cohort was used as the control group. Treatment response was assessed among the RCPD cohort. RESULTS Thirty-nine patients are included: 13 RCPD [mean age: 31.1 (SD: 12.6) years, female sex: 11 (85%)] and 26 asymptomatic [mean age: 32.1 (SD: 1.5) years, female sex: 22 (85%)]. The RCPD cohort, compared to the asymptomatic cohort, exhibited significantly greater upper esophageal sphincter (UES) length [4.5 (SD: 0.7) vs 3.7 (0.9) cm, P = .01] and higher UES basal pressures [91.9 (35.0) vs 49.7 (25.5) mm Hg, P = .002]. Patients with RCPD demonstrated higher rates of ineffective swallows [70.0% (31.6%) vs 15.4% (21.6%), P < .001] and incomplete bolus clearance [81% (22.0%) vs 21.8% (30.0%), P < .001]. All patients who underwent cricopharyngeal botulinum injections experienced initial improvement of symptoms with 3 patients requiring repeat intervention. CONCLUSION RCPD is associated with a longer UES, elevated UES basal pressures, and an increased incidence of ineffective esophageal motility. This study is the first to compare preoperative manometry results among patients with RCPD to those of an asymptomatic cohort, providing insights into the mechanism of RCPD.
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Affiliation(s)
- Andrew Yousef
- Department of Otolaryngology, University of California San Diego, La Jolla, California, USA
| | - Amanda Krause
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Priya Sharma
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Philip A Weissbrod
- Department of Otolaryngology, University of California San Diego, La Jolla, California, USA
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Latorre-Rodríguez AR, Golla M, Arjuna A, Bremner RM, Mittal SK. Impaired esophagogastric junction relaxation and lung transplantation outcomes. Dis Esophagus 2024; 37:doae030. [PMID: 38688726 DOI: 10.1093/dote/doae030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/13/2024] [Accepted: 04/08/2024] [Indexed: 05/02/2024]
Abstract
The implications of impaired esophagogastric junction relaxation (i.e. esophagogastric junction outflow obstruction and achalasia) in lung transplants recipients (LTRs) are unclear. Thus, we examined the prevalence and clinical outcomes of LTRs with an abnormally elevated integrated relaxation pressure (IRP) on high-resolution manometry before lung transplantation (LTx). After IRB approval, we reviewed data on LTRs who underwent LTx between January 2019 and August 2022 with a preoperative median IRP >15 mmHg. Differences in overall survival and chronic lung allograft dysfunction (CLAD)-free survival between LTRs with a normalized median IRP after LTx (N-IRP) and those with persistently high IRP (PH-IRP) were assessed using Kaplan-Meier curves and the log-rank test. During the study period, 352 LTx procedures were performed; 44 (12.5%) LTRs had an elevated IRP before LTx, and 37 (84.1%) completed a postoperative manometry assessment (24 [70.6%] males; mean age, 65.2 ± 9.1 years). The median IRP before and after LTx was 18.7 ± 3.8 mmHg and 12 ± 5.6 mmHg, respectively (P < 0.001); the median IRP normalized after LTx in 24 (64.9%) patients. Two-year overall survival trended lower in the N-IRP group than the PH-IRP group (77.2% vs. 92.3%, P = 0.086), but CLAD-free survival (P = 0.592) and rates of primary graft dysfunction (P = 0.502) and acute cellular rejection (P = 0.408) were similar. An abnormally elevated IRP was common in LTx candidates; however, it normalized in roughly two-thirds of patients after LTx. Two-year survival trended higher in the PH-IRP group, despite similar rates of primary graft dysfunction and acute cellular rejection as well as similar CLAD-free survival between the groups.
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Affiliation(s)
- Andrés R Latorre-Rodríguez
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
- Grupo de Investigación Clínica, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, D.C., Colombia
| | - Madison Golla
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Ashwini Arjuna
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
- School of Medicine, Creighton University, Phoenix, AZ, USA
| | - Ross M Bremner
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
- School of Medicine, Creighton University, Phoenix, AZ, USA
| | - Sumeet K Mittal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
- School of Medicine, Creighton University, Phoenix, AZ, USA
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Savarino EV, Salvador R, Ghisa M, Mari A, Forattini F, Costantini A, De Giorgio R, Zaninotto G. Research gap in esophageal achalasia: a narrative review. Dis Esophagus 2024; 37:doae024. [PMID: 38525929 DOI: 10.1093/dote/doae024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 03/08/2024] [Indexed: 03/26/2024]
Abstract
In recent years, new translational evidence, diagnostic techniques, and innovative therapies have shed new light on esophageal achalasia and revamped the attention on this relatively rare motility disorder. This narrative review aims to highlight the most recent progress and the areas where further research is needed. The four senior authors identified five topics commonly discussed in achalasia management: i.e. pathogenesis, role of functional lumen imaging probe in the diagnostic flow chart of achalasia, how to define the outcome of achalasia treatments, how to manage persistent chest pain after the treatment, and if achalasia patients' may benefit from a regular follow-up. We searched the bibliographic databases to identify systematic reviews, meta-analyses, randomized control trials, and original research articles in English up to December 2023. We provide a summary with the most recent findings in each of the five topics and the critical points where to address future research, such as the immune-genetic patterns of achalasia that might explain the transition among the different phenotypes, the need for a validated clinical definition of treatment success, the use of neuromodulators to manage chest pain, and the need for identifying achalasia patients at risk for cancer and who may benefit of long-term follow-up. Although undoubtedly, progress has been made on the definition and management of achalasia, unmet needs remain. Debated aspects range from mechanistic insights, symptoms, objective measure relationships, and accurate clinical responses to therapeutic interventions. Translational research is eagerly awaited to answer these unresolved questions.
