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Steffens FC, Dahlheim M, Günther P, Mehrabi A, Vuille-Dit-Bille RN, Fetzner UK, Gerdes B, Frongia G. Impact of previous abdominal surgery on the outcome of fundoplication for medically refractory gastroesophageal reflux disease in children and young adults. Eur Surg 2022. [DOI: 10.1007/s10353-022-00775-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Summary
Importance
Fundoplication (FP) is a well-established surgical treatment for gastroesophageal reflux disease (GERD) refractory to medical therapy in children and young adults. During FP, previous abdominal surgery (PAS) can impair the patient’s outcome by causing technical difficulties and increasing intra- and postoperative complication rates.
Objective
The aim of this study was to determine the impact of PAS on the short- and long-term outcome following FP for refractory GERD in a cohort of patients aged < 23 years.
Methods
We retrospectively analyzed 182 patients undergoing a total of 201 FP procedures performed at our university center for pediatric surgery from February 1999 to October 2019. Pre-, intra-, and postoperative variables were recorded and their impact on the rate of intraoperative complications and revision FP (reFP) was analyzed.
Results
A total of 201 FP procedures were performed on 182 patients: 119 (59.2%) as Thal-FP (180° anterior wrap) and 82 (40.8%) as Nissen-FP (360°circular wrap; 67.2% laparoscopic, 32.8% open, 8.9% conversion). The presence of PAS (95 cases, 47.3%) was associated with significantly longer operative times for FP (153.4 ± 53.7 vs.126.1 ± 56.4 min, p = 0.001) and significantly longer hospital stays (10.0 ± 7.0 vs. 7.0 ± 4.0 days, p < 0.001), while the rates of intraoperative surgical complications (1.1% vs. 1.9%, p = 1.000) and the rate re-FP in the long term (8.4% vs. 15.1%, p = 0.19) during a follow-up period of 53.4 ± 44.5 months were comparable to the group without PAS.
Conclusion
In cases of PAS in children and young adults, FP for refractory GERD might necessitate longer operative times and longer hospital stays but can be performed with surgery-related short- and long-term complication rates comparable to cases without PAS.
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Utility of Functional Lumen Imaging Probe in Long-Term Follow-Up of Children with Esophageal Atresia: A Single-Center Retrospective Study. CHILDREN 2022; 9:children9101426. [PMID: 36291362 PMCID: PMC9600905 DOI: 10.3390/children9101426] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 09/16/2022] [Accepted: 09/17/2022] [Indexed: 11/23/2022]
Abstract
Long term follow-up of patients with esophageal atresia (EA) may be hampered by esophageal dysmotility, which affects quality of life and might lead to late complications. The endoluminal functional lumen imaging probe (EndoFlip™ Medtronic, Crospon Inc.) is an innovative diagnostic tool that assesses esophageal distensibility. Our aim was to report the use of EndoFlip™ in an EA follow-up, in order to describe distensibility patterns and to determine its possible role for functional evaluation of patients. We retrospectively collected data of EA patients, with a minimum follow-up of 9 years, who required endoscopic evaluation and underwent EndoFlip™. An adaptation of the Medtronic EF-322 protocol was applied and distensibility data were compared to those reported by Pandolfino et al. Nine patients (median age 13 years) were included in the study. The median minimum distensibility was 2.58 mm2/mmHg. Signs of peristalsis were observed in three patients. In one case, the esophagogastric junction (EGJ) after Toupet fundoplication showed low distensibility. EGJ distensibility values of 2.58 mm2/mmHg (median) confirmed both good esophagogastric continence and compliance. Esophagitis and absent peristalsis were found in one patient together with partial stenosis of the fundoplication, confirming the importance of surgical adaptation. Esophageal body distensibility was higher than that of the EGJ. Considering the presence of symptoms, the EndoFlip™ results seem to correlate better with the clinical picture. EndoFlip™ use was safe and feasible in children. It allowed for the measurement of esophageal distensibility and diameter and the acquisition of indirect information on motility with clinical implications. The routine use of EndoFlip™ could be part of EA follow-up, although considerable research is needed to correlate Endoflip™ system measurements to EA patient outcomes.
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Prachasitthisak N, Purcell M, Krishnan U. Role of Esophageal High-Resolution Manometry in Pediatric Patients. Pediatr Gastroenterol Hepatol Nutr 2022; 25:300-311. [PMID: 35903488 PMCID: PMC9284111 DOI: 10.5223/pghn.2022.25.4.300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 01/23/2022] [Accepted: 05/02/2022] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Dysphagia, vomiting and feeding difficulties are common symptoms, with which children present. Esophageal function testing with high resolution manometry can help in diagnosing and treating these patients. We aim to access the clinical utility of high-resolution manometry of esophagus in symptomatic pediatric patients. METHODS A retrospective chart review was done on all symptomatic patients who underwent esophageal high-resolution manometry between 2010 and 2019 at Sydney Children's Hospital, Australia. Manometry results were categorized based on Chicago classification. Demographic data, indication of procedure, manometric findings, and details of treatment changes were obtained and analyzed. RESULTS There were 62 patients with median age of 10 years (9 months-18 years). The main indication for the procedure was dysphagia (56%). Thirty-two percent of patients had a co-morbid condition, with esophageal atresia accounting for 16%. The majority (77%) of patients had abnormal manometry which included, ineffective esophageal motility in 45.2%. In esophageal atresia cohort, esophageal pressurization was seen in 50%, aperistalsis in 40% and 10% with prior fundoplication had esophago-gastric junction obstruction. Patients with esophago-gastric junction obstruction or achalasia were treated by either pneumatic dilation or Heller's myotomy. Patients with ineffective esophageal motility and rumination were treated with a trial of prokinetics/dietary texture modification and diaphragmatic breathing. CONCLUSION Esophageal high-resolution manometry has a role in the evaluation of symptomatic pediatric patients. The majority of our patients had abnormal results which led to change in treatments, with either medication, surgery and/or feeding modification with resultant improvement in symptoms.
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Affiliation(s)
- Noparat Prachasitthisak
- Department of Pediatric Gastroenterology, Sydney Children's Hospital, Randwick, Australia.,Division of Gastroenterology, Department of Pediatrics, Queen Sirikit National Institute of Child Health, Ministry of Public Health, College of Medicine, Rangsit University, Bangkok, Thailand
| | - Michael Purcell
- Department of Pediatric Gastroenterology, Sydney Children's Hospital, Randwick, Australia
| | - Usha Krishnan
- Department of Pediatric Gastroenterology, Sydney Children's Hospital, Randwick, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, Australia
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4
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van Lennep M, Chung E, Jiwane A, Saoji R, Gorter RR, Benninga MA, Krishnan U, van Wijk MP. Fundoplication in children with esophageal atresia: preoperative workup and outcome. Dis Esophagus 2022; 35:6535694. [PMID: 35211748 PMCID: PMC9562824 DOI: 10.1093/dote/doac006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 01/18/2022] [Indexed: 12/11/2022]
Abstract
Up to 45% of esophageal atresia (EA) patients undergo fundoplication during childhood. Their esophageal dysmotility may predispose to worse fundoplication outcomes compared with patients without EA. We therefore compared fundoplication outcomes and symptoms pre- and post-fundoplication in EA patients with matched patients without EA. A retrospective review of patients with- and without EA who underwent a fundoplication was performed between 2006 and 2017. Therapeutic success was defined as complete sustained resolution of symptoms that were the reason to perform fundoplication. Fundoplication indications of 39 EA patients (49% male; median age 1.1 [0.1-17.0] yrs) and 39 non-EA patients (46% male; median age 1.3 [0.3-17.0] yrs) included respiratory symptoms, brief resolved unexplained events, typical symptoms of gastroesophageal reflux disease, recurrent strictures and respiratory problems. Post-fundoplication, therapeutic success was achieved in 5 (13%) EA patients versus 29 (74%) non-EA patients (P<0.001). Despite therapeutic success, all 5 (13%) EA patients developed postoperative sustained symptoms/complications versus 12 (31%) non-EA patients. Eleven (28%) EA patients versus 3 (8%) non-EA patients did not achieve any therapeutic success (P=0.036). Remaining patients achieved partial therapeutic success. EA patients suffered significantly more often from postoperative sustained dysphagia (41% vs. 13%; P=0.039), gagging (33% vs. 23%; P<0.001) and bloating (40% vs. 17%; P=0.022). Fundoplication outcomes in EA patients are poor and EA patients are more susceptible to post-fundoplication sustained symptoms and complications compared with patients without EA. The decision to perform fundoplication in EA patients with proven gastroesophageal reflux disease needs to be made with caution after thorough multidisciplinary evaluation.
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Affiliation(s)
- Marinde van Lennep
- Department of Pediatric Gastroenterology and Nutrition, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Eric Chung
- Department of Paediatric Gastroenterology, Sydney Children’s Hospital, Sydney, New South Wales, Australia
| | - Ashish Jiwane
- Department of Paediatric Surgery, Sydney Children’s Hospital, Sydney, New South Wales, Australia
| | - Rajendra Saoji
- Children’s Surgical and Endoscopy Center, Midas Heights, Nagpur, India
| | - Ramon R Gorter
- Department of Pediatric Surgery, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marc A Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Michiel P van Wijk
- Address correspondence to: Michiel P. van Wijk, MD, PhD, Meibergdreef 9 (room H7-221), 1105 AZ Amsterdam.
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5
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Miller J, Khlevner J, Rodriguez L. Upper Gastrointestinal Functional and Motility Disorders in Children. Pediatr Clin North Am 2021; 68:1237-1253. [PMID: 34736587 DOI: 10.1016/j.pcl.2021.07.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Children with disorders affecting the sensory and motor functions of the esophagus will present primarily with swallowing dysfunction, dysphagia, and chest pain, and those with disorders affecting the normal function of the stomach will present with symptoms like abdominal pain, nausea, and vomiting. Recent advances in the mechanisms of disease and technology have increased our understanding of gastrointestinal physiology and that knowledge has been applied to develop new diagnostic studies and therapeutic interventions. We present an overview of the clinical presentation, diagnosis, and treatment of common primary and secondary functional and motility disorders affecting the upper gastrointestinal tract in children.
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Affiliation(s)
- Jonathan Miller
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, 3959 Braodway CHN7, New York, NY 10032, USA
| | - Julie Khlevner
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, 3959 Braodway CHN7, New York, NY 10032, USA
| | - Leonel Rodriguez
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Yale New Haven Children's Hospital, Yale University School of Medicine, 333 Cedar Street, LMP 4093, New Haven, CT 06510, USA.
