1
|
Benson J, Boutros C, Khan SZ, Lyons J, Hashimoto DA, Marks JM. Evaluation of postoperative esophagram following peroral endoscopic myotomy (POEM). Surg Endosc 2024:10.1007/s00464-024-11023-2. [PMID: 39039293 DOI: 10.1007/s00464-024-11023-2] [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: 03/14/2024] [Accepted: 06/30/2024] [Indexed: 07/24/2024]
Abstract
INTRODUCTION The routine use of post-operative esophogram has come under evaluation for multiple upper GI surgeries such as with bariatric surgery and gastric resections. A major complication following Per Oral Endoscopic Myotomy (POEM) is a leak from the myotomy site. A post-operative contrast esophogram is often utilized to evaluate the presence of a leak, however it is not a standardized care practice for all patients. Presently it is selectively performed depending on physician assessment intra-operatively. This project will evaluate the necessity of post-operative contrast esophogram following POEM. MATERIALS AND METHODS We retrospectively reviewed 277 patients diagnosed with achalasia who underwent POEM by two surgeons from 2011 to 2022. 173 patients met the inclusion criteria. A post-operative esophogram was used for the evaluation of a leak. Post-operative esophagram were selectively performed on day 1 following surgery using a water-soluble material. Data was evaluated using Stata. RESULTS There were 3 detected leaks in the group that underwent esophagrams compared to the non-esophagram group in the early post-operative period. The overall complication rate was 5.5% in the non-esophagram versus 7.9% in the esophagram group. Length of stay was 1.48 days in the non-UGI vs 1.76 days in the esophagram group. Readmission rate was 10.9% in non-esophagram versus 8.7% in esophagram group. CONCLUSION There was no statistically significant difference in outcomes in patients undergoing POEM who received post-operative esophagram verses patients who did not receive post-operative esophagram. The routine use of a contrast esophogram to detect a leak following POEM may not be justified. This study suggests that esophagrams should be performed depending on the clinical signs/symptoms post-operatively that would warrant imaging and intervention.
Collapse
Affiliation(s)
- Jamie Benson
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
- Case Western Reserve University, Cleveland, OH, USA.
| | - Christina Boutros
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
- Case Western Reserve University, Cleveland, OH, USA
| | - Saher-Zahra Khan
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
- Case Western Reserve University, Cleveland, OH, USA
| | - Joshua Lyons
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
- Case Western Reserve University, Cleveland, OH, USA
| | - Daniel A Hashimoto
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jeffrey M Marks
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
- Case Western Reserve University, Cleveland, OH, USA
| |
Collapse
|
2
|
Alzahrani MA, Alfahadi MA, Alshehri MA, Alamri AH, Almahjani EA, Alahmari AM, Al-Shahrani AA, Alshahrani AS, Almanjahi IM, Alqarni AM. Association of esophageal motility disorder symptoms with Chicago classification versions 3.0 and 4.0 using high-resolution esophageal manometry: A single-center experience from Saudi Arabia. Saudi J Gastroenterol 2024; 30:96-102. [PMID: 37602637 PMCID: PMC10980293 DOI: 10.4103/sjg.sjg_243_23] [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: 07/03/2023] [Accepted: 07/11/2023] [Indexed: 08/22/2023] Open
Abstract
BACKGROUND Esophageal motility disorders (EMDs) can significantly impact patients' quality of life. The Chicago Classification (CC) was developed as a robust framework to enable clinicians to better understand and classify the nature of motility disorders. Previous studies have primarily focused on the CC version 3.0 (CCv3.0), and data regarding the correlation between symptoms and CC version 4.0 (CCv4.0) in the Saudi Arabian population are lacking. This study aimed to assess the correlation between symptoms and CCv3.0 and CCv4.0 using high-resolution esophageal manometry (HRM) in Saudi Arabia, to evaluate the diagnostic performance of both classifications. METHODS A total of 182 patients presenting with esophageal symptoms were included in this study. HRM was performed to assess esophageal motility, and patients' reported symptoms were recorded. The association between HRM findings and symptomatic variables was analyzed using sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). RESULTS Variability was observed in the diagnostic performance of symptomatic variables for major EMDs. CCv4.0 demonstrated a higher sensitivity for dysphagia than CCv3.0; however, it exhibited lower sensitivity to atypical gastroesophageal reflux disease (GERD) symptoms. Noncardiac chest pain (NCCP) exhibited the highest specificity and PPV, whereas typical GERD symptoms showed lower specificity. CONCLUSION CCv4.0 demonstrated potential improvements in sensitivity for dysphagia, but lower sensitivity for atypical GERD symptoms, compared with CCv3.0. These insights provide guidance for clinicians in Saudi Arabia and contribute to understanding the diagnostic performance of CCv3.0 and CCv4.0.
Collapse
Affiliation(s)
- Mohammed A. Alzahrani
- Department of Internal Medicine, College of Medicine, King Khalid University, Aseer Central Hospital, Abha, Saudi Arabia
| | | | - Meshref A. Alshehri
- Department of Gastroenterology and Hepatology, King Fahad Medical City, Riyadh, Saudi Arabia
| | | | - Eman A. Almahjani
- Department of Internal Medicine, Aseer Central Hospital, Abha, Saudi Arabia
| | - Aishah M. Alahmari
- Department of Internal Medicine, Aseer Central Hospital, Abha, Saudi Arabia
| | - Abdullah A. Al-Shahrani
- Department of Internal Medicine, College of Medicine, King Khalid University, Aseer Central Hospital, Abha, Saudi Arabia
| | - Abdulaziz S. Alshahrani
- Department of Internal Medicine, College of Medicine, Najran University, Najran, Saudi Arabia
| | | | - Abdullah M. Alqarni
- Department of Occupational Health, Aseer Central Hospital, Abha, Saudi Arabia
| |
Collapse
|
3
|
Low EE, Hasan A, Fehmi SA, Chang MA, Kwong W, Krinsky ML, Anand G, Greytak M, Kaizer A, Yadlapati R. Diagnostic methods to measure spastic segment and guide tailored myotomy length in type 3 achalasia. Neurogastroenterol Motil 2023; 35:e14625. [PMID: 37288617 PMCID: PMC10726676 DOI: 10.1111/nmo.14625] [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: 04/17/2023] [Revised: 05/27/2023] [Accepted: 05/30/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND Myotomy length in type 3 achalasia is generally tailored based on segment of spasticity on high-resolution manometry (HRM). Potential of length of tertiary contractions on barium esophagram (BE) or length of thickened circular muscle on endoscopic ultrasound (EUS) to guide tailored myotomy is less understood. This study aimed to assess agreement between spastic segments lengths on HRM, BE, and EUS among patients with type 3 achalasia. METHODS This retrospective study included adults with type 3 achalasia on HRM between November 2019 and August 2022 who underwent evaluation with EUS and/or BE. Spastic segments were defined as HRM-distance between proximal borders of lower esophageal sphincter and high-pressure area (isobaric contour ≥70 mmHg); EUS-length of thickened circular muscle (≥1.2 mm) from proximal border of esophagogastric junction (EGJ) to the transition to a non-thickened circular muscle; BE-distance between EGJ to proximal border of tertiary contractions. Pairwise comparisons assessed for correlation (Pearson's) and intraclass correlation classification (ICC) agreement. KEY RESULTS Twenty-six patients were included: mean age 66.9 years (SD 13.8), 15 (57.7%) male. Spastic segments were positively correlated on HRM and BE with good agreement (ICC 0.751, [95% CI 0.51, 0.88]). Spastic segments were negatively correlated with poor agreement on HRM and EUS (ICC -0.04, [-0.45, 0.39]) as well as BE and EUS (ICC -0.03, [-0.47, 0.42]). CONCLUSIONS & INFERENCES Length of spastic segment was positively correlated on HRM and BE while negatively correlated when compared to EUS, supporting the common use of HRM and highlighting the uncertain role for EUS in tailoring myotomy length for type 3 achalasia.
Collapse
Affiliation(s)
- Eric E. Low
- Division of Gastroenterology, University of California, San Diego, San Diego, California, USA
| | - Aws Hasan
- Division of Gastroenterology, University of California, San Diego, San Diego, California, USA
| | - Syed Abbas Fehmi
- Division of Gastroenterology, University of California, San Diego, San Diego, California, USA
| | - Michael A. Chang
- Division of Gastroenterology, University of California, San Diego, San Diego, California, USA
| | - Wilson Kwong
- Division of Gastroenterology, University of California, San Diego, San Diego, California, USA
| | - Mary L. Krinsky
- Division of Gastroenterology, University of California, San Diego, San Diego, California, USA
| | - Gobind Anand
- Division of Gastroenterology, University of California, San Diego, San Diego, California, USA
| | - Madeline Greytak
- Division of Gastroenterology, University of California, San Diego, San Diego, California, USA
| | - Alexander Kaizer
- Department of Biostatistics and Informatics, University of Colorado, Denver, Colorado, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California, San Diego, San Diego, California, USA
| |
Collapse
|
4
|
Mubashir M, Andrus V, Okuampa D, Neice M, Armstrong E, Canezaro H, Dies R, Deville A, Kawji L, Rashid S, Raza SM, Hafiz N, Faisal ASM, Bhuiyan MAN, Cai Q. Short-term Outcome of Peroral Endoscopic Myotomy Performed by the Same Endoscopist on Achalasia and Nonachalasia Esophageal Motility Disorders. Surg Laparosc Endosc Percutan Tech 2023; 33:577-582. [PMID: 37852237 DOI: 10.1097/sle.0000000000001240] [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: 05/19/2023] [Accepted: 07/31/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) is a relatively new but increasingly therapeutic option for achalasia. In recent years, POEM has been used for nonachalasia esophageal motility disorders (NAEMDs), such as diffuse esophageal spasm, esophagogastric junction outlet obstruction, and hypercontractile disorder, with some clinical success. No studies thus far compare the outcomes of these two groups. We perform the first head-to-head comparison of outcomes after POEM in patients with achalasia and NAEMD. PATIENTS AND METHODS A retrospective analysis of all patients undergoing POEM at one university hospital by a single expert endoscopist from July 2021 to December 2022 was performed. All patients were symptomatic, and the presence of esophageal motility disorders was confirmed using multiple diagnostic modalities. These patients were then divided into 2 groups, achalasia and NAEMD, based on the underlying diagnosis. Statistical analysis of different clinical outcomes, including effectiveness and safety, was performed. RESULTS Thirty-seven patients (mean age: 59.55, females: 22) underwent POEM in the study period. Twenty patients had achalasia and 17 patients had NAEMD. The median myotomy length was 5.5 cm for the achalasia group and 10 cm for the NAEMD group. This excluded patients with esophagogastric junction outlet obstruction in which the median myotomy length was 3 cm. The procedure time, the duration of hospital stays, the rates of same-day discharge, and complications were similar between the two. Short-term outcomes of POEM for the two groups were similar with improvement in 94% of patients in the achalasia group and 93.75% in the NAEMD group. CONCLUSION Contrary to prior observations, our study highlights that POEM is equally effective in achieving clinical improvement in patients with NAEMD as achalasia over 6 months of follow-up. In addition, POEM has a comparable safety profile in both patient groups making it a feasible therapeutic option for these debilitating and challenging disorders.
Collapse
Affiliation(s)
- Maryam Mubashir
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
| | - Victoria Andrus
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
| | - David Okuampa
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
| | - Michelle Neice
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
| | - Elizabeth Armstrong
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
| | - Hailey Canezaro
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
| | - Ross Dies
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
| | - Ashely Deville
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
| | - Lena Kawji
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
| | - Shazia Rashid
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
| | - Syed Musa Raza
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
| | - Nazar Hafiz
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
| | - Abu Saleh Mosa Faisal
- Department of Internal Medicine, Division of Clinical Informatics, Louisiana State University Health Science Center at Shreveport, Shreveport, LA
| | - Mohammad Alfrad Nobel Bhuiyan
- Department of Internal Medicine, Division of Clinical Informatics, Louisiana State University Health Science Center at Shreveport, Shreveport, LA
| | - Qiang Cai
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
| |
Collapse
|
5
|
Denzer U, Müller M, Kreuser N, Thieme R, Hoffmeister A, Feisthammel J, Niebisch S, Gockel I. [Therapy of esophageal motility disorders]. Laryngorhinootologie 2023; 102:824-838. [PMID: 37263277 DOI: 10.1055/a-1949-3583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Esophageal motility disorders are diseases in which there are malfunctions of the act of swallowing due to a change in neuromuscular structures. The main symptom is therefore dysphagia for solid and/or liquid foods, often accompanied by symptoms such as chest pain, regurgitation, heartburn, and weight loss. Esophageal manometry is the gold standard in diagnostics. Endoscopy and radiology serve to exclude inflammatory or malignant changes. With the introduction of high-resolution esophageal manometry (HRM), the diagnosis of esophageal motility disorders has improved and led to a new classification with the Chicago Classification, which has been modified several times in the last decade, most recently in 2020 with the Chicago Classification v4.0. Compared to the previous version 3.0, there are some important changes that are presented based on the most important esophageal motility disorders in everyday clinical practice.
