Severely disordered esophageal peristalsis is not a contraindication to laparoscopic Nissen fundoplication

A Tailored Approach to Laparoscopic Fundoplication: Outcomes in Patients with Esophageal Dysmotility

BACKGROUND

Esophageal dysmotility is a common finding in patients being evaluated for antireflux surgery, although its implication remains unclear. We aimed to evaluate outcomes of patients with esophageal dysmotility after fundoplication.

METHODS

A retrospective review of a prospective quality-database was performed. All patients who underwent laparoscopic Nissen (NF) or Toupet (TF) fundoplication were included. Esophageal dysmotility was defined using the Chicago Classification v4.0 and conventional metrics, creating three sub-groups: ineffective esophageal motility (IEM), distal/diffuse esophageal spasm (DES), and hypercontractile esophagus (HE). Quality of life (QOL) outcomes were measured by the Reflux Severity Index (RSI), Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL), and Dysphagia Scores.

RESULTS

Of 487 patients included, 99 (20.3%) had esophageal dysmotility (49 IEM, 40 DES, 10 HE). While a majority in the dysmotility group (81.8%) underwent TF, most patients in the normal group (76.5%) underwent NF (p < 0.001). On multivariable analysis controlling for sex, age, BMI, hiatal hernia, and surgery type, the normal group had higher Dysphagia Scores at 3 weeks (2.2 ± 0.9 vs. 1.7 ± 0.8, p < 0.001), but not at 6-month, 1-year, 2-year, or 5-year follow-up. There were no differences between normal and dysmotility groups in terms of RSI or GERD-HRQL scores at any time point. Patients with different sub-types of esophageal dysmotility had similar QOL outcomes at all time points.

CONCLUSION

Patients with esophageal dysmotility had similar outcomes compared to those with normal motility after fundoplication, suggesting the tailored approach favoring partial fundoplication for patients with dysmotility as part of an appropriate treatment algorithm.

Effect of electrical stimulation therapy of the lower esophageal sphincter in GERD patients with ineffective esophageal motility

BACKGROUND

Electrical stimulation therapy (EST) of the lower esophageal sphincter (LES) is a novel technique in antireflux surgery. Due to the minimal alteration at the LES during surgery, LES-EST is meant to be ideal for patients with gastroesophageal reflux disease (GERD) and ineffective esophageal motility (IEM). The aim of this prospective trial (NCT03476265) is to evaluate health-related quality of life and esophageal acid exposure after LES-EST in patients with GERD and IEM.

METHODS

This is a prospective non-randomized open-label study. Patients with GERD and IEM undergoing LES-EST were included. Follow-up (FUP) at 12 months after surgery included health-related quality of life (HRQL) assessment with standardized questionnaires (GERD-HRQL) and esophageal functional testing.

RESULTS

According to the study protocol, 17 patients fulfilled eligibility criteria. HRQL score for heartburn and regurgitation improved from 21 (interquartile range (IQR) 15-27) to 7.5 (1.25-19), p = 0.001 and from 17 (11-23.5) to 4 (0-12), p = 0.003, respectively. There was neither significant improvement of esophageal acid exposure nor reduction of number of reflux events in pH impedance measurement. Distal contractile integral improved from 64 (11.5-301) to 115 (IQR 10-363) mmHg s cm, p = 0.249. None of the patients showed any sign of dysphagia after LES-EST. One patient needed re-do surgery and re-implantation of the LES-EST due to breaking of the lead after one year.

CONCLUSION

Although patient satisfaction improved significantly after surgery, this study fails to demonstrate normalization or significant improvement of acid exposure in the distal esophagus after LES-EST.

Patients with ineffective esophageal motility benefit from laparoscopic antireflux surgery

BACKGROUND

Gastroesophageal reflux disease (GERD) is a common chronic disorder of the gastrointestinal tract, affecting more than 50% of Americans. The development of GERD may be associated with ineffective esophageal motility (IEM). The impact of esophageal motility on outcomes post laparoscopic antireflux surgery (LARS), including quality of life (QOL), remains to be defined. The purpose of this study is to analyze and compare QOL outcomes following LARS among patients with and without ineffective esophageal motility (IEM).

