Impaired bolus transit across the esophagogastric junction in postfundoplication dysphagia

Pressure dynamics of the esophagogastric junction at rest and during inspiratory maneuvers after Nissen fundoplication

Low sphincter pressure and inability of the crural diaphragm to elevate it at the esophagogastric junction are important pathophysiological mechanisms of gastroesophageal reflux disease (GERD). The object of this study was to depict how Nissen fundoplication changed the resting and inspiratory pressures of the anti-reflux barrier. We selected 14 patients (eight males; mean age 42.7 years; mean body mass index 27.8) for surgery. They answered symptoms questionnaires and underwent high-resolution manometry (HRM) before and 6 months after Nissen fundoplication. We used a standard manometric protocol (resting and liquid swallows) and assessment of esophagogastric junction (EGJ) pressure metrics during standardized forced inspiratory maneuvers against increasing loads (Threshold Maneuvers). We used the Wilcoxon test for comparison of pre and postoperative data. After fundoplication, heartburn and regurgitation scores diminished remarkably (from 4.5 and 2, respectively, to zero; P = 0.002 and P = 0.0005, respective medians). Also, the median expiratory EGJ pressure had a significant increase from 8.1 to 18.1 mmHg (P = 0.002), while mean respiratory pressure and EGJ contractility integral (EGJ-CI) increased without statistical significance (P = 0.064 and P = 0.06, respectively). Axial EGJ displacement was lower after fundoplication. The EGJ relaxation pressure (P = 0.001), the mean distal esophageal intrabolus pressure (P = 0.01) and the distal latency (P = 0.017) increased after fundoplication. There was a reduction in the contraction front velocity (P = 0.043). During evaluation with standardized inspiratory maneuvers, the inspiratory EGJ pressures (under loads of 12, 24, 36 and 48 cmH2O) were lower after surgery for all loads (median for load 12 cmH2O: 145.6 vs. 102.7 mmHg; P = 0.004). Fundoplication and hiatal closure increased the expiratory EGJ pressure and promoted a great GERD symptom relief. The surgery seemed to overcompensate a reduced EGJ mobility and inspiratory pressure.

Concise Review: Applicability of High-resolution Manometry in Gastroesophageal Reflux Disease

Manometry, particularly high-resolution manometry is the preferred diagnostic tool used to evaluate esophageal motor function. This investigation is strongly indicated in the setting of dysphagia, but is also useful in gastroesophageal reflux disease (GERD), especially in case of failure of conventional treatment to exclude alternative diagnoses and prior to anti-reflux surgery. Moreover, ineffective esophagogastric junction barrier function and esophageal motor dysfunction are pathophysiological mechanisms in GERD and can be identified by manometry. The recent international guidelines have positioned high-resolution manometry as an important part of functional diagnostic work up in GERD in order to identify the GERD phenotype to guide specific treatment. The proposed manometric identification and measurement is based on the Chicago classification version 4.0 adding with new established metrics for GERD evaluation.

More beads, more peristaltic reserve, better outcomes: factors predicting postoperative dysphagia after magnetic sphincter augmentation

INTRODUCTION

Magnetic sphincter augmentation (MSA) offers a minimally invasive anti-reflux alternative to fundoplication for gastroesophageal reflux disease. The most common side effect of MSA is dysphagia, which may require dilation or even device removal. The incidence of dysphagia may be reduced by MSA sizing and preoperative motility studies. Multiple rapid swallows (MRS) is a provocative maneuver during high-resolution esophageal manometry (HRM) that assesses peristaltic reserve. We evaluated factors predicting development of dysphagia following MSA.

MATERIALS AND METHODS

A retrospective review of a prospectively maintained database identified patients undergoing MSA. Preoperative work-up included barium swallow, esophagogastroduodenoscopy, and esophageal manometry. Peristaltic augmentation was defined as a ratio > 1 of the distal contractile integral (DCI) following MRS and the mean DCI of the 10 baseline wet swallows during manometry. Demographics, MSA implant size, and postoperative symptom data were gathered on all patients.

RESULTS

Sixty-eight patients underwent MSA. Mean age was 51.7 years, average BMI was 25.8 kg/m². 15 (22.1%) of patients had severe dysphagia requiring endoscopic dilation. Peristaltic augmentation with MRS was significantly higher in patients without dysphagia (46.1% vs 6.3% p = 0.026). 33.3% of patients requiring dilatation exhibited complete absence of smooth muscle contraction following MRS (DCI = 0). The ratio of the DCI of MRS/wet swallows predicting dysphagia following MSA was 0.56. Patients with a small (12-14 beads) versus a larger MSA implant (15-17 beads) had a significantly higher rate of postoperative dysphagia (58.5% vs 30.0% p = 0.026).

