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Catchlove W, Liao S, Lim G, Brown W, Burton P. Mechanism of Staple Line Leak After Sleeve Gastrectomy via Isobaric Pressurisation Concentrating Stress Forces at the Proximal Staple Line. Obes Surg 2022; 32:2525-2536. [PMID: 35639242 PMCID: PMC9273565 DOI: 10.1007/s11695-022-06110-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 05/06/2022] [Accepted: 05/11/2022] [Indexed: 11/26/2022]
Abstract
Purpose Staple line leak following sleeve gastrectomy is a significant problem and has been hypothesised to be related to hyperpressurisation in the proximal stomach. There is, however, little objective evidence demonstrating how these forces could be transmitted to the luminal wall. We aimed to define conditions in the proximal stomach and simulate the transmission of stress forces in the post-operative stomach using a finite element analysis (FEA). Materials and Methods The manometry of fourteen patients post sleeve gastrectomy was compared to ten controls. Manometry, boundary conditions, and volumetric CT were integrated to develop six models. These models delineated luminal wall stress in the proximal stomach. Key features were then varied to establish the influence of each factor. Results The sleeve gastrectomy cohort had a significantly higher peak intragastric isobaric pressures 31.58 ± 2.1 vs. 13.49 ± 1.3 mmHg (p = 0.0002). Regions of stress were clustered at the staple line near the GOJ, and peak stress was observed there in 67% of models. A uniform greater curvature did not fail or concentrate stress under maximal pressurisation. Geometric variation demonstrated that a larger triangulated apex increased stress by 17% (255 kPa versus 218 kPa), with a 37% increase at the GOJ (203kPA versus 148kPA). A wider incisura reduced stress at the GOJ by 9.9% (128 kPa versus 142 kPa). Conclusion High pressure events can occur in the proximal stomach after sleeve gastrectomy. Simulations suggest that these events preferentially concentrate stress forces near the GOJ. This study simulates how high-pressure events could translate stress to the luminal wall and precipitate leak. Graphical Abstract ![]()
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Affiliation(s)
- William Catchlove
- Department of Surgery, Central Clinical School, Monash University, Alfred Health Centre, Level 6, 99 Commercial Road, Melbourne, VIC, 3002, Australia.
- Oesophago-Gastric and Bariatric Surgery Unit, Alfred Hospital, Melbourne, VIC, Australia.
| | - Sam Liao
- Department of Mechanical and Aerospace Engineering, Monash University, Melbourne, VIC, Australia
| | - Gillian Lim
- Department of Surgery, Central Clinical School, Monash University, Alfred Health Centre, Level 6, 99 Commercial Road, Melbourne, VIC, 3002, Australia
- Oesophago-Gastric and Bariatric Surgery Unit, Alfred Hospital, Melbourne, VIC, Australia
| | - Wendy Brown
- Department of Surgery, Central Clinical School, Monash University, Alfred Health Centre, Level 6, 99 Commercial Road, Melbourne, VIC, 3002, Australia
- Oesophago-Gastric and Bariatric Surgery Unit, Alfred Hospital, Melbourne, VIC, Australia
| | - Paul Burton
- Department of Surgery, Central Clinical School, Monash University, Alfred Health Centre, Level 6, 99 Commercial Road, Melbourne, VIC, 3002, Australia
- Oesophago-Gastric and Bariatric Surgery Unit, Alfred Hospital, Melbourne, VIC, Australia
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The consumption of snacks and soft drinks between meals may contribute to the development and to persistence of gastro-esophageal reflux disease. Med Hypotheses 2019; 125:84-88. [DOI: 10.1016/j.mehy.2019.02.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 12/18/2018] [Accepted: 02/09/2019] [Indexed: 01/10/2023]
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Wallner B, Björ O, Andreasson A, Hellström PM, Forsberg AM, Talley NJ, Agreus L. Identifying clinically relevant sliding hiatal hernias: a population-based endoscopy study. Scand J Gastroenterol 2018; 53:657-660. [PMID: 29616831 DOI: 10.1080/00365521.2018.1458896] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES The clinical relevance of small to moderate sliding hiatal hernias is controversial. The aims of the present study were to (1) investigate which symptoms are associated with sliding hiatal hernias and (2) define the length of a sliding hiatal hernia at which gastrointestinal symptoms occur. METHODS A study population representative of the general Swedish population answered a questionnaire regarding gastrointestinal symptoms and was investigated with an upper endoscopy. The length of any sliding hiatal hernia was measured. RESULTS Only reflux-related symptoms were associated with length of the hiatal hernia (acid regurgitation OR 1.46, CI 1.19-1.79, heartburn OR 1.27, CI 1.05-1.54), and the association did not become significant until an axial hiatal hernia length of 2 cm. CONCLUSIONS Only reflux symptoms could be attributed to sliding hiatal hernias. Hiatal hernias less than 2 cm should be considered clinically insignificant.