METHODS

This is a single-institution, retrospective review of a prospectively maintained database of patients who underwent LARS, from January 2012 to July 2019, for treatment of GERD at our institution. Patients undergoing revisional surgery were excluded. Patients with normal peristalsis (non-IEM) were distinguished from those with IEM, defined using the Chicago classification, on manometric studies. Four validated QOL surveys were used to assess outcomes: Reflux Symptom Index (RSI), Gastroesophageal Reflux Disease Health-Related QOL (GERD-HRQL), Laryngopharyngeal Reflux Health-Related QOL (LPR-HRQL), and Swallowing Disorders (SWAL) survey.

RESULTS

203 patients with complete manometric data were identified (75.4% female) and divided into two groups, IEM (n = 44) and non-IEM (n = 159). IEM and Non-IEM groups were parallel in age (58.1 ± 15.3 vs. 62.2 ± 12 years, p = 0.062), body mass index (27.4 ± 4.1 vs. 28.2 ± 4.9 kg/m², p = 0.288), distribution of comorbid disease, sex, and ASA scores. The groups differed in manometry findings and Johnson-DeMeester score (IEM: 38.6 vs. Non-IEM: 24.0, p = 0.023). Patients in both groups underwent similar rates of Nissen fundoplication (IEM: 84.1% vs. Non-IEM: 93.7%, p = 0.061) with greater improvements in dysphagia (IEM: 27.4% vs. 44.2%) in Non-IEM group but comparable benefit in reflux reduction (IEM: 80.6% vs. 72.4%) in both groups at follow-up. There were no differences in postoperative outcomes. Satisfaction rates with LARS were similar between groups (IEM: 80% vs. non-IEM: 77.9%, p > 0.05).

CONCLUSION

Patients with ineffective esophageal motility derive significant benefits in perioperative and QOL outcomes after LARS. Nevertheless, as anticipated, their baseline dysmotility may reduce the degree of improvement in dysphagia rates post-surgery compared to patients with normal motility. Furthermore, the presence of preoperative IEM should not be a contraindication for complete fundoplication. Key to optimal outcomes after LARS is careful patient selection based on objective perioperative data, including manometry evaluation, with the purpose of tailoring surgery to provide effective reflux control and improved esophageal clearance.

Tailoring Endoscopic and Surgical Treatments for Gastroesophageal Reflux Disease

The incidence of gastroesophageal reflux disease (GERD) remains on the rise. Pathophysiology of GERD is multifactorial, revolving around an incompetent esophagogastric junction as an antireflux barrier, with other comorbid conditions contributing to the disease. Proton pump inhibitors remain the most common treatment of GERD. Endoscopic therapy has gained popularity as a less invasive option. The presence of esophageal dysmotility complicates the choice of surgical fundoplication. Most literature demonstrates that fundoplication is safe in the setting of ineffective or weak peristalsis and that postoperative dysphagia cannot be predicted by preoperative manometry parameters. More data are needed on the merits of endoluminal approaches to GERD.

Ameliorating Effects and Autonomic Mechanisms of Transcutaneous Electrical Acustimulation in Patients With Gastroesophageal Reflux Disease

BACKGROUND/AIM

Gastric dysmotility is one of pathophysiologies of gastroesophageal reflux disease (GERD). The aim of this study was to investigate the effects of transcutaneous electrical acustimulation (TEA) on gastric accommodation and gastric slow waves, and evaluate possible mechanisms in patients with GERD.

METHODS

Thirty patients were studied in two randomized sessions of sham-TEA and TEA with the measurements of esophageal high-resolution manometry (HRM), gastric accommodation assessed by a nutrient-drinking test, electrogastrogram (EGG), electrocardiogram (ECG), and postprandial dyspeptic symptoms.

RESULTS

Compared with sham-TEA, TEA improved nutrient drinking-induced fullness (42.0 ± 3.3 vs. 31.0 ± 3.5, P = 0.003) at 10 min after the drink, and belching right after the drink (22.0 ± 4.6 vs. 11.7 ± 3.1, P = 0.012) and at 10 min (16.0 ± 3.8 vs. 3.0 ± 1.5, P = 0.002) after the drink. TEA also improved gastric accommodation (954 ± 37 mL vs. 857 ± 47 mL, P = 0.001) and normalized maximal drink-induced impairment in gastric slow waves. Concurrently, TEA enhanced vagal activity assessed from spectral analysis of heart rate variability in the postprandial state (0.42 ± 0.03 vs. 0.49 ± 0.04, P = 0.039). The vagal activity was positively correlated with the percentage of normal slow waves (r = 0.528; P = 0.003) and negatively correlated with the regurgitation score (r = -0.408, P = 0.025).