CONCLUSION

Adequate peristaltic reserve and larger device size correlate with decreased incidence of dysphagia following MSA implantation without compromising the anti-reflux barrier. Routine assessment of peristaltic reserve during preoperative HRM should be considered prior to MSA placement.

Asymmetrical elevation of esophagogastric junction pressure suggests hiatal repair contributes to antireflux surgery dysphagia

The radial distribution of esophago-gastric junction (EGJ) pressures with regard to troublesome dysphagia (TDysph) after antireflux surgery is poorly understood. Before and after antireflux surgery, end-expiratory and peak-inspiratory EGJ pressures were measured at eight angles of 45° radial separation in patients with reflux disease. All 34 patients underwent posterior crural repair, then either 90° anterior (N = 13) or 360° fundoplication (N = 21). Dysphagia was assessed prospectively using a validated questionnaire (score range 0-45) and TDysph defined as a dysphagia score that was ≥5 above pre-op baseline. Compared with before surgery, for 90° fundoplication, end-expiratory EGJ pressures were highest in the left-anterolateral sectors, the position of the partial fundoplication. In other sectors, pressures were uniformly elevated. Compared with 90° fundoplication, radial pressures after 360° fundoplication were higher circumferentially (P = 0.004), with a posterior peak. Nine patients developed TDysph after surgery with a greater increase in end-expiratory and peak-inspiratory EGJ pressures (P = 0.03 and 0.03, respectively) and significantly higher inspiratory pressure at the point of maximal radial pressure asymmetry (P = 0.048), compared with 25 patients without TDysph. Circumferential elevation of end-expiratory EGJ pressure after 90° and 360° fundoplication suggests hiatal repair elevates EGJ pressure by extrinsic compression. The highly localized focal point of elevated EGJ pressure upon inspiration in patients with TDysph after surgery is indicative of a restrictive diaphragmatic hiatus in the presence of a fundoplication.

Clinical Significance of Esophageal Outflow Resistance Imposed by a Nissen Fundoplication

BACKGROUND

Attention has been focused on the amplitude of esophageal body contraction to avoid persistent dysphagia after a Nissen fundoplication. The current recommended level is a contraction amplitude in the distal third of esophagus above the fifth percentile. We hypothesized that a more physiologic approach is to measure outflow resistance imposed by a fundoplication, which needs to be overcome by the esophageal contraction amplitude.

STUDY DESIGN

The esophageal outflow resistance, as reflected by the intra-bolus pressure (iBP) measured 5 cm above the lower esophageal sphincter (LES), was measured in 53 normal subjects and 37 reflux patients with normal esophageal contraction amplitude, before and after a standardized Nissen fundoplication. All were free of postoperative dysphagia. A test population of 100 patients who had a Nissen fundoplication was used to validate the threshold of outflow resistance to avoid persistent postoperative dysphagia.

RESULTS

The mean (SD) amplitude of the iBP in normal subjects was 6.8 (3.7) mmHg and in patients before fundoplication was 3.6 (7.0) mmHg (p = 0.003). After Nissen fundoplication, the mean (SD) amplitude of the iBP increased to 12.0 (3.2) mmHg (p < 0.0001 vs normal subjects or preoperative values). The 95th percentile value for iBP after a Nissen fundoplication was 20.0 mmHg and was exceeded by esophageal contraction in all patients in the validation population, and 97% of these patients were free of persistent postoperative dysphagia at a median 50-month follow-up.

CONCLUSIONS

Nissen fundoplication increases the outflow resistance of the esophagus and should be constructed to avoid an iBP > 20 mmHg. Patients whose distal third esophageal contraction amplitude is >20 mmHg have a minimal risk of dysphagia after a tension-free Nissen fundoplication.

What Is the Impact of High-Resolution Manometry in the Functional Diagnostic Workup of Gastroesophageal Reflux Disease?

International guidelines agree that high-resolution esophageal manometry (HRM) is an integral part of the diagnostic evaluation of patients with refractory reflux symptoms and should be performed before antireflux surgery. Its most important goal is to explore differential diagnoses, in particular major esophageal motility disturbances, that may be responsible for symptoms. HRM additionally provides insights into all relevant pathomechanisms of gastroesophageal reflux disease (GERD): It can reveal important information on the morphology and function of the esophagogastric junction (EGJ), the presence of a hiatus hernia, transient lower esophageal sphincter relaxations, and dysmotility of the esophageal body. To obtain this information, a 3-step hierarchical system has been proposed for the algorithmic characterization of esophageal motor function. The first step is to investigate the morphology and contractility of the EGJ, the second to monitor esophageal body motor patterns in response to water swallows, and the third to determine the contraction reserve in patients with abnormal esophageal motor function using provocation tests. Observations made with HRM can not only explain the cause of symptoms in GERD patients but may also have the potential to direct specific treatment.