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Affiliation(s)
- Edoardo Vincenzo Savarino
- Gastroenterology Unit, Azienda Ospedale Università of Padua, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Renato Salvador
- Chirurgia Generale 1, Azienda Ospedale Università of Padua, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Matteo Ghisa
- Gastroenterology Unit, Azienda Ospedale Università of Padua, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Amir Mari
- Gastroenterology Unit, Nazareth Hospital EMMS, The Azrieli Faculty of Medicine, Bar-Ilan University, Tel Aviv, Israel
| | - Francesca Forattini
- Chirurgia Generale 1, Azienda Ospedale Università of Padua, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Andrea Costantini
- Chirurgia Generale 1, Azienda Ospedale Università of Padua, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Roberto De Giorgio
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
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Pomenti S, Nathanson J, Phipps M, Aneke-Nash C, Katzka D, Freedberg D, Jodorkovsky D. Esophagogastroduodenoscopy findings that do no not explain dysphagia are associated with underutilization of high-resolution manometry. Dis Esophagus 2024; 37:doae028. [PMID: 38582609 DOI: 10.1093/dote/doae028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 03/15/2024] [Accepted: 03/17/2024] [Indexed: 04/08/2024]
Abstract
In patients with dysphagia that is not explained by upper endoscopy, high-resolution esophageal manometry (HRM) is the next logical step in diagnostic testing. This study investigated predictors of failure to refer for HRM after an upper endoscopy that was performed for but did not explain dysphagia. This was a retrospective cohort study of patients >18 years of age who underwent esophagogastroduodenoscopy (EGD) for dysphagia from 2015 to 2021. Patients with EGD findings that explained dysphagia (e.g. esophageal mass, eosinophilic esophagitis, Schatzki ring, etc.) were excluded from the main analyses. The primary outcome was failure to refer for HRM within 1 year of the index non-diagnostic EGD. We also investigated delayed referral for HRM, defined as HRM performed after the median. Multivariable logistic regression modeling was used to identify risk factors that independently predicted failure to refer for HRM, conditioned on the providing endoscopist. Among 2132 patients who underwent EGD for dysphagia, 1240 (58.2%) did not have findings to explain dysphagia on the index EGD. Of these 1240 patients, 148 (11.9%) underwent HRM within 1 year of index EGD. Endoscopic findings (e.g. hiatal hernia, tortuous esophagus, Barrett's esophagus, surgically altered anatomy not involving the gastroesophageal junction, and esophageal varices) perceived to explain dysphagia were independently associated with failure to refer for HRM (adjusted odds ratio 0.45, 95% confidence interval 0.25-0.80). Of the 148 patients who underwent HRM within 1 year of index EGD, 29.7% were diagnosed with a disorder of esophagogastric junction outflow, 17.6% with a disorder of peristalsis, and 2.0% with both disorders of esophagogastric outflow and peristalsis. The diagnosis made by HRM was similar among those who had incidental EGD findings that were non-diagnostic for dysphagia compared with those who had completely normal EGD findings. Demographic factors including race/ethnicity, insurance type, and income were not associated with failure to refer for HRM or delayed HRM. Patients with dysphagia and endoscopic findings unrelated to dysphagia have a similar prevalence of esophageal motility disorders to those with normal endoscopic examinations, yet these patients are less likely to undergo HRM. Provider education is indicated to increase HRM referral in these patients.
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Affiliation(s)
- Sydney Pomenti
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - John Nathanson
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - Meaghan Phipps
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - Chino Aneke-Nash
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - David Katzka
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - Daniel Freedberg
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - Daniela Jodorkovsky
- Department of Medicine, Division of Digestive Diseases, Mount Sinai Doctors, New York, NY, USA
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Bernardi F, Ungaro F, D’Amico F, Zilli A, Parigi TL, Massimino L, Allocca M, Danese S, Furfaro F. The Role of Viruses in the Pathogenesis of Immune-Mediated Gastro-Intestinal Diseases. Int J Mol Sci 2024; 25:8301. [PMID: 39125870 PMCID: PMC11313478 DOI: 10.3390/ijms25158301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Revised: 07/23/2024] [Accepted: 07/24/2024] [Indexed: 08/12/2024] Open
Abstract
Immune-mediated gastrointestinal (GI) diseases, including achalasia, celiac disease, and inflammatory bowel diseases, pose significant challenges in diagnosis and management due to their complex etiology and diverse clinical manifestations. While genetic predispositions and environmental factors have been extensively studied in the context of these conditions, the role of viral infections and virome dysbiosis remains a subject of growing interest. This review aims to elucidate the involvement of viral infections in the pathogenesis of immune-mediated GI diseases, focusing on achalasia and celiac disease, as well as the virome dysbiosis in IBD. Recent evidence suggests that viral pathogens, ranging from common respiratory viruses to enteroviruses and herpesviruses, may trigger or exacerbate achalasia and celiac disease by disrupting immune homeostasis in the GI tract. Furthermore, alterations in the microbiota and, specifically, in the virome composition and viral-host interactions have been implicated in perpetuating chronic intestinal inflammation in IBD. By synthesizing current knowledge on viral contributions to immune-mediated GI diseases, this review aims to provide insights into the complex interplay between viral infections, host genetics, and virome dysbiosis, shedding light on novel therapeutic strategies aimed at mitigating the burden of these debilitating conditions on patients' health and quality of life.
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Affiliation(s)
- Francesca Bernardi
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, 20132 Milan, Italy; (F.B.); (F.U.); (F.D.); (A.Z.); (T.L.P.); (L.M.); (M.A.); (S.D.)
- Gastroenterology and Endoscopy, Vita-Salute San Raffaele University, Via Olgettina, 58, 20132 Milan, Italy
| | - Federica Ungaro
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, 20132 Milan, Italy; (F.B.); (F.U.); (F.D.); (A.Z.); (T.L.P.); (L.M.); (M.A.); (S.D.)
| | - Ferdinando D’Amico
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, 20132 Milan, Italy; (F.B.); (F.U.); (F.D.); (A.Z.); (T.L.P.); (L.M.); (M.A.); (S.D.)
| | - Alessandra Zilli
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, 20132 Milan, Italy; (F.B.); (F.U.); (F.D.); (A.Z.); (T.L.P.); (L.M.); (M.A.); (S.D.)
| | - Tommaso Lorenzo Parigi
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, 20132 Milan, Italy; (F.B.); (F.U.); (F.D.); (A.Z.); (T.L.P.); (L.M.); (M.A.); (S.D.)
| | - Luca Massimino
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, 20132 Milan, Italy; (F.B.); (F.U.); (F.D.); (A.Z.); (T.L.P.); (L.M.); (M.A.); (S.D.)
| | - Mariangela Allocca
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, 20132 Milan, Italy; (F.B.); (F.U.); (F.D.); (A.Z.); (T.L.P.); (L.M.); (M.A.); (S.D.)
| | - Silvio Danese
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, 20132 Milan, Italy; (F.B.); (F.U.); (F.D.); (A.Z.); (T.L.P.); (L.M.); (M.A.); (S.D.)
- Gastroenterology and Endoscopy, Vita-Salute San Raffaele University, Via Olgettina, 58, 20132 Milan, Italy
| | - Federica Furfaro
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, 20132 Milan, Italy; (F.B.); (F.U.); (F.D.); (A.Z.); (T.L.P.); (L.M.); (M.A.); (S.D.)