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6
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He S, Jia Y, Xu F, Li Q, Xiong X, Wang H, Jing X, Yang X, He L, Wang H, Tao X. Transient delayed gastric emptying following laparoscopic Nissen fundoplication for gastroesophageal reflux disease. Langenbecks Arch Surg 2021; 406:1397-1405. [PMID: 33825044 DOI: 10.1007/s00423-021-02156-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 03/22/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Although laparoscopic Nissen fundoplication (LNF) is a kind of minimally invasive surgery, some transition time may still be required to allow the fundoplicated stomach to adapt to the new anatomical position. We observed transient delayed gastric emptying (DGE) post-LNF in our preliminary study. This study aimed to investigate the occurrence rate and development of transient DGE post-LNF. METHODS Patients who underwent LNF for gastroesophageal reflux disease (GERD) at our institution were recruited consecutively. They were treated with standardized LNF and prospectively followed up for 2 months. Proper diet guidance and/or pharmacologic therapy were given during these 2 months. GERD Health-Related Quality of Life (GERD-HRQL), DGE symptoms, and DGE status were evaluated preoperatively and postoperatively. RESULTS Fifty-one patients underwent LNF and completed a 2-month follow-up. LNF succeeded in all patients. Prior to LNF, no DGE was identified. At the 1-month follow-up, LNF led to a significant reduction in the GERD-HRQL total score but a significantly increased DGE score. Endoscopically, DGE was identified in forty-seven (n = 47, 92.2%) patients. At the 2-month follow-up, the GERD-HRQL scores continued to show decreases compared to the 1 month. The DGE score returned to the baseline value. Endoscopically, no DGE was identified in any patients (n = 0, 0.0%). CONCLUSIONS Transient DGE is a very common one-month post-LNF but can recover quickly in the second month following LNF.
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Affiliation(s)
- Suyu He
- The Fourth Department of the Digestive Disease Center, Suining Central Hospital, Sichuan, 629000, China.
| | - Yingdong Jia
- The First Department of the Digestive Disease Center, Suining Central Hospital, Sichuan, China
| | - Fei Xu
- The Fourth Department of the Digestive Disease Center, Suining Central Hospital, Sichuan, 629000, China
| | - Qianlong Li
- The Fourth Department of the Digestive Disease Center, Suining Central Hospital, Sichuan, 629000, China
| | - Xin Xiong
- The Fourth Department of the Digestive Disease Center, Suining Central Hospital, Sichuan, 629000, China
| | - Hui Wang
- The Fourth Department of the Digestive Disease Center, Suining Central Hospital, Sichuan, 629000, China
| | - Xiaojuan Jing
- The Endoscopy Center, Suining Central Hospital, Sichuan, China
| | - Xuejun Yang
- The First Department of the Digestive Disease Center, Suining Central Hospital, Sichuan, China
| | - Lianfen He
- The Fourth Department of the Digestive Disease Center, Suining Central Hospital, Sichuan, 629000, China
| | - Hanmei Wang
- The Fourth Department of the Digestive Disease Center, Suining Central Hospital, Sichuan, 629000, China
| | - Xin Tao
- The Nutrition Department, Suining Central Hospital, Sichuan, China
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Omari TI, Krishnan U. What is the role of high-resolution oesophageal manometry in paediatrics? J Paediatr Child Health 2020; 56:1754-1759. [PMID: 33197976 DOI: 10.1111/jpc.15057] [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: 11/12/2019] [Revised: 06/11/2020] [Accepted: 06/15/2020] [Indexed: 12/21/2022]
Abstract
Abnormal oesophageal motility may impair oesophageal bolus transport leading to symptoms of chest pain and regurgitation. Oesophageal pathophysiology may include neuromuscular and/or structural defects leading to weak, incoordinate or absent peristalsis and impaired oesophago-gastric junction relaxation. Understanding these mechanisms is important to determine the appropriate course of therapy. Whilst, barium oesophagram is the mainstay for clinical investigation of oesophageal motility, high-resolution manometry is now more widely available. This review describes the potential value of high-resolution manometry in paediatric gastroenterology practise.
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Affiliation(s)
- Taher I Omari
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Usha Krishnan
- Paediatric Gastroenterology, Sydney Children's Hospital, Sydney, New South Wales, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
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8
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Ambartsumyan L, Khlevner J, Nurko S, Rosen R, Kaul A, Pandolfino JE, Ratcliffe E, Yacob D, Li BU, Punati J, Sood M, Rao SSC, Levitt MA, Cocjin J, Rodriguez L, Flores A, Rosen JM, Belkind-Gerson J, Saps M, Garza JM, Fortunato J, Schroedl RL, Keefer L, Friedlander J, Heuckeroth RO, Rao M, El-Chammas K, Vaz K, Chumpitazi BP, Sanghavi R, Matta S, Danialifar T, Di Lorenzo C, Darbari A. Proceedings of the 2018 Advances In Motility and In NeuroGastroenterology: AIMING for the Future Single Topic Symposium. J Pediatr Gastroenterol Nutr 2020; 71:e59-e67. [PMID: 32287151 PMCID: PMC8451965 DOI: 10.1097/mpg.0000000000002720] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Motility and functional disorders are common in children and often debilitating, yet these disorders remain challenging to treat effectively. At the 2018 Annual North American Society for Pediatric Gastroenterology, Hepatology and Nutrition meeting, the Neurogastroenterology and Motility Committee held a full day symposium entitled, 2018 Advances In Motility and In NeuroGastroenterology - AIMING for the future. The symposium aimed to explore clinical paradigms in pediatric gastrointestinal motility disorders and provided a foundation for advancing new scientific and therapeutic research strategies. METHODS The symposium brought together leading experts throughout North America to review the state of the art in the diagnosis and management of motility and functional disorders in children. Presentations were divided into esophageal, antral duodenal, and colorectal modules. Each module included oral presentations by experts in the respective fields, leading to thought-provoking discussions. There were 2 breakout sessions with small group discussions on select topics, focusing on defining scientific insights into the diagnosis and management of pediatric functional gastrointestinal and motility disorders in a systematic, segment-based approach. CONCLUSIONS The field of neurogastroenterology has made remarkable progress in the last decade. The current report summarizes the major learning points from the symposium highlighting the diagnosis and promising therapies on the horizon for pediatric neurogastrointestinal and motility disorders.
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Affiliation(s)
| | - Julie Khlevner
- Division of Gastroenterology, Hepatology and Nutrition, Columbia University College of Physicians and Surgeons, New York, NY
| | - Samuel Nurko
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
| | - Rachel Rosen
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
| | - Ajay Kaul
- Division of Gastroenterology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229
| | - John E. Pandolfino
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL
| | | | - Desale Yacob
- Division of Gastroenterology, Nationwide Children’s Hospital, Columbus, OH
| | - B U.K. Li
- Division of Pediatric Gastroenterology and Nutrition, Medical College of Wisconsin, Milwaukee, WI
| | - Jaya Punati
- Division of Gastroenterology, Children’s Hospital of Los Angeles, Los Angeles, CA
| | - Manu Sood
- Division of Pediatric Gastroenterology and Nutrition, Medical College of Wisconsin, Milwaukee, WI
| | - Satish SC Rao
- Division of Gastroenterology, Department of Medicine, Augusta University Medical Center, Augusta, GA
| | - Marc A Levitt
- Division of Colorectal Surgery, Children’s National Hospital, Washington, DC
| | - Jose Cocjin
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Mercy Kansas City, Kansas City, MO
| | - Leonel Rodriguez
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Yale School of Medicine, New Haven, CT
| | - Alejandro Flores
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
| | - John M Rosen
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Mercy Kansas City, Kansas City, MO
| | - Jaime Belkind-Gerson
- Division of Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Colorado, Aurora, CO
| | - Miguel Saps
- Division of Pediatric Gastroenterology and Nutrition, University of Miami, Miami, FL
| | - Jose M Garza
- Children’s Center for Digestive Health Care, Atlanta, GA
| | - John Fortunato
- Division of Gastroenterology, Ann & Robert H Lurie Children’s Hospital, Chicago, IL
| | - Rose L Schroedl
- Division of Gastroenterology, Nationwide Children’s Hospital, Columbus, OH
| | - Laurie Keefer
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Joel Friedlander
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Yale School of Medicine, New Haven, CT
| | - Robert O. Heuckeroth
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania and The Children's Hospital of Philadelphia - Research Institute, Philadelphia, PA
| | - Meenakshi Rao
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
| | - Khalil El-Chammas
- Division of Gastroenterology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229
| | - Karla Vaz
- Division of Gastroenterology, Nationwide Children’s Hospital, Columbus, OH
| | | | - Rina Sanghavi
- Division of Pediatric Gastroenterology, University of Texas Southwestern Medical Center Dallas, TX
| | - Sravan Matta
- Pediatric Gastroenterology and Nutrition, Kaiser Permanente Sacramento Medical Center, Sacramento, CA
| | - Tanaz Danialifar
- Division of Gastroenterology, Children’s Hospital of Los Angeles, Los Angeles, CA
| | - Carlo Di Lorenzo
- Division of Gastroenterology, Nationwide Children’s Hospital, Columbus, OH
| | - Anil Darbari
- Division of Pediatric Gastroenterology and Nutrition, Children’s National Hospital, Washington, DC
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Cock C, Leibbrandt RE, Dinning PG, Costa MC, Wiklendt L, Omari TI. Changes in specific esophageal neuromechanical wall states are associated with conscious awareness of a solid swallowed bolus in healthy subjects. Am J Physiol Gastrointest Liver Physiol 2020; 318:G946-G954. [PMID: 32281396 DOI: 10.1152/ajpgi.00235.2019] [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] [Indexed: 01/31/2023]
Abstract
Esophageal neuromechanical wall states are the physical manifestations of circular muscle inhibition and contraction resulting from neural inputs and leading to bolus propulsion. A novel method infers esophageal neuromechanical wall states through simultaneous determination of pressure and diameter in vivo using impedance manometry. We hypothesized that changes in esophageal neuromechanical wall states relate to conscious awareness of esophageal bolus passage ("bolus perception"). Seven healthy participants were selected for perception of solid bolus passage and were compared with seven healthy participants with no conscious awareness of solid bolus passage. Participants were studied using impedance manometry (MMS Solar, Unisensor, 20 Hz). Subjects swallowed ten 5-ml liquid and ten 2-cm square saline-soaked bread boluses and rated bolus perception using a visual analog scale. Esophageal neuromechanical wall states were calculated and analyzed. Proportions of time spent in states with and without luminal distension were compared using a two-proportions Z-test. Bolus perception was associated with neuromechanical wall states corresponding to luminal distension more frequently than matching states without distension in the proximal esophagus (P < 0.001) and transition zone (P < 0.001), whereas there were no differences for the distal esophagus. In healthy volunteers, perceived swallows relate to changes in esophageal neuromechanical wall states in the proximal esophagus. We postulate that these changes relate to bolus retention and summation of active and passive wall tension activating intramural tension receptors.NEW & NOTEWORTHY This study explores esophageal neuromechanical wall states derived from changes in pressure and impedance-derived distension in relation to conscious awareness of esophageal solid bolus transit in healthy volunteers. There are increases in neuromechanical wall states indicative of esophageal distension in healthy volunteers with conscious awareness of bolus transit as compared with unaware individuals. Bolus-based esophageal distension is postulated as a mechanism for esophageal symptoms such as dysphagia.