Collapse
Affiliation(s)
- Ulrike Denzer
- Gastroenterologie, Endokrinologie, Stoffwechsel und klinische Infektiologie, Universitätsklinikum Gießen und Marburg - Standort Marburg, Marburg, Germany
| | - Michaela Müller
- Klinik und Poliklinik für Gastroenterologie, Endokrinologie, Stoffwechsel und klinische Infektiologie, Universitätsklinikum Gießen und Marburg, Marburg, Germany
| | - Nicole Kreuser
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - René Thieme
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Albrecht Hoffmeister
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Juergen Feisthammel
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Stefan Niebisch
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Ines Gockel
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| |
Collapse
|
6
|
Mussies C, van Lennep M, van der Lee JH, Singendonk MJ, Benninga MA, Bastiaansen BA, Fockens P, Bredenoord AJ, van Wijk MP. Protocol for an international multicenter randomized controlled trial assessing treatment success and safety of peroral endoscopic myotomy vs endoscopic balloon dilation for the treatment of achalasia in children. PLoS One 2023; 18:e0286880. [PMID: 37796851 PMCID: PMC10553306 DOI: 10.1371/journal.pone.0286880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 05/13/2023] [Indexed: 10/07/2023] Open
Abstract
INTRODUCTION Achalasia is a rare neurodegenerative esophageal motility disorder characterized by incomplete lower esophageal sphincter (LES) relaxation, increased LES tone and absence of esophageal peristalsis. Achalasia requires invasive treatment in all patients. Conventional treatment options include endoscopic balloon dilation (EBD) and laparoscopic Heller's myotomy (LHM). Recently, a less invasive endoscopic therapy has been developed; Peroral Endoscopic Myotomy (POEM). POEM integrates the theoretical advantages of both EBD and LHM (no skin incisions, less pain, short hospital stay, less blood loss and a durable myotomy). Our aim is to compare efficacy and safety of POEM vs. EBD as primary treatment for achalasia in children. METHODS AND ANALYSIS This multi-center, and center-stratified block-randomized controlled trial will assess safety and efficacy of POEM vs EBD. Primary outcome measure is the need for retreatment due to treatment failure (i.e. persisting symptoms (Eckardt score > 3) with evidence of recurrence on barium swallow and/or HRM within 12 months follow-up) as assed by a blinded end-point committee (PROBE design). DISCUSSION This RCT will be the first one to evaluate which endoscopic therapy is most effective and safe for treatment of naïve pediatric patients with achalasia.
Collapse
Affiliation(s)
- Carlijn Mussies
- Emma Children’s Hospital—Amsterdam UMC, Location University of Amsterdam, Pediatric Gastroenterology, Amsterdam, The Netherlands
| | - Marinde van Lennep
- Emma Children’s Hospital—Amsterdam UMC, Location University of Amsterdam, Pediatric Gastroenterology, Amsterdam, The Netherlands
| | - Johanna H. van der Lee
- Emma Children’s Hospital—Amsterdam UMC, Location University of Amsterdam, Pediatric Clinical Research Office, Amsterdam, The Netherlands
- Knowledge Institute of the Dutch Association of Medical Specialists, Utrecht, The Netherlands
| | - Maartje J. Singendonk
- Emma Children’s Hospital—Amsterdam UMC, Location University of Amsterdam, Pediatric Gastroenterology, Amsterdam, The Netherlands
| | - Marc. A. Benninga
- Emma Children’s Hospital—Amsterdam UMC, Location University of Amsterdam, Pediatric Gastroenterology, Amsterdam, The Netherlands
| | - Barbara A. Bastiaansen
- Gastroenterology & Hepatology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Paul Fockens
- Gastroenterology & Hepatology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Gastroenterology & Hepatology, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Albert J. Bredenoord
- Gastroenterology & Hepatology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Michiel P. van Wijk
- Emma Children’s Hospital—Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
7
|
Müller M, Denzer UW, Kreuser N, Thieme R, Hoffmeister A, Feisthammel J, Niebisch S, Gockel I. [Diagnosis of esophageal motility disorders - Significance of the new Chicago classification v4.0]. Laryngorhinootologie 2023; 102:742-753. [PMID: 37253378 DOI: 10.1055/a-1949-3531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Esophageal motility disorders are diseases in which there are malfunctions of the act of swallowing due to a change in neuromuscular structures. The main symptom is therefore dysphagia for solid and/or liquid foods, often accompanied by symptoms such as chest pain, regurgitation, heartburn, and weight loss. Esophageal manometry is the gold standard in diagnostics. Endoscopy and radiology serve to exclude inflammatory or malignant changes. With the introduction of high-resolution esophageal manometry (HRM), the diagnosis of esophageal motility disorders has improved and led to a new classification with the Chicago Classification, which has been modified several times in the last decade, most recently in 2021 with the Chicago Classification v4.0. Compared to the previous version 3.0, there are some important changes that are presented based on the most important esophageal motility disorders in everyday clinical practice.
Collapse
Affiliation(s)
- Michaela Müller
- Klinik und Poliklinik für Gastroenterologie, Endokrinologie, Stoffwechsel und klinische Infektiologie, Universitätsklinikum Gießen und Marburg - Standort Marburg, Marburg, Germany
| | - Ulrike W Denzer
- Klinik und Poliklinik für Gastroenterologie, Endokrinologie, Stoffwechsel und klinische Infektiologie, Universitätsklinikum Gießen und Marburg - Standort Marburg, Marburg, Germany
| | - Nicole Kreuser
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - René Thieme
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Albrecht Hoffmeister
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Juergen Feisthammel
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Stefan Niebisch
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Ines Gockel
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| |
Collapse
|
8
|
Halasz V, Knittel L, Fox MR. Opioid-Induced Esophageal Dysmotility (OIED) - A Case Report. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:1221-1224. [PMID: 36516950 DOI: 10.1055/a-1977-0077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Recent studies have shown that chronic opioid use is associated with an increased risk of symptomatic esophageal motility disorders. Opioid-induced esophageal dysfunction (OIED) is most often identified in patients taking high doses of opioids. This condition is associated with poorer treatment outcomes than primary motility disorders and management of these cases is further complicated by the presence of chronic pain, opioid addiction, and physical and psychological comorbidity.We present the case of a 68-year-old Caucasian woman with OIED, induced by the chronic intake of low-dose Fentanyl and Tramadol prescribed to treat severe back pain. The clinical course highlights the sometimes difficult diagnosis and management of this recently recognized condition.
Collapse
Affiliation(s)
- Victoria Halasz
- Center for Integrative Gastroenterology, Klinik Arlesheim AG, Arlesheim, Switzerland
| | - Leonhard Knittel
- Center for Integrative Gastroenterology, Klinik Arlesheim AG, Arlesheim, Switzerland
| | - Mark Robert Fox
- Center for Integrative Gastroeneterology, Klinik Arlesheim AG, Arlesheim, Switzerland
- Klinik für Gastroenterologie und Hepatologie, UniversitätsSpital Zürich, Zürich, Switzerland
| |
Collapse
|
9
|
S2k-Leitlinie Gastroösophageale Refluxkrankheit und eosinophile Ösophagitis der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – März 2023 – AWMF-Registernummer: 021–013. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:862-933. [PMID: 37494073 DOI: 10.1055/a-2060-1069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
|
10
|
Hernández Mondragón OV, Solórzano Pineda OM. Peroral esophageal myotomy for esophageal motility disorders. Minerva Gastroenterol (Torino) 2023; 69:193-208. [PMID: 37191670 DOI: 10.23736/s2724-5985.22.02987-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
The concept of third space endoscopy first described in 2007, was adapted and performed in humans in 2010 by Inoue et al. in a group of patients with esophageal achalasia (EA). Since then, esophageal endoscopic myotomy (E-POEM), has been performed in more than 10,000 patients worldwide up to now. Safety and efficacy have been confirmed at early, mid and long-term evaluations, in different gastrointestinal diseases including achalasia, refractory gastroparesis, and other esophageal motility disorders (EMD). Nowadays, this treatment has shown to be not only an excellent option, but also with its excellent outcomes, the first option in certain clinical scenarios such as type III achalasia. Thus, the minimal invasive nature of POEM gives us multiple advantages compared with the classical treatments that includes pneumatic dilation (PD) and laparoscopic Heller myotomy (LHM), including not only clinical aspects but also economical. High resolution manometry (HRM) has substantially redefined the actual approach of esophageal motility disorders with the major changes in instrumental use, diagnostic algorithms, and therapeutics. The previous Chicago's classification V 3.0 clearly improved our knowledge about pathophysiology of spastic esophageal motor disorders, however, with its recent update (Chicago V 4.0), multiple changes in diagnosis and treatment are expected. In the present article, we aimed to review and analyze the most important aspects about the results of E-POEM in the management of EMD according to the view of the new Chicago's classification V 4.0.
Collapse
Affiliation(s)
| | - Omar M Solórzano Pineda
- Department of Gastrointestinal Endoscopy, XXI Century National Medical Center, Mexico City, Mexico
| |
Collapse
|
11
|
Müller M, Denzer UW, Kreuser N, Thieme R, Hoffmeister A, Feisthammel J, Niebisch S, Gockel I. [Diagnosis of esophageal motility disorders - Significance of the new Chicago classification v4.0]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:284-296. [PMID: 35839796 DOI: 10.1055/a-1833-9366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Esophageal motility disorders are diseases in which there are malfunctions of the act of swallowing due to a change in neuromuscular structures. The main symptom is therefore dysphagia for solid and/or liquid foods, often accompanied by symptoms such as chest pain, regurgitation, heartburn, and weight loss. Esophageal manometry is the gold standard in diagnostics. Endoscopy and radiology serve to exclude inflammatory or malignant changes. With the introduction of high-resolution esophageal manometry (HRM), the diagnosis of esophageal motility disorders has improved and led to a new classification with the Chicago Classification, which has been modified several times in the last decade, most recently in 2021 with the Chicago Classification v4.0. Compared to the previous version 3.0, there are some important changes that are presented based on the most important esophageal motility disorders in everyday clinical practice.
Collapse
Affiliation(s)
- Michaela Müller
- Klinik und Poliklinik für Gastroenterologie, Endokrinologie, Stoffwechsel und klinische Infektiologie, Universitätsklinikum Gießen und Marburg - Standort Marburg, Marburg, Germany
| | - Ulrike W Denzer
- Klinik und Poliklinik für Gastroenterologie, Endokrinologie, Stoffwechsel und klinische Infektiologie, Universitätsklinikum Gießen und Marburg - Standort Marburg, Marburg, Germany
| | - Nicole Kreuser
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - René Thieme
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Albrecht Hoffmeister
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Juergen Feisthammel
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Stefan Niebisch
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Ines Gockel
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| |
Collapse
|
12
|
Denzer UW, Müller M, Kreuser N, Thieme R, Hoffmeister A, Feisthammel J, Niebisch S, Gockel I. [Therapy of esophageal motility disorders]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:183-197. [PMID: 35835360 DOI: 10.1055/a-1833-9299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Esophageal motility disorders are diseases in which there are malfunctions of the act of swallowing due to a change in neuromuscular structures. The main symptom is therefore dysphagia for solid and/or liquid foods, often accompanied by symptoms such as chest pain, regurgitation, heartburn, and weight loss. Esophageal manometry is the gold standard in diagnostics. Endoscopy and radiology serve to exclude inflammatory or malignant changes. With the introduction of high-resolution esophageal manometry (HRM), the diagnosis of esophageal motility disorders has improved and led to a new classification with the Chicago Classification, which has been modified several times in the last decade, most recently in 2020 with the Chicago Classification v4.0. Compared to the previous version 3.0, there are some important changes that are presented based on the most important esophageal motility disorders in everyday clinical practice.