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Torborg SR, Kim AYE, Rameau A. New developments in the application of artificial intelligence to laryngology. Curr Opin Otolaryngol Head Neck Surg 2024:00020840-990000000-00141. [PMID: 39146248 DOI: 10.1097/moo.0000000000000999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2024]
Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize the existing literature on artificial intelligence technology utilization in laryngology, highlighting recent advances and current barriers to implementation. RECENT FINDINGS The volume of publications studying applications of artificial intelligence in laryngology has rapidly increased, demonstrating a strong interest in utilizing this technology. Vocal biomarkers for disease screening, deep learning analysis of videolaryngoscopy for lesion identification, and auto-segmentation of videofluoroscopy for detection of aspiration are a few of the new ways in which artificial intelligence is poised to transform clinical care in laryngology. Increasing collaboration is ongoing to establish guidelines and standards for the field to ensure generalizability. SUMMARY Artificial intelligence tools have the potential to greatly advance laryngology care by creating novel screening methods, improving how data-heavy diagnostics of laryngology are analyzed, and standardizing outcome measures. However, physician and patient trust in artificial intelligence must improve for the technology to be successfully implemented. Additionally, most existing studies lack large and diverse datasets, external validation, and consistent ground-truth references necessary to produce generalizable results. Collaborative, large-scale studies will fuel technological innovation and bring artificial intelligence to the forefront of patient care in laryngology.
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Affiliation(s)
- Stefan R Torborg
- Sean Parker Institute for the Voice, Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine
- Weill Cornell/Rockefeller/Sloan Kettering Tri-Institutional MD-PhD Program, New York, New York, USA
| | - Ashley Yeo Eun Kim
- Sean Parker Institute for the Voice, Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine
| | - Anaïs Rameau
- Sean Parker Institute for the Voice, Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine
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Visaggi P, Ghisa M, Vespa E, Barchi A, Mari A, Pasta A, Marabotto E, de Bortoli N, Savarino EV. Optimal Assessment, Treatment, and Monitoring of Adults with Eosinophilic Esophagitis: Strategies to Improve Outcomes. Immunotargets Ther 2024; 13:367-383. [PMID: 39071859 PMCID: PMC11283784 DOI: 10.2147/itt.s276869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 07/20/2024] [Indexed: 07/30/2024] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic type 2 inflammation-mediated disease characterized by an eosinophil-predominant inflammation of the esophagus and symptoms of esophageal dysfunction. Relevant treatment outcomes in the setting of EoE include the improvement of histology, symptoms, and endoscopy findings, quality of life (QoL), and the psychological burden of the disease. Established validated tools for the assessment of EoE include questionnaires on dysphagia and QoL (ie, DSQ, EEsAI, and EoE-IQ). More recently, esophageal symptom-specific anxiety and hypervigilance, assessed using the esophageal hypervigilance and anxiety scale (EHAS), have emerged as contributors to disease burden, confirming the importance of psychological aspects in EoE patients. The EoE endoscopic reference score (EREFS) is the only validated endoscopy score in EoE and can quantify mucosal disease burden. However, esophageal panometry using the functional lumen imaging probe (FLIP) and high-resolution manometry (HRM) have shown potential to optimize the assessment of fibrostenotic features of EoE, providing novel insights into the pathophysiology of symptoms. There is a growing number of licenced and off-label therapeutic options in EoE, with various randomized controlled trials demonstrating the efficacy of proton pump inhibitors, topical steroids, food elimination diets, biological drugs, and esophageal dilatation. However, standardized optimal management strategies of EoE are currently lacking. In this review, we provide an overview of established and novel assessment tools in EoE including patient reported outcomes, FLIP panometry, HRM, endoscopy, and histology outcome measures to improve the outcomes of EoE patients. In addition, we summarize available therapeutic options for EoE based on the most recent evidence.
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Affiliation(s)
- Pierfrancesco Visaggi
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Matteo Ghisa
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Edoardo Vespa
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, 20132, Italy
| | - Alberto Barchi
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, 20132, Italy
| | - Amir Mari
- Gastroenterology Unit, Nazareth Hospital EMMS, Azrieli Faculty of Medicine, Bar Ilan University, Ramat Gan, Israel
| | - Andrea Pasta
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Elisa Marabotto
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
- IRCCS Policlinico San Martino, Genoa, Italy
| | - Nicola de Bortoli
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Edoardo Vincenzo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
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Zanini LYK, Herbella FAM, Patti MG. CRITICAL ANALYSIS OF HYPERCONTRACTILE WAVES VIGOR TO DEFINE HYPERCONTRACTILE ESOPHAGUS DISEASE. ARQUIVOS DE GASTROENTEROLOGIA 2024; 61:e24022. [PMID: 39046006 DOI: 10.1590/s0004-2803.24612024-022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 05/09/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND The current definition for hypercontractile esophagus was arbitrarily set at the uppermost range in volunteers for a specific equipment. OBJECTIVE This study aims to critically analyze the concept of hypercontractile waves to redefine hypercontractile esophagus parameters. METHODS We reviewed 500 unselected and consecutive HRM tests (5000 waves) performed in a water -perfused system. RESULTS Mean distal contractility integral (DCI) was 825±1492 (0-42775) mmHg.cm.s, two standard deviations above average = 3810; 95th percentile = 2798 mmHg.cm.s. CONCLUSION In healthy volunteers, two standard deviations above average is 4000 mmHg.cm.s, we thus suggest this value to define hypercontractile waves and define hypercontractile esophagus in a water-perfused HRM system.
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Nishikawa Y, Inoue H, Tanaka I, Ito S, Azuma D, Ushikubo K, Yamamoto K, Okada H, Toshimori A, Tanabe M, Onimaru M, Ito T, Yokoyama N, Shimamura Y. Impact of peroral endoscopic myotomy on the endoscopic pressure study integrated system. Dig Endosc 2024. [PMID: 39021248 DOI: 10.1111/den.14882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 06/18/2024] [Indexed: 07/20/2024]
Abstract
OBJECTIVES The endoscopic pressure study integrated system (EPSIS) is an endoscopic diagnostic system utilized for evaluation of lower esophageal sphincter function. Although previous studies have determined that EPSIS was effective as a tool for the diagnosis of achalasia, it remains uncertain if EPSIS can detect significant changes before and after peroral endoscopic myotomy (POEM), which is the premier treatment for achalasia. This study aimed to evaluate the effectiveness of EPSIS as an objective diagnostic tool for assessing the clinical effect of POEM. METHODS We conducted a retrospective analysis of patients who underwent POEM from January 2022 to December 2023. The patients underwent EPSIS preoperatively and 2 months postoperatively. Intragastric pressure (IGP) parameters, including the maximum IGP, IGP difference, and waveform gradient were compared pre- and post-POEM. These parameters also were compared between two groups: the postoperative gastroesophageal reflux disease (GERD) group and the non-GERD group. RESULTS A total of 50 patients were analyzed. The mean maximum IGP was significantly lower postoperatively than preoperatively (15.0 mmHg vs. 19.8 mmHg, P < 0.001). The mean IGP difference and waveform gradient were also significantly lower postoperatively than preoperatively (8.0 mmHg vs. 12.2 mmHg, P < 0.001; and 0.26 mmHg/s vs. 0.43 mmHg/s, P < 0.001, respectively). The mean postoperative waveform gradient was significantly lower in the GERD group (17 patients, 34%) than in the non-GERD group (33 patients, 66%) (0.207 mmHg vs. 0.291 mmHg, P = 0.034). CONCLUSION The results supported the use of EPSIS as an effective diagnostic tool for assessing the effect of POEM.