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Affiliation(s)
- Charles Cock
- Department of Gastroenterology and Hepatology, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Richard E Leibbrandt
- Department of Gastroenterology and Hepatology, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.,Department of Human Physiology, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Phil G Dinning
- Department of Gastroenterology and Hepatology, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.,Department of Human Physiology, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Marcello C Costa
- Department of Human Physiology, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Lukasz Wiklendt
- Department of Human Physiology, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Taher I Omari
- Department of Gastroenterology and Hepatology, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.,Department of Human Physiology, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
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10
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GER characteristics after fundoplication in children with aerodigestive disorders. J Pediatr Surg 2020; 55:456-460. [PMID: 31767193 DOI: 10.1016/j.jpedsurg.2019.08.049] [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: 08/20/2018] [Revised: 08/11/2019] [Accepted: 08/31/2019] [Indexed: 11/22/2022]
Abstract
PURPOSE The purpose of this study was to determine GER characteristics after Nissen fundoplication in children with aerodigestive disorders using pH-impedance technology. METHODS In this cross-sectional study, the institutional database of Cincinnati Children's Hospital Medical Center was reviewed to identify patients ages below 21 years who had a Nissen fundoplication and underwent esophageal pH-impedance (pH-MII) monitoring over a nine-year period. All reflux-related metrics were modeled as a Poisson random variable as a function of time since fundoplication. RESULTS A total of 242 patients were included in the study. The range for time since surgery was 1-192 months. Median total reflux events were 8.5 episodes per 24 h, median acidic reflux events were 0, and median proximal reflux event was 2. There was no significant trend towards increasing reflux episodes over time. CONCLUSIONS Children had a low number of reflux events after a fundoplication, as measured by pH-impedance, and there was no statistically significant increase observed in the number of reflux events over time. Despite most patients having a functional fundoplication with minimal reflux events throughout the entire age range, up to 58% of our cohort was still on a proton pump inhibitor.
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11
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Abstract
The literal definition of dysphagia is "disturbed eating". However, it is more accurately described in clinical practice as a sensation of food or liquid being stuck in the esophagus or chest. If this sensation is associated with pain, it is labeled odynophagia, and if it is associated with persistent obstruction and bolus retention, it is categorized as a food impaction. Through research and technological advances, we continue to expand our understanding of the etiologies and underlying pathophysiology relating to this complaint. However, for now, our clinical algorithms focus on endoscopy and manometry to break down dysphagia into three categories: obstructive dysphagia, esophageal motility disorders, and functional dysphagia. Here, we review some critical pitfalls in our current clinical diagnoses, new proposed underlying mechanisms of esophageal motor disorders, and developing technologies to aid in diagnosis and treatment.
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Affiliation(s)
- Joseph Triggs
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern Medicine, Northwestern University, Feinberg School of Medicine, 676 St Clair Street, Suite 14-009, Chicago, IL, 60611-2951, USA
| | - John Pandolfino
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern Medicine, Northwestern University, Feinberg School of Medicine, 676 St Clair Street, Suite 14-009, Chicago, IL, 60611-2951, USA
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12
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Abstract
Purpose of the review Gastroesophageal reflux disease (GERD) is frequently implicated as a cause for respiratory disease. However, there is growing evidence that upper gastrointestinal dysmotility may play a significantly larger role in genesis of respiratory symptoms and development of underlying pulmonary pathology. This paper will discuss the differential diagnosis for esophageal and gastric dysmotility in aerodigestive patients and will review the key diagnostic and therapeutic interventions for this dysmotility. Recent findings Previous studies have shown an association between GERD and pulmonary pathology in children with aerodigestive disorders. Recent publications have demonstrated the presence of esophageal and gastric dysfunction, using fluoroscopic and nuclear medicine studies, in aerodigestive patients who commonly present to pulmonary and otolaryngology clinics. High-resolution impedance manometry (HRIM) has revolutionized our understanding of esophageal dysmotility and its role in pathogenesis of aspiration and esophageal dysfunction and subsequent respiratory compromise. Summary Esophageal and gastric dysmotility have a profound effect on development of respiratory symptoms and pulmonary sequalae in aerodigestive patients. However, our understanding of the pathophysiology is in its infancy. Prospective studies in are needed to address key clinical questions such as: What degree of dysmotility initiates respiratory compromise? What diagnostic tests and therapeutic options best predict aerodigestive outcomes?
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van Lennep M, Singendonk MMJ, Dall'Oglio L, Gottrand F, Krishnan U, Terheggen-Lagro SWJ, Omari TI, Benninga MA, van Wijk MP. Oesophageal atresia. Nat Rev Dis Primers 2019; 5:26. [PMID: 31000707 DOI: 10.1038/s41572-019-0077-0] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Oesophageal atresia (EA) is a congenital abnormality of the oesophagus that is caused by incomplete embryonic compartmentalization of the foregut. EA commonly occurs with a tracheo-oesophageal fistula (TEF). Associated birth defects or anomalies, such as VACTERL association, trisomy 18 or 21 and CHARGE syndrome, occur in the majority of patients born with EA. Although several studies have revealed signalling pathways and genes potentially involved in the development of EA, our understanding of the pathophysiology of EA lags behind the improvements in surgical and clinical care of patients born with this anomaly. EA is treated surgically to restore the oesophageal interruption and, if present, ligate and divide the TEF. Survival is now ~90% in those born with EA with severe associated anomalies and even higher in those born with EA alone. Despite these achievements, long-term gastrointestinal and respiratory complications and comorbidities in patients born with EA are common and lead to decreased quality of life. Oesophageal motility disorders are probably ubiquitous in patients after undergoing EA repair and often underlie these complications and comorbidities. The implementation of several new diagnostic and screening tools in clinical care, including high-resolution impedance manometry, pH-multichannel intraluminal impedance testing and disease-specific quality of life questionnaires now provide better insight into these problems and may contribute to better long-term outcomes in the future.
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Affiliation(s)
- Marinde van Lennep
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology and Nutrition, Amsterdam, The Netherlands
| | - Maartje M J Singendonk
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology and Nutrition, Amsterdam, The Netherlands
| | - Luigi Dall'Oglio
- Digestive Endoscopy and Surgery Unit, Bambino Gesu Children's Hospital-IRCCS, Rome, Italy
| | - Fréderic Gottrand
- CHU Lille, University Lille, National Reference Center for Congenital Malformation of the Esophagus, Department of Pediatric Gastroenterology Hepatology and Nutrition, Lille, France
| | - Usha Krishnan
- Department of Paediatric Gastroenterology, Sydney Children's Hospital, Sydney, New South Wales, Australia
- Discipline of Paediatrics, School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Suzanne W J Terheggen-Lagro
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Pulmonology, Amsterdam, The Netherlands
| | - Taher I Omari
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
- Center for Neuroscience, Flinders University, Adelaide, South Australia, Australia
| | - Marc A Benninga
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology and Nutrition, Amsterdam, The Netherlands.
| | - Michiel P van Wijk
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology and Nutrition, Amsterdam, The Netherlands
- Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit, Pediatric Gastroenterology, Amsterdam, The Netherlands
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Omari T, Connor F, McCall L, Ferris L, Ellison S, Hanson B, Abu-Assi R, Khurana S, Moore D. A study of dysphagia symptoms and esophageal body function in children undergoing anti-reflux surgery. United European Gastroenterol J 2018; 6:819-829. [PMID: 30023059 PMCID: PMC6047286 DOI: 10.1177/2050640618764936] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 02/22/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The role of high-resolution esophageal impedance manometry (HRIM) for establishing risk for dysphagia after anti-reflux surgery is unclear. We conducted a prospective study of children with primary gastroesophageal reflux (GER) disease, for whom symptoms of dysphagia were determined pre-operatively and then post-operatively and we examined for features that may predict post-operative dysphagia. METHODS Thirteen children (aged 6.8-15.5 years) undergoing work-up prior to 360o Nissen fundoplication were included in the study. A dysphagia score assessed symptoms at pre-operative study and post-operatively (mean 1.4 years). A HRIM procedure recorded 5-ml liquid, 5-ml viscous and 2-cm solid boluses. We assessed esophageal motility, esophago-gastric junction (EGJ) morphology, EGJ contractility and pressure-flow variables indicative of bolus distension pressures and bolus clearance pressures. A composite pressure-flow index score was also derived. RESULTS Pre-operative pressure-flow index was positively correlated with post-operative dysphagia score (viscous bolus r = 0.771, p < 0.005). Of three variables that comprise the pressure-flow index, the ramp pressure measured during bolus clearance was the main driver of the effect seen (viscous bolus r = 0.819, p < 0.005). CONCLUSIONS In order to mitigate symptoms in relation to anti-reflux surgery, dysphagia symptoms and esophageal function need to be pre-operatively assessed. In patients with normal motility, an elevated pressure-flow index may predict post-operative dysphagia.
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Affiliation(s)
- T Omari
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
- Centre for Neuroscience, Flinders University, Adelaide, Australia
| | - F Connor
- Department of Gastroenterology, Royal Children's Hospital, Brisbane, Australia
| | - L McCall
- Gastroenterology Unit, Women's & Children's Hospital, Adelaide, Australia
| | - L Ferris
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
- Centre for Neuroscience, Flinders University, Adelaide, Australia
| | - S Ellison
- Gastroenterology Unit, Women's & Children's Hospital, Adelaide, Australia
| | - B Hanson
- UCL Mechanical Engineering, University College London, London, UK
| | - R Abu-Assi
- Gastroenterology Unit, Women's & Children's Hospital, Adelaide, Australia
| | - S Khurana
- Paediatric Surgery & Urology, Women's & Children's Hospital, Adelaide, Australia
| | - D Moore
- Gastroenterology Unit, Women's & Children's Hospital, Adelaide, Australia
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15
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Rosen R, Garza JM, Tipnis N, Nurko S. An ANMS-NASPGHAN consensus document on esophageal and antroduodenal manometry in children. Neurogastroenterol Motil 2018; 30:10.1111/nmo.13239. [PMID: 29178261 PMCID: PMC5823717 DOI: 10.1111/nmo.13239] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 09/27/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Upper gastrointestinal symptoms in children are common and motility disorders are considered in the differential diagnosis. High resolution esophageal manometry (HRM) has revolutionized the study of esophageal physiology, and the addition of impedance has provided new insights into esophageal function. Antroduodenal motility has provided insight into gastric and small bowel function. PURPOSE This review highlights some of the recent advances in pediatric esophageal and antroduodenal motility testing including indications, preparation, performance, and interpretation of the tests. This update is the second part of a two part series on manometry studies in children (first part was on anorectal and colonic manometry [Neurogastroenterol Motil. 2016;29:e12944]), and has been endorsed by the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) and the American Neurogastroenterology and Motility Society (ANMS).