CONCLUSIONS

Acute TEA increases gastric accommodation, improves gastric slow waves, and reduces postprandial fullness and belching, possibly mediated via the vagal mechanisms.

Role and safety of fundoplication in esophageal disease and dysmotility syndromes

Gastroesophageal reflux disease (GERD) is quite prevalent worldwide, especially in the western hemisphere. The pathophysiology of GERD is complex, involving an incompetent esophagogastric junction (EGJ) as an anti-reflux barrier, as well as other co-morbid conditions such as gastroparesis, hiatal herniation or hyper acid secretion. Esophageal dysmotility is also frequently encountered in GERD, further contributing to the disease in the form of fragmented peristalsis, ineffective esophageal motility (IEM) or the more severe aperistalsis. The latter is quite common in systemic connective tissue disorders such as scleroderma. The main stay treatment of GERD is pharmacologic with proton pump inhibitors (PPI), with surgical fundoplication offered to patients who are not responsive to medications or would like to discontinue them for medical or other reasons. The presence of esophageal dysmotility that can worsen or create dysphagia can potentially influence the choice of fundoplication (partial or complete), or whether it is even possible. Most of the existing literature demonstrates that fundoplication may be safe in the setting of ineffective or weak peristalsis, and that post-operative dysphagia cannot be reliably predicted by pre-operative manometry parameters. In cases of complete aperistalsis (scleroderma-like esophagus), partial fundoplication can be offered in select patients who exhibit prominent reflux symptoms after a comprehensive multidisciplinary evaluation. Roux-en-Y gastric bypass is an alternative to fundoplication in patients with this extreme form of esophageal dysmotility, after careful consideration of the nutritional status.

Electrical lower esophageal sphincter augmentation in patients with GERD and severe ineffective esophageal motility-a safety and efficacy study

Background

Laparoscopic fundoplication (LF), even if performed in specialized centers, can be followed by long-term side effects such as dysphagia, gas bloating or inability to belch. Patients with an ineffective esophageal motility (IEM) and concurrent GERD are prone to postoperative dysphagia after LF. The aim of this study is to evaluate the safety and efficacy of electrical lower esophageal sphincter stimulation in patients with IEM and GERD.

Methods

This is a prospective, open-label single center study. Patients with PPI-refractory GERD and ineffective esophageal motility were included for lower esophageal sphincter electrical stimulation (LES-EST). Patients underwent prospective follow-up including physical examination, interrogation of the device and were surveyed for changes in the health-related quality of life score.

Results

According to power analysis, 17 patients were included in this study. Median distal contractile integral (DCI) was 64 mmHg s cm (quartiles 11.5–301). Median total % pH < 4 was 8.9 (quartiles 4–21.6). Twelve patients (70.6%) underwent additional hiatal repair. At 1-month follow-up, none of the patients showed any clinical or radiological signs of dysphagia. There were no procedure related severe adverse events. Mean total HQRL improved from baseline 37.53 (SD 15.07) to 10.93 (SD 9.18) at follow-up (FUP) (mean difference 24.0 CI 15.93–32.07) p < 0.001.

Conclusions

LES-EST was introduced as a potential technique to avoid side effects of LF. LES-EST significantly improved health related quality of life and does not impair swallowing in patients with GERD and ineffective esophageal motility.

Alternative therapies for GERD: a way to personalized antireflux surgery

Gastroesophageal reflux disease (GERD) is a common disorder, known to affect about 20% of the Western population. Although conventional medical or surgical treatment has proven effective, there is certainly room for improvements. As only 10% of GERD patients are finally treated by antireflux surgery, a large therapeutic window exists. This treatment gap consists of patients who are not effectively treated with proton pump inhibitor but do not want to run the potential risks of conventional surgery. During the last two decades, several novel and intriguing options for the surgical treatment of GERD have been introduced and found their way into clinical use. The following summary will give an update of certain alternative therapeutic options to treat GERD or its pathological consequences.

Endoscopic Fundoplication: Effectiveness for Controlling Symptoms of Gastroesophageal Reflux Disease

OBJECTIVE

Transoral incisionless fundoplication (TIF) is a completely endoscopic approach to treat gastroesophageal reflux disease (GERD). We previously reported our initial results demonstrating safety and early effectiveness. We now present an updated experience describing outcomes with longer follow-up.