The role of preoperative high resolution manometry in predicting dysphagia after laparoscopic Nissen fundoplication

BACKGROUND

Laparoscopic fundoplication is an accepted surgical management of refractory gastro-esophageal reflux disease (GERD). The use of high resolution esophageal manometry (HRM) in preoperative evaluation is often applied to determine the degree of fundoplication to optimize reflux control while minimizing adverse sequela of postoperative dysphagia.

OBJECTIVE

Assess the role of preoperative HRM in predicting surgical outcomes, specifically risk assessment of postoperative dysphagia and quality of life, among patients receiving laparoscopic Nissen fundoplication for GERD with immediate postoperative (< 4 weeks clinic), short-term (3-month clinic), and long-term (34 ± 10.4 months of telephone) follow-up.

METHODS

Retrospective analysis of 146 patients over the age of 18 who received laparoscopic Nissen fundoplication at University of Vermont Medical Center from July 1, 2011 through December 31, 2014 was completed, of which 52 patients with preoperative HRM met inclusion criteria. Exclusion criteria included history of: (a) named esophageal motility disorder or aperistalsis; (b) esophageal cancer; (c) paraesophageal hernia noted intraoperatively.

RESULTS

Elevated basal integrated relaxation pressure (IRP), which is the mean of 4 s of maximal lower esophageal sphincter (LES) relaxation within 10 s of swallowing, was significantly correlated with worsened severity of post-fundoplication dysphagia (r = 0.572, p < 0.0001 with sensitivity and NPV of 100%) and poorer quality of life (r = 0.348, p = 0.018) at up to 3-years follow-up. The presence of preoperative dysphagia was independently related to post-fundoplication dysphagia at short-term (r = 0.403, p = 0.018) and long-term follow-up (r = 0.415, p = 0.005). Also, both elevated mean wave amplitude (r=-0.397, p = 0.006) and distal contractile integral (DCI) (r = - 0.294, p = 0.047) were significantly, inversely correlated to post-Nissen dysphagia. No significant association was demonstrated between other preoperative HRM parameters and surgical outcomes.

CONCLUSIONS

Inadequacy of lower esophageal sphincter (LES) relaxation with swallowing as delineated by elevated IRP is significantly predictive of worse long-term postoperative outcomes including dysphagia and quality of life scores. Further assessment of tailoring anti-reflux surgical approach with partial vs. total fundoplication to functionally resistant LES is required.

High-resolution Manometry in Patients with Gastroesophageal Reflux Disease Before and After Fundoplication

Background/Aims

The study aimed to determine pre- and post-fundoplication esophagogastric junction (EGJ) pressure and esophageal peristalsis by high-resolution manometry (HRM) in patients with gastroesophageal reflux disease (GERD).

Methods

Pre-operative and post-operative HRM data from 25 patients with GERD were analyzed using ManoView version 2.0.1. with updated software for Chicago classification and pressure topography. The study involved swallowing water boluses of 10 mL in the upright position.

Results

Significant increase of mean basal EGJ pressure and minimal basal EGJ pressure was found in post-operative as compared with pre-operative patients (P < 0.05 and P < 0.001, respectively). Integrated relaxation pressure (IRP) reached higher values in post-operative patients than in pre-operative patients (P < 0.001). Intra-bolus pressure (IBP) was significantly higher (P < 0.05) and contractile front velocity (CFV) was slower (P < 0.01) in post-operative patients than in pre-operative patients. Moreover significant increase of distal contractile integral (DCI) was found in post-operative patients (P < 0.05). Hiatal hernia was detected by HRM in 11 pre-operative patients. Fifteen out of 25 post-operative patients complained of dysphagia.

Conclusions

Fundoplication restores the antireflux barrier by reinforcing EGJ basal pressures, repairing hiatal hernias, and enhances peristaltic function of the esophagus by increasing DCI. However slight IRP elevation found in post-fundoplication patients may result in bolus pressurization and motility disorders.

What is the role of radiological testing of lower esophageal sphincter function?

Radiological fluoroscopic evaluation remains the primary imaging modality of choice to evaluate patients with swallowing disorders, despite the increasing availability and technical advantages of nonradiological techniques and the current radiological focus on cross-sectional imaging studies, such as computed tomography and magnetic resonance imaging. The radiological swallowing evaluation should be tailored to assess the entire upper gastrointestinal tract, including the lower esophageal sphincter. Fluoroscopy enables the simultaneous assessment of esophageal motility disorders, as well as structural pathologies, including strictures, webs, rings, diverticula, and tumors. Mono- and double-contrast esophagrams and solid bolus tests together allow assessment of lower esophageal sphincter function and complement other methods, such as endoscopy, manometry, or impedance planimetry. Here we review the role of radiological studies for correct assessment of structural and functional pathologies at the level of the lower esophageal sphincter.