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Affiliation(s)
- Rachel Rosen
- Aerodigestive Center, Boston Children’s Hospital
| | - Jose M. Garza
- Children’s Center for Digestive Health Care, and Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Neelesh Tipnis
- Department of Pediatrics University of Mississippi Medical Center
| | - Samuel Nurko
- Center for Motility and Functional Gastrointestinal Disorders, Boston Children’s Hospital
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16
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Rosen R, Vandenplas Y, Singendonk M, Cabana M, DiLorenzo C, Gottrand F, Gupta S, Langendam M, Staiano A, Thapar N, Tipnis N, Tabbers M. Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr 2018; 66:516-554. [PMID: 29470322 PMCID: PMC5958910 DOI: 10.1097/mpg.0000000000001889] [Citation(s) in RCA: 456] [Impact Index Per Article: 76.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
This document serves as an update of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) 2009 clinical guidelines for the diagnosis and management of gastroesophageal reflux disease (GERD) in infants and children and is intended to be applied in daily practice and as a basis for clinical trials. Eight clinical questions addressing diagnostic, therapeutic and prognostic topics were formulated. A systematic literature search was performed from October 1, 2008 (if the question was addressed by 2009 guidelines) or from inception to June 1, 2015 using Embase, MEDLINE, the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Clinical Trials. The approach of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) was applied to define and prioritize outcomes. For therapeutic questions, the quality of evidence was also assessed using GRADE. Grading the quality of evidence for other questions was performed according to the Quality Assessment of Studies of Diagnostic Accuracy (QUADAS) and Quality in Prognostic Studies (QUIPS) tools. During a 3-day consensus meeting, all recommendations were discussed and finalized. In cases where no randomized controlled trials (RCT; therapeutic questions) or diagnostic accuracy studies were available to support the recommendations, expert opinion was used. The group members voted on each recommendation, using the nominal voting technique. With this approach, recommendations regarding evaluation and management of infants and children with GERD to standardize and improve quality of care were formulated. Additionally, 2 algorithms were developed, 1 for infants <12 months of age and the other for older infants and children.
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Affiliation(s)
- Rachel Rosen
- Center for Motility and Functional Gastrointestinal Disorders, Division of Gastroenterology, Children's Hospital Boston, Boston, MA
| | - Yvan Vandenplas
- KidZ Health Castle, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | | | - Michael Cabana
- Division of General Pediatrics, University of California, San Francisco, CA
| | - Carlo DiLorenzo
- Division of Pediatric Gastroenterology, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Frederic Gottrand
- CHU Lille, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Lille, France
| | - Sandeep Gupta
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Illinois, Peoria, IL
| | - Miranda Langendam
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center/University of Amsterdam, Amsterdam, The Netherlands
| | - Annamaria Staiano
- Department of Translational Medical Science, Section of Pediatrics, University of Naples ‘‘Federico II,’’ Naples, Italy
| | - Nikhil Thapar
- Great Ormond Street Hospital for Children, London, UK
| | - Neelesh Tipnis
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS
| | - Merit Tabbers
- Emma Children's Hospital/AMC, Amsterdam, The Netherlands
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Franciosi JP, Mougey EB, Williams A, Gomez Suarez RA, Thomas C, Creech CL, George K, Corao D, Lima JJ. Association between CYP2C19 extensive metabolizer phenotype and childhood anti-reflux surgery following failed proton pump inhibitor medication treatment. Eur J Pediatr 2018; 177:69-77. [PMID: 29209919 DOI: 10.1007/s00431-017-3051-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 11/10/2017] [Accepted: 11/14/2017] [Indexed: 12/13/2022]
Abstract
UNLABELLED When pediatric gastroesophageal reflux disease (GERD) that is refractory to proton pump inhibitor (PPI) medication treatment is identified in clinical practice and anti-reflux surgery (ARS) is being considered, genetic factors related to PPI metabolism by the CYP2C19 enzyme are currently not part of the clinical decision-making process. Our objective was to test the hypothesis that the distribution of the extensive metabolizer (EM) phenotypes among children undergoing ARS after failing PPI therapy would differ compared to controls (children with no history of ARS). We conducted a case-control study between children across the Nemours Health System from 2000 to 2014 who received ARS after failing PPI therapy and a control group comprised of healthy children. Our results demonstrated 2.9% of ARSs vs 20.8% of controls were poor metabolizers (PMs), 55.9% of ARSs vs 49.0% of controls were normal metabolizers (NMs), and 41.2% of ARSs vs 30.2% of controls were EMs; p = 0.035. Next, we performed a multiple-regression model to account for race as a potential confounding variable and the EM group was significantly associated with ARS compared to controls (OR 9.78, CI 1.25-76.55, p < 0.03). CONCLUSION Among children with medically refractory GERD despite PPI therapy, carriage of CYP2C19*17 allele corresponding to the EM phenotype was associated with ARS. Prospective comparative personalized medicine effectiveness studies are needed to determine if CYP2C19 genotype-guided dosing improves response to PPI therapy without a corresponding increase in adverse effects in children. What is known: • Anti-reflux surgery (ARS) is one of the most common surgical procedures performed in children for the indication of refractory gastroesophageal reflux disease (GERD). What is new: • Individualizing PPI medication dosing based on CYP2C19 diplotype may avoid GERD treatment failures and reduce the need for anti-reflux surgery (ARS).
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Affiliation(s)
- James P Franciosi
- Division of Gastroenterology, Hepatology and Nutrition, Nemours Children's Hospital, 13535 Nemours Parkway, Orlando, FL, 32827, USA.
| | - Edward B Mougey
- Center for Pharmacogenomics and Translational Research, Nemours Children's Health System, Jacksonville, FL, USA
| | - Andre Williams
- Center for Health Care Delivery Science, Nemours Children's Health System, Jacksonville, FL, USA
| | - Roberto A Gomez Suarez
- Division of Gastroenterology, Hepatology and Nutrition, Nemours Children's Hospital, 13535 Nemours Parkway, Orlando, FL, 32827, USA
| | | | | | | | - Diana Corao
- Department of Pathology, A.I. DuPont Hospital for Children, Wilmington, DE, USA
| | - John J Lima
- Center for Pharmacogenomics and Translational Research, Nemours Children's Health System, Jacksonville, FL, USA
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18
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Jancelewicz T, Lopez ME, Downard CD, Islam S, Baird R, Rangel SJ, Williams RF, Arnold MA, Lal D, Renaud E, Grabowski J, Dasgupta R, Austin M, Shelton J, Cameron D, Goldin AB. Surgical management of gastroesophageal reflux disease (GERD) in children: A systematic review. J Pediatr Surg 2017; 52:1228-1238. [PMID: 27823773 DOI: 10.1016/j.jpedsurg.2016.09.072] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 09/20/2016] [Indexed: 01/28/2023]
Abstract
OBJECTIVE The goal of this systematic review by the American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee was to derive recommendations from the medical literature regarding the surgical treatment of pediatric gastroesophageal reflux disease (GERD). METHODS Five questions were addressed by searching the MEDLINE, Cochrane, Embase, Central, and National Guideline Clearinghouse databases using relevant search terms. Consensus recommendations were derived for each question based on the best available evidence. RESULTS There was insufficient evidence to formulate recommendations for all questions. Fundoplication does not affect the rate of hospitalization for aspiration pneumonia, apnea, or reflux-related symptoms. Fundoplication is effective in reducing all parameters of esophageal acid exposure without altering esophageal motility. Laparoscopic fundoplication may be comparable to open fundoplication with regard to short-term clinical outcomes. Partial fundoplication and complete fundoplication are comparable in effectiveness for subjective control of GERD. Fundoplication may benefit GERD patients with asthma, but may not improve outcomes in patients with neurologic impairment or esophageal atresia. Overall GERD recurrence rates are likely below 20%. CONCLUSIONS High-quality evidence is lacking regarding the surgical management of GERD in the pediatric population. Definitive conclusions regarding the effectiveness of fundoplication are limited by patient heterogeneity and lack of a standardized outcomes reporting framework. TYPE OF STUDY Systematic review of level 1-4 studies. LEVEL OF EVIDENCE Level 1-4 (mainly level 3-4).
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Affiliation(s)
- Tim Jancelewicz
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, 49 North Dunlap, Second Floor, Memphis, TN, 38105.
| | - Monica E Lopez
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Cynthia D Downard
- Division of Pediatric Surgery, Hiram C. Polk, Jr., M.D. Department of Surgery, Program Director, Pediatric Surgery Fellowship, University of Louisville, Louisville, KY
| | | | - Robert Baird
- Department of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, QC
| | - Shawn J Rangel
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Regan F Williams
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, 49 North Dunlap, Second Floor, Memphis, TN, 38105
| | - Meghan A Arnold
- CS Mott Children's Hospital, University of Michigan, Ann Arbor, MI
| | - Dave Lal
- Division of Pediatric Surgery, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI
| | - Elizabeth Renaud
- Department of Surgery, Division of Pediatric Surgery, Albany Medical Center, Albany, NY
| | - Julia Grabowski
- Ann and Robert H. Lurie Children's Hospital, Northwestern University, Chicago, IL
| | - Roshni Dasgupta
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Medical Center, Cincinnati, OH
| | - Mary Austin
- Department of Pediatric Surgery, The University of Texas Medical School at Houston and in Surgical Oncology and Pediatrics at the UT M.D., Anderson Cancer Center, Houston, TX
| | - Julia Shelton
- Division of Pediatric Surgery, University of Iowa Children's Hospital, Iowa City, IA
| | - Danielle Cameron
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Adam B Goldin
- Division of Pediatric General and Thoracic Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, WA
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20
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Jadcherla SR. Advances with Neonatal Aerodigestive Science in the Pursuit of Safe Swallowing in Infants: Invited Review. Dysphagia 2017; 32:15-26. [PMID: 28044203 PMCID: PMC5303645 DOI: 10.1007/s00455-016-9773-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 12/21/2016] [Indexed: 11/26/2022]
Abstract
Feeding, swallowing, and airway protection are three distinct entities. Feeding involves a process of sequential, neurosensory, and neuromotor interactions of reflexes and behaviors facilitating ingestion. Swallowing involves anterograde bolus movement during oral-, pharyngeal-, and esophageal phases of peristalsis into stomach. During these events, coordination with airway protection is vital for homeostasis in clearing any material away from airway vicinity. Neurological-airway-digestive inter-relationships are critical to the continuum of successful feeding patterns during infancy, either in health or disease. Neonatal feeding difficulties encompass a heterogeneous group of neurological, pulmonary, and aerodigestive disorders that present with multiple signs posing as clinical conundrums. Significant research breakthroughs permitted understanding of vagal neural pathways and functional aerodigestive connectivity involved in regulating swallowing and aerodigestive functions either directly or indirectly by influencing the supra-nuclear regulatory centers and peripheral effector organs. These neurosensory and neuromotor pathways are influenced by pathologies during perinatal events, prematurity, inflammatory states, and coexisting medical and surgical conditions. Approaches to clarify pathophysiologic mapping of aerodigestive interactions, as well as translating these discoveries into the development of personalized and simplified feeding strategies to advance child health are discussed in this review article.