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Affiliation(s)
- Yohei Nishikawa
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Ippei Tanaka
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Shotaro Ito
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Daisuke Azuma
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Kei Ushikubo
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Kazuki Yamamoto
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Hiroki Okada
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Akiko Toshimori
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Mayo Tanabe
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Manabu Onimaru
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Takayoshi Ito
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Noboru Yokoyama
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Yuto Shimamura
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
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Davis TA, Rogers BD, Llanos-Chea A, Krasaelap A, Banks D, Ambartsumyan L, Sanchez RE, Yacob D, Baker C, Rey AP, Desai C, Rottier A, Jayaraman M, Khorrami C, Dorfman L, El-Chammas K, Mansi S, Chiou E, Chumpitazi BP, Balakrishnan K, Puri NB, Rodriguez L, Garza JM, Saps M, Gyawali CP, Patel D. Ineffective esophageal motility: Characterization and outcomes across pediatric neurogastroenterology and motility centers in the United States. J Pediatr Gastroenterol Nutr 2024. [PMID: 39010786 DOI: 10.1002/jpn3.12324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 06/03/2024] [Accepted: 06/28/2024] [Indexed: 07/17/2024]
Abstract
OBJECTIVES Ineffective esophageal motility (IEM) on high-resolution manometry (HRM) is not consistently associated with specific clinical syndromes or outcomes. We evaluated the prevalence, clinical features, management, and outcomes of pediatric IEM patients across the United States. METHODS Clinical and manometric characteristics of children undergoing esophageal HRM during 2021-2022 were collected from 12 pediatric motility centers. Clinical presentation, test results, management strategies, and outcomes were compared between children with IEM and normal HRM. RESULTS Of 236 children (median age 15 years, 63.6% female, 79.2% Caucasian), 62 (23.6%) patients had IEM, and 174 (73.7%) patients had normal HRM, with similar demographics, medical history, clinical presentation, and median symptom duration. Reflux monitoring was performed more often for IEM patients (25.8% vs. 8.6%, p = 0.002), but other adjunctive testing was similar. Among 101 patients with follow-up, symptomatic cohorts declined in both groups in relation to the initial presentation (p > 0.107 for each comparison) with management targeting symptoms, particularly acid suppression. Though prokinetics were used more often and behavioral therapy less often in IEM (p ≤ 0.015 for each comparison), symptom outcomes were similar between IEM and normal HRM. Despite a higher proportion with residual dysphagia on follow-up in IEM (64.0% vs. 39.1%, p = 0.043), an alternate mechanism for dysphagia was identified more often in IEM (68.8%) compared to normal HRM (27.8%, p = 0.017). CONCLUSIONS IEM is a descriptive manometric pattern rather than a clinical diagnosis requiring specific intervention in children. Management based on clinical presentation provides consistent symptom outcomes.
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Affiliation(s)
- Trevor A Davis
- Division of Pediatric Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Benjamin D Rogers
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
- Division of Gastroenterology, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Alejandro Llanos-Chea
- Division of Pediatric Gastroenterology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Amornluck Krasaelap
- Division of Pediatric Gastroenterology, Children's Mercy, Kansas City, Missouri, USA
| | - Darnna Banks
- Division of Pediatric Gastroenterology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Lusine Ambartsumyan
- Division of Pediatric Gastroenterology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Raul E Sanchez
- Division of Pediatric Gastroenterology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Desale Yacob
- Division of Pediatric Gastroenterology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Corey Baker
- Division of Pediatric Gastroenterology, Connecticut Children's Medical Center, Hartford, Connecticut, USA
| | - Adriana Prada Rey
- Division of Pediatric Gastroenterology, Universidad El Bosque, Bogotá, Colombia
| | - Chaitri Desai
- Division of Pediatric Gastroenterology, Children's Mercy, Kansas City, Missouri, USA
| | - Aaron Rottier
- Division of Gastroenterology, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Mayuri Jayaraman
- Division of Pediatric Gastroenterology, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Camila Khorrami
- Division of Pediatric Gastroenterology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Lev Dorfman
- Division of Pediatric Gastroenterology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Khalil El-Chammas
- Division of Pediatric Gastroenterology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Sherief Mansi
- Division of Pediatric Gastroenterology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Eric Chiou
- Division of Pediatric Gastroenterology, Texas Children's Hospital, Houston, Texas, USA
| | - Bruno P Chumpitazi
- Division of Pediatric Gastroenterology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kesha Balakrishnan
- Division of Pediatric Gastroenterology, Texas Children's Hospital, Houston, Texas, USA
| | - Neetu B Puri
- Division of Pediatric Gastroenterology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Leonel Rodriguez
- Division of Pediatric Gastroenterology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jose M Garza
- Division of Pediatric Gastroenterology, Neurogastroenterology and Motility Program at Children's Healthcare of Atlanta & GI Care for Kids, Atlanta, Georgia, USA
| | - Miguel Saps
- Division of Pediatric Gastroenterology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Chandra Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Dhiren Patel
- Division of Pediatric Gastroenterology, Saint Louis University School of Medicine, St. Louis, Missouri, USA
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Jiang Y, Vazquez-Reyes R, Kamal A, Zikos T, Triadafilopoulos G, Clarke JO. Functional lumen imaging probe use in a high-volume practice: Practical and technical implications. World J Gastrointest Endosc 2024; 16:396-405. [PMID: 39072247 PMCID: PMC11271713 DOI: 10.4253/wjge.v16.i7.396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 05/17/2024] [Accepted: 06/13/2024] [Indexed: 07/08/2024] Open
Abstract
BACKGROUND The functional lumen imaging probe (FLIP) is a Food and Drug Administration approved tool to aid the diagnosis and management of esophageal disorders. However, widespread adoption of FLIP remains limited and its utility in high-volume practices remains unclear. AIM To analyze large sample data on clinical use of FLIP and provide insight on several technical aspects when performing FLIP. METHODS We conducted a retrospective comparative and descriptive analysis of FLIP procedures performed by a single provider at an academic medical center. There was a total of 398 FLIP procedures identified. Patient medical records were reviewed and data regarding demographics and procedural details were collected. Statistical tests, including chi-squared, t-test, and multivariable logistic and linear regression, were performed. RESULTS There was an increase in FLIP cases with each successive time period of 13 months (n = 68, 146, 184, respectively) with notable rises specifically for indications of dysphagia and gastroesophageal reflux disease. There was a shift toward use of the longer FLIP balloon catheter for diagnostic purposes (overall 70.4% vs 29.6%, P < 0.01). Many cases (42.8%) were performed in conjunction with other diagnostics/interventions, such as dilation and wireless pH probe placement. Procedures were nearly equally performed with anesthesia vs moderate sedation (51.4% anesthesia), with no major complications. Patients who had anesthesia were less likely to have recurrent antegrade contractions [odds ratio (OR) = 0.4, 95%CI: 0.3-0.8] and were also more likely to have absent contractility (OR = 2.4, 95%CI: 1.3-4.4). CONCLUSION FLIP cases have increased in our practice with expanding indications for its use. Given limited normative data, providers should be aware of several potential technical issues, including the possible impact of sedation choice when assessing esophageal motility patterns.