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Affiliation(s)
- Bengt Wallner
- a Department of Surgical and Perioperative Sciences, Surgery , Umeå University Hospital , Umeå , Sweden
| | - Ove Björ
- b Department of Radiation Science, Division of Oncology , Umeå University , Umeå , Sweden
| | - Anna Andreasson
- c Division of Family Medicine and Primary Care , Karolinska Institutet , Huddinge , Sweden.,d Stress Research Institute, Stockholm University , Stockholm , Sweden.,e Department of Psychology , Macquarie University , North Ryde , NSW , Australia
| | - Per M Hellström
- f Department of Medical Science , Uppsala University , Uppsala , Sweden
| | - Anna M Forsberg
- g Department of Medicin Solna , Karolinska Institutet , Stockholm , Sweden
| | - Nicholas J Talley
- c Division of Family Medicine and Primary Care , Karolinska Institutet , Huddinge , Sweden.,h Faculty of Health and Medicine , University of Newcastle , Newcastle , Australia
| | - Lars Agreus
- c Division of Family Medicine and Primary Care , Karolinska Institutet , Huddinge , Sweden
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Liao D, Lottrup C, Fynne L, McMahon BP, Krogh K, Drewes AM, Zhao J, Gregersen H. Axial Movements and Length Changes of the Human Lower Esophageal Sphincter During Respiration and Distension-induced Secondary Peristalsis Using Functional Luminal Imaging Probe. J Neurogastroenterol Motil 2018; 24:255-267. [PMID: 29605981 PMCID: PMC5885725 DOI: 10.5056/jnm17084] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 09/29/2017] [Accepted: 12/12/2017] [Indexed: 12/16/2022] Open
Abstract
Background/Aims Efficient transport through the esophago-gastric junction (EGJ) requires synchronized circular and longitudinal muscle contraction of the esophagus including relaxation of the lower esophageal sphincter (LES). However, there is a scarcity of technology for measuring esophagus movements in the longitudinal (axial) direction. The aim of this study is to develop new analytical tools for dynamic evaluation of the length change and axial movement of the human LES based on the functional luminal imaging probe (FLIP) technology and to present normal signatures for the selected parameters. Methods Six healthy volunteers without hiatal hernia were included. Data were analyzed from stepwise LES distensions at 20, 30, and 40 mL bag volumes. The bag pressure and the diameter change were used for motion analysis in the LES. The cyclic bag pressure frequency was used to distinguish dynamic changes of the LES induced by respiration and secondary peristalsis. Results Cyclic fluctuations of the LES were evoked by respiration and isovolumetric distension, with phasic changes of bag pressure, diameter, length, and axial movement of the LES narrow zone. Compared to the respiration-induced LES fluctuations, peristaltic contractions increased the contraction pressure amplitude (P < 0.001), shortening (P < 0.001), axial movement (P < 0.001), and diameter change (P < 0.01) of the narrow zone. The length of the narrow zone shortened as function of the pressure increase. Conclusions FLIP can be used for evaluation of dynamic length changes and axial movement of the human LES. The method may shed light on abnormal longitudinal muscle activity in esophageal disorders.