Investigation of Dysphagia After Antireflux Surgery by High-resolution Manometry: Impact of Multiple Water Swallows and a Solid Test Meal on Diagnosis, Management, and Clinical Outcome

BACKGROUND & AIMS

Management of patients with dysphagia, regurgitation, and related symptoms after antireflux surgery is challenging. This prospective, case-control study tested the hypothesis that compared with standard high-resolution manometry (HRM) with single water swallows (SWS), adding multiple water swallows (MWS) and a solid test meal increases diagnostic yield and clinical impact of physiological investigations.

METHODS

Fifty-seven symptomatic and 12 asymptomatic patients underwent HRM with SWS, MWS, and a solid test meal. Dysphagia and reflux were assessed by validated questionnaires. Diagnostic yield of standard and full HRM studies with 24-hour pH-impedance monitoring was compared. Pneumatic dilatation was performed for outlet obstruction on HRM studies. Clinical outcome was assessed by questionnaires and an analogue scale with "satisfactory" defined as at least 40% symptom improvement requiring no further treatment.

RESULTS

Postoperative esophagogastric junction pressure was similar in all groups. Abnormal esophagogastric junction morphology (double high pressure band) was more common in symptomatic than in control patients (13 of 57 vs 0 of 12, P = .004). Diagnostic yield of HRM was 11 (19%), 11 (19%), and 33 of 57 (58%), with SWS, MWS, and solids, respectively (P < .001); it was greatest for solids in patients with dysphagia (19 of 27, 70%). Outlet obstruction was present in 4 (7%), 11 (19%), and 15 of 57 patients (26%) with SWS, MWS, and solids, respectively (P < .009). No asymptomatic control had clinically relevant dysfunction on solid swallows. Dilatation was performed in 12 of 15 patients with outlet obstruction during the test meal. Symptom response was satisfactory, good, or excellent in 7 of 12 (58%) with no serious complications.

CONCLUSIONS

The addition of MWS and a solid test meal increases the diagnostic yield of HRM studies in patients with symptoms after fundoplication and identifies additional patients with outlet obstruction who benefit from endoscopic dilatation.

Susceptibility to dysphagia after fundoplication revealed by novel automated impedance manometry analysis

BACKGROUND

Conventional measures of esophageal pressures or bolus transport fail to identify patients at risk of dysphagia after laparoscopic fundoplication.

METHODS

Liquid and viscous swallows were evaluated with impedance/manometry in 19 patients with reflux disease before and after surgery. A new method of automated impedance manometry (AIM) analysis correlated esophageal pressure with impedance data and automatically calculated a range of pressure and bolus movement variables. An iterative analysis determined whether any variables were altered in relation to dysphagia. Standard measures of esophago-gastric junction pressure, bolus presence time, and total bolus transit time were also evaluated.

KEY RESULTS

At 5 months postop, 15 patients reported some dysphagia, including 7 with new-onset dysphagia. For viscous boluses, three AIM-derived pressure-flow variables recorded preoperatively varied significantly in relation to postoperative dysphagia. These were: time from nadir esophageal impedance to peak esophageal pressure (TNadImp-PeakP), median intra-bolus pressure (IBP, mmHg), and the rate of bolus pressure rise (IBP slope, mmHgs(-1) ). These variables were combined to form a dysphagia risk index (DRI=IBP×IBP_slope/TNadImp-PeakP). DRI values derived from preoperative measurements were significantly elevated in those with postoperative dysphagia (DRI=58, IQR=21-408 vs no dysphagia DRI=9, IQR=2-19, P<0.02). A DRI >14 was optimally predictive of dysphagia (sensitivity 75% and specificity 93%).

CONCLUSIONS & INFERENCES

Before surgery, a greater and faster compression of a swallowed viscous bolus with less bolus flow time relates to postoperative dysphagia. Thus, susceptibility to postfundoplication dysphagia is related to a pre-existing sub-clinical variation of esophageal function.

Dysphagia postfundoplication: more commonly hiatal outflow resistance than poor esophageal body motility

BACKGROUND

Historically, risk assessment for postfundoplication dysphagia has been focused on esophageal body motility, which has proven to be an unreliable prediction tool. Our aim was to determine factors responsible for persistent postoperative dysphagia.

METHODS

Fourteen postfundoplication patients with primary dysphagia were selected for focused study. Twenty-five asymptomatic post-Nissen patients and 17 unoperated subjects served as controls. Pre- and postoperative clinical and high-resolution manometry parameters were compared.

RESULTS

Thirteen of the 14 symptomatic patients (92.9%) had normal postoperative esophageal body function, determined manometrically. In contrast, 13 of 14 (92.9%) had evidence of esophageal outflow obstruction, 9 of 14 (64.3%) manometrically, and 4 of 14 (28.6%) on endoscopy/esophagram. Median gastroesophageal junction integrated relaxation pressure was significantly greater (16.2 mm Hg) in symptomatic than in asymptomatic post-Nissen patients (11.1 mm Hg, P = .05) or unoperated subjects (10.6 mm Hg, P = .02). Sixty-four percent (9/14) of symptomatic patients had an increased mean relaxation pressure. Dysphagia was present in 9 of 14 (64.3%) preoperatively, and elevated postoperative relaxation pressure was independently associated with dysphagia.