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Affiliation(s)
- Yan Jiang
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood, CA 94063, United States
| | - Raul Vazquez-Reyes
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood, CA 94063, United States
| | - Afrin Kamal
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood, CA 94063, United States
| | - Thomas Zikos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood, CA 94063, United States
| | - George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood, CA 94063, United States
| | - John O Clarke
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood, CA 94063, United States
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Yang W, Huang Y, He L, Chen D, Wu S, Tian Y, Zheng J, Yang J, Song G. Utilizing Esophageal Motility Tests in Diagnosing and Evaluating Gastroesophageal Reflux Disease. Diagnostics (Basel) 2024; 14:1467. [PMID: 39061603 PMCID: PMC11276196 DOI: 10.3390/diagnostics14141467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Revised: 06/20/2024] [Accepted: 07/03/2024] [Indexed: 07/28/2024] Open
Abstract
Gastroesophageal reflux disease (GERD), a prevalent clinical condition, is often attributed to aberrant esophageal motility, leading to gastric content reflux and associated symptoms or complications. The rising incidence of GERD presents an escalating healthcare challenge. Endoscopic and esophageal reflux monitoring can provide a basis for the diagnosis of patients with gastroesophageal reflux disease, but when the diagnostic basis is at an inconclusive value, some additional supportive evidence will be needed. Advanced technology is the key to improving patient diagnosis, accurate assessment, and the development of effective treatment strategies. High-resolution esophageal manometry (HREM) and endoscopic functional lumen imaging probe (EndoFLIP) represent the forefront of esophageal motility assessment. HREM, an evolution of traditional esophageal manometry, is considered the benchmark for identifying esophageal motility disorders. Its widespread application in esophageal dynamics research highlights its diagnostic significance. Concurrently, EndoFLIP's emerging clinical relevance is evident in diagnosing and guiding the treatment of coexisting esophageal motility issues. This review integrates contemporary research to delineate the contributions of HREM, EndoFLIP, and novel technologies in GERD. It examines their efficacy in facilitating an accurate diagnosis, differentiating similar gastrointestinal disorders, quantifying the extent of reflux, assessing the severity of the disease, forecasting patient responsiveness to proton pump inhibitor therapy, and guiding decisions for surgical interventions. The overarching aim is to deepen the understanding of GERD's underlying mechanisms and advance the formulation of holistic, efficacious treatment approaches.
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Affiliation(s)
- Wangliu Yang
- Department of Gastroenterology, The Affiliated Hospital of Guizhou Medical University, Guiyang 550004, China; (W.Y.); (Y.H.); (L.H.); (J.Z.)
| | - Yurong Huang
- Department of Gastroenterology, The Affiliated Hospital of Guizhou Medical University, Guiyang 550004, China; (W.Y.); (Y.H.); (L.H.); (J.Z.)
| | - Lei He
- Department of Gastroenterology, The Affiliated Hospital of Guizhou Medical University, Guiyang 550004, China; (W.Y.); (Y.H.); (L.H.); (J.Z.)
| | - Dongmei Chen
- Department of Gastroenterology, Liupanshui Municipal People’s Hospital, Liupanshui 553000, China; (D.C.); (S.W.); (Y.T.)
| | - Sheng Wu
- Department of Gastroenterology, Liupanshui Municipal People’s Hospital, Liupanshui 553000, China; (D.C.); (S.W.); (Y.T.)
| | - Yan Tian
- Department of Gastroenterology, Liupanshui Municipal People’s Hospital, Liupanshui 553000, China; (D.C.); (S.W.); (Y.T.)
| | - Juan Zheng
- Department of Gastroenterology, The Affiliated Hospital of Guizhou Medical University, Guiyang 550004, China; (W.Y.); (Y.H.); (L.H.); (J.Z.)
| | - Jie Yang
- Department of Gastroenterology, The Affiliated Hospital of Guizhou Medical University, Guiyang 550004, China; (W.Y.); (Y.H.); (L.H.); (J.Z.)
| | - Gengqing Song
- Department of Gastroenterology and Hepatology, Metrohealth Medical Center, Case Western Reserve University, Cleveland, OH 44106, USA
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Feka J, Saad M, Boyle N, Paireder M, Kristo I, Rieder E, Asari R, Schoppmann SF. Multicentric short term and safety study of ineffective esophageal motility patients treated with RefluxStop device. Sci Rep 2024; 14:15425. [PMID: 38965324 PMCID: PMC11224307 DOI: 10.1038/s41598-024-65751-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 06/24/2024] [Indexed: 07/06/2024] Open
Abstract
Gastroesophageal reflux disease (GERD) presents a general health problem with a variety of symptoms and an impairment of life quality. Conservative therapies do not offer sufficient symptom relief in up to 30% of patients. Patients who suffer from ineffective esophageal motility (IEM) and also GERD may exhibit symptoms ranging from mild to severe. In cases where surgical intervention becomes necessary for this diverse group of patients, it is important to consider the potential occurrence of postoperative dysphagia. RefluxStop is a new alternative anti-reflux surgery potentially reducing postoperative dysphagia rates. In this bicentric tertiary hospital observational study consecutive patients diagnosed with PPI refractory GERD and IEM that received RefluxStop implantation were included. A first safety and efficacy evaluation including clinical examination and GERD-HRQL questionnaire was conducted. 40 patients (25 male and 15 female) were included. 31 patients (77.5%) were on PPI at time of surgery, with mean acid exposure time of 8.14% ± 2.53. The median hospital stay was 3 days. Postoperative QoL improved significantly measured by GERD HRQL total score from 32.83 ± 5.08 to 6.6 ± 3.71 (p < 0.001). A 84% reduction of PPI usage (p < 0.001) was noted. 36 patients (90%) showed gone or improved symptoms and were satisfied at first follow-up. Two severe adverse events need mentioning: one postoperative slipping of the RefluxStop with need of immediate revisional operation on the first postoperative day (Clavien-Dindo Score 3b) and one device migration with no necessary further intervention. RefluxStop device implantation is safe and efficient in the short term follow up in patients with GERD and IEM. Further studies and longer follow-up are necessary to prove long-lasting positive effects.