METHODS

For a three-year period, TIF procedures were performed on 80 patients. Preoperative workup routinely consisted of contrast esophagram and manometry. PH testing was reserved for patients with either atypical symptoms or typical symptoms unresponsive to proton-pump inhibitors (PPIs). Heartburn severity was longitudinally assessed using the GERD health-related quality of life index. Safety analysis was performed on all 80 patients, and an effectiveness analysis was performed on patients with at least 6-month follow-up.

RESULTS

Mean procedure time was 75 minutes. There were seven (8.75%) grade 2 complications and one (1.25%) grade 3 complication (aspiration pneumonia). The median length of stay was 1 day (mean, 1.4). Forty-one patients had a minimum of 6-month of follow-up (mean, 24 months; range, 6-68 months). The mean satisfaction scores at follow-up improved significantly from baseline (P < 0.001). Sixty-three percent of patients had completely stopped or reduced their PPI dose. Results were not impacted by impaired motility; however, the presence of a small hiatal hernia or a Hill grade 2/4 valve was associated with reduced GERD health-related quality of life scores postoperatively.

CONCLUSIONS

At a mean follow-up of 24 months, TIF is effective. Although symptoms and satisfaction improved significantly, many patients continued to take PPIs. Future studies should focus on longer-term durability and comparisons with laparoscopic techniques.

Effects of the body mass index (BMI) on the surgical outcomes of laparoscopic fundoplication for gastro-esophageal reflux disease: a propensity score-matched analysis

PURPOSE

In the present study, we examined how the body mass index (BMI) affected the outcomes of laparoscopic fundoplication for GERD in patients, whose backgrounds were matched in a propensity score-matched analysis.

METHODS

We divided the patients into two groups (BMI <25 kg/m² and BMI ≥25 kg/m²). The following background information was matched for the propensity score-matched analysis: sex, age, degree of esophageal hiatal hernia, acid exposure time, and degree of reflux esophagitis. In total, 105 subjects were extracted in each group. The surgical outcomes and postoperative outcomes of patients with BMI <25 kg/m² (Group A) and those with BMI ≥25 kg/m² (Group B) were compared and examined.

RESULTS

There were no differences in the surgical procedure, intraoperative complications, or estimated blood loss (p = 0.876, p = 0.516, p = 0.438, respectively); however, the operative time was significantly prolonged in Group B (p = 0.003). The rate of postoperative recurrence in Group A was 17% (15/87 patients), while that in Group B was 11% (12/91 patients), and did not differ to a statistically significant extent (p = 0.533).

CONCLUSIONS

Although the operative time for GERD in obese patients was prolonged in comparison with non-obese patients, there was no difference in the rate of postoperative recurrence.

Laparoscopic Partial Fundoplication in Case of Gastroesophageal Reflux Disease Patient with Absent Esophageal Motility

The surgical indications for the treatment of gastroesophageal reflux disease (GERD) in patients with esophageal motility disorders have been debated. We report a case of antireflux surgery performed in a patient with absent esophageal motility as categorized by the Chicago classification (2011). A 54-year-old man underwent laparoscopic Toupet fundoplication due to apparent GERD and desire to discontinue all medications. After surgery, his subjective symptoms improved. Furthermore, objective findings including manometry and 24-hour pH-metry also improved. In our experience, antireflux surgery can improve GERD symptoms patients, even with absent esophageal motility.

Esophageal hypomotility and spastic motor disorders: current diagnosis and treatment

Esophageal hypomotility (EH) is characterized by abnormal esophageal peristalsis, either from a reduction or absence of contractions, whereas spastic motor disorders (SMD) are characterized by an increase in the vigor and/or propagation velocity of esophageal body contractions. Their pathophysiology is not clearly known. The reduced excitation of the smooth muscle contraction mediated by cholinergic neurons and the impairment of inhibitory ganglion neuronal function mediated by nitric oxide are likely mechanisms of the peristaltic abnormalities seen in EH and SMD, respectively. Dysphagia and chest pain are the most frequent clinical manifestations for both of these dysfunctions, and gastroesophageal reflux disease (GERD) is commonly associated with these motor disorders. The introduction of high-resolution manometry (HRM) and esophageal pressure topography (EPT) has significantly enhanced the ability to diagnose EH and SMD. Novel EPT metrics in particular the development of the Chicago Classification of esophageal motor disorders has enabled improved characterization of these abnormalities. The first step in the management of EH and SMD is to treat GERD, especially when esophageal testing shows pathologic reflux. Smooth muscle relaxants (nitrates, calcium channel blockers, 5-phosphodiesterase inhibitors) and pain modulators may be useful in the management of dysphagia or pain in SMD. Endoscopic Botox injection and pneumatic dilation are the second-line therapies. Extended myotomy of the esophageal body or peroral endoscopic myotomy (POEM) may be considered in highly selected cases but lack evidence.