Collapse
Affiliation(s)
- Ulrike W Denzer
- Klinik und Poliklinik für Gastroenterologie, Endokrinologie, Stoffwechsel und klinische Infektiologie, Universitätsklinikum Gießen und Marburg, Marburg, Germany
| | - Michaela Müller
- Klinik und Poliklinik für Gastroenterologie, Endokrinologie, Stoffwechsel und klinische Infektiologie, Universitätsklinikum Gießen und Marburg, Marburg, Germany
| | - Nicole Kreuser
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - René Thieme
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Albrecht Hoffmeister
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Juergen Feisthammel
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Stefan Niebisch
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Ines Gockel
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| |
Collapse
|
13
|
Slim N, Williamson JM. Achalasia: investigation and management. Br J Hosp Med (Lond) 2023; 84:1-9. [PMID: 36708337 DOI: 10.12968/hmed.2022.0437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Achalasia, characterised by the absence of peristalsis and failure of relaxation of the lower oesophageal sphincter, is an uncommon degenerative condition that results in dysphagia. If left untreated it can lead to aspiration, oesophageal perforation, oesophagitis and malnutrition. It has a range of immune, allergic, viral and genetic aetiological causes. Successful diagnosis relies on the use of oesophagogastroduodenoscopy, barium swallow and oesophageal manometry to characterise the severity of the disease and to rule out underlying malignancy. Although no treatment can reverse the degenerative process, therapeutic strategies including lifestyle modification, medication, endoscopic and operative intervention can help to reduce symptoms. This article reviews the latest methods used to investigate and manage achalasia.
Collapse
Affiliation(s)
- Naim Slim
- Department of General Surgery, The Great Western Hospital, Swindon, UK
| | | |
Collapse
|
14
|
Wilson H, Mocanu V, Wong C, Karmali S. The Utility of the Marshmallow Barium Swallow Esophagogram for Investigation of Ineffective Esophageal Motility: A Systematic and Narrative Review. JOURNAL OF GASTROINTESTINAL AND ABDOMINAL RADIOLOGY 2022. [DOI: 10.1055/s-0042-1751256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
Abstract
Abstract
Objectives Current gold standard investigations to determine the pathology of ineffective esophageal motility (IEM) are invasive and resource-intensive. Marshmallow barium swallow esophagogram (MBSE) is emerging as a more feasible modality; however, our understanding of its role in the clinical setting is limited. Our aim was to appraise the current literature and describe the effectiveness and limitations of MBSE as a potential diagnostic tool when investigating the pathological cause of IEM.
Methods A search in PubMed was conducted on May 23, 2021. Search terms included “marshmallow” AND “barium.” We included all studies which examined MBSE in the context of esophageal disease. The primary outcome of interest was to characterize the use of MBSE in current literature.
Results A total of 12 studies were retrieved after initial search with 9 studies meeting final inclusion criteria. A total of 375 patients were included, with 296 patients (79%) having a relevant diagnosis or symptom prompting investigation with MBSE. The most common diagnoses included referral to a gastroenterology clinic for a barium swallow (44%), post-Angelchik insertion (23%), and dysphagia (13%). Esophageal disease was identified in both the MBSE and other screening tests in 63% participants, whereas in 27% participants abnormalities were only seen using the MBSE.
Conclusion There is currently limited high-quality evidence on the use of MBSE to diagnose IEM. Further large-scale studies comparing its use in patients with different pathologic causes of IEM and of older age are required to further delineate the optimal delivery of this emerging diagnostic modality.
Collapse
Affiliation(s)
- H. Wilson
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - V. Mocanu
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - C. Wong
- Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - S. Karmali
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
15
|
Ullal TV, Marks SL, Belafsky PC, Conklin JL, Pandolfino JE. A Comparative Assessment of the Diagnosis of Swallowing Impairment and Gastroesophageal Reflux in Canines and Humans. Front Vet Sci 2022; 9:889331. [PMID: 35754550 PMCID: PMC9228035 DOI: 10.3389/fvets.2022.889331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 05/05/2022] [Indexed: 11/24/2022] Open
Abstract
Swallowing impairment is a highly prevalent and clinically significant problem affecting people and dogs. There are myriad causes of swallowing impairment of which gastroesophageal reflux is the most common in both species. Similarities in anatomy and physiology between humans and canines results in analogous swallowing disorders including cricopharyngeus muscle achalasia, esophageal achalasia, hiatal herniation, and gastroesophageal reflux with secondary esophagitis and esophageal dysmotility. Accordingly, the diagnostic approach to human and canine patients with swallowing impairment is similar. Diagnostic procedures such as swallowing fluoroscopy, high-resolution manometry, pH/impedance monitoring, and endolumenal functional luminal imaging probe can be performed in both species; however, nasofacial conformation, increased esophageal length, and the difficulty of completing several of these procedures in awake dogs are inherent challenges that need to be considered. Human patients can convey their symptoms and respond to verbal cues, whereas veterinarians must rely on clinical histories narrated by pet owners followed by comprehensive physical examination and observation of the animal eating different food consistencies and drinking water. Dogs may also be unwilling to drink or eat in the hospital setting and may be resistant to physical restraint during diagnostic procedures. Despite the species differences and diagnostic challenges, dogs are a natural animal model for many oropharyngeal and esophageal disorders affecting people, which presents a tremendous opportunity for shared learnings. This manuscript reviews the comparative aspects of esophageal anatomy and physiology between humans and canines, summarizes the diagnostic assessment of swallowing impairment in both species, and discusses future considerations for collaborative medicine and translational research.
Collapse
Affiliation(s)
- Tarini V Ullal
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States
| | - Stanley L Marks
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States
| | - Peter C Belafsky
- Department of Otolaryngology, Center for Voice and Swallowing, School of Medicine, University of California, Davis, Davis, CA, United States
| | - Jeffrey L Conklin
- The Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, UCLA Robert G. Kardashian Center for Esophageal Health, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - John E Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| |
Collapse
|
16
|
Application of In Vivo Imaging Techniques and Diagnostic Tools in Oral Drug Delivery Research. Pharmaceutics 2022; 14:pharmaceutics14040801. [PMID: 35456635 PMCID: PMC9025904 DOI: 10.3390/pharmaceutics14040801] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 03/25/2022] [Accepted: 03/27/2022] [Indexed: 02/04/2023] Open
Abstract
Drug absorption following oral administration is determined by complex and dynamic interactions between gastrointestinal (GI) physiology, the drug, and its formulation. Since many of these interactions are not fully understood, the COST action on “Understanding Gastrointestinal Absorption-related Processes (UNGAP)” was initiated in 2017, with the aim to improve the current comprehension of intestinal drug absorption and foster future developments in this field. In this regard, in vivo techniques used for the characterization of human GI physiology and the intraluminal behavior of orally administered dosage forms in the GI tract are fundamental to gaining deeper mechanistic understanding of the interplay between human GI physiology and drug product performance. In this review, the potential applications, advantages, and limitations of the most important in vivo techniques relevant to oral biopharmaceutics are presented from the perspectives of different research fields.
Collapse
|
17
|
Doyle R, Bate S, Devenney J, Agwaonye S, Hastings M, Wych J, Archbold S, Vasant DH. Evaluating the impact of an enhanced triage process on the performance and diagnostic yield of oesophageal physiology studies post COVID-19. BMJ Open Gastroenterol 2021; 8:e000810. [PMID: 34933867 PMCID: PMC8692781 DOI: 10.1136/bmjgast-2021-000810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 12/06/2021] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES The COVID-19 pandemic significantly impacted on the provision of oesophageal physiology investigations. During the recovery phase, triaging tools were empirically recommended by national bodies for prioritisation of referrals amidst rising waiting lists and reduced capacity. We evaluated the performance of an enhanced triage process (ETP) consisting of telephone triage combined with the hierarchical 'traffic light system' recommended in the UK for prioritising oesophageal physiology referrals. DESIGN In a cross-sectional study of patients referred for oesophageal physiology studies at a tertiary centre, data were compared between patients who underwent oesophageal physiology studies 6 months prior to the COVID-19 pandemic and those who were investigated within 6 months after service resumption with implementation of the ETP. OUTCOME MEASURES Adjusted time from referral to investigation; non-attendance rates; the detection of Chicago Classification (CC) oesophageal motility disorders on oesophageal manometry and severity of acid reflux on 24 hours pH/impedance monitoring. RESULTS Following service resumption, the ETP reduced non-attendance rates from 9.1% to 2.8% (p=0.021). Use of the 'traffic light system' identified a higher proportion of patients with CC oesophageal motility disorders in the 'amber' and 'red' triage categories, compared with the 'green' category (p=0.011). ETP also reduced the time to test for those who were subsequently found to have a major CC oesophageal motility diagnosis compared with those with minor CC disorders and normal motility (p=0.004). The ETP did not affect the yield or timing of acid reflux studies. CONCLUSION ETPs can effectively prioritise patients with oesophageal motility disorders and may therefore have a role beyond the current pandemic.
Collapse
Affiliation(s)
- Rebecca Doyle
- Neurogastroenterology Unit, Manchester University NHS Foundation Trust, Manchester, UK
| | - Sebastian Bate
- Research and Innovation, Manchester University NHS Foundation Trust, Manchester, UK
- University of Manchester, Manchester, UK
| | - Jade Devenney
- Neurogastroenterology Unit, Manchester University NHS Foundation Trust, Manchester, UK
| | - Sophia Agwaonye
- Neurogastroenterology Unit, Manchester University NHS Foundation Trust, Manchester, UK
| | - Margaret Hastings
- Neurogastroenterology Unit, Manchester University NHS Foundation Trust, Manchester, UK
| | - Jane Wych
- Neurogastroenterology Unit, Manchester University NHS Foundation Trust, Manchester, UK
| | - Sharon Archbold
- Neurogastroenterology Unit, Manchester University NHS Foundation Trust, Manchester, UK
| | - Dipesh H Vasant
- Neurogastroenterology Unit, Manchester University NHS Foundation Trust, Manchester, UK
- University of Manchester, Manchester, UK
| |
Collapse
|
18
|
Predictors of Abnormal Functional Luminal Impedance Planimetry Findings in Non-mechanical Esophagogastric Junction Outflow Obstruction. Dig Dis Sci 2021; 66:3968-3975. [PMID: 33249528 PMCID: PMC8248766 DOI: 10.1007/s10620-020-06726-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 11/17/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Esophagogastric junction outflow obstruction (EGJOO) is a common but nonspecific motility pattern identified by esophageal high-resolution manometry (HRM). Functional luminal impedance planimetry (FLIP) provides information regarding lower esophageal sphincter (LES) mechanics, which can identify achalasia spectrum disorders and is useful in evaluating EGJOO. However, the relationship between HRM and FLIP parameters in EGJOO is not clearly defined. AIMS To identify predictors of abnormal FLIP findings in patients with non-mechanical EGJOO. METHODS This is a retrospective cohort study of patients with non-mechanical EGJOO who underwent FLIP between 10/1/16 and 7/1/19. Demographic data including age and gender, examination indication, concomitant medications, HRM parameters, symptom burden, and FLIP metrics of diameter and distensibility index (DI) were collected. DI was categorized as not low (DI > 2.8), borderline low (DI 1.1-2.8), and definitely low (DI ≤ 1). Kruskal-Wallis and Fisher's exact tests were used to assess the relationship between HRM and FLIP parameters and to identify predictors of abnormal FLIP. RESULTS Among the 44 patients studied, most were female (n = 33, 75%) and the median age was 63. The median IRP was 18.2, and 10 (23%) patients used chronic narcotics. Lower total heartburn and regurgitation scores, and LES diameter by FLIP are associated with definitely low DI. CONCLUSIONS In patients with non-mechanical EGJOO, reflux burden scores and FLIP diameters can aid in predicting DI. These results may provide useful adjunctive data to help in differentiating which patients have meaningful outflow obstruction.
Collapse
|
19
|
Ghisa M, Laserra G, Marabotto E, Ziola S, Tolone S, de Bortoli N, Frazzoni M, Mauro A, Penagini R, Savarino V, Barberio B, Giannini EG, Zentilin P, Gyawali CP, Savarino E. Achalasia and Obstructive Motor Disorders Are Not Uncommon in Patients With Eosinophilic Esophagitis. Clin Gastroenterol Hepatol 2021; 19:1554-1563. [PMID: 32763482 DOI: 10.1016/j.cgh.2020.07.056] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/25/2020] [Accepted: 07/29/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND An association has been reported between achalasia and eosinophilic esophagitis (EoE). We performed a retrospective study of high-resolution manometry (HRM) patterns in a large cohort of patients with EoE. MATERIAL AND METHODS We collected data from consecutive patients with a new diagnosis of EoE from 2012 through 2019 undergoing HRM during the initial assessment at different centers in Italy. Demographic, clinical, endoscopic and histological characteristics were recorded at baseline and during management. Diagnoses of EoE and esophageal motility disorders were made according to established criteria. Treatments offered included proton pump inhibitors and topical steroids for EoE, and pneumatic dilation and myotomy for achalasia. Response to therapy was defined as less than 15 eosinophils per high power field in esophageal biopsies. RESULTS Of 109 consecutive patients (mean age 37 years, 82 male), 68 (62%) had normal findings from HRM. Among 41 patients with motor disorders, 24 (59%) had minor motor disorders and 17 (41%) presented with major motor disorders, including 8 with achalasia (1 with type 1, 4 with type 2, and 3 with type 3). Achalasia and nonachalasia obstructive motor disorders had 14.7% prevalence among patients with EoE. Achalasia was more frequent in women, with longer diagnostic delay and abnormal esophagogram (P < .05) compared with EoE without achalasia or obstructive motor disorders. Clinical features and endoscopic findings did not differ significantly between patients with EoE with vs without achalasia and obstructive motor disorders. A higher proportion of patients without achalasia and obstructive motor disorders responded to topical steroids than patients with these features (P < .005). Invasive achalasia management was required for symptom relief in 50% of patients with achalasia and obstructive motor disorders. CONCLUSION Achalasia and obstructive motor disorders are found in almost 15% of patients with EoE, and esophageal eosinophilia might cause these disorders. Patients with EoE who do not respond to standard treatments might require targeted muscle disruption.