CONCLUSION

These data suggest that postoperative alterations in hiatal functional anatomy are the primary factors responsible for post-Nissen dysphagia. Impaired relaxation of the neo-high pressure zone, recognizable as an abnormal relaxation pressure, best discriminates patients with dysphagia from those without symptoms postfundoplication.

Evaluation of the esophagogastric junction using high resolution manometry and esophageal pressure topography

BACKGROUND

The assessment of the esophagogastric junction (EGJ) is the most challenging aspect of clinical esophageal manometry. Although conventional manometric systems can be optimized toward interrogating specific aspects of the EGJ, they are too limited in recording channels and/or fidelity for a comprehensive assessment. The technological advantages inherent in high resolution manometry (HRM) with esophageal pressure topography (EPT) analysis substantially change this equation providing a technology sufficiently robust to dynamically record the contractile activity within the EGJ with both good fidelity and good spatial resolution.

PURPOSE

This review is an update on our understanding of the application of HRM and EPT to the analysis of EGJ function. With respect to sphincter relaxation, the integrated relaxation pressure (IRP) has proven to be a robust metric in differentiating intact from impaired EGJ relaxation. In the process, it revealed that impaired EGJ relaxation could occur not only in the setting of achalasia but also with other causes of EGJ outflow obstruction including hiatus hernia. The morphological description of the EGJ by EPT has also revealed not only a spectrum of abnormality ranging from an intact sphincter to overt herniation, but also the surprise finding of spontaneous conversion among sphincter configurations, emphasizing its dynamic nature. With respect to barrier function, preliminary data have refocused on the crural diaphragm as a key-differentiating feature between preserved and compromised function. Finally, although the accomplishments summarized above are substantial, much work remains to fully exploit the potential of EPT in the clinical characterization of the EGJ.

Dysphagia and gastroesophageal junction resistance to flow following partial and total fundoplication

BACKGROUND

Esophageal peristalsis and basal gastroesophageal junction (GEJ) pressure correlate poorly with dysphagia.

AIM

To determine intraluminal pressures that reflect GEJ function and to determine manometric correlates for dysphagia before and after fundoplication.

METHODS

The relationships between maximal intrabolus pressure, residual GEJ relaxation pressure and peak peristaltic pressure for water swallows were determined in normal volunteers and patients with reflux disease before and after fundoplication. GEJ anatomy was assessed by radiological, endoscopic and surgical criteria, whilst dysphagia was measured with a validated composite dysphagia score.

RESULTS

Dysphagia was significantly associated with lower peak peristaltic pressure in the distal esophagus and the presence of a hiatus hernia preoperatively, as well as higher residual pressure on GEJ relaxation postoperatively. Peak distal peristaltic pressure and residual GEJ relaxation pressure were predictors of intrabolus pressure after total fundoplication (p<0.002). Residual GEJ relaxation pressure was four times higher after 360° fundoplication (N=19) compared to 90° fundoplication (N=14, p<0.0001). Similarly, intrabolus pressure was elevated 2.5 times after 360° fundoplication and nearly doubled after 90° fundoplication and both were significantly different from controls (N=22) and reflux disease patients (N=53, p<0.0001).

CONCLUSIONS

Gastroesophageal junction impedance to flow imposed by fundoplication is associated with dysphagia when there is suboptimal distal esophageal contraction strength and relatively high residual GEJ relaxation pressure.

Postoperative problems 2011: fundoplication and obesity surgery

Although the surgical treatment of both GERD and obesity is very successful, these procedures have a significant impact on the physiology and function of the proximal GI tract. With the increasing prevalence of both GERD and obesity, more and more patients present at the motility outpatient clinic with symptoms related to surgical interventions for these medical problems. In this review, we describe the main complications following antireflux surgery: dysphagia, gas bloat syndrome, recurrent (persistent) GERD symptoms, and dyspeptic symptoms. The most common motility-related complications of obesity surgery are dumping syndrome and esophageal dysmotility.

High-resolution manometry

The following presents commentaries on the interest of high-resolution manometry for understanding the anatomy and physiology of the esophagogastric junction; the subtypes of achalasia, as diagnosed by high-resolution manometry; the interest of high-resolution manometry in the evaluation of dysphagia following fundoplication; and the appropriate clinical protocol for high-resolution manometry.