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Affiliation(s)
- Sudarshan R Jadcherla
- The Neonatal and Infant Feeding Disorders Program, Department of Neonatology, Nationwide Children's Hospital, Columbus, OH, USA.
- Innovative Infant Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.
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21
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Gottrand F, Gottrand M, Sfeir R, Michaud L. Gastroesophageal Reflux and Esophageal Atresia. GASTROESOPHAGEAL REFLUX IN CHILDREN 2017:147-164. [DOI: 10.1007/978-3-319-60678-1_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
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22
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A review of postsurgical dysphagia in nonmalignant disease. Curr Opin Otolaryngol Head Neck Surg 2016; 24:477-482. [DOI: 10.1097/moo.0000000000000306] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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23
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ESPGHAN-NASPGHAN Guidelines for the Evaluation and Treatment of Gastrointestinal and Nutritional Complications in Children With Esophageal Atresia-Tracheoesophageal Fistula. J Pediatr Gastroenterol Nutr 2016; 63:550-570. [PMID: 27579697 DOI: 10.1097/mpg.0000000000001401] [Citation(s) in RCA: 214] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Esophageal atresia (EA) is one of the most common congenital digestive anomalies. With improvements in surgical techniques and intensive care treatments, the focus of care of these patients has shifted from mortality to morbidity and quality-of-life issues. These children face gastrointestinal (GI) problems not only in early childhood but also through adolescence and adulthood. There is, however, currently a lack of a systematic approach to the care of these patients. The GI working group of International Network on Esophageal Atresia comprises members from ESPGHAN/NASPGHAN and was charged with the task of developing uniform evidence-based guidelines for the management of GI complications in children with EA. METHODS Thirty-six clinical questions addressing the diagnosis, treatment, and prognosis of the common GI complications in patients with EA were formulated. Questions on the diagnosis, and treatment of gastroesophageal reflux, management of "cyanotic spells," etiology, investigation and management of dysphagia, feeding difficulties, anastomotic strictures, congenital esophageal stenosis in EA patients were addressed. The importance of excluding eosinophilic esophagitis and associated GI anomalies in symptomatic patients with EA is discussed as is the quality of life of these patients and the importance of a systematic transition of care to adulthood. A systematic literature search was performed from inception to March 2014 using Embase, MEDLINE, the Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Clinical Trials, and PsychInfo databases. The approach of the Grading of Recommendations Assessment, Development and Evaluation was applied to evaluate outcomes. During 2 consensus meetings, all recommendations were discussed and finalized. The group members voted on each recommendation, using the nominal voting technique. Expert opinion was used where no randomized controlled trials were available to support the recommendation.
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Nikaki K, Ooi JLS, Sifrim D. Chicago Classification of Esophageal Motility Disorders: Applications and Limits in Adults and Pediatric Patients with Esophageal Symptoms. Curr Gastroenterol Rep 2016; 18:59. [PMID: 27738966 DOI: 10.1007/s11894-016-0532-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The Chicago classification (CC) is most valued for its systematic approach to esophageal disorders and great impact in unifying practice for esophageal manometric studies. In view of the ever-growing wealth of knowledge and experience gained by the expanding use of high-resolution manometry (HRM) in various clinical scenarios, the CC is regularly updated. Its clinical impact and ability to predict clinical outcome, both in adults and pediatrics, will be further promoted by recognizing its current limitations, incorporating new metrics in its diagnostic algorithms and adjusting the HRM protocols based on the clinical question posed. Herein, we discuss the current limitations of the CC and highlight some areas of improvement for the future.
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Affiliation(s)
- Kornilia Nikaki
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 26 Ashfield Street, E1 2AJ, London, UK
| | - Joanne Li Shen Ooi
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 26 Ashfield Street, E1 2AJ, London, UK
| | - Daniel Sifrim
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 26 Ashfield Street, E1 2AJ, London, UK.
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25
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Walczak CC, Jones CA, McCulloch TM. Pharyngeal Pressure and Timing During Bolus Transit. Dysphagia 2016; 32:104-114. [PMID: 27565155 DOI: 10.1007/s00455-016-9743-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 08/09/2016] [Indexed: 01/26/2023]
Abstract
Determining intrabolus pressure (IBP) at the upper esophageal sphincter (UES) and in the esophagus has given compelling evidence that IBP can be a predictor for swallowing dysfunction. Studies have looked most superiorly at the low hypopharynx region but there has been no inquiry into what IBP measures throughout the entire pharynx can tell us. We present a study to describe the pressures within and surrounding the moving bolus throughout the pharynx and into the UES. Simultaneous high-resolution manometry (HRM) and videofluoroscopy were performed in ten healthy subjects swallowing ten 10 mL thin-liquid barium boluses. Three events surrounding bolus movement were tracked via videofluoroscopy, and two additional events were found using manometric measures. As the bolus passes through the pharynx, low pressure is created at and below the head of the bolus. A modest pressure increase is seen as the bolus passes through the pharynx, and finally, high pressure is observed at the bolus tail, followed by an even larger pressure generation of a clearance event. HRM allows for greater resolution in data collection in the pharynx and in this study, aided in identifying semi-unique characteristics around the hypopharynx and the UES which are consistent with the complex anatomy of the regions and the transition of the UES from active closure to relaxed opening. In the future, additional studies designed to look at aged and diseased populations may lead to better understanding of disease etiology, and treatment options.
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Affiliation(s)
- Chelsea C Walczak
- Division of Otolaryngology, Department of Surgery, University of Wisconsin-Madison, Madison, WI, USA
| | - Corinne A Jones
- Division of Otolaryngology, Department of Surgery, University of Wisconsin-Madison, Madison, WI, USA.,Department of Communication Sciences and Disorders, University of Wisconsin-Madison, Madison, WI, USA.,Neuroscience Training Program, University of Wisconsin-Madison, Madison, WI, USA
| | - Timothy M McCulloch
- Division of Otolaryngology, Department of Surgery, University of Wisconsin-Madison, Madison, WI, USA. .,Department of Communication Sciences and Disorders, University of Wisconsin-Madison, Madison, WI, USA.
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26
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Laparoscopic Nissen fundoplication mainly reduces the volume of acid reflux and potentially improves mucosal integrity up to the middle esophagus in neurologically impaired children detected by esophageal combined pH-multichannel intraluminal impedance measurements. J Pediatr Surg 2016; 51:1283-7. [PMID: 26906020 DOI: 10.1016/j.jpedsurg.2016.01.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 01/06/2016] [Accepted: 01/21/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND The aim of this study was to evaluate detailed changes of gastroesophageal reflux disease (GERD) in children before and after laparoscopic Nissen fundoplication (LNF) utilizing esophageal combined pH-multichannel intraluminal impedance (pH/MII) measurements. PATIENTS AND METHODS Thirteen patients with neurological impairment, who received laparoscopic Nissen fundoplication (LNF) owing to refractory pathological GERD, were enrolled in this study. 24h pH/MII was conducted in all patients before and one year after LNF. Each parameter of the pH/MII was evaluated and compared each other. RESULTS Both the mean pH index and bolus exposure index after LNF were significantly lower than those before LNF. The mean numbers of total and nonacid reflux episodes after LNF were significantly lower than those before LNF. The mean numbers of total, acid and nonacid proximal reflux episodes after LNF were significantly lower than those before LNF. The mean baseline impedance values from Z3 to Z6 after LNF were significantly higher than those before LNF. CONCLUSIONS The present study provides new insights into the effects of LNF in pediatric patients, which prevents mainly acid reflux episodes from rising to the proximal esophagus, and is expected to improve the mucosal integrity up to the middle esophagus.
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Mauritz FA, Conchillo JM, van Heurn LWE, Siersema PD, Sloots CEJ, Houwen RHJ, van der Zee DC, van Herwaarden-Lindeboom MYA. Effects and efficacy of laparoscopic fundoplication in children with GERD: a prospective, multicenter study. Surg Endosc 2016; 31:1101-1110. [PMID: 27369283 PMCID: PMC5315717 DOI: 10.1007/s00464-016-5070-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 06/21/2016] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Laparoscopic antireflux surgery (LARS) in children primarily aims to decrease reflux events and reduce reflux symptoms in children with therapy-resistant gastroesophageal reflux disease (GERD). The aim was to objectively assess the effect and efficacy of LARS in pediatric GERD patients and to identify parameters associated with failure of LARS. METHODS Twenty-five children with GERD [12 males, median age 6 (2-18) years] were included prospectively. Reflux-specific questionnaires, stationary manometry, 24-h multichannel intraluminal impedance pH monitoring (MII-pH monitoring) and a 13C-labeled Na-octanoate breath test were used for clinical assessment before and 3 months after LARS. RESULTS After LARS, three of 25 patients had persisting/recurrent reflux symptoms (one also had persistent pathological acid exposure on MII-pH monitoring). New-onset dysphagia was present in three patients after LARS. Total acid exposure time (AET) (8.5-0.8 %; p < 0.0001) and total number of reflux episodes (p < 0.001) significantly decreased and lower esophageal sphincter (LES) resting pressure significantly increased (10-24 mmHg, p < 0.0001) after LARS. LES relaxation, peristaltic contractions and gastric emptying time did not change. The total number of reflux episodes on MII-pH monitoring before LARS was a significant predictor for the effect of the procedure on reflux reduction (p < 0.0001). CONCLUSIONS In children with therapy-resistant GERD, LARS significantly reduces reflux symptoms, total acid exposure time (AET) and number of acidic as well as weakly acidic reflux episodes. LES resting pressure increases after LARS, but esophageal function and gastric emptying are not affected. LARS showed better reflux reduction in children with a higher number of reflux episodes on preoperative MII-pH monitoring.