Collapse
Affiliation(s)
- Matteo Ghisa
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Giorgio Laserra
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Elisa Marabotto
- Gastroenterology Unit, Department of Internal Medicine and Medical Specialties, University of Genoa, Genoa, Italy
| | - Sebastiano Ziola
- Gastroenterology Unit, Department of Internal Medicine and Medical Specialties, University of Genoa, Genoa, Italy
| | - Salvatore Tolone
- Surgery Unit, Department of Surgery, University of Campania Luigi Vanvitelli, Caserta, Italy
| | - Nicola de Bortoli
- Gastrointestinal Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | | | - Aurelio Mauro
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Roberto Penagini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Vincenzo Savarino
- Gastroenterology Unit, Department of Internal Medicine and Medical Specialties, University of Genoa, Genoa, Italy
| | - Brigida Barberio
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Edoardo Giovanni Giannini
- Gastroenterology Unit, Department of Internal Medicine and Medical Specialties, University of Genoa, Genoa, Italy
| | - Patrizia Zentilin
- Gastroenterology Unit, Department of Internal Medicine and Medical Specialties, University of Genoa, Genoa, Italy
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy.
| |
Collapse
|
20
|
Chandan S, Facciorusso A, Khan SR, Ramai D, Mohan BP, Bilal M, Dhindsa B, Kassab LL, Goyal H, Perisetti A, Bhat I, Singh S, McDonough S, Adler DG. Short versus standard esophageal myotomy in achalasia patients: a systematic review and meta-analysis of comparative studies. Endosc Int Open 2021; 9:E1246-E1254. [PMID: 34447872 PMCID: PMC8383091 DOI: 10.1055/a-1490-8493] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 03/17/2021] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Despite the clinical efficacy of peroral endoscopic myotomy (POEM), postoperative symptomatic gastroesophageal reflux disease (GERD) remains a major concern. While it is known that length of the gastric myotomy affects postoperative GERD, the clinical relevance of variation in esophageal myotomy length is not well known. We performed a systematic review and meta-analysis of studies comparing outcomes of short versus standard myotomy length in patients with achalasia. Patients and methods We searched multiple databases from inception through November 2020 to identify studies that reported on outcomes of achalasia patients who underwent short compared with standard esophageal myotomy. Meta-analysis was performed to determine pooled odds ratio (OR) of clinical success, GERD outcomes, and adverse events with the two techniques. Results 5 studies with 474 patients were included in the final analysis (short myotomy group 214, standard myotomy group 260). There was no difference in clinical success (OR 1.17, 95 % confidence interval [CI] 0.54-2.52; I2 0 %; P = 0.69), postoperative symptomatic GERD (OR 0.87, 95 %CI 0.44-1.74; I2 29 %; P = 0.70), and overall adverse events (OR 0.52, 95 %CI 0.19-1.38; I2 40 %; P = 0.19), between the two groups. Incidence of postoperative erosive esophagitis as determined by endoscopy was lower in the short myotomy group (OR 0.50, 95 %CI 0.24-1.03; I2 0 %; P = 0.06). Conclusion Our analysis showed that performing POEM with short esophageal myotomy in achalasia was as safe and effective as standard myotomy, with lower incidence of postoperative erosive esophagitis.
Collapse
Affiliation(s)
- Saurabh Chandan
- Division of Gastroenterology and Hepatology, CHI Creighton University Medical Center, Omaha, Nebraska, United States
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Surgical and Medical Sciences, University of Foggia, Foggia, Italy
| | - Shahab R. Khan
- Section of Gastroenterology, Rush University Medical Center, Chicago, Illinois, United States
| | - Daryl Ramai
- Internal Medicine, Brooklyn Hospital Center, Brooklyn, New York, United States
| | - Babu P. Mohan
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Mohammad Bilal
- Division of Gastroenterology, University of Minnesota and Minneapolis VA Health Care System, Minneapolis, Minnesota, United States
| | - Banreet Dhindsa
- Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, Nebraska, United States
| | - Lena L. Kassab
- Internal Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | - Hemant Goyal
- Gastroenterology, Wright Center for Graduate Medical Education, Scranton, Philadelphia, United States
| | - Abhilash Perisetti
- Gastroenterology and Hepatology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - Ishfaq Bhat
- Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, Nebraska, United States
| | - Shailender Singh
- Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, Nebraska, United States
| | - Stephanie McDonough
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Douglas G. Adler
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, United States
| |
Collapse
|
21
|
Long-term outcomes of treatments for achalasia. Curr Opin Gastroenterol 2021; 37:408-413. [PMID: 33859101 DOI: 10.1097/mog.0000000000000744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
PURPOSE OF REVIEW Idiopathic achalasia is a primary motility disorder of the esophagus that results in dysphagia, weight loss, and impaired quality of life. Several treatment options are available to gastroenterologists, and insights on the long-term outcome of these modalities are discussed. RECENT FINDINGS Peroral endoscopic myotomy (POEM) represents a novel endoscopic technique in the treatment of achalasia. Studies on long-term outcomes and comparison to other well-known treatment modalities such as laparoscopic Heller myotomy (LHM) and pneumodilation have recently been published. POEM and LHM both have excellent 2-year success rates for relieving achalasia symptoms, but reflux disease and erosive esophagitis are more prevalent following POEM. SUMMARY Several treatment modalities with excellent long-term outcomes are available for the treatment of achalasia. The different options should be discussed with patients and treatments should be tailored to their individual needs.
Collapse
|
22
|
Godoy-Salgado DC, Toro-Monjaraz EM, Padilla-Cortés T, Cadena-León JF, Zárate-Mondragón F, Loredo-Mayer A, Ignorosa-Arellano K, Cervantes-Bustamante R, Ramírez-Mayans JA. Esophagogastric junction outflow obstruction in the differential diagnosis of post-fundoplication dysphagia in children. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2021; 86:253-258. [PMID: 34210459 DOI: 10.1016/j.rgmxen.2021.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 06/05/2020] [Indexed: 12/01/2022]
Abstract
INTRODUCTION AND AIMS Post-fundoplication dysphagia is resolved with no therapeutic intervention in the majority of cases but it can persist in 5.3% of children that undergo the procedure. Among the differential diagnoses, esophagogastric junction outflow obstruction (EGJOO) is a disorder that should be suspected if there is a persistence of dysphagia. The aim of our study was to describe the clinical characteristics, treatment, and follow-up in a case series of patients diagnosed with post-fundoplication EGJOO. MATERIALS AND METHODS The clinical records of patients diagnosed with EGJOO at a tertiary care hospital within the time frame of September 2015 to September 2019 were reviewed, with respect to manometry, etiology, treatment, and clinical course of the disease. RESULTS Of the 213 high-resolution esophageal manometries performed, 4 patients met the criteria for post-fundoplication EGJOO. The primary symptom was dysphagia, presenting 15 days after the procedure. Esophageal dilations were carried out on all the patients but with no improvement. Symptoms related to the condition resolved spontaneously in three of the four patients. CONCLUSION The management of children with post-fundoplication EGJOO continues to be a challenge. Even though more than half of the cases resolve with no intervention, optimum management of the motility disorder is still limited, given the scant experience with the condition in the pediatric population.
Collapse
Affiliation(s)
- D C Godoy-Salgado
- Departamento de Gastroenterología y nutrición Pediátrica, Instituto Nacional de Pediatría, Mexico City, Mexico
| | - E M Toro-Monjaraz
- Departamento de Gastroenterología y nutrición Pediátrica, Instituto Nacional de Pediatría, Mexico City, Mexico.
| | - T Padilla-Cortés
- Departamento de Gastroenterología y nutrición Pediátrica, Instituto Nacional de Pediatría, Mexico City, Mexico
| | - J F Cadena-León
- Departamento de Gastroenterología y nutrición Pediátrica, Instituto Nacional de Pediatría, Mexico City, Mexico
| | - F Zárate-Mondragón
- Departamento de Gastroenterología y nutrición Pediátrica, Instituto Nacional de Pediatría, Mexico City, Mexico
| | - A Loredo-Mayer
- Departamento de Gastroenterología y nutrición Pediátrica, Instituto Nacional de Pediatría, Mexico City, Mexico
| | - K Ignorosa-Arellano
- Departamento de Gastroenterología y nutrición Pediátrica, Instituto Nacional de Pediatría, Mexico City, Mexico
| | - R Cervantes-Bustamante
- Departamento de Gastroenterología y nutrición Pediátrica, Instituto Nacional de Pediatría, Mexico City, Mexico
| | - J A Ramírez-Mayans
- Departamento de Gastroenterología y nutrición Pediátrica, Instituto Nacional de Pediatría, Mexico City, Mexico
| |
Collapse
|
23
|
Achem SR, Vazquez-Elizondo G, Fass R. Jackhammer Esophagus: Current Concepts and Dilemmas. J Clin Gastroenterol 2021; 55:369-379. [PMID: 33337637 DOI: 10.1097/mcg.0000000000001472] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 10/23/2020] [Indexed: 12/27/2022]
Abstract
Jackhammer esophagus (JE) is a recently recognized esophageal motility disorder that is characterized by hypercontractile peristalsis. More than 500 cases have been reported in the literature. Among patients referred for esophageal motility disorders, the prevalence of JE ranges from 0.42% to 9%, with most series describing a prevalence of 2% to 4%. Most cases are women (60.5%). The mean reported age of patients with JE is 65.2 years, and patients commonly have dysphagia (62.8%). Reflux symptoms occur in ∼40% of patients, and chest pain affects more than one-third of patients (36.4%). JE is a heterogenous disorder that is associated with several conditions, including obesity, opioid use, lung transplantation, eosinophilic infiltration of the esophagus, neoplasia, and systemic diseases. The cause and pathogenesis remain unknown, but several observations suggest that it is the result of multiple conditions that likely precipitate increased excitation and abnormal inhibition of neuromuscular function. The natural course of JE also is unknown, but progression to achalasia has been observed in a few patients. Treatment is challenging, in part because of the insufficient understanding of the disorder's underlying mechanisms. Various therapeutic modalities have been used, ranging from observation only to pharmacologic and endoscopic interventions (eg, botulinum toxin injection) to peroral endoscopic myotomy. Treatment efficacy remains largely anecdotal and insufficiently studied.
Collapse
Affiliation(s)
- Sami R Achem
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL
| | | | - Ronnie Fass
- Division of Gastroenterology and Hepatology, Metro Health Medical Center, Cleveland, OH
| |
Collapse
|
24
|
Physiological and pathological roles of the accommodation response in lower esophageal sphincter relaxation during wet swallows. Sci Rep 2021; 11:7898. [PMID: 33846463 PMCID: PMC8042112 DOI: 10.1038/s41598-021-87052-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 03/16/2021] [Indexed: 01/01/2023] Open
Abstract
The preparatory accommodation response of lower esophageal sphincter (LES) before swallowing is one of the mechanisms involved in LES relaxation during wet swallows, however, the physiological and/or pathological roles of LES accommodation remain to be determined in humans. To address this problem, we conducted a prospective observational study of 38 patients with normal high-resolution manometry (HRM) and 23 patients with idiopathic esophagogastric junction outflow obstruction (EGJOO) to assess dry and wet swallows. The LES accommodation measurement was proposed for practical use in evaluating the LES accommodation response. Although swallow-induced LES relaxation was observed in both dry and wet swallows, LES accommodation (6.4, 3.1–11.1 mmHg) was only observed in wet swallows. The extent of LES accommodation was impaired in idiopathic EGJOO (0.6, − 0.6–6 mmHg), and the LES accommodation measurement of patients with idiopathic EGJOO (36.8, 29.5–44.3 mmHg) was significantly higher in comparison to those with normal HRM (23.8, 18–28.6 mmHg). Successful LES relaxation in wet swallowing can be achieved by LES accommodation in combination with swallow-induced LES relaxation. Impaired LES accommodation is characteristic of idiopathic EGJOO. In addition to the IRP value, the LES accommodation measurement may be useful for evaluating the LES relaxation function in clinical practice.