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Affiliation(s)
- J Feka
- Department of Surgery, Division of General Surgery, Comprehensive Cancer Center, Upper-GI Unit, Medical University of Vienna, Spitalgasse 23, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - M Saad
- Department of Surgery, Division of General Surgery, Comprehensive Cancer Center, Upper-GI Unit, Medical University of Vienna, Spitalgasse 23, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - N Boyle
- Department of Surgery, King Edward VII's Hospital, London, UK
| | - M Paireder
- Department of Surgery, Division of General Surgery, Comprehensive Cancer Center, Upper-GI Unit, Medical University of Vienna, Spitalgasse 23, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - I Kristo
- Department of Surgery, Division of General Surgery, Comprehensive Cancer Center, Upper-GI Unit, Medical University of Vienna, Spitalgasse 23, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - E Rieder
- Department of Surgery, Division of General Surgery, Comprehensive Cancer Center, Upper-GI Unit, Medical University of Vienna, Spitalgasse 23, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - R Asari
- Department of Surgery, Division of General Surgery, Comprehensive Cancer Center, Upper-GI Unit, Medical University of Vienna, Spitalgasse 23, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - S F Schoppmann
- Department of Surgery, Division of General Surgery, Comprehensive Cancer Center, Upper-GI Unit, Medical University of Vienna, Spitalgasse 23, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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Al Mowafy EA, AboKresha MM, Elkhadry SW, Hashem MB, Elganzory A, Sayed SA, Khaskia MA. Insights into the current state of knowledge, practice, and attitudes of physicians regarding gastrointestinal motility disorders in Egypt. BMC Gastroenterol 2024; 24:215. [PMID: 38965460 PMCID: PMC11225201 DOI: 10.1186/s12876-024-03296-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 06/14/2024] [Indexed: 07/06/2024] Open
Abstract
BACKGROUND Gastrointestinal (GI) motility disorders are common in clinical settings, but physicians still lack sufficient understanding and effective management of these conditions. METHODS This research assessed Egyptian physicians' knowledge, practices, and attitudes towards GI motility disorders. A cross-sectional survey employing a self-administered questionnaire was carried out among physicians in Egypt. The questionnaire addressed various aspects of physicians' understanding, practices, and attitudes regarding GI motility disorders. Data analysis was conducted using descriptive statistics and presented as frequencies and percentages. RESULTS A total of 462 physicians took part in the study. Although nearly two-thirds of them knew about GI motility studies, a notable proportion lacked adequate knowledge about GI motility disorders. Notably, 84.2% correctly identified dysphagia as a critical symptom suggestive of an upper GI motility disorder. However, 13.4% incorrectly linked hematemesis with an upper GI motility disorder, and 16.7% expressed uncertainty. In terms of practice, around half of the participants encountered a small number of patients with GI motility disorders (less than 5 per week or even fewer). Only 29.7% felt confident in managing patients with motility disorders. Most participating physicians expressed a willingness to participate in training programs focused on motility disorders. CONCLUSIONS This study underscores a knowledge gap among Egyptian physicians concerning GI motility disorders. It suggests the necessity of tailored education and training programs to improve their competency and practice in this domain.
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Affiliation(s)
| | | | - Sally Waheed Elkhadry
- Epidemiology and Preventive Medicine Department, National Liver Institute, Menoufia University, Menoufia, Egypt.
| | | | - Ahmed Elganzory
- Tropical Medicine Department, Ain Shams University, Cairo, Egypt
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Chambo L, Pandolfino JE, Halder S, Kahrilas PJ, Konda V, Carlson DA. Discriminating "impaired" from "disordered" contractile response on FLIP panometry by utilizing pressure measurement. Neurogastroenterol Motil 2024; 36:e14818. [PMID: 38764235 DOI: 10.1111/nmo.14818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Revised: 04/29/2024] [Accepted: 05/04/2024] [Indexed: 05/21/2024]
Abstract
BACKGROUND Functional lumen imaging probe (FLIP) panometry evaluates esophageal motility, including the contractile response to distension, that is, secondary peristalsis. Impaired/disordered contractile response (IDCR) is an abnormal, but nonspecific contractile response that can represent either hypomotility or spastic motor disorders on high-resolution manometry (HRM). We hypothesized that FLIP pressure could be incorporated to clarify IDCR and aimed to determine its utility in a cohort of symptomatic esophageal motility patients. METHODS 173 adult patients that had IDCR on FLIP panometry and HRM with a conclusive Chicago Classification v4.0 (CCv4.0) diagnosis were included and analyzed as development (n = 118) and validation (n = 55) cohorts. FLIP pressure values were assessed for prediction of either hypomotility or spasm, defined on HRM/CCv4.0. KEY RESULTS HRM/CCv4.0 diagnoses were normal motility in 48 patients (28%), "hypomotility" (ineffective esophageal motility, absent contractility, or Type I or II achalasia) in 89 (51%), and "spasm" (Type III achalasia, distal esophageal spasm, or hypercontractile esophagus) in 36 (21%). The pressure at esophagogastric junction-distensibility index (DI) (60 mL) was lower in hypomotility (median [interquartile range] 34 [28-42] mmHg) than in spasm (49 [40-62] mmHg; p < 0.001) and had an area under the receiver operating characteristic curve of 0.80 (95% CI 0.73-0.88) for hypomotility and 0.76 (0.69-0.83) for spasm. For "spasm" on HRM, a threshold FLIP pressure of >35 mmHg provided 90% sensitivity (47% specificity) while >55 mmHg provided 93% specificity (40% sensitivity). CONCLUSION & INFERENCES Pressure on FLIP panometry can help clarify the significance of IDCR, with low-pressure IDCR associated with hypomotility and high-pressure IDCR suggestive of spastic motor disorders.