EAES recommendations for the management of gastroesophageal reflux disease

BACKGROUND

Gastroesophageal reflux disease (GERD) is one of the most frequent benign disorders of the upper gastrointestinal tract. Management of GERD has always been controversial since modern medical therapy is very effective, but laparoscopic fundoplication is one of the few procedures that were quickly adapted to the minimal access technique. The purpose of this project was to analyze the current knowledge on GERD in regard to its pathophysiology, diagnostic assessment, medical therapy, and surgical therapy, and special circumstances such as GERD in children, Barrett's esophagus, and enteroesophageal and duodenogastroesophageal reflux.

METHODS

The European Association of Endoscopic Surgery (EAES) has tasked a group of experts, based on their clinical and scientific expertise in the field of GERD, to establish current guidelines in a consensus development conference. The expert panel was constituted in May 2012 and met in September 2012 and January 2013, followed by a Delphi process. Critical appraisal of the literature was accomplished. All articles were reviewed and classified according to the hierarchy of level of evidence and summarized in statements and recommendations, which were presented to the scientific community during the EAES yearly conference in a plenary session in Vienna 2013. A second Delphi process followed discussion in the plenary session.

RESULTS

Recommendations for pathophysiologic and epidemiologic considerations, symptom evaluation, diagnostic workup, medical therapy, and surgical therapy are presented. Diagnostic evaluation and adequate selection of patients are the most important features for success of the current management of GERD. Laparoscopic fundoplication is the most important therapeutic technique for the success of surgical therapy of GERD.

CONCLUSIONS

Since the background of GERD is multifactorial, the management of this disease requires a complex approach in diagnostic workup as well as for medical and surgical treatment. Laparoscopic fundoplication in well-selected patients is a successful therapeutic option.

A Case of Postfundoplication Dysphagia without Symptomatic Improvement after Endoscopic Dilatation

Laparoscopic fundoplication is a treatment option for gastroesophageal reflux disease refractory to medical treatment. When deciding whether or not to undergo surgery, patients with refractory gastroesophageal reflux disease and esophageal motility disorder need to fully understand the operative procedure, postoperative complications, and residual symptoms such as dysphagia, globus sensation, and recurrence of reflux. Herein, we report a case of a patient diagnosed with gastroesophageal reflux disease and aperistalsis who underwent Nissen (total, 360°) fundoplication after lack of response to medical treatment and subsequently underwent pneumatic dilatation due to unrelieved postoperative dysphagia and globus sensation.

Laparoscopic fundoplication with or without pyloroplasty in patients with gastroesophageal reflux disease after lung transplantation: how I do it

INTRODUCTION

Several studies have confirmed that gastroesophageal reflux disease (GERD) in lung transplant patients is a risk factor for the development and progression of bronchiolitis obliterans syndrome (BOS), a form of rejection after lung transplantation. Moreover, numerous reports indicate that surgical correction of GERD may control the decline in lung function characteristic of BOS. Although laparoscopic fundoplication is an accepted treatment option for these patients with GERD, the surgical technique, which often includes a laparoscopic pyloroplasty, has not been standardized.

METHODS

The purpose of this article is to describe a step-by-step approach to the laparoscopic treatment of GERD in lung transplant patients. We also address specific technical concerns encountered in the surgical management of this high-risk patient population; we provide data on the safety of this operation; and we illustrate the evidence-based rationale for each technical step of the procedure.

Evidence-based appraisal in laparoscopic Nissen and Toupet fundoplications for gastroesophageal reflux disease

AIM: To demonstrate the optimal surgical procedure for gastroesophageal reflux disease.

METHODS: The electronic databases of Medline, Elsevier, Springerlink and Embase over the last 16 years were searched. All clinical trials involved in the outcomes of laparoscopic Nissen fundoplication (LNF) and laparoscopic Toupet fundoplication (LTF) were identified. The data of assessment in benefits and adverse results of LNF and LTF were extracted and compared using meta-analysis.