Perception of dysphagia: lack of correlation with objective measurements of esophageal function

BACKGROUND

The mechanism underlying increased perception of food bolus passage in the absence of esophageal mechanical obstruction has not been completely elucidated. A correlation between the intensity of the symptom and the severity of esophageal dysfunction, either motility (manometry) or bolus transit (impedance) has not been clearly demonstrated. The aim of this study was to analyze the correlation between objective esophageal function assessment (with manometry and impedance) and perception of bolus passage in healthy volunteers (HV) with normal and pharmacologically-induced esophageal hypocontractility, and in patients with gastro-esophageal reflux disease (GERD) with and without ineffective esophageal motility (IEM).

METHODS

Combined manometry-impedance was performed in 10 HV, 19 GERD patients without IEM and nine patients with IEM. Additionally, nine HV were studied after 50 mg sildenafil, which induced esophageal peristaltic failure. Perception of each 5 mL viscous swallow was evaluated using a 5-point scale. Manometry identified hypocontractility (contractions lower than 30 mmHg) and impedance identified incomplete bolus clearance.

KEY RESULTS

In HV and in GERD patients with and without IEM, there was no association between either manometry or impedance and perception on per swallow analysis (OR: 0.842 and OR: 2.017, respectively), as well as on per subject analysis (P = 0.44 and P = 0.16, respectively). Lack of correlation was also found in HV with esophageal hypocontractility induced by sildenafil.

CONCLUSIONS & INFERENCES

There is no agreement between objective measurements of esophageal function and subjective perception of bolus passage. These results suggest that increased bolus passage perception in patients without mechanical obstruction might be due to esophageal hypersensitivity.

Esophagogastric junction distensibility after fundoplication assessed with a novel functional luminal imaging probe

OBJECTIVE

The aim of the study was to compare the esophagogastric junction (EGJ) compliance in response to controlled distension in fundoplication (FP) patients and controls using the functional luminal imaging probe (FLIP).

BACKGROUND

FP aims to replicate normal EGJ distensibility. FLIP is a new technology that uses impedance planimetry to measure intraluminal cross-sectional area (CSA) during controlled distension.

METHODS

Ten controls and ten FP patients were studied with high-resolution esophageal pressure topography (HREPT) and then the FLIP placed across the EGJ. Deglutitive and interdeglutitive EGJ distensibility was assessed with volume-controlled distension. The FLIP measured eight CSAs spaced 4 mm apart within a cylindrical saline-filled bag along with the corresponding intrabag pressure.

RESULTS

The EGJ formed an hourglass shape during distensions with the central constriction at the diaphragmatic hiatus. The distensibility of the hiatus was significantly greater during deglutitive relaxation in both subject groups, but FP patients exhibited reduced EGJ distensibility and compliance compared to controls. During the interglutitive period, the corresponding increase in intrabag pressures at larger volumes were also greater in FP patients implying a longer segment of EGJ constriction. The EGJ distensibility characteristics did not correlate with HREPT measures.

CONCLUSIONS

FLIP technology was used to compare EGJ distensibility in FP patients and control subjects. The least distensible locus within the EGJ was always at the hiatus. EGJ distensibility was significantly reduced, and the length of constriction increased in FP patients. Future FLIP studies will compare patients with and without post-FP dysphagia and gas bloat, symptoms suggestive of an overly restrictive FP.

Regurgitation in healthy and non healthy infants

Uncomplicate regurgitation in otherwise healthy infants is not a disease. It consists of milk flow from mouth during or after feeding. Common causes include overfeeding, air swallowed during feeding, crying or coughing; physical exam is normal and weight gain is adequate. History and physical exam are diagnostic, and conservative therapy is recommended. Pathologic gastroesophageal reflux or gastroesophageal reflux disease refers to infants with regurgitation and vomiting associated with poor weight gain, respiratory symptoms, esophagitis. Reflux episodes occur most often during transient relaxations of the lower esophageal sphincter unaccompanied by swallowing, which permit gastric content to flow into the esophagus. A minor proportion of reflux episodes occurs when the lower esophageal sphincter fails to increase pressure during a sudden increase in intraabdominal pressure or when lower esophageal sphincter resting pressure is chronically reduced. Alterations in several protective mechanisms allow physiologic reflux to become gastroesophageal reflux disease; diagnostic approach is both clinical and instrumental: radiological series are useful to exclude anatomic abnormalities; pH-testing evaluates the quantity, frequency and duration of the acid reflux episodes; endoscopy and biopsy are performed in the case of esophagitis. Therapy with H2 receptor antagonists and proton pump inhibitors are suggested.

Study of swallowing sound at the esophagogastric junction before and after fundoplication

INTRODUCTION

Swallowing sounds can be heard in the lower esophagus by xiphoid auscultation. We hypothesize that the xiphoid sound analysis could provide information concerning the integrity of the esophagogastric junction (EGJ), i.e., superposition of the lower esophageal sphincter (LES) and the diaphragm to assess clinical diagnosis of gastroesophageal reflux disease (GERD) and results of Nissen fundoplication (NF). The aim was to evaluate the changes in sound parameters using our acoustic technique after reorganization of the EGJ after NF.