Collapse
|
25
|
Cho YK. [Pharmacological Treatments of Esophageal Dysphagia]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2021; 77:71-76. [PMID: 33632997 DOI: 10.4166/kjg.2021.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 02/19/2021] [Accepted: 02/22/2021] [Indexed: 11/03/2022]
Abstract
Patients with esophageal dysphagia need a step-by-step approach for diagnosis and treatment. Endoscopic with biopsy and barium esophagogram are the essential tests evaluating anatomical abnormality and esophageal bolus stasis. Further imaging or esophageal function tests such as high-resolution esophageal manometry, functional endoluminal imaging probe, CT or endoscopic ultrasound are required. In the case of dysphagia due to esophageal motility disorder, whether it is the major motility disorder or minor motility disorder should be identified in high resolution manometry. Major motility disorders show esophagogastric junction obstruction or major peristaltic defects. In this case, the severity of the symptoms should be assessed and patients who need endoscopic or surgical treatment targeting lower esophageal sphincter should be screened. Impaired lower esophageal sphincter relaxation (achalasia, esophagogastric junction outflow obstruction, esophageal spasm or abnormal hypercontraction (jackhammer esophagus), hypotensive contraction (ineffective esophageal motility, failed peristalsis), esophageal hypersensitivity (noncardiac chest pain), gastroesophageal reflux disease and esophageal bolus stasis are the possible mechanisms causing dysphagia symptoms. The proper medical treatment depends on underlying mechanisms.
Collapse
Affiliation(s)
- Yu Kyung Cho
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| |
Collapse
|
26
|
Mendo R, Barreiro P, Rodrigues J, Félix C, O'Neill C, Carina I, Chivia J, Chagas C. Peroral Endoscopic Myotomy for Esophageal Achalasia in Portugal: Outcomes of the First Prospective Series. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2020; 28:162-169. [PMID: 34056038 DOI: 10.1159/000511528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 08/16/2020] [Indexed: 11/19/2022]
Abstract
Background Peroral endoscopic myotomy (POEM) is an innovative achalasia treatment procedure that involves myotomy of the lower esophageal sphincter through a submucosal tunneling approach, combining the efficacy of surgical myotomy with the benefit of being a less invasive treatment. At this time, no data are available of POEM in Portugal. This study aimed to examine the safety and short-term outcomes of POEM in a Portuguese center. Methods Fifty POEM were performed on 49 consecutive patients at our institution between January 2017 and January 2020. A prospective study of a consecutive series of patients was conducted, including procedure time, myotomy location and length, adverse events and clinical success. An Eckardt score of ≤3 after POEM was deemed as a successful outcome. Gastroesophageal reflux disease (GERD) was evaluated based on symptoms and on upper endoscopy, which was performed at 3-6 months postoperatively to check for reflux esophagitis. Results POEM was successfully completed in all cases: 70% (n = 35) were naïve and 30% (n = 15) had previous treatments. The mean procedure time was 73.4 ± 22.6 min (range 45-125 min). There were no major adverse events. Minor adverse events were rare (8%), and there was no perioperative mortality. The Eckardt score significantly decreased from 6.9 ± 2.4 preoperatively to 0.5 ± 1.0 postoperatively (p < 0.05). Overall clinical success was documented in 98, 98 and 95.2% at 1, 3 and 6 months, respectively. These short-term outcomes after POEM were independent of previous treatments. Symptomatic GERD was seen in 22.4% of patients. Conclusions Our results confirm the safety and excellent short-term efficacy of POEM in a Portuguese center. This supports POEM as one of the first-line achalasia therapies in Portugal when performed by experienced operators.
Collapse
Affiliation(s)
- Rui Mendo
- Department of Gastroenterology, Centro Hospitalar Lisboa Ocidental, Hospital de Egas Moniz, Lisbon, Portugal
| | - Pedro Barreiro
- Department of Gastroenterology, Centro Hospitalar Lisboa Ocidental, Hospital de Egas Moniz, Lisbon, Portugal.,Department of Gastroenterology, Hospital dos Lusíadas, Lisbon, Portugal
| | - José Rodrigues
- Department of Gastroenterology, Centro Hospitalar Lisboa Ocidental, Hospital de Egas Moniz, Lisbon, Portugal
| | - Catarina Félix
- Department of Gastroenterology, Centro Hospitalar Lisboa Ocidental, Hospital de Egas Moniz, Lisbon, Portugal
| | - Catarina O'Neill
- Department of Gastroenterology, Centro Hospitalar Lisboa Ocidental, Hospital de Egas Moniz, Lisbon, Portugal
| | - Iala Carina
- Department of Gastroenterology, Centro Hospitalar Lisboa Ocidental, Hospital de Egas Moniz, Lisbon, Portugal
| | - Joyce Chivia
- Department of Gastroenterology, Centro Hospitalar Lisboa Ocidental, Hospital de Egas Moniz, Lisbon, Portugal
| | - Cristina Chagas
- Department of Gastroenterology, Centro Hospitalar Lisboa Ocidental, Hospital de Egas Moniz, Lisbon, Portugal
| |
Collapse
|
27
|
Kim JY, Min YW. Peroral Endoscopic Myotomy for Esophageal Motility Disorders. Clin Endosc 2020; 53:638-645. [PMID: 33212547 PMCID: PMC7719430 DOI: 10.5946/ce.2020.223] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 09/22/2020] [Indexed: 12/11/2022] Open
Abstract
Peroral endoscopic myotomy (POEM) is one of the most clinically successful tunnel-based minimally invasive endoscopic treatments. The classic indications of POEM include achalasia of all types, including failed prior treatments, and expanded indications include the non-achalasia esophageal motility disorders, such as esophagogastric junction outflow obstruction, diffuse esophageal spasm, and jackhammer esophagus. For achalasia treatment, POEM has achieved a comparable surgical efficacy and a safety outcome and, therefore, has emerged as a first-line treatment. For non-achalasia esophageal motility disorders, POEM has also shown high clinical response rates. The complication rate of POEM for esophageal motility disorders is low and most complications are managed with conservative treatment. Currently, POEM is a representative procedure of natural orifice transluminal endoscopic surgery, which has shown a good clinical efficacy with low complication rates for esophageal motility disorders including achalasia. However, further studies are needed to treat non-achalasia motility disorder via POEM.
Collapse
Affiliation(s)
- Jun Young Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yang Won Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| |
Collapse
|
28
|
Chadalavada P, Thota PN, Raja S, Sanaka MR. Peroral Endoscopic Myotomy as a Novel Treatment for Achalasia: Patient Selection and Perspectives. Clin Exp Gastroenterol 2020; 13:485-495. [PMID: 33173323 PMCID: PMC7648548 DOI: 10.2147/ceg.s230436] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 10/19/2020] [Indexed: 12/12/2022] Open
Abstract
Achalasia is a rare esophageal motility disorder characterized by esophageal aperistalsis and impaired relaxation of lower esophageal sphincter. There is no cure for achalasia and all the current treatments are aimed at palliation of symptoms by reducing the lower esophageal sphincter pressure. Currently, laparoscopic Heller myotomy (LHM) with partial fundoplication is considered the most effective and durable treatment option owing to its superiority over other treatments such as pneumatic dilation. Advancements in interventional endoscopy led to a novel minimally invasive endoscopic alternative to LHM, namely peroral endoscopic myotomy (POEM). In the last decade since its inception, POEM expanded rapidly throughout the world due to excellent safety profile and its efficacy comparable to LHM. The main drawback of POEM is gastroesophageal reflux disease since it is not combined with an anti-reflux procedure. The current review focuses on the indications, contraindications, technique, outcomes of POEM in various patient populations, and complications along with its effectiveness in comparison to LHM and pneumatic dilation.
Collapse
Affiliation(s)
| | - Prashanthi N Thota
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Siva Raja
- Department of Cardiothoracic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Madhusudhan R Sanaka
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
29
|
Affiliation(s)
- Ravinder Mittal
- From the Division of Gastroenterology, Department of Medicine, University of California, San Diego, San Diego (R.M.); and the Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville (M.F.V.)
| | - Michael F Vaezi
- From the Division of Gastroenterology, Department of Medicine, University of California, San Diego, San Diego (R.M.); and the Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville (M.F.V.)
| |
Collapse
|
30
|
Caruso AM, Milazzo M, Tulone V, Acierno C, Girgenti V, Amoroso S, Bommarito D, Calcaterra V, Pelizzo G. High Resolution Manometry Guidance During Laparoscopic Fundoplication in Pediatric Surgically "Fragile" Patients: Preliminary Report. CHILDREN-BASEL 2020; 7:children7110215. [PMID: 33171722 PMCID: PMC7695016 DOI: 10.3390/children7110215] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/04/2020] [Accepted: 11/05/2020] [Indexed: 12/12/2022]
Abstract
Background: High resolution manometry (HRM), has been recently introduced in clinical practice to detect esophageal intraluminal pressure and esophageal motor function. We evaluated the feasibility and usefulness of intraoperative esophageal HRM during antireflux laparoscopic procedures in pediatric cases with neurological impairment (NI) or esophageal atresia (EA). Methods: From January to November 2019, seven children (5 NI, 2 EA) with gastroesophageal reflux (GER) were enrolled. Data on intraoperative pressure changes of the esophagogastric junction (EGJ) and postoperative follow-up data were collected. Results: Average preoperative LES pressures were not significantly different from postoperative pressures. A sliding hernia was detected in all patients as evidenced by EGJ double peak pressures. Hernia correction after esophageal traction was complete in 71.4% of the patients, and residual hernia (<2 cm) was detected in 28.6%. Postoperative EGJ pressures were higher compared to preoperative sphincteric pressures (p < 0.001); in NI patients, higher postoperative values were noted compared to EA (p = 0.05). No sliding hernia and/or GER relapses were recorded. Two patients reported dysphagia postoperatively. Conclusions: Intraoperative HRM may optimize esophageal pressure changes during laparoscopic fundoplication. Further studies are needed to confirm the usefulness of a tailored surgical approach to reduce postoperative complications.
Collapse
Affiliation(s)
- Anna Maria Caruso
- Pediatric Surgery Unit, Children’s Hospital, ARNAS Civico-Di Cristina-Benfratelli, 90127 Palermo, Italy; (A.M.C.); (M.M.); (V.T.); (C.A.); (V.G.); (S.A.); (D.B.)
| | - Mario Milazzo
- Pediatric Surgery Unit, Children’s Hospital, ARNAS Civico-Di Cristina-Benfratelli, 90127 Palermo, Italy; (A.M.C.); (M.M.); (V.T.); (C.A.); (V.G.); (S.A.); (D.B.)
| | - Vincenzo Tulone
- Pediatric Surgery Unit, Children’s Hospital, ARNAS Civico-Di Cristina-Benfratelli, 90127 Palermo, Italy; (A.M.C.); (M.M.); (V.T.); (C.A.); (V.G.); (S.A.); (D.B.)
| | - Carlo Acierno
- Pediatric Surgery Unit, Children’s Hospital, ARNAS Civico-Di Cristina-Benfratelli, 90127 Palermo, Italy; (A.M.C.); (M.M.); (V.T.); (C.A.); (V.G.); (S.A.); (D.B.)
| | - Vincenza Girgenti
- Pediatric Surgery Unit, Children’s Hospital, ARNAS Civico-Di Cristina-Benfratelli, 90127 Palermo, Italy; (A.M.C.); (M.M.); (V.T.); (C.A.); (V.G.); (S.A.); (D.B.)
| | - Salvatore Amoroso
- Pediatric Surgery Unit, Children’s Hospital, ARNAS Civico-Di Cristina-Benfratelli, 90127 Palermo, Italy; (A.M.C.); (M.M.); (V.T.); (C.A.); (V.G.); (S.A.); (D.B.)
| | - Denisia Bommarito
- Pediatric Surgery Unit, Children’s Hospital, ARNAS Civico-Di Cristina-Benfratelli, 90127 Palermo, Italy; (A.M.C.); (M.M.); (V.T.); (C.A.); (V.G.); (S.A.); (D.B.)
| | - Valeria Calcaterra
- Pediatric and Adolescent Unit, Department of Internal Medicine, University of Pavia, 27100 Pavia, Italy;
- Pediatric Unit, “V. Buzzi” Children’s Hospital, University of Milano, 20154 Milano, Italy
| | - Gloria Pelizzo
- Pediatric Surgery Unit, “V. Buzzi” Children’s Hospital, University of Milano, 20154 Milano, Italy
- Department of Biomedical and Clinical Science, “L. Sacco”, University of Milano, 20154 Milano, Italy
- Correspondence:
| |
Collapse
|
31
|
Cho YK. [Diagnostic Approach for Esophagogastric Junction Outflow Obstruction]. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2020; 76:179-184. [PMID: 33100312 DOI: 10.4166/kjg.2020.76.4.179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 10/19/2020] [Accepted: 10/20/2020] [Indexed: 06/11/2023]
Abstract
Esophageal manometry is the gold standard test for diagnosing primary esophageal motility disorder. With the various metrics of the high-resolution esophageal manometry, the Chicago classification provides a standard approach for the manometric diagnosis of esophageal motor disorders. In the Chicago classification, the esophagogastric junction dysfunction is an important major motor disorder, which includes achalasia subtypes and esophagogastric junction outflow obstruction. Esophagogastric junction outflow obstruction is defined manometrically as normal or weak esophageal peristalsis with incomplete relaxation of the lower esophageal sphincter. It is a heterogeneous disorder and usually has a benign clinical course. The small portion of an esophagogastric junction outflow obstruction is early or variant achalasia. In such cases, treatments directing the lower esophageal sphincter, such as balloon dilatation or per oral endoscopic myotomy, may be necessary. An adjunctive high-resolution manometry provocation test or other esophageal function tests, such as timed barium esophagogram, can help select those patients and predict the treatment outcomes.