RESULTS: We ultimately identified a total of 32 references reporting nine randomized controlled trials, eight prospective cohort trials and 15 retrospective trials. These studies reported a total of 6236 patients, of whom 4252 (68.18%) underwent LNF and 1984 (31.82%) underwent LTF. There were no differences between LNF and LTF in patients’ satisfaction, perioperative complications, postoperative heartburn, reflux recurrence and re-operation. Both LNF and LTF enhanced the function of lower esophageal sphincter and improved esophagitis. The postoperative dysphagia, gas-bloating syndrome, inability to belch and the need for dilatation after LNF were more common than after LTF. Subgroup analyses showed that dysphagia after LNF and LTF was similar in patients with normal esophageal peristalsis (EP), but occurred more frequently in patients with weak EP after LNF than after LTF. Furthermore, patients with normal EP after LNF still had a higher risk of developing dysphagia than did patients with abnormal EP after LTF.

CONCLUSION: Compared with LNF, LTF offers equivalent symptom relief and reduces adverse results.

Laparoscopic Nissen fundoplication combined with posterior gastropexy in surgical treatment of GERD

BACKGROUND

Laparoscopic Nissen fundoplication (LNF) has become established as the procedure of choice in the surgical management of the majority of patients suffering from gastroesophageal reflux disease (GERD). Postoperative paraesophageal herniation has an incidence range up to 7% in the immediate postoperative period.

AIM

A prospective randomized trial was scheduled to study the role of posterior gastropexy, in combination with LNF, in prevention of paraesophageal herniation and improvement of postoperative results in surgical treatment of GERD.

PATIENTS AND METHODS

Eighty-two patients with GERD were randomized to LNF combined with (group A, n = 40) or without (group B, n = 42) posterior gastropexy. Subjective evaluation using disease-specific and generic questionnaires and structured interviews, and objective evaluation by endoscopy, esophageal manometry, and 24-h pH monitoring, were performed before operation, at 2 and 12 months after surgery, and then every year. Crura approximation was performed by stitches if the diameter was less than 6 cm, or with a patch to reinforce the conventional crural closure or by tension-free technique to close the hiatus. Posterior gastropexy (group A) was performed with one stitch between the posterior wall of the wrap and the crura near the arcuate ligament.

RESULTS

Sixteen patients of group A and 15 patients of group B with concomitant abdominal diseases had simultaneous procedures [cholecystectomy 25, vagotomy 2, ventral hernia repair 1, gastric polypectomy 1, gastric fundus diverticulectomy 1, gastrointestinal stromal tumor (GIST) wedge resection 1]. In mean follow-up of 48 +/- 26 months (range 7-94 months), one patient of group B presented with paraesophageal herniation in the first postoperative month (reoperation), while recurrent gastroesophageal reflux (Visick III or IV), successfully treated by medication, was noted in three patients of group B and in one patient of group A. Only mild dysphagia, during the first two postoperative months, was noted in nine patients of group A and eight patients of group B. Six patients of each group with Barrett's esophagus had endoscopic improvement after the second postoperative month. Visick score in groups A/B was I in 26/11 (P < 0.0001), II in 13/27 (P = 0.037), III in 1/2 (not significant, NS), and IV in 0/2. Generally, Visick score was I or II in 39/38 in groups A/B (97.5%/90.5%, NS) and III or IV in 1/4 (2.5%/9.5%, P < 0.0001).

CONCLUSIONS

LNF combined with posterior gastropexy may prevent postoperative paraesophageal or sliding herniation in surgical treatment of GERD, providing better early and long-term postoperative results. (Registered Clinical Trial number: NCT00872755. www.clinicaltrials.gov .).

Advances in esophageal motor disorders

PURPOSE OF REVIEW

Esophageal motor disorders, often leading to dysphagia and chest pain, continue to pose diagnostic and therapeutic problems. In the past 12 months important new information regarding esophageal motor disorders was published. This information will be reviewed in this paper.

RECENT FINDINGS

A number of studies have addressed the issue of heterogeneity in achalasia, the best defined esophageal motility disorder. The spastic esophageal motility disorders nutcracker esophagus and diffuse esophageal spasm may coexist with gastroesophageal reflux disease, which has consequences for the management of patients with these disorders. The entity labelled ineffective esophageal motility is associated with reflux esophagitis, but also with morbid obesity. For the detection of disordered transit caused by ineffective esophageal motility, application of intraluminal impedance monitoring in conjunction with manometry leads to improved diagnosis. New data on the effect of Nissen fundoplication on esophageal motility were published during the last year.

SUMMARY

Recent knowledge on the heterogeneity of achalasia and the association of spastic esophageal motor disorders and ineffective motility with reflux disease will help the clinician in the management of patients with these disorders.