METHODS

For 21 patients with GERD and hiatus hernia, two microphones were placed below the cricoid and on the xiphoid cartilages. The frequency and duration of xiphoid sounds, esophageal transit time were calculated. We defined the xiphoid sound as composed of vibration groups separated by periods >100 ms. The number of vibration groups, number of vibrations per group, and interval between groups were also calculated.

RESULTS

The xiphoid sound frequency was increased after NF, and the esophageal transit time and xiphoid sound duration were significantly decreased. A significant correlation was found between xiphoid sound duration and LES-diaphragm displacement. The number of vibration groups and interval between groups were reduced after NF.

CONCLUSION

The acoustic technique for swallowing revealed the effects of NF upon the dynamic profile of the EGJ. The organization of vibration groups at the EGJ suggested that the passage of the bolus was modified by hiatus hernia, i.e., dissociation between the LES and the diaphragm and regularized by NF. Concomitant acoustic and radiologic study should contribute to better understanding of sound related to EGJ structure and boli.

Long-term outcomes of revisional surgery following laparoscopic fundoplication

Background

A small proportion of patients who have laparoscopic antireflux procedures require revisional surgery. This study investigated long-term clinical outcomes.

Methods

Patients requiring late revisional surgery following laparoscopic fundoplication for gastro-oesophageal reflux were identified from a prospective database. Long-term outcomes were determined using a questionnaire evaluating symptom scores for heartburn, dysphagia and satisfaction.

Results

The database search found 109 patients, including 98 (5·6 per cent) of 1751 patients who had primary surgery in the authors' unit. Indications for surgical revision were dysphagia (52 patients), recurrent reflux (36), mechanical symptoms related to paraoesophageal herniation (16) and atypical symptoms (five). The median time to revision was 26 months. Outcome data were available for 104 patients (median follow-up 66 months) and satisfaction data for 102, 88 of whom were highly satisfied (62·7 per cent) or satisfied (23·5 per cent) with the outcome. Patients who had revision for dysphagia had a higher incidence of poorly controlled heartburn (20 versus 2 per cent; P = 0·004), troublesome dysphagia (16 versus 6 per cent; P = 0·118) and a lower satisfaction score (P = 0·023) than those with recurrent reflux or paraoesophageal herniation.

Conclusion

Revisional surgery following laparoscopic fundoplication can produce good long-term results, but revision for dysphagia has less satisfactory outcomes.

Esophageal motility testing: impedance-based transit measurement and high-resolution manometry

Esophageal function tests are widely used, not only to obtain insight into esophageal physiology and pathophysiology in a research setting, but also to diagnose esophageal motor disorders in patients with symptoms such as dysphagia and chest pain. While esophageal function testing has long been considered almost synonymous with manometry, recently new techniques such as impedance measurement and high-resolution manometry have emerged. With impedance monitoring the transit of a bolus through the esophagus can be studied without the use of ionizing radiation. High-resolution manometry offers a highly detailed and comprehensive view of esophageal pressure patterns. Multichannel high resolution manometry with color plotting facilitates positioning of the catheter and interpretation of the tracings. In this article the development, clinical usefulness, and indications of these new tests are discussed.

Pathogenesis of gastro-oesophageal reflux disease and novel options for its therapy

Better understanding of the mechanisms that lead to reflux disease is an important area for future research, given the very high prevalence of this problem. During the lifetime of this journal, much has been learnt about the pathophysiology of reflux disease. Abnormally, frequent acid reflux plays a key role in pathogenesis: this reflux occurs predominantly during transient lower oesophageal sphincter relaxations. Analysis of the literature suggests that the importance of transient relaxations as the major permissive event for occurrence of acid reflux is currently substantially underestimated. 'Transient relaxation' is an inexact descriptor, as this motor programme includes inhibition of the diaphragmatic hiatus and distal oesophageal body circular muscle and contraction of the oesophageal longitudinal muscle. Laxity of the diaphragmatic hiatus and hiatus hernia are probably important factors that increase the probability for acid reflux to occur during transient relaxations and in allowing strain-induced reflux episodes. The importance of straining and low basal tone of the lower oesophageal sphincter in causing abnormal reflux has probably been overestimated, but these need more investigation. High resolution manometry is the key method for acquisition of important new insights into the normal and disordered mechanics of the antireflux function of the gastro-oesophageal junction, but as yet, the potential of this technique has been tapped relatively little. In the future, improved understanding of the mechanics of the gastro-oesophageal junction should lead to improved physical antireflux procedures. Much progress has been made in defining the control of transient relaxations and this has been translated into several promising options for a new class of drug that treats reflux disease by inhibition of transient relaxations. Clinical trials on these agents appear imminent.