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Affiliation(s)
- Donghua Liao
- GIOME Academia, Department of Medicine, Aarhus University, Aarhus, Denmark
| | - Christian Lottrup
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Lotte Fynne
- Neurogastroenterology Unit, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Barry P McMahon
- TAGG Research Center, Tallaght Hospital and Trinity College, Dublin, Ireland
| | - Klaus Krogh
- Neurogastroenterology Unit, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Asbjørn M Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Jingbo Zhao
- GIOME Academia, Department of Medicine, Aarhus University, Aarhus, Denmark
| | - Hans Gregersen
- GIOME, Department of Surgery, Chinese University of Hong Kong and Prince of Wales Hospital, Hong Kong
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Kaplan M, Tanoglu A, Sakin YS, Akyol T, Oncu K, Kara M, Yazgan Y. Landmark reading alterations in patients with gastro-oesophageal reflux symptoms undergoing diagnostic gastroscopy. Arab J Gastroenterol 2016; 17:176-180. [PMID: 27889322 DOI: 10.1016/j.ajg.2016.08.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 08/21/2016] [Accepted: 08/28/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND STUDY AIMS There is still a debate about the exact measurement of the oesophagogastric junction and the diaphragmatic hiatus among clinicians. The aim of this study was to investigate the differences between landmark readings of gastroscopy on intubation and extubation, and to correlate these readings with a gastro-oesophageal reflux questionnaire. PATIENTS AND METHODS 116 cases who underwent diagnostic gastroscopy between January 2013 and June 2013 were included in this study. Landmark measurements were noted while withdrawing the endoscope and were also evaluated after the gastric air was fully emptied. We first used a frequency scale for the gastro-oesophageal reflux disease symptoms (FSSG) questionnaire in order to investigate dysmotility and acid reflux symptoms in the study population and correlated the FSSG questionnaire with intubation and extubation measurements at endoscopic examination. RESULTS Mean age of included subjects was 49.41±17.7 (19-82) years. Males and females were equally represented. On FSSG scores, the total dysmotility score was 7.99±5.06 and the total score was 15.18±10.11. The difference between intubation and extubation measurements ranged from -3cm to +2cm (mean: -0.4). When an FSSG score of 30 was accepted as a cut-off value, we detected a significant difference between the measurements (p<0.05; t: 0.048). CONCLUSION Accuracy of landmark measurements during gastroscopy is clearly affected from insertion or withdrawal of the endoscope. When differences in measurements between insertion and withdrawal were evident, comparable with the FSSG scores, the results became significantly different. In conclusion, according to FSSG scores, these measurements should be performed at the end of the endoscopy.
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Affiliation(s)
- Mustafa Kaplan
- GATA Haydarpasa Training Hospital, Internal Medicine Department, 34668 Uskudar, Istanbul, Turkey.
| | - Alpaslan Tanoglu
- GATA Haydarpasa Training Hospital, Gastroenterology Department, 34668 Uskudar, Istanbul, Turkey.
| | - Yusuf Serdar Sakin
- GATA Ankara Training Hospital, Gastroenterology Department, 06034 Ankara, Turkey.
| | - Taner Akyol
- GATA Haydarpasa Training Hospital, Gastroenterology Department, 34668 Uskudar, Istanbul, Turkey.
| | - Kemal Oncu
- GATA Haydarpasa Training Hospital, Gastroenterology Department, 34668 Uskudar, Istanbul, Turkey.
| | - Muammer Kara
- GATA Haydarpasa Training Hospital, Gastroenterology Department, 34668 Uskudar, Istanbul, Turkey.
| | - Yusuf Yazgan
- GATA Haydarpasa Training Hospital, Gastroenterology Department, 34668 Uskudar, Istanbul, Turkey.