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Affiliation(s)
- Femke A Mauritz
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Room: KE.04.140.5, PO Box 85090, 3508 AB, Utrecht, The Netherlands. .,Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - J M Conchillo
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - L W E van Heurn
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam Medical Center, Amsterdam, The Netherlands
| | - P D Siersema
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - C E J Sloots
- Department of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - R H J Houwen
- Department of Pediatric Gastroenterology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - D C van der Zee
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Room: KE.04.140.5, PO Box 85090, 3508 AB, Utrecht, The Netherlands
| | - M Y A van Herwaarden-Lindeboom
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Room: KE.04.140.5, PO Box 85090, 3508 AB, Utrecht, The Netherlands
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Huang L, Xu AM. Post-surgical gastrointestinal reflux disease: Status quo and treatment. Shijie Huaren Xiaohua Zazhi 2016; 24:2601-2607. [DOI: 10.11569/wcjd.v24.i17.2601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Reflux is a common and tricky morbidity after gastrointestinal surgery which is caused by the destruction of physiological anti-reflux barriers, greatly affecting patients' postoperative quality of life. Gastroenterologists are now actively trying very hard to explore feasible, effective, and safe anti-reflux approaches. Conservative medical treatment, typically with proton pump inhibitors, is easily accepted by patients, however, its long-term adverse events are noteworthy. In the surgical aspect, laparoscopic anti-reflux surgery is gaining more and more popularity, after the first case of fundoplication. Besides, other operations, such as bariatric surgery, pediatric surgery, and pulmonary transplantation, are also frequently complicated by post-operative digestive reflux. Herein we systematically review the status quo and treatment modalities for post-surgical reflux disease, with the hope to facilitate surgeons to cope with this challenging issue appropriately.
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Rommel N, Omari TI, Selleslagh M, Kritas S, Cock C, Rosan R, Rodriguez L, Nurko S. High-resolution manometry combined with impedance measurements discriminates the cause of dysphagia in children. Eur J Pediatr 2015; 174:1629-37. [PMID: 26105773 DOI: 10.1007/s00431-015-2582-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 06/07/2015] [Accepted: 06/12/2015] [Indexed: 11/25/2022]
Abstract
UNLABELLED Pressure-flow analysis allows assessing esophageal bolus transport in relation to esophageal pressures. This study aimed to characterize pressure-flow metrics in relation to dysphagia in paediatric patients. We analysed esophageal pressure-impedance recordings of 5 ml liquid and viscous swallows from 35 children (17 M, mean 10.5 ± 0.8 years). Primary indication for referral was gastroesophageal reflux disease (GERD) (9), post-fundoplication dysphagia (5), idiopathic dysphagia (16), trachea-esophageal fistula (2) and other (3). Peristaltic function was assessed using the 20 mmHg iso-contour defect and the timing between bolus pressure and flow was assessed using the Pressure Flow Index, a metric elevated in relation to dysphagia. Patients were stratified in relation to dysphagia and to peristaltic defect size. Dysphagia was characterized by a weaker peristalsis for liquids and higher Pressure Flow Index for viscous. When patients were stratified based on weak or normal peristalsis, dysphagia with weak peristalsis related to a larger iso-contour defect size and dysphagia with normal peristalsis related to higher Pressure Flow Index. CONCLUSION Pressure-flow analysis enables differentiation of patients with dysphagia due to weak peristalsis (poor bolus clearance) from abnormal bolus flow resistance (esophageal outflow obstruction). This new dichotomous categorization of esophageal function may help guide the selection of optimal treatment such as pharmacological or endoscopic therapy. WHAT IS KNOWN • Pressure-flow analysis (PFA) can detect abnormalities in esophageal motility using integrated analysis of bolus propulsion and bolus flow during swallowing. • AIM analysis has recently been reported to be useful in identifying subtle pre-operative esophageal dysfunction in adult patients who developed post-fundoplication dysphagia as well as in patients with non-obstructive dysphagia. WHAT IS NEW • Pressure-flow parameters can distinguish the cause of dysphagia in paediatric patients. • Combined high-resolution manometry and impedance measurements with pressure-flow analysis can differentiate paediatric patients with dysphagia symptoms in relation to either weak peristalsis (poor bolus clearance) or over-pressurization (abnormal bolus flow resistance). HOW MIGHT IT IMPACT ON CLINICAL PRACTICE IN THE FUTURE? • This study supports the use of a novel objective analysis method on recordings that are readily used in paediatric clinical practice. • The pressure-flow approach allows discriminating esophageal dysfunction in relation to dysphagia symptoms in children. This has not been achieved in children with current analysis methods. • The new findings of this study allow a dichotomous categorization of esophageal function, which may help to guide the selection of the most optimal treatment such as pharmacological or endoscopic therapy.
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Affiliation(s)
- Nathalie Rommel
- Neurosciences, ExpORL, University of Leuven, Leuven, Belgium.
- Neurogastroenterology & Motility, Gastroenterology, University Hospital Leuven, Leuven, Belgium.
- Translational Research Center for Gastrointestinal Diseases (TARGID), University of Leuven, Leuven, Belgium.
| | - Taher I Omari
- Translational Research Center for Gastrointestinal Diseases (TARGID), University of Leuven, Leuven, Belgium.
- School of Medicine, Flinders University, Bedford Park, South Australia, Australia.
- The Robinson Institute, University of Adelaide, Adelaide, South Australia, Australia.
| | - Margot Selleslagh
- Neurosciences, ExpORL, University of Leuven, Leuven, Belgium.
- Translational Research Center for Gastrointestinal Diseases (TARGID), University of Leuven, Leuven, Belgium.
| | - Stamatiki Kritas
- Translational Research Center for Gastrointestinal Diseases (TARGID), University of Leuven, Leuven, Belgium.
| | - Charles Cock
- School of Medicine, Flinders University, Bedford Park, South Australia, Australia.
- Investigation and Procedures Unit, Repatriation General Hospital, Daw Park, South Australia, Australia.
| | - Rachel Rosan
- Harvard Medical School, Boston, MA, USA.
- Centre for Motility and Functional GI Disorders, Boston Children's Hospital , Boston, MA, USA.
| | - Leonel Rodriguez
- Harvard Medical School, Boston, MA, USA.
- Centre for Motility and Functional GI Disorders, Boston Children's Hospital , Boston, MA, USA.
| | - Samuel Nurko
- Harvard Medical School, Boston, MA, USA.
- Centre for Motility and Functional GI Disorders, Boston Children's Hospital , Boston, MA, USA.
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Lau C. Development of Suck and Swallow Mechanisms in Infants. ANNALS OF NUTRITION & METABOLISM 2015; 66 Suppl 5:7-14. [PMID: 26226992 PMCID: PMC4530609 DOI: 10.1159/000381361] [Citation(s) in RCA: 105] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Preterm infants' hospital discharge is often delayed due to their inability to feed by mouth safely and competently. No evidence-based supported guidelines are currently available for health-care professionals caring for these infants. Available interventions advocating benefits are not readily acknowledged for lack of rigorous documentation inasmuch as any improvements may ensue from infants' normal maturation. Through research, a growing understanding of the development of nutritive sucking skills has emerged, shedding light on how and why infants may encounter oral feeding difficulties due to the immaturity of specific physiologic functions. Unfortunately, this knowledge has yet to be translated to the clinical practice to improve the diagnoses of oral feeding problems through the development of relevant assessment tools and to enhance infants' oral feeding skills through the development of efficacious preventive and therapeutic interventions. This review focuses on the maturation of the various physiologic functions implicated in the transport of a bolus from the oral cavity to the stomach. Although infants' readiness for oral feeding is deemed attained when suck, swallow, and respiration are coordinated, we do not have a clear definition of what coordination implies. We have learned that each of these functions encompasses a number of elements that mature at different times and rates. Consequently, it would appear that the proper functioning of sucking, the swallow processing, and respiration need to occur at two levels: first, the elements within each function must reach an appropriate functional maturation that can work in synchrony with each other to generate an appropriate suck, swallow process, and respiration; and second, the elements of all these distinct functions, in turn, must be able to do the same at an integrative level to ensure the safe and efficient transport of a bolus from the mouth to the stomach.
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Affiliation(s)
- Chantal Lau
- Department of Pediatrics/Neonatology, Baylor College of Medicine, Houston, Tex., USA
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Abstract
Oesophageal dysphagia is a common symptom, which might be related to severe oesophageal diseases such as carcinomas. Therefore, an organic process must be ruled out in the first instance by endoscopy in all patients presenting with dysphagia symptoms. The most prevalent obstructive aetiologies are oesophageal cancer, peptic strictures and eosinophilic oesophagitis. Eosinophilic oesophagitis is one of the most common causes of dysphagia in adults and children, thus justifying the need to obtain oesophageal biopsy samples from all patients presenting with unexplained dysphagia. With the advent of standardized high-resolution manometry and specific metrics to characterize oesophageal motility, the Chicago classification has become a gold-standard algorithm for manometric diagnosis of oesophageal motor disorders. In addition, sophisticated investigations and analysis methods that combine pressure and impedance measurement are currently in development. In the future, these techniques might be able to detect subtle pressure abnormalities during bolus transport, which could further explain pathophysiology and symptoms. The degree to which novel approaches will help distinguish dysphagia caused by motor abnormalities from functional dysphagia still needs to be determined.
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Singendonk MMJ, Kritas S, Cock C, Ferris LF, McCall L, Rommel N, van Wijk MP, Benninga MA, Moore D, Omari TI. Pressure-flow characteristics of normal and disordered esophageal motor patterns. J Pediatr 2015; 166:690-6.e1. [PMID: 25596103 DOI: 10.1016/j.jpeds.2014.12.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 10/14/2014] [Accepted: 12/01/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To perform pressure-flow analysis (PFA) in a cohort of pediatric patients who were referred for diagnostic manometric investigation. STUDY DESIGN PFA was performed using purpose designed Matlab-based software. The pressure-flow index (PFI), a composite measure of bolus pressurization relative to flow and the impedance ratio, a measure of the extent of bolus clearance failure were calculated. RESULTS Tracings of 76 pediatric patients (32 males; 9.1 ± 0.7 years) and 25 healthy adult controls (7 males; 36.1 ± 2.2 years) were analyzed. Patients mostly had normal motility (50%) or a category 4 disorder and usually weak peristalsis (31.5%) according to the Chicago Classification. PFA of healthy controls defined reference ranges for PFI ≤142 and impedance ratio ≤0.49. Pediatric patients with pressure-flow (PF) characteristics within these limits had normal motility (62%), most patients with PF characteristics outside these limits also had an abnormal Chicago Classification (61%). Patients with high PFI and disordered motor patterns all had esophagogastric junction outflow obstruction. CONCLUSIONS Disordered PF characteristics are associated with disordered esophageal motor patterns. By defining the degree of over-pressurization and/or extent of clearance failure, PFA may be a useful adjunct to esophageal pressure topography-based classification.