New technologies to evaluate esophageal function

This review provides an overview of the recent advances made in diagnostic technologies of esophageal functional disorders. There is discussion of technologies that evaluate esophageal motor function with special attention to high-resolution manometry and esophageal manometry combined with intraluminal impedance testing. Technologies to evaluate gastroesophageal reflux disease are presented with focus on 24-h ambulatory pH monitoring with intraluminal impedance testing and 48-h ambulatory catheter-free pH monitoring. These new technologies have advanced the study and treatment of esophageal disorders in that they allow for more accurate diagnosis of known esophageal disorders and have introduced previously unexplored disorders, such as achalasia with shortening of the esophagus and nonacid reflux.

High-resolution manometry of the esophagus: more than a colorful view on esophageal motility?

Since the introduction of pressure measurement of the esophagus, there has been a stepwise improvement in manometric techniques and the recognition of esophageal manometry as a useful tool to evaluate esophageal function in clinical practice. The newest development in this field is high-resolution manometry of the esophagus. In this review, we will briefly discuss the indications for esophageal manometry and we will focus on the development of the technique of high-resolution manometry and the new insights that were obtained by using this emerging tool. We conclude that high-resolution esophageal manometry with spatiotemporal plotting of signals is a valuable research tool. Clinically, the solid-state high-resolution technique is attractive because it makes it easy to perform a high-quality manometric test. However, future studies will have to determine whether the yield of the technique is higher than that of conventional manometry.

Multichannel intraluminal impedance for the assessment of post-fundoplication dysphagia

Dysphagia often occurs after fundoplication, although its pathophysiology is not clear. We sought to better understand postfundoplication dysphagia by measuring esophageal clearance with multichannel intraluminal impedance (MII) along with more traditional work-up (manometry, upper gastrointestinal imaging [UGI], endoscopy). We evaluated 80 consecutive patients after laparoscopic fundoplication between April 2002 and November 2004. Patients were evaluated clinically and underwent simultaneous manometry and MII, 24-hour pH monitoring, endoscopy, and UGI. For analysis, patients were divided into the following groups based on the presence of dysphagia and fundoplication anatomy (by UGI/endoscopy): (1) Dysphagia and normal anatomy; (2) Dysphagia and abnormal anatomy; (3) No dysphagia and abnormal anatomy; and (4) No dysphagia and normal anatomy. Patients with dysphagia (Groups 1 & 2) had similar peristalsis (manometry), but were more likely to have impaired clearance by MII (32 pts, 62%) than those without dysphagia (9 pts, 32%, P = 0.01). Patients with abnormal anatomy (Groups 2 & 3) were also more likely to have impaired esophageal clearance (66%vs. 38%, P = 0.01). Finally, of patients that had normal fundoplication anatomy, those with dysphagia were much more likely to have impaired clearance (12 pts, 52%) than those with dysphagia (4 pts, 21%, P = 0.03). MII after fundoplication provides objective evidence of esophageal clearance, and is commonly abnormal in patients with abnormal fundoplication anatomy and/or dysphagia. Esophageal clearance is impaired in the majority of patients with postoperative dysphagia, even with normal fundoplication anatomy and normal peristalsis. MII may detect disorders in esophageal motility not detected by manometry.

Effects of partial (Belsey Mark IV) and complete (Nissen) fundoplication on proximal gastric function and esophagogastric junction dynamics

OBJECTIVES

This study aimed to assess the effects of Belsey Mark IV 270 degrees (partial) and Nissen 360 degrees (complete) fundoplication on proximal stomach function, transient lower esophageal sphincter relaxation (TLESR) elicitation and the esophagogastric junction (EGJ) pressure profile during TLESR to further elucidate the mechanism of action of fundoplication.

METHODS

Ten patients after partial and 10 patients after complete fundoplication were studied. High-resolution EGJ manometry and pH recording were performed for 1 h at baseline and 2 h following meal ingestion (500 mL/300 kcal). Three dimensional (3D) ultrasonographic images of the stomach were acquired every 15 min after meal ingestion. From the 3D ultrasonographic images, proximal gastric volumes were computed.

RESULTS

Postprandial proximal to complete gastric volume distribution ratios were larger among patients after partial (0.42 +/- 0.028) compared with patients after complete fundoplication (0.37 +/- 0.035; p < 0.05). Partial fundoplication patients had a markedly greater postprandial rate of TLESR (1.7 +/- 0.3/h) than patients after complete fundoplication (0.8 +/- 0.2/h; p < 0.05). The axial EGJ pressure profile was minimally affected by partial fundoplication but instead markedly changed after complete fundoplication.

CONCLUSIONS

Patients after partial fundoplication exhibit a larger meal-induced increase in proximal stomach volume, a higher TLESR rate, and a minimally affected axial EGJ pressure profile compared to patients after complete fundoplication.