Collapse
Affiliation(s)
- Yu Kyung Cho
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| |
Collapse
|
32
|
Discordance between high-resolution manometry, esophagoscopy and contrast esophagogram in determining landmarks for per-oral endoscopic myotomy in spastic esophageal disorders: a word of caution. Surg Endosc 2020; 35:5613-5619. [PMID: 33048228 DOI: 10.1007/s00464-020-08064-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 09/29/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Myotomy length for per-oral endoscopic myotomy (POEM) is standardized for type I and II achalasia. However, for type III achalasia, jackhammer esophagus, diffuse esophageal spasms and esophagogastric junction outflow obstruction, there is no standard. Determining myotomy length based on the high-pressure zone found during high-resolution manometry (HRM) and spastic length found during esophagography may be used to determine adequate myotomy length without excess muscle destruction. METHODS The records of patients who have undergone POEM procedures at our institution had the following data gleaned: age, sex, esophageal spastic diagnosis, length of high-pressure zone and lower esophageal sphincter (LES) position by HRM, length of spastic esophagus by esophagography, position of the z-line by esophagoscopy and length of myotomy performed. Outcomes were assessed based on patient symptomatic improvement and need for re-intervention. RESULTS 71 patients were evaluated for POEM, with 67 completing POEM. There was an average difference in LES position by HRM and z-line position by esophagoscopy of 3.9 ± 3.0 cm. There was an average difference in high-pressure zone by HRM and spastic length by esophagography of 4.9 ± 3.2 cm. Overall, with a median of 20 months follow-up, 74% achieved long-term symptomatic improvement, with 17 patients requiring re-intervention. CONCLUSIONS Discordance among HRM, esophagography and esophagoscopy can be significant. Caution should be employed with using these methods to determine myotomy length in POEM.
Collapse
|
33
|
Lazarescu A, Chan WW, Gyawali CP, Lee YY, Xiao Y, Wu P. Updates on diagnostic modalities for esophageal dysphagia. Ann N Y Acad Sci 2020; 1481:108-116. [PMID: 32875574 DOI: 10.1111/nyas.14453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/26/2020] [Accepted: 07/07/2020] [Indexed: 12/20/2022]
Abstract
Esophageal dysphagia is a common symptom in adults. Fluoroscopic contrast studies, endoscopy, and esophageal manometry have been used in the diagnosis of esophageal dysphagia for many years. The diagnostic yield has been improved with new test protocols that highlight abnormal bolus transit in the esophagus and outflow obstruction, as well as new high-definition and high-resolution technical advances in equipment. Functional luminal impedance planimetry and the addition of impedance to high-resolution esophageal manometry have also allowed the assessment of new parameters to better understand esophageal structure and function. In this concise review, we describe the role and utility of various diagnostic modalities in the assessment of patients with esophageal dysphagia.
Collapse
Affiliation(s)
- Adriana Lazarescu
- Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - Walter W Chan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri
| | - Yeong Yeh Lee
- School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia
| | - Yinglian Xiao
- Department of Gastroenterology, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, PR China
| | - Peter Wu
- Department of Gastroenterology and Hepatology, St. George Hospital, Kogarah, New South Wales, Australia
| |
Collapse
|
34
|
Jehangir A, Tanner S, Malik Z, Parkman HP. Characterizing the proximal esophageal segment in patients with symptoms of esophageal dysmotility. Neurogastroenterol Motil 2020; 32:e13888. [PMID: 32485784 DOI: 10.1111/nmo.13888] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 03/25/2020] [Accepted: 04/29/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Proximal esophageal striated muscle contractility may be abnormal in patients with esophageal symptoms, but is not assessed in the Chicago Classification (CC) v3.0. We aimed to (a) determine the prevalence of abnormal proximal esophageal contractility in patients with esophageal symptoms; (b) compare proximal esophageal contractility in patients with different esophageal motility disorders; (c) assess the association of abnormal proximal esophageal contractility with esophageal symptoms. METHODS Patients undergoing high-resolution esophageal manometry (HREM) from 7/2019 to 11/2019 and healthy volunteers (HVs) were studied. Measurements of the proximal esophageal segment included the vigor of contractility of the proximal esophagus (proximal contractile integral/PCI). Patients rated gastrointestinal symptoms' severity. KEY RESULTS HREM was performed on 221 patients (63.8% females, mean age 57.1 ± 1.1 years) and 19 HVs. Mean PCI in HVs was 299.5 ± 30.6 (95% CI 32.3-566.7 mm Hg. s. cm). Of all patients, 61 (27.6%) had abnormal PCI. HVs and patients with different esophageal motility disorders had significantly different PCI (P < .01). Type 1 achalasia patients had weaker PCI than patients with absent contractility (P = .02). Patients with abnormal PCI had more severe dysphagia (P = .02), nausea (P = .03), vomiting (P = .03), and lower bolus clearance (P < .01) than patients with normal PCI. CONCLUSIONS AND INFERENCES Abnormal PCI was found in a fourth of patients with esophageal symptoms. PCI may be useful to distinguish some esophageal motility disorders. Patients with abnormal PCI had a higher severity of some upper gastrointestinal symptoms than patients with normal PCI. Assessing the proximal esophageal segment on HREM may be useful in characterizing patients with esophageal symptoms.
Collapse
Affiliation(s)
- Asad Jehangir
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania, USA
| | - Samuel Tanner
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania, USA
| | - Zubair Malik
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania, USA
| | - Henry P Parkman
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania, USA
| |
Collapse
|
35
|
Obstrucción del tracto de salida de la unión esofagogástrica en el diagnóstico diferencial de disfagia posfunduplicatura en niños. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2020. [DOI: 10.1016/j.rgmx.2020.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
|
36
|
Cisternas D, Monrroy H, Riquelme A, Padilla O, Fuentes-López E, Valle A, Mejia R, Hani A, Ardila-Hani AF, Leguizamo AM, Bilder C, Ditaranto A, Remes-Troche JM, Ruiz de León A, Pérez de la Serna J, Marin I, Serra J. Fair reliability of eckardt scores in achalasia and non-achalasia patients: Psychometric properties of the eckardt spanish version in a multicentric study. Neurogastroenterol Motil 2020; 32:e13827. [PMID: 32100424 DOI: 10.1111/nmo.13827] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 02/05/2020] [Accepted: 02/06/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Eckardt symptom score (ESS) is the most used tool for the evaluation of esophageal symptoms. Recent data suggest that it might have suboptimal reliability and validity. The aims of this study were as follows: (a) Develop and validate an international Spanish ESS version. (b) Perform psychometric ESS evaluation in patients with achalasia and non-achalasia patients. METHODS Eckardt symptom score translation was performed by Delphi process. ESS psychometric evaluation was done in two different samples of patients referred for manometry. First sample: 430 dysphagia non-achalasia patients. Second sample: 161 achalasia patients. Internal consistency was evaluated using Cronbach's α and Guttman coefficient (<0.5 = unacceptable. 0.5-0.7 = fair. >0.7 = acceptable). KEY RESULTS Our data show that in patients without and with achalasia, ESS behaves similarly. Both show a fair reliability with Cronbach's α of 0.57 and 0.65, respectively. Based on our results, we recommend interpretation of the Spanish ESS be done with caution. The psychometric quality of the ESS could not be improved by removal of any items based on the single-factor structure of the scale and no items meeting criteria for elimination. CONCLUSIONS AND INFERENCES Eckardt symptom score Spanish translation was developed. ESS showed a fair reliability for the evaluation of patients with any causes of dysphagia. Our results highlight the need for development and psychometric validation of new dysphagia scoring tools.
Collapse
Affiliation(s)
- Daniel Cisternas
- Facultad de Medicina Clínica Alemana, Clínica Alemana de Santiago, Universidad del Desarrollo. Santiago, Chile
| | - Hugo Monrroy
- Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | | | - Eduardo Fuentes-López
- Department of Health Sciences, Faculty of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Arturo Valle
- Facultad de Medicina Clínica Alemana, Clínica Alemana de Santiago, Universidad del Desarrollo. Santiago, Chile
| | - Ricardo Mejia
- Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Albis Hani
- San Ignacio Hospital, Pontificia Universidad Javeriana, Bogota, Colombia
| | | | | | - Claudio Bilder
- School of Medicine, Hospital Universitario, Fundación Favaloro, Buenos Aires, Argentina
| | - Andres Ditaranto
- School of Medicine, Hospital Universitario, Fundación Favaloro, Buenos Aires, Argentina
| | | | | | | | - Ingrid Marin
- Motility and Functional Gut Disorders Unit, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), University Hospital Germans Trias i Pujol, Universitat Autonoma de Barcelona, Badalona, Spain
| | - Jordi Serra
- Motility and Functional Gut Disorders Unit, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), University Hospital Germans Trias i Pujol, Universitat Autonoma de Barcelona, Badalona, Spain
| |
Collapse
|
37
|
Hoshikawa Y, Hoshino S, Kawami N, Tanabe T, Hanada Y, Takenouchi N, Goto O, Kaise M, Iwakiri K. Possible new endoscopic finding in patients with achalasia: "Gingko leaf sign". Esophagus 2020; 17:208-213. [PMID: 31227944 DOI: 10.1007/s10388-019-00684-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 06/16/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND The diagnosis of achalasia can occasionally be difficult because of the low prevalence of apparent endoscopic abnormal findings, such as dilation and food residue, and lack of "esophageal rosette" in some patients. We have found a new endoscopic finding "Gingko leaf sign", which consists of not being able to see the full extent of the esophageal palisade vessels and a Gingko leaf-shaped morphology of a longitudinal section of the esophagogastric junction at the end of a deep inspiration, in some achalasia patients without "esophageal rosette". The aim of the study was to investigate the prevalence of "Gingko leaf sign" in these patients. METHODS We retrospectively compared the prevalence of "Gingko leaf sign" between 11 achalasia patients without "esophageal rosette" and 22 age-/gender-matched healthy subjects. The diagnoses of achalasia were based on the results of high-resolution manometry. We also investigated the characteristics of the patients with "Gingko leaf sign". RESULTS All the patients had "Gingko leaf sign", in contrast to none of the healthy subjects (p < 0.001). Four of 11 patients did not require any therapy. Six of seven patients did not relapse after balloon dilatation, but one patient required per-oral endoscopic myotomy 8 months after balloon dilatation. CONCLUSION All our achalasia patients without "esophageal rosette" had "Gingko leaf sign". It is possibly a useful endoscopic finding in achalasia patients without "esophageal rosette".
Collapse
Affiliation(s)
- Yoshimasa Hoshikawa
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Shintaro Hoshino
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Noriyuki Kawami
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Tomohide Tanabe
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Yuriko Hanada
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Nana Takenouchi
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Osamu Goto
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Mitsuru Kaise
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Katsuhiko Iwakiri
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan.
| |
Collapse
|
38
|
Triadafilopoulos G, Kamal A, Zikos T, Nguyen L, Clarke JO. Changes in high-resolution manometric diagnosis over time: implications for clinical decision-making. Dis Esophagus 2020; 33:5697879. [PMID: 31909786 DOI: 10.1093/dote/doz094] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 09/25/2019] [Accepted: 10/22/2019] [Indexed: 12/11/2022]
Abstract
Although High resolution esophageal manometry (HRM) is the gold standard to assess esophageal motility, little is known about the stability of the manometric diagnosis over time and its implications for management. To assess the stability and usefulness of repeat HRM in patients presenting with esophageal symptoms over time we performed this retrospective study of patients with esophageal symptoms. Medical records, questionnaires, and HRM tracing were independently reviewed using the Chicago classification. The primary objective was to assess the stability of the manometric diagnosis over time; secondary objective was its change (positive or negative). At least one repeat study was performed in 86 patients (36% women, ages 20-86, with mild to moderate symptoms), while 26 had a third procedure. Mean intervals between studies were 15 ± 1.6 months (for baseline v. first study) and 13 ± 0.8 months (for second to third study). Of the 27 patients initially with a normal study, 11 changed (five had esophago-gastric junction outflow obstruction [EGJOO], two diffuse esophageal spasm [DES], one jackhammer esophagus [JE], and three ineffective esophageal motility [IEM] [41% change]). Of the 24 patients with initial EGJOO, only nine retained it (65.2% change). Of nine patients with initial DES, four changed (44.4% change). Similarly, different diagnosis was seen in 7 of 24 initial IEM patients (22.7% change). Only one patient had achalasia initially and this remained stable. Additional changes were noted on a third HRM. Fluidity in the HRM diagnosis over time questions its validity at any timepoint and raises doubts about the need for intervention.