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Abstract
Manometry and impedance provide only surrogate information regarding longitudinal wall function and are focused on contractile amplitude and lumen content. Ultrasound imaging provides a unique perspective of esophageal function by providing important information regarding longitudinal muscle contraction. Laser Doppler assessment of perfusion may be an important complementary tool to assess abnormal wall blood perfusion as a possible mechanism of pain.
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Affiliation(s)
- Ravinder K. Mittal
- Department of Medicine, Division of Gastroenterology, San Diego VA Health Care System & University of California, San Diego, CA, USA
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A catheter-based acoustic interrogation device for monitoring motility dynamics of the lower esophageal sphincter. SENSORS 2014; 14:14700-11. [PMID: 25120160 PMCID: PMC4178998 DOI: 10.3390/s140814700] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 08/02/2014] [Accepted: 08/05/2014] [Indexed: 01/08/2023]
Abstract
This paper presents novel minimally-invasive, catheter-based acoustic interrogation device for monitoring motility dynamics of the lower esophageal sphincter (LES). A micro-oscillator actively emitting sound wave at 16 kHz is located at one side of the LES, and a miniature microphone is located at the other side of the sphincter to capture the sound generated from the oscillator. Thus, the dynamics of the opening and closing of the LES can be quantitatively assessed. In this paper, experiments are conducted utilizing an LES motility dynamics simulator. The sound strength is captured by the microphone and is correlated to the level of LES opening and closing controlled by the simulator. Measurements from the simulator model show statistically significant (p < 0.05) Pearson correlation coefficients (0.905 on the average in quiet environment and 0.736 on the average in noisy environment, D.O.F. = 9). Measuring the level of LES opening and closing has the potential to become a valuable diagnostic technique for understanding LES dysfunction and the disorders associated with it.
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Lee YY, Wirz AA, Whiting JGH, Robertson EV, Smith D, Weir A, Kelman AW, Derakhshan MH, McColl KEL. Waist belt and central obesity cause partial hiatus hernia and short-segment acid reflux in asymptomatic volunteers. Gut 2014; 63:1053-60. [PMID: 24064007 DOI: 10.1136/gutjnl-2013-305803] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Abstract
OBJECTIVE There is a high incidence of inflammation and metaplasia at the gastro-oesophageal junction (GOJ) in asymptomatic volunteers. Additionally, the majority of patients with GOJ adenocarcinomas have no history of reflux symptoms. We report the effects of waist belt and increased waist circumference (WC) on the physiology of the GOJ in asymptomatic volunteers. DESIGN 12 subjects with normal and 12 with increased WC, matched for age and gender were examined fasted and following a meal and with waist belts on and off. A magnet was clipped to the squamo-columnar junction (SCJ). Combined assembly of magnet-locator probe, 12-channel pH catheter and 36-channel manometer was passed. RESULTS The waist belt and increased WC were each associated with proximal displacement of SCJ within the diaphragmatic hiatus (relative to upper border of lower oesophageal sphincter (LOS), peak LOS pressure point and pressure inversion point, and PIP (all p<0.05). The magnitude of proximal migration of SCJ during transient LOS relaxations was reduced by 1.6-2.6 cm with belt on versus off (p=0.01) and in obese versus non-obese (p=0.04), consistent with its resting position being already proximally displaced. The waist belt, but not increased WC, was associated with increased LOS pressure (vs intragastric pressure) and movement of pH transition point closer to SCJ. At 5 cm above upper border LOS, the mean % time pH <4 was <4% in all studied groups. Acid exposure 0.5-1.5 cm above SCJ was increased, with versus without, belt (p=0.02) and was most marked in obese subjects with belt. CONCLUSIONS Our findings indicate that in asymptomatic volunteers, waist belt and central obesity cause partial hiatus herniation and short-segment acid reflux. This provides a plausible explanation for the high incidence of inflammation and metaplasia and occurrence of neoplasia at the GOJ in subjects without a history of reflux symptoms.