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Affiliation(s)
- Maartje M J Singendonk
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital AMC, Amsterdam, The Netherlands; Gastroenterology Unit, Women's and Children's Health Network, North Adelaide, Australia.
| | - Stamatiki Kritas
- Gastroenterology Unit, Women's and Children's Health Network, North Adelaide, Australia; Translational Research Center for Gastrointestinal Diseases, University of Leuven, Leuven, Belgium
| | - Charles Cock
- Department of Gastroenterology and Hepatology, Repatriation General Hospital, South Australia, Australia
| | - Lara F Ferris
- Gastroenterology Unit, Women's and Children's Health Network, North Adelaide, Australia
| | - Lisa McCall
- Gastroenterology Unit, Women's and Children's Health Network, North Adelaide, Australia
| | - Nathalie Rommel
- Translational Research Center for Gastrointestinal Diseases, University of Leuven, Leuven, Belgium; Department of Neurosciences, ExpORL, University of Leuven, Leuven, Belgium
| | - Michiel P van Wijk
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital AMC, Amsterdam, The Netherlands
| | - Marc A Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital AMC, Amsterdam, The Netherlands
| | | | - Taher I Omari
- Gastroenterology Unit, Women's and Children's Health Network, North Adelaide, Australia; Department of Gastroenterology and Hepatology, Repatriation General Hospital, South Australia, Australia; School of Medicine, Flinders University, Bedford Park, South Australia, Australia
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Omari TI, Szczesniak MM, Maclean J, Myers JC, Rommel N, Cock C, Cook IJ. Correlation of esophageal pressure-flow analysis findings with bolus transit patterns on videofluoroscopy. Dis Esophagus 2014; 29:166-73. [PMID: 25515292 DOI: 10.1111/dote.12300] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pressure-flow analysis quantifies the interactions between bolus transport and pressure generation. We undertook a pilot study to assess the interrelationships between pressure-flow metrics and fluoroscopically determined bolus clearance and bolus transport across the esophagogastric junction (EGJ). We hypothesized that findings of abnormal pressure-flow metrics would correlate with impaired bolus clearance and reduced flow across the EGJ. Videofluoroscopic images, impedance, and pressure were recorded simultaneously in nine patients with dysphagia (62-82 years, seven male) tested with liquid barium boluses. A 3.6 mm diameter solid-state catheter with 25 × 1 cm pressure/12 × 2 cm impedance was utilized. Swallowed bolus clearance was assessed using a validated 7-point radiological bolus transport scale. The cumulative period of bolus flow across the EGJ was also fluoroscopically measured (EGJ flow time). Pressure only parameters included the length of breaks in the 20 mmHg iso-contour and the 4 second integrated EGJ relaxation pressure (IRP4s). Pressure-flow metrics were calculated for the distal esophagus, these were: time from nadir impedance to peak pressure (TNadImp to PeakP) to quantify bolus flow timing; pressure flow index (PFI) to integrate bolus pressurization and flow timing; and impedance ratio (IR) to assess bolus clearance. When compared with controls, patients had longer peristaltic breaks, higher IRs, and higher residual EGJ relaxation pressures (break length of 8 [2, 13] vs. 2 [0, 2] cm, P = 0.027; IR 0.5 ± 0.1 vs. 0.3 ± 0.0, P = 0.019; IRP4s 11 ± 2 vs. 6 ± 1 mmHg, P = 0.070). There was a significant positive correlation between higher bolus transport scores and longer peristaltic breaks (Spearman correlation r = 0.895, P < 0.001) and with higher IRs (r = 0.661, P < 0.05). Diminished EGJ flow times correlated with a shorter TNadImp to PeakP (r = -0.733, P < 0.05) and a higher IR (r = -0.750, P < 0.05). Longer peristaltic breaks and higher IR correlate with failed bolus clearance on videofluoroscopy. The metric TNadImp to PeakP appears to be a marker of the period of time over which the bolus flows across the EGJ.
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Affiliation(s)
- T I Omari
- Gastroenterology Unit, Women's and Children's Health Network, Adelaide, South Australia, Australia.,School of Paediatrics and Reproductive Health, University of Adelaide, Adelaide, South Australia, Australia.,School of Medicine, Flinders University, Bedford Park, South Australia, Australia.,Translational Research Center for Gastrointestinal Diseases, University of Leuven, Leuven, Belgium
| | - M M Szczesniak
- Department of Speech Pathology, St George Hospital, Sydney, New South Wales, Australia
| | - J Maclean
- Department of Speech Pathology, St George Hospital, Sydney, New South Wales, Australia
| | - J C Myers
- Discipline of Surgery, University of Adelaide, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - N Rommel
- Translational Research Center for Gastrointestinal Diseases, University of Leuven, Leuven, Belgium.,Neurosciences, ExpORL, University of Leuven, Leuven, Belgium
| | - C Cock
- Investigation and Procedures Unit, Repatriation General Hospital, Adelaide, South Australia, Australia
| | - I J Cook
- Department of Speech Pathology, St George Hospital, Sydney, New South Wales, Australia
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Ozcan CU, Yilmaz O, Gurer DE, Ayhan S, Taneli C, Genc A. Evaluation of the relation between interstitial cells of cajal (CD117) and serotonin receptor (5HT-3A) with postfundoplication dysphagia. Int J Surg 2014; 13:137-141. [PMID: 25498492 DOI: 10.1016/j.ijsu.2014.11.053] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 11/17/2014] [Accepted: 11/25/2014] [Indexed: 01/29/2023]
Abstract
OBJECTIVE The aim of the present study is to investigate the effect of Nissen fundoplication to the pacemaker cells of an intestinal system and the serotonin receptors on an ICC membrane. METHODS Sixteen adult male rats were taken into study. Rats were divided in to the following two groups. Nissen fundoplication was performed to study group (Group 1) and no surgical procedures were applied to control group (group 2). The rats who were subjected to surgery and the rats without surgery were sacrificed on to postoperative 14 days. Specimens for the pathologic analysis were obtained from upper esophagus (group A) and esophagogastric junction (EGJ) (group B). Distribution of ICC and 5HT-3A were evaluated separately. RESULTS There was a significant difference (p=0.01, p=0.02, respectively) regarding number of cells stained with CD117 between the group 1B-2B and group 2A-2B. Also there was a significant difference between (p=0.01, p=0.01 respectively) number of cells stained with 5HT-3A in groups 1A-1B and 2A-2B. However, no correlation was detected between group 1B-2B for 5HT-3A. CONCLUSION A reduction in the number of ICC was observed in esophagogastric junctions of the fundoplication group but 5HT-3A distribution did not show a significant difference. A decrease in the number of ICC may be effective at postfundoplication dysphagia.
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Affiliation(s)
- Cansu Unden Ozcan
- Balikesir University, Med. Faculty, Dept. of Pediatric Surgery, Balikesir, Turkey
| | - Omer Yilmaz
- Celal Bayar University, Med. Faculty, Dept. of Pediatric Surgery, Manisa, Turkey.
| | - Deniz Ersayin Gurer
- Celal Bayar University, Med. Faculty, Dept. of Pediatric Surgery, Manisa, Turkey
| | - Semin Ayhan
- Celal Bayar University, Med. Faculty, Dept. of Pathology, Manisa, Turkey
| | - Can Taneli
- Celal Bayar University, Med. Faculty, Dept. of Pediatric Surgery, Manisa, Turkey
| | - Abdulkadir Genc
- Celal Bayar University, Med. Faculty, Dept. of Pediatric Surgery, Manisa, Turkey
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Abstract
The decision to initiate enteral feedings is multifaceted, involving medical, financial, cultural, and emotional considerations. Children who have developmental or acquired disabilities are at risk for having primary and secondary conditions that affect growth and nutritional well-being. This clinical report provides (1) an overview of clinical issues in children who have developmental or acquired disabilities that may prompt a need to consider nonoral feedings, (2) a systematic way to support the child and family in clinical decisions related to initiating nonoral feeding, (3) information on surgical options that the family may need to consider in that decision-making process, and (4) pediatric guidance for ongoing care after initiation of nonoral feeding intervention, including care of the gastrostomy tube and skin site. Ongoing medical and psychosocial support is needed after initiation of nonoral feedings and is best provided through the collaborative efforts of the family and a team of professionals that may include the pediatrician, dietitian, social worker, and/or therapists.
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Omari T, Tack J, Rommel N. Impedance as an adjunct to manometric testing to investigate symptoms of dysphagia: What it has failed to do and what it may tell us in the future. United European Gastroenterol J 2014; 2:355-66. [PMID: 25360313 DOI: 10.1177/2050640614549096] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 07/31/2014] [Indexed: 12/17/2022] Open
Abstract
Dysphagia is a common reason for referral for investigations of oesophageal motility. Impedance measurement has now been incorporated into commercially available diagnostic manometry systems for more than a decade. This innovation, which offered the ability to record patterns of bolus transport without the need for simultaneous radiology, has for the most part failed to live up to expectations, offering few additional diagnostic insights. This review examines the potential pitfalls related to how impedance patterns are currently analysed and introduces and discusses the new concept of pressure-flow analysis integrating pressure and impedance measurements to derive new metrics linked to the pressures occurring within and around the bolus as it is being transported.