Collapse
Affiliation(s)
- George Triadafilopoulos
- Stanford Esophageal Multidimensional Program in Innovation and Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Afrin Kamal
- Stanford Esophageal Multidimensional Program in Innovation and Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Thomas Zikos
- Stanford Esophageal Multidimensional Program in Innovation and Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Linda Nguyen
- Stanford Esophageal Multidimensional Program in Innovation and Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - John O Clarke
- Stanford Esophageal Multidimensional Program in Innovation and Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA
| |
Collapse
|
39
|
Podboy AJ, Hwang JH, Rivas H, Azagury D, Hawn M, Lau J, Kamal A, Friedland S, Triadafilopoulos G, Zikos T, Clarke JO. Long-term outcomes of per-oral endoscopic myotomy compared to laparoscopic Heller myotomy for achalasia: a single-center experience. Surg Endosc 2020; 35:792-801. [DOI: 10.1007/s00464-020-07450-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 02/11/2020] [Indexed: 02/07/2023]
|
40
|
Abstract
BACKGROUND Esophageal motility disorders which include achalasia, esophagogastric junction outflow obstruction (EGJ outflow obstruction), jackhammer esophagus (JE), distal esophageal spasm (DES), etc. are rare disease of unknown causes. The diagnosis is based on endoscopy, barium meal, and high-resolution manometry (HRM). With the development of endoscopy, peroral endoscopic myotomy (POEM) has emerged as a standard method for the treatment of achalasia. PURPOSE The purpose of this article is to enable gastroenterologists to have a more comprehensive understanding of the application status, technical characteristics, clinical efficacy and future prospect of POEM in the treatment of esophageal motility disorders. METHODS Through a large number of reading literature, combined with clinical practice, summary and analysis of the indications, procedure, efficacy, complications, and controversies of POEM in the treatment of esophageal motility disorders, as well as the current and future perspectives of POEM were studied. RESULTS POEM is safe and effective in the treatment of esophageal motility disorders, but the GERD reflux rate is higher. CONCLUSIONS POEM can be a new option for the treatment of esophageal movement disorders, but large sample, multi-center, long-term study reports are needed, and it promotes the development of NOTES technology.
Collapse
|
41
|
Chan MQ, Balasubramanian G. Esophageal Dysphagia in the Elderly. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2019; 17:534-553. [PMID: 31741211 DOI: 10.1007/s11938-019-00264-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW With a globally aging population, dysphagia is a growing health concern among elderly. Increasing reflux disease has contributed to an increased prevalence of dysphagia from peptic strictures and esophageal cancer. Dysphagia can lead to malnutrition and aspiration pneumonia, causing considerable morbidity and mortality. This review article focuses on recent advances in the approach and management of esophageal dysphagia. RECENT FINDINGS Endoscopic functional luminal imaging probe is a novel test that complements upper endoscopy, esophagram, and esophageal manometry for evaluation of esophageal dysphagia. Opioid induced esophageal dysfunction (OIED) is an emerging clinical entity that can mimic achalasia. Strictures refractory to dilation can be treated with intralesional steroid injections, electrosurgical incision, or esophageal stents. Peroral endoscopic myotomy (POEM) is gaining in popularity for treatment of achalasia and other spastic disorders of esophagus. Treatment of esophageal dysphagia may include proton pump inhibitors, endoscopic dilation, or surgery and requires a personalized approach based on risks and benefits. POEM is a valuable therapy for achalasia, but further studies are needed to evaluate its use, and other alternatives, for treatment of OIED and spastic esophageal disorders.
Collapse
Affiliation(s)
- Megan Q Chan
- Department of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, 395 W. 12th Avenue, 2nd floor, Columbus, OH, USA
| | - Gokulakishnan Balasubramanian
- Department of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, 395 W. 12th Avenue, 2nd floor, Columbus, OH, USA.
| |
Collapse
|
42
|
Abstract
The impact of opioid use on the lower gastrointestinal tract is well described, but recent opioid crisis has caused increased awareness of the detrimental effects of these drugs on esophageal and gastroduodenal motility. Opioid use has been associated with increased incidence of spastic esophageal motility disorders and gastroduodenal dysfunction. Opioid receptors are present with high abundance in the myenteric and submucosal plexus of the enteric nervous system. Activation of these receptors leads to suppressed excitability of the inhibitory musculomotor neurons and unchecked tonic contraction of the autogenic musculature (such as the lower esophageal sphincter and the pylorus).
Collapse
|
43
|
Quader F, Mauro A, Savarino E, Tolone S, de Bortoli N, Franchina M, Ghisa M, Edelman K, Jha LK, Penagini R, Gyawali CP. Jackhammer esophagus with and without esophagogastric junction outflow obstruction demonstrates altered neural control resembling type 3 achalasia. Neurogastroenterol Motil 2019; 31:e13678. [PMID: 31310444 DOI: 10.1111/nmo.13678] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 06/10/2019] [Accepted: 07/02/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Esophageal hypercontractility can manifest with and without esophagogastric junction (EGJ) outflow obstruction. We investigated clinical presentations and motility patterns in patients with esophageal hypercontractile disorders. METHODS Esophageal HRM studies fulfilling Chicago Classification 3.0 criteria for jackhammer esophagus (distal contractile integral, DCI >8000 mmHg.cm.s in ≥ 20% swallows) with (n = 30) and without (n = 83) EGJ obstruction (integrated relaxation pressure, IRP > 15 mm Hg) were retrospectively reviewed from five centers (4 in Europe, 1 in US). Single swallows (SS) and multiple rapid swallows (MRS) were analyzed using HRM software tools (IRP, DCI, distal latency, DL); MRS: SS DCI ratio >1 defined contraction reserve. Comparison groups were achalasia type 3 (n = 72, positive control for abnormal inhibition and EGJ obstruction) and healthy controls (n = 18). Symptoms, HRM metrics, and MRS contraction reserve were analyzed within jackhammer subgroups and comparison groups. KEY RESULTS The esophageal smooth muscle was excessively stimulated at baseline in jackhammer subgroups, with lack of augmentation following MRS identified more often compared with controls (P = .003) and type 3 achalasia (P = .07). Consistently abnormal inhibition was identified in type 3 achalasia (47%), and to a lower extent in jackhammer with obstruction (37%, P = .33), jackhammer esophagus (28%, P = .01), and controls (11%, P < .01 compared with type 3 achalasia). Perceptive symptoms (heartburn, chest pain) were common in jackhammer esophagus (P < .01 compared with type 3 achalasia), while transit symptoms (dysphagia) were more frequent with presence of EGJ obstruction (P ≤ .01 compared with jackhammer without obstruction). CONCLUSIONS AND INFERENCES The balance of excessive excitation and abnormal inhibition defines clinical and manometric manifestations in esophageal hypercontractile disorders.
Collapse
Affiliation(s)
- Farhan Quader
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - Aurelio Mauro
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy.,Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Edoardo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Salvatore Tolone
- General, Mini-Invasive and Bariatric Surgery Unit, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Nicola de Bortoli
- Division of Gastroenterology, Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Cisanello Hospital, Pisa, Italy
| | - Marianna Franchina
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy.,Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Matteo Ghisa
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Krista Edelman
- Division of Gastroenterology, Duke University, Durham, NC, USA.,Richmond Gastroenterology Associates, Richmond, VA, USA
| | - Lokesh K Jha
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Roberto Penagini
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy.,Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| |
Collapse
|
44
|
Abstract
PURPOSE OF REVIEW This review presents an overview of the diagnostic approach to esophageal dysphagia and summarizes recent epidemiological trends and technical advancements. RECENT FINDINGS The evaluation of dysphagia begins with a detailed history followed by endoscopy to evaluate for any structural abnormalities including malignancy. This is especially true given the emergence of eosinophilic esophagitis (EoE) as a dominant cause of esophageal dysphagia. In fact, it is now standard practice to obtain esophageal biopsies during endoscopy performed to evaluate dysphagia, since EoE can present without the characteristic mucosal features of rings, furrows, and exudate. Achalasia is also more frequently encountered since the introduction of high-resolution manometry (HRM) and the Chicago Classification into clinical practice. The Chicago Classification provides a stepwise diagnostic algorithm for evaluating HRM studies and systematically diagnosing esophageal motility disorders. Lastly, the functional lumen imaging probe (FLIP) is a novel technology that has added insight into both achalasia and EoE. Measuring esophageal distensibility with FLIP has useful prognostic implications for both diseases, and FLIP can identify motility abnormalities in achalasics not detected with HRM. A careful history is key to the efficient evaluation of dysphagia, and endoscopy is usually the first diagnostic study to obtain. For patients with prominent reflux symptoms, an empiric trial with proton pump inhibitors is reasonable then because reflux disease is such a common cause of dysphagia. Thereafter, patients should undergo HRM to evaluate for a motility disorder, and FLIP can provide complementary data to guide management.
Collapse
Affiliation(s)
- Jooho P Kim
- Feinberg School of Medicine, Department of Medicine, Northwestern University, 676 St Clair St, 14th floor, Chicago, IL, 60611-2951, USA
| | - Peter J Kahrilas
- Feinberg School of Medicine, Department of Medicine, Northwestern University, 676 St Clair St, 14th floor, Chicago, IL, 60611-2951, USA.
| |
Collapse
|
45
|
Babaei A, Szabo A, Shad S, Massey BT. Chronic daily opioid exposure is associated with dysphagia, esophageal outflow obstruction, and disordered peristalsis. Neurogastroenterol Motil 2019; 31:e13601. [PMID: 30993800 PMCID: PMC6559831 DOI: 10.1111/nmo.13601] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 03/14/2019] [Accepted: 04/02/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Opioid receptors are present in the esophagus, and chronic opioid therapy may be associated with esophageal dysfunction. Given the current opioid epidemic in the United States, the potential contribution of opioids to esophageal dysmotility is important from both public health and patient care perspectives. Therefore our aim is to investigate the potential contribution of opioids to dysphagia and the prevalence of major motor disorders in patients undergoing manometric evaluation. METHODS The anonymized electronic medical records of patients linked to their de-identified high-resolution manometry (HRM) studies were reviewed. The patients were grouped based on their opioid exposure history at the time of HRM: opioid-naïve and chronic daily users. The oral morphine milligram equivalent daily dose (MMED) of opioids was computed. KEY RESULTS: 10% of patients referred for esophageal HRM were taking opioid analgesics on a chronic daily basis, and they had a significantly higher prevalence of dysphagia than their opioid-naïve counterparts. The chronic daily opioid users displayed a significantly higher prevalence of achalasia type 3 (ACH3) and esophagogastric junction outflow obstruction (EGJOO) motility phenotypes. The MMED of opioids was a significant predictor of esophageal pressure metrics and motility diagnoses (P < 0.0001). CONCLUSIONS Chronic daily opioid intake is associated with impaired deglutitive LES relaxation and disorganized peristaltic sequence. While a minority of patients on chronic daily opioid therapy present with major esophageal motor disorders, they comprise nearly half of ACH3 and a third of EGJOO motility phenotypes.