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Affiliation(s)
- Leya Chambo
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Northwestern University, Chicago, Illinois, USA
| | - John E Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Northwestern University, Chicago, Illinois, USA
| | - Sourav Halder
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Northwestern University, Chicago, Illinois, USA
| | - Peter J Kahrilas
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Northwestern University, Chicago, Illinois, USA
| | - Vani Konda
- Division of Gastroenterology, Baylor University Medical Center, Dallas, Texas, USA
| | - Dustin A Carlson
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Northwestern University, Chicago, Illinois, USA
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Bach L, Vela MF. Esophagogastric Junction Outflow Obstruction (EGJOO): A Manometric Phenomenon or Clinically Impactful Problem. Curr Gastroenterol Rep 2024; 26:173-180. [PMID: 38539024 DOI: 10.1007/s11894-024-00928-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2024] [Indexed: 07/10/2024]
Abstract
PURPOSE OF REVIEW Esophagogastric junction outflow obstruction (EGJOO), defined manometrically by impaired esophagogastric junction relaxation (EGJ) with preserved peristalsis, can be artifactual, due to secondary etiologies (mechanical, medication-induced), or a true motility disorder. The purpose of this review is to go over the evolving approach to diagnosing and treating clinically relevant EGJOO. RECENT FINDINGS Timed barium esophagram (TBE) and the functional lumen imaging probe (FLIP) are useful to identify clinically relevant EGJOO that merits lower esophageal sphincter (LES) directed therapies. There are no randomized controlled trials evaluating EJGOO treatment. Uncontrolled trials show effectiveness for pneumatic dilation and peroral endoscopic myotomy to treat confirmed EGJOO; Botox and Heller myotomy may also be considered but data for confirmed EGJOO is more limited. Diagnosis of clinically relevant idiopathic EGJOO requires symptoms, exclusion of mechanical and medication-related etiologies, and confirmation of EGJ obstruction by TBE or FLIP. Botox LES injection has limited durability, it can be used in patients who are not candidates for other treatments. PD and POEM are effective in confirmed EGJOO, Heller myotomy may also be considered but data for confirmed EGJOO is limited. Randomized controlled trials are needed to clarify optimal management of EGJOO.
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Affiliation(s)
- Laura Bach
- Mayo Clinic Arizona, 13400 E. Shea Blvd, Scottsdale, AZ, USA
| | - Marcelo F Vela
- Mayo Clinic Arizona, 13400 E. Shea Blvd, Scottsdale, AZ, USA.
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Salvador R, Capovilla G, Santangelo M, Vittori A, Forattini F, Provenzano L, Nicoletti L, Costantini A, Moletta L, Valmasoni M, Costantini M, Savarino EV. Manometric identikit of a functioning and effective fundoplication for gastroesophageal reflux disease in the high-resolution manometry ERA. United European Gastroenterol J 2024; 12:749-760. [PMID: 38409901 PMCID: PMC11249834 DOI: 10.1002/ueg2.12553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 12/28/2023] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND The pathophysiological and clinical value of performing High-Resolution Manometry (HRM) after laparoscopic fundoplication (LF) for gastroesophageal reflux disease (GERD) is still unclear and debated. OBJECTIVE We sought to establish the HRM parameters indicative of functioning fundoplications, and whether HRM could distinguish them from tight or defective ones. METHODS The study involved patients with GERD who underwent laparoscopic Nissen (LN) or Toupet (LT) fundoplication between 2010 and 2022. HRM and 24-h pH monitoring were performed before and 6 months after surgery. The study population was divided into 5 groups: LN and LT patients with normal 24h-pH findings (LNpH- and LTpH-, respectively); LN and LT patients with pathological 24h-pH findings (LNpH+ and LTpH + groups, respectively); and patients with a postoperative dysphagia intensity score >2 (Dysphagia group). The novel Hiatal Morphology (HM) classification was applied, envisaging 3 different subtypes: HM1 (normal), HM2 (intrathoracic fundoplication), and HM3 (slipped fundoplication). RESULTS Among the 132 patients recruited during the study period, 46 were in the LNpH- group, 51 in the LTpH- group, 15 in the LNpH + group, 7 in the LTpH + group, and 5 in the Dysphagia group. In multivariate analysis, postoperative abdominal lower esophageal sphincter length (p = 0.001) and HM2 (p < 0.001) were both independently associated with surgical failure. Integrated relaxation pressure was significantly higher in the Dysphagia group than in the LNpH- group. CONCLUSION This study generated reference HRM values for an effective LF, and confirms that using HRM to assess the neo-sphincter and HM improves the clinical assessment in cases of symptom recurrence.