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Affiliation(s)
- T Omari
- School of Medicine, Flinders University, Bedford Park, Australia ; The Robinson Institute, University of Adelaide, Adelaide, Australia ; Translational Research Center for Gastrointestinal Diseases, University of Leuven, Belgium
| | - J Tack
- Translational Research Center for Gastrointestinal Diseases, University of Leuven, Belgium
| | - N Rommel
- Translational Research Center for Gastrointestinal Diseases, University of Leuven, Belgium ; Neurosciences, ExpORL, University of Leuven, Belgium
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Singendonk MMJ, Kritas S, Cock C, Ferris L, McCall L, Rommel N, van Wijk MP, Benninga MA, Moore D, Omari TI. Applying the Chicago Classification criteria of esophageal motility to a pediatric cohort: effects of patient age and size. Neurogastroenterol Motil 2014; 26:1333-41. [PMID: 25053225 DOI: 10.1111/nmo.12397] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 06/16/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Applying the 2012 Chicago Classification (CC) of esophageal motility disorders to pediatric patients is problematic as it relies upon adult-derived criteria. As shorter esophageal length and smaller esophago-gastric junction (EGJ) diameter may influence CC metrics, we explored the potential for age- and size-adjustment of diagnostic criteria. METHODS We evaluated 76 high-resolution solid state impedance-manometry recordings in children referred for manometry (32M; mean age 9 ± 1 years) and 25 recordings from healthy adult subjects (7M; mean age 36 ± 2 years). CC metrics; integrated relaxation pressure (IRP4s, mmHg), contractile front velocity (CFV, cm/s), distal contractile integral (DCI, mmHg cm/s), distal latency (DL, s), and peristaltic break size (BS, cm) were derived for 10 liquid swallows using CC analysis software. Effects of age and size were examined using regression analysis. KEY RESULTS Younger patient age and shorter size correlated significantly with greater IRP4s (p < 0.05), shorter DL (p < 0.001) and smaller BS (p < 0.05). Standard diagnostic CC criteria were adjusted using the slope of the linear regression equation to define the age/size-related trend. Sixty-six percent of the pediatric cohort showed abnormal motility when applying standard CC criteria. Adjustment for age and size reduced this to 50% and 53% respectively, with the largest reduction being in the IRP4s- and DL-dependent disorders EGJ outflow obstruction and diffuse esophageal spasm (13% to 7% and 5% and 14% to 1 and 5%, respectively). CONCLUSIONS & INFERENCES CC metrics, particularly IRP4s and DL, are age and size dependent, and therefore, require adjustment to improve accuracy of diagnosis of esophageal motility disorders in children.
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Affiliation(s)
- M M J Singendonk
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital AMC, Amsterdam, The Netherlands; Gastroenterology Unit, Women's and Children's Health Network, North Adelaide, Australia
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Omari TI, Wauters L, Rommel N, Kritas S, Myers JC. Oesophageal pressure-flow metrics in relation to bolus volume, bolus consistency, and bolus perception. United European Gastroenterol J 2014; 1:249-58. [PMID: 24917969 DOI: 10.1177/2050640613492157] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Accepted: 05/07/2013] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The utility of combined oesophageal pressure-impedance recording has been enhanced by automation of data analysis. OBJECTIVE To understand how oesophageal function as measured by automated impedance manometry (AIM) pressure-flow analysis varies with bolus characteristics and subjective perception of bolus passage. METHODS Oesophageal pressure-impedance recordings of 5 and 10 ml liquid or viscous swallows and 2 and 4 cm solid swallows from 20 healthy control subjects (five male; 25-73 years) were analysed. Metrics indicative of bolus pressurization (intrabolus pressure and intrabolus pressure slope) were derived. Bolus flow resistance, the relationship between bolus pressurization and flow timing, was assessed using a pressure-flow index. Bolus retention was assessed using the ratio of nadir impedance to peak pressure impedance (impedance ratio). Subjective perception of bolus passage was assessed swallow by swallow. RESULTS Viscosity increased the bolus flow resistance and reduced bolus clearance. Responses to boluses of larger volume and more viscous consistency revealed a positive correlation between bolus pressurization and oesophageal peak pressure. Flow resistance was higher in subjects who perceived bolus hold up of solids. CONCLUSIONS Bolus volume and bolus type alter oesophageal function and impact AIM analysis metrics descriptive of oesophageal function. Perception of bolus transit was associated with heightened bolus pressurization relative to bolus flow.
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Affiliation(s)
- Taher I Omari
- Women's and Children's Health Network, Adelaide, Australia ; University of Adelaide, Adelaide, Australia
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Mirić M, Turkalj M, Nogalo B, Erceg D, Perica M, Plavec D. Lung diffusion capacity in children with respiratory symptoms and untreated GERD. Med Sci Monit 2014; 20:774-81. [PMID: 24816214 PMCID: PMC4026150 DOI: 10.12659/msm.890336] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) is associated with many respiratory disorders, among which, chronic cough, laryngitis, and asthma are among the most common. We investigated lung function, including gas diffusion capacity, in children with poor asthma control or chronic laryngitis with untreated GERD. MATERIAL AND METHODS A total of 71 children, aged 6-17 years, with chronic respiratory and other symptoms suggestive for GERD, were enrolled and divided into 2 groups: chronic laryngitis and asthma. Participants underwent 24-hour pH monitoring and lung function assessment, measurement of single-breath diffusing capacity of the lung for carbon monoxide (DLCO), and fraction of exhaled nitric oxide (FENO) measurement. RESULTS 24-hour pH monitoring was positive for GERD in 92.1% of preselected children with asthma and 90.1% of children with chronic recurrent laryngitis. All flows (PEF, MEF75, MEF50, and MEF25) were significantly lower in the asthma group, while FENO and DLCO were significantly lower in the laryngitis group. A significant inverse relationship was found between DLCO and all reflux indexes in the laryngitis group. Each unit change of Johnson-DeMeester score and Boix-Ochoa score increased the odds for significantly lower DLCO in laryngitis patients by 3.9% and 5.5%, respectively. CONCLUSIONS In children with uncontrolled asthma and chronic laryngitis, the regurgitation of gastric contents due to GERD contributes to poor asthma control and aggravation of chronic laryngitis. Despite having normal lung function, the gas diffusion capacity should be controlled in patients with GERD and chronic laryngitis, and it might be the very first abnormality in distal airways.
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Affiliation(s)
- Mirjana Mirić
- Department for Anesthesiology, Reanimatology and Intensive Care Medicine, University Hospital Center Zagreb, Zagreb, Croatia
| | - Mirjana Turkalj
- Department of Pediatric Allergology and Pulmonology, Children's Hospital Srebrnjak, Reference Center for Clinical Immunology in Children Aappointed by the Ministry of Health and Social Welfare of the Republic of Croatia, Zagreb, Croatia
| | - Boro Nogalo
- Department of Pediatric Allergology and Pulmonology, Children's Hospital Srebrnjak, Reference Center for Clinical Immunology in Children Aappointed by the Ministry of Health and Social Welfare of the Republic of Croatia, Zagreb, Croatia
| | - Damir Erceg
- Department of Pediatric Allergology and Pulmonology, Children's Hospital Srebrnjak, Reference Center for Clinical Immunology in Children Aappointed by the Ministry of Health and Social Welfare of the Republic of Croatia, Zagreb, Croatia
| | - Marija Perica
- Department of Pediatric Allergology and Pulmonology, Children's Hospital Srebrnjak, Reference Center for Clinical Immunology in Children Aappointed by the Ministry of Health and Social Welfare of the Republic of Croatia, Zagreb, Croatia
| | - Davor Plavec
- Department of Pediatric Allergology and Pulmonology, Children's Hospital Srebrnjak, Reference Center for Clinical Immunology in Children Aappointed by the Ministry of Health and Social Welfare of the Republic of Croatia, Zagreb, Croatia
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New insights in gastroesophageal reflux, esophageal function and gastric emptying in relation to dysphagia before and after anti-reflux surgery in children. Curr Gastroenterol Rep 2014; 15:351. [PMID: 24014120 DOI: 10.1007/s11894-013-0351-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
In children with gastroesophageal reflux (GER) disease refractory to pharmacological therapies, anti-reflux surgery (fundoplication) may be a treatment of last resort. The applicability of fundoplication has been hampered by the inability to predict which patient may benefit from surgery and which patient is likely to develop post-operative dysphagia. pH impedance measurement and conventional manometry are unable to predict dysphagia, while the role of gastric emptying remains poorly understood. Recent data suggest that the selection of patients who will benefit from surgery might be enhanced by automated impedance manometry pressure-flow analysis (AIM) analysis, which relates bolus movement and pressure generation within the esophageal lumen.
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Abstract
Paediatric GERD is complicated to manage, as symptoms are diverse and often difficult to interpret. In infants, regurgitation is a common physiological condition. Nevertheless, when it occurs frequently (>4 times per day) and causes the infant distress, parents often seek medical help. In children 2-10 years of age, GERD is often considered to cause extra-oesophageal symptoms, despite the absence of hard evidence. Diagnostic investigations often lack solid validation and the signs and symptoms of GERD overlap with those of cow's milk protein allergy and eosinophillic oesophagitis. Reassurance, dietary treatment and positional adaptations are recommended for troublesome infant reflux. Anti-acid medication, mainly PPIs, is over-used in infants even though, in many children, reflux is not an acid-related condition. Moreover, evidence is increasing that PPIs cause adverse events such as gastroenteritis and respiratory tract infections. Management in children older than 10 years is similar to that in adults. Using prokinetics to treat nonerosive reflux disease remains only a promising theoretical concept, as no such molecule is currently available. Today, the adverse effects of each prokinetic molecule largely outweigh its potential benefit. Laparoscopic surgery is indicated in children who have life-threatening symptoms or in cases of drug dependence.
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Affiliation(s)
- Yvan Vandenplas
- Department of Pediatrics, UZ Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
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Chen CL, Yi CH, Liu TT, Hsu CS, Omari TI. Characterization of esophageal pressure-flow abnormalities in patients with non-obstructive dysphagia and normal manometry findings. J Gastroenterol Hepatol 2013; 28:946-53. [PMID: 23432518 DOI: 10.1111/jgh.12176] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/19/2013] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Patients with non-obstructive dysphagia (NOD) report symptoms of impaired esophageal bolus transit without evidence of bolus stasis. In such patients, manometric investigation may diagnose esophageal motility disorders; however, many have normal motor patterns. We hypothesized that patients with NOD would demonstrate evidence of high flow-resistance during bolus passage which in turn would relate to the reporting of bolus hold up perception. METHODS Esophageal pressure-impedance recordings of 5 mL liquid and viscous swallows from 18 NOD patients (11 male; 19-71 years) and 17 control subjects (9 male; 25-60 years) were analyzed. The relationship between intrabolus pressure and bolus flow timing in the esophagus was assessed using the pressure flow index (PFI). Bolus perception was assessed swallow by swallow using standardized descriptors. RESULTS NOD patients were characterized by a higher PFI than controls. The PFI defined a pressure-flow abnormality in all patients who appeared normal based on the assessment esophageal motor patterns and bolus clearance. The PFI was higher for individual swallows during which subjects reported perception of bolus passage. CONCLUSION Bolus flow-resistance is higher in NOD patients compared with controls as well as higher in relation to perception of bolus transit, suggesting the presence of an esophageal motility disorder despite normal findings on conventional analysis.
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Affiliation(s)
- Chien-Lin Chen
- Department of Medicine, Buddhist Tzu Chi General Hospital and Tzu Chi University, Taiwan
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