Collapse
Affiliation(s)
- Arash Babaei
- Division of Gastroenterology, Department of Medicine, National Jewish Health, Denver, CO, USA,Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Aniko Szabo
- Institute for Health and Equity, Division of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sadaf Shad
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Benson T. Massey
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| |
Collapse
|
46
|
Tariq H, Makker J, Chime C, Kamal MU, Rafeeq A, Patel H. Revisiting the Reliability of the Endoscopy and Sedation-Assisted High-Resolution Esophageal Motility Assessment. Gastroenterology Res 2019; 12:157-165. [PMID: 31236157 PMCID: PMC6575134 DOI: 10.14740/gr1185] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 05/23/2019] [Indexed: 02/07/2023] Open
Abstract
Background Esophageal high-resolution manometry (HRM) is performed for evaluation of dysphagia or the pre-operative evaluation before esophageal surgery. The esophageal manometry parameters, interpreted as per the Chicago classification (CC), are meant to be acquired in an awake state. At times, the patient intolerance or inability to traverse the manometry catheter across the esophagogastric junction (EGJ) renders incomplete esophageal motility evaluation; hence, sedation or endoscopy assistance is required. There have been concerns raised regarding the use of sedation and resultant alteration of the manometry parameters. The aims were to study the effects of intravenous sedation on esophageal motility parameters and analyze its impact on outcomes of patients with dysphagia who are intolerant to awake manometry procedure. Methods The study population comprised patients who had sedation or the endoscopy assistance for the HRM. The indication for HRM, necessity for the sedation, manometry findings, barium esophagogram results, procedural timings and patient outcomes were reviewed. The diagnostic impact of the 10% correction in integrated relaxation pressure (IRP) was also studied. Results There were 14 patients from 179 awake manometry procedures that required the sedation or the endoscopy assistance. The mean age was 60.7 years and there was equal gender distribution. Dysphagia (n = 9) remained the predominant indication for the HRM, followed by the pre-operative evaluation for the esophageal surgery (n = 5). In eight patients, awake manometry failed due to the coiling of the catheter above the EGJ and six patients were intolerant to awake catheter insertion technique. Six patients were diagnosed with achalasia and two with EGJ obstruction. The correction of the possible 10% inflation of the IRP did not alter the final diagnosis in majority except one patient with the EGJ obstruction. The findings of the barium esophagogram corroborated the manometry diagnosis. Conclusion Esophageal HRM should be done in awake state as much as possible. Sedation may be a feasible option as against aborting the further workup in patients who fail with current techniques involving awake catheter insertion. However, one needs to be mindful of sedation effects on manometry parameters and interpret results carefully.
Collapse
Affiliation(s)
- Hassan Tariq
- Department of Medicine, BronxCare Health System, Bronx, NY 10457, USA.,Division of Gastroenterology, Department of Medicine, BronxCare Health System, Bronx, NY 10457, USA
| | - Jasbir Makker
- Department of Medicine, BronxCare Health System, Bronx, NY 10457, USA.,Division of Gastroenterology, Department of Medicine, BronxCare Health System, Bronx, NY 10457, USA
| | - Chukwononso Chime
- Department of Medicine, BronxCare Health System, Bronx, NY 10457, USA.,Division of Gastroenterology, Department of Medicine, BronxCare Health System, Bronx, NY 10457, USA
| | | | - Ahmed Rafeeq
- Department of Medicine, BronxCare Health System, Bronx, NY 10457, USA.,Division of Gastroenterology, Department of Medicine, BronxCare Health System, Bronx, NY 10457, USA
| | - Harish Patel
- Department of Medicine, BronxCare Health System, Bronx, NY 10457, USA.,Division of Gastroenterology, Department of Medicine, BronxCare Health System, Bronx, NY 10457, USA
| |
Collapse
|
47
|
Barriers in Neurogastroenterology and Motility Training Experience for Pediatric Gastroenterology Fellows. J Pediatr Gastroenterol Nutr 2019; 68:806-810. [PMID: 30664565 PMCID: PMC6534453 DOI: 10.1097/mpg.0000000000002282] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Neurogastroenterology and motility (NGM) disorders are common and have a high health care burden. Although pediatric gastroenterology fellows are expected to obtain comprehensive training in the diagnosis and management of NGM disorders, there is ongoing concern for unmet training needs and lack of exposure in treating patients who suffer from NGM problems. METHODS We conducted a cross-section survey of trainees listed as pediatric gastroenterology fellows in North American training programs in 2018 via direct E-mail and the pediatric gastroenterology listserv. Eighty-one pediatric gastroenterology fellows responded to the anonymous survey. RESULTS A total of 53.1% of the fellows reported interest in NGM; however, 75.1% of the fellows believed they had not been adequately trained in NGM during their fellowship. Eighty percent of fellows with 2 weeks or less of dedicated motility training reported that they received inadequate NGM training, compared to 46.2% fellows who received 1 or more months of dedicated motility training (P = 0.0148). The majority of fellows reported not being comfortable in performing gastrointestinal (GI) motility studies. The majority of fellows also reported not being comfortable in interpreting GI motility studies. CONCLUSIONS Although most pediatric gastroenterology fellows expressed interest in NGM, the lack of exposure and dedicated training in motility during fellowship were identified as barriers to pursuing motility-focused careers. Furthermore, most fellows reported limited comfort with performing and/or interpreting motility studies. Changes are needed to encourage fellows to develop their interest and expertise in NGM.
Collapse
|
48
|
Mion F, Marjoux S, Subtil F, Pioche M, Rivory J, Roman S, Zerbib F. Botulinum toxin for the treatment of hypercontractile esophagus: Results of a double-blind randomized sham-controlled study. Neurogastroenterol Motil 2019; 31:e13587. [PMID: 30974039 DOI: 10.1111/nmo.13587] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 03/08/2019] [Accepted: 03/08/2019] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Botulinum toxin injection is known to be efficient to treat achalasia. We conducted a randomized trial in order to evaluate its efficacy to treat symptomatic hypercontractile esophageal disorders as characterized by esophageal high-resolution manometry. METHODS Patients with significant dysphagia and/or thoracic pain related to an hypercontractile esophageal motility disorder as defined by the Chicago Classification were randomized to receive an injection of botulinum toxin (100 U in 10 points in the distal part of the esophageal wall) or a sham procedure. Symptoms were assessed at 3 months with the Eckardt score. Patients could receive a first or second botulinum toxin injection 1 month later if symptoms persisted. RESULTS Twenty-three patients (13 women, mean age 60 years) were included: 13 received botulinum toxin injection, and 10 a sham procedure. The improvement of symptoms at 3 months was significant compared to baseline, but similar in the active treatment and sham procedure arms. However, there was no change in quality of life scores. Seventeen patients received a second injection at 4 months. There was a significant trend toward improvement of symptoms up to the end of follow-up at 12 months, without a significant relationship with the administration of botulinum toxin. DISCUSSION Botulinum toxin injection is not superior to a sham procedure to improve symptoms related to hypercontractile esophageal disorders, suggesting an important placebo effect in for this type of disease. This observation must be taken into account when evaluating more aggressive therapies such as endoscopic myotomy (clinicaltrials.gov: NCT01955174).
Collapse
Affiliation(s)
- François Mion
- Hospices Civils de Lyon, Hospital E. Herriot, Digestive Physiology, Lyon, France.,Physiology Department, Université de Lyon, Lyon, France.,LabTau, INSERM U1032, Lyon, France
| | - Sophie Marjoux
- Hospices Civils de Lyon, Hospital E. Herriot, Digestive Physiology, Lyon, France
| | - Fabien Subtil
- Biostatistics Department, Hospices Civils de Lyon, Hospital E. Herriot, Lyon, France
| | - Mathieu Pioche
- Gastroenterology, Hospices Civils de Lyon, Hospital E. Herriot, Lyon, France
| | - Jerome Rivory
- Gastroenterology, Hospices Civils de Lyon, Hospital E. Herriot, Lyon, France
| | - Sabine Roman
- Hospices Civils de Lyon, Hospital E. Herriot, Digestive Physiology, Lyon, France.,Physiology Department, Université de Lyon, Lyon, France.,LabTau, INSERM U1032, Lyon, France
| | - Frank Zerbib
- CHU Bordeaux, Gastroenterology, Université de Bordeaux, Bordeaux, France
| |
Collapse
|
49
|
Savarino E, Marabotto E, Bodini G, Furnari M, Della Coletta M, Ghisa M, Barberio B, Frazzoni M, De Bortoli N, Zentilin P, Pellegatta G, Tolone S, Ottonello A, Savarino V. Advancements in the use of manometry and impedance testing for esophageal functional disorders. Expert Rev Gastroenterol Hepatol 2019; 13:425-435. [PMID: 30896306 DOI: 10.1080/17474124.2019.1595587] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The utilization of high-resolution manometry (HRM) has enhanced our understanding and assessment of esophageal motor disorders. Moreover, the combination of impedance technology with HRM (HRIM) has further improved our knowledge of esophageal physiology and the clinical evaluation of dysmotility, thanks to the addition of accurate measurement of bolus transit. Areas covered. This paper provides an overview of current knowledge in the use of HRIM for the study of esophageal functional disorders by reporting mainly the results of many publications and several systematic reviews in this field. Expert opinion. HRIM has represented a relevant improvement in the assessment of esophageal motility and has required the development of new metrics, such as the esophageal impedance integral ratio, the bolus flow time, the nadir impedance pressure and the impedance bolus height, which increase the evaluation of esophageal bolus transit. An extension of impedance is represented by functional lumen imaging probe (FLIP), which determines the biophysical properties and the distensibility of the esophagus and permits to detect contractility patterns not seen on HRM alone. We eagerly wait for a new and fruitful iteration of the Chicago Classification, now in version 3.0, which can cover the ongoing clinical experience of HRIM.
Collapse
Affiliation(s)
- Edoardo Savarino
- a Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology , University of Padua , Padua , Italy
| | - Elisa Marabotto
- b Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties , University of Genoa , Genoa , Italy
| | - Giorgia Bodini
- b Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties , University of Genoa , Genoa , Italy
| | - Manuele Furnari
- b Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties , University of Genoa , Genoa , Italy
| | - Marco Della Coletta
- a Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology , University of Padua , Padua , Italy
| | - Matteo Ghisa
- a Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology , University of Padua , Padua , Italy
| | - Brigida Barberio
- a Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology , University of Padua , Padua , Italy
| | - Marzio Frazzoni
- c Digestiva Pathophysiology Unit , Baggiovara Hospital , Modena , Italy
| | - Nicola De Bortoli
- d Gastrointestinal Unit, Department of Translational Research and New Technologies in Medicine and Surgery , University of Pisa , Pisa , Italy
| | - Patrizia Zentilin
- b Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties , University of Genoa , Genoa , Italy
| | - Gaia Pellegatta
- b Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties , University of Genoa , Genoa , Italy
| | - Salvatore Tolone
- e Surgery Unit, Department of Surgery , University of Campania Luigi Vanvitelli , Caserta , Italy
| | - Andrea Ottonello
- f Department of Surgical Science and Integrated Diagnostics , University of Genoa , Genoa , Italy
| | - Vincenzo Savarino
- b Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties , University of Genoa , Genoa , Italy
| |
Collapse
|
50
|
Blais P, Bennett MC, Gyawali CP. Upper esophageal sphincter metrics on high-resolution manometry differentiate etiologies of esophagogastric junction outflow obstruction. Neurogastroenterol Motil 2019; 31:e13558. [PMID: 30815910 DOI: 10.1111/nmo.13558] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 12/19/2018] [Accepted: 01/04/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Upper esophageal sphincter (UES) metrics on high-resolution manometry (HRM), particularly nadir UES residual pressure (UES-RP), are abnormal in achalasia and may help characterize the underlying mechanism or predict management outcome in esophagogastric junction outflow obstruction (EGJOO). METHODS A database of consecutive patients undergoing esophageal HRM from 2008 to 2013 yielded 134 patients (59.8 ± 1.4 years, 68% F) with EGJOO. Final clinical diagnoses and treatment response were extracted from chart review. Esophageal body, UES, and lower esophageal sphincter (LES) metrics were compared between EGJOO and asymptomatic healthy controls (n = 16, 27.7 ± 0.7 years, 56% F). Logistic regression evaluated differences between HRM metrics amongst etiologies of EGJOO grouped into motor versus mechanical disorders. KEY RESULTS Distal contractile integral, distal latency, and nadir UES-RP were significantly different between EGJOO subgroups (P ≤ 0.01 for each comparison), but only nadir UES-RP remained independently predictive of subgroups (adjusted odds ratio 1.15, 95% confidence intervals 1.05-1.27, P < 0.01). Nadir UES-RP was highest in achalasia variants, and lowest in mechanical EGJOO and controls (P < 0.001). Of 19 patients who underwent LES myotomy, durable benefit was reported by 68.4% over mean 3.6 years of follow-up. Significantly higher nadir UES-RP was noted with symptom relief (3.4 vs -0.7 mm Hg with symptom recurrence, 95% confidence intervals of difference = 1.35-6.83). A threshold UES-RP of ≥2.0 mm Hg yielded a sensitivity of 84.6% and specificity of 83.3% in predicting symptom resolution following myotomy. CONCLUSIONS AND INFERENCES Nadir UES-RP offers clues to differentiation of subtypes within EGJOO and may predict symptom outcome from myotomy.
Collapse
Affiliation(s)
- Pierre Blais
- Division of Gastroenterology, Washington University School of Medicine, Saint Louis, Missouri
| | - Michael C Bennett
- Division of Gastroenterology, Washington University School of Medicine, Saint Louis, Missouri
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, Saint Louis, Missouri
| |
Collapse
|