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Affiliation(s)
- Renato Salvador
- Department of Surgery, Oncology and GastroenterologyUniversity of PaduaSchool of MedicinePadovaItaly
- Chirurgia Generale 1Azienda Ospedale Università of PaduaPaduaItaly
| | - Giovanni Capovilla
- Department of Surgery, Oncology and GastroenterologyUniversity of PaduaSchool of MedicinePadovaItaly
- Chirurgia Generale 1Azienda Ospedale Università of PaduaPaduaItaly
| | - Matteo Santangelo
- Department of Surgery, Oncology and GastroenterologyUniversity of PaduaSchool of MedicinePadovaItaly
- Chirurgia Generale 1Azienda Ospedale Università of PaduaPaduaItaly
| | - Arianna Vittori
- Department of Surgery, Oncology and GastroenterologyUniversity of PaduaSchool of MedicinePadovaItaly
- Chirurgia Generale 1Azienda Ospedale Università of PaduaPaduaItaly
| | - Francesca Forattini
- Department of Surgery, Oncology and GastroenterologyUniversity of PaduaSchool of MedicinePadovaItaly
- Chirurgia Generale 1Azienda Ospedale Università of PaduaPaduaItaly
| | - Luca Provenzano
- Department of Surgery, Oncology and GastroenterologyUniversity of PaduaSchool of MedicinePadovaItaly
- Chirurgia Generale 1Azienda Ospedale Università of PaduaPaduaItaly
| | - Loredana Nicoletti
- Department of Surgery, Oncology and GastroenterologyUniversity of PaduaSchool of MedicinePadovaItaly
- Chirurgia Generale 1Azienda Ospedale Università of PaduaPaduaItaly
| | - Andrea Costantini
- Department of Surgery, Oncology and GastroenterologyUniversity of PaduaSchool of MedicinePadovaItaly
- Chirurgia Generale 1Azienda Ospedale Università of PaduaPaduaItaly
| | - Lucia Moletta
- Department of Surgery, Oncology and GastroenterologyUniversity of PaduaSchool of MedicinePadovaItaly
- Chirurgia Generale 1Azienda Ospedale Università of PaduaPaduaItaly
| | - Michele Valmasoni
- Department of Surgery, Oncology and GastroenterologyUniversity of PaduaSchool of MedicinePadovaItaly
- Chirurgia Generale 1Azienda Ospedale Università of PaduaPaduaItaly
| | - Mario Costantini
- Department of Surgery, Oncology and GastroenterologyUniversity of PaduaSchool of MedicinePadovaItaly
- Chirurgia Generale 1Azienda Ospedale Università of PaduaPaduaItaly
| | - Edoardo V. Savarino
- Department of Surgery, Oncology and GastroenterologyUniversity of PaduaSchool of MedicinePadovaItaly
- Gastroenterology UnitAzienda Ospedale Università of PaduaPaduaItaly
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Shou Y, Wang X, Liu D. Factors associated with peroral endoscopic myotomy for achalasia outcomes: systematic review and meta-analysis. Surg Endosc 2024; 38:3503-3519. [PMID: 38782829 DOI: 10.1007/s00464-024-10862-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 04/14/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) is an emerging effective treatment for achalasia. However, a significant proportion of patients do not respond well to the treatment. After over a decade of clinical practice, potential risk factors associated with POEM failure have been identified. This meta-analysis aimed to summarize the evidence of risk factors for POEM failure. METHODS A systematic literature search was conducted on PubMed, Embase, Web of Science, and Cochrane Library from inception to June 10th, 2022. We included English studies that reported POEM outcomes in achalasia patients and identified risk factors for POEM failure. Relevant information was extracted and analyzed using fixed- or randomized-effect models to pool the effect size. RESULTS A total of 27 studies comprising 9371 patients with achalasia were included in this review. The pooled failure rate was 8% (90% CI 7%-10%). We identified sigmoid esophagus (OR 1.90, 95% CI 1.45-2.47), type I achalasia (OR 1.30, 95% CI 1.04-1.63), and type III achalasia (OR 1.26, 95% CI 0.89-1.78) were associated with a worse clinical response. Conversely, type II achalasia was associated with a better response (OR 0.59, 95% CI 0.47-0.75). Prior treatment with Heller myotomy (OR 5.75, 95% CI 3.97-8.34) and prior balloon dilation (OR 1.18, 95% CI 1.07-1.29) were also associated with a higher risk of clinical failure. CONCLUSION Our meta-analysis results demonstrated that sigmoid esophagus, manometric achalasia subtype, and prior treatment were associated with POEM failure. This information could be used to guide treatment decisions and improve the success rate of POEM in achalasia patients.
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Affiliation(s)
- Yajun Shou
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan Province, China
- Research Center of Digestive Diseases, Central South University, Changsha, 410011, Hunan Province, China
- Clinical Research Center of Digestive Diseases of Hunan Province, Changsha, 410011, Hunan Province, China
| | - Xiandi Wang
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan Province, China
- Research Center of Digestive Diseases, Central South University, Changsha, 410011, Hunan Province, China
- Clinical Research Center of Digestive Diseases of Hunan Province, Changsha, 410011, Hunan Province, China
| | - Deliang Liu
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan Province, China.
- Research Center of Digestive Diseases, Central South University, Changsha, 410011, Hunan Province, China.
- Clinical Research Center of Digestive Diseases of Hunan Province, Changsha, 410011, Hunan Province, China.
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Patti MG, Herbella FA. Laparoscopic heller myotomy versus peroral endoscopic myotomy for the treatment of achalasia. Curr Opin Gastroenterol 2024; 40:314-318. [PMID: 38661336 DOI: 10.1097/mog.0000000000001024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
PURPOSE OF REVIEW To compare different therapeutic modalities and determine their role in the treatment of esophageal achalasia. RECENT FINDINGS The last 3 decades have seen a significant improvement in the diagnosis and treatment of esophageal achalasia. Conventional manometry has been replaced by high-resolution manometry, which has determined a more precise classification of achalasia in three subtypes, with important treatment implications. Therapy, while still palliative, has evolved tremendously. While pneumatic dilatation was for a long time the main choice of treatment, this approach slowly changed at the beginning of the nineties when minimally invasive surgery was adopted, initially thoracoscopically and then laparoscopically with the addition of partial fundoplication. And in 2010, the first report of a new endoscopic technique - peroral endoscopic myotomy (POEM) - was published, revamping the interest in the endoscopic treatment of achalasia. SUMMARY This review focuses particularly on the comparison of POEM and laparoscopic Heller myotomy (LHM) with partial fundoplication as primary treatment modality for esophageal achalasia. Based on the available data, we believe that LHM with partial fundoplication should be the primary treatment modality in most patients. POEM should be selected when surgical expertise is not available, for type III achalasia, for the treatment of recurrent symptoms, and for patients who had prior abdominal operations that would make LHM challenging and unsafe.
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Affiliation(s)
- Marco G Patti
- Department of Surgery, University of Virginia, Charlottesville, Virginia, USA
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Smout A, Bredenoord AJ, Oude Nijhuis R. Inability to belch syndrome: what the gastroenterologist needs to know. Curr Opin Gastroenterol 2024; 40:285-290. [PMID: 38662363 DOI: 10.1097/mog.0000000000001022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
PURPOSE OF REVIEW To review recent publications on the inability to belch syndrome. RECENT FINDINGS Five recent retrospective case series indicate that the inability to belch syndrome usually starts in early childhood and is often accompanied by gurgling noises in the chest, pain in the chest or upper abdomen, bloating, and excessive flatulence. Currently, the vast majority of patients who have been identified with inability to belch have self-diagnosed the syndrome on the basis of information available on the internet. A favorable response to injection of botulinum toxin in the cricopharyngeus muscle is regarded as confirmation of the diagnosis. In a mechanistic study in eight patients, absence of reflexogenic relaxation of the upper esophageal sphincter upon rapid gaseous esophageal distension was confirmed to play a pivotal role in the pathogenesis of the syndrome. SUMMARY The inability to belch syndrome, caused by failure of the upper esophageal sphincter to relax when the esophageal body is distended, clearly exists and may not be as rare as thought hitherto. However, overdiagnosis is also likely to occur because the diagnosis is usually made on the basis of symptoms only. The efficacy of botulinum toxin injection in the upper sphincter needs to be assessed in double-blind placebo-controlled studies.
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Affiliation(s)
- André Smout
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, the Netherlands
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