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Affiliation(s)
- Yeong Yeh Lee
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK School of Medical Sciences, Universiti Sains Malaysia, Kota Bahru, Kelantan, Malaysia
| | - Angela A Wirz
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - James G H Whiting
- Department of Bioengineering, University of Strathclyde, Glasgow, UK
| | - Elaine V Robertson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Donald Smith
- Medical Devices Unit, Department of Clinical Physics, Southern General Hospital, Glasgow, UK
| | - Alexander Weir
- Medical Devices Unit, Department of Clinical Physics, Southern General Hospital, Glasgow, UK
| | - Andrew W Kelman
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Mohammad H Derakhshan
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Kenneth E L McColl
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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Abstract
High-resolution manometry (HRM) allows nuanced evaluation of esophageal motor function, and more accurate evaluation of lower esophageal sphincter (LES) function, in comparison with conventional manometry. Pathophysiologic correlates of gastroesophageal reflux disease (GERD) and esophageal peristaltic performance are well addressed by this technique. HRM may alter the surgical decision by assessment of esophageal peristaltic function and exclusion of esophageal outflow obstruction before antireflux surgery. Provocative testing during HRM may assess esophageal smooth muscle peristaltic reserve and help predict the likelihood of transit symptoms following antireflux surgery. HRM represents a continuously evolving new technology that compliments the evaluation and management of GERD.
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Affiliation(s)
- Michael Mello
- Division of Gastroenterology, Washington University School of Medicine, Campus Box 8124, 660 South Euclid Avenue, St Louis, MO 63110, USA
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, Campus Box 8124, 660 South Euclid Avenue, St Louis, MO 63110, USA.
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Lee YY, McColl KEL. Disruption of the gastroesophageal junction by central obesity and waist belt: role of raised intra-abdominal pressure. Dis Esophagus 2014; 28:318-25. [PMID: 24575877 DOI: 10.1111/dote.12202] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Obesity is a major reason for the recent increase in incidence of reflux disease and cancers at the distal esophagus and gastroesophageal junction (GOJ) and is mediated through a rise in the intra-abdominal pressure (IAP) but the exact mechanisms are unclear. Raised IAP from obesity and with application of waist belt produces mechanical distortion of the GOJ through formation of partial hiatus hernia. Even though there is no trans-sphincteric acid reflux, there is increased ingress of acid into the lower sphincter (intra-sphincteric reflux) as a consequence of raised IAP. In addition, short segment acid reflux is more evident in obese subjects with a belt on. Acid pocket is also enlarged in hiatus hernia, and acts as a reservoir of acid available to reflux whenever the sphincter fails. Above mechanisms may explain the common occurrence of cardiac lengthening and inflammation found in asymptomatic obese subjects. The inflamed cardia is also immunohistochemically similar to non-intestinal Barrett's mucosa, which is of etiological importance for cancers at the GOJ. Interventions that can reduce the mechanical distortion and acid exposure at the GOJ, including diet, exercise, drugs, sphincter augmentation therapy, and surgery, are clinically relevant in the treatment of gastroesophageal reflux disease but more data are needed whether if these strategies are also effective in preventing cancer. As a conclusion, raised IAP produces silent mechanical disruption of the GOJ, which may explain the high occurrence of cancers in this region and it is potentially reversible with early interventions.
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Affiliation(s)
- Y Y Lee
- School of Medical Sciences, Universiti Sains Malaysia, Kota Bahru, Kelantan, Malaysia; Department of Medicine, Section of Gastroenterology and Hepatology, Medical College of Georgia, Georgia Regents University, Augusta, Georgia, USA
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Lee YY. Relevance of position and movement of the gastroesophageal junction in gastroesophageal reflux disease. J Neurogastroenterol Motil 2013; 19:549. [PMID: 24199021 PMCID: PMC3816195 DOI: 10.5056/jnm.2013.19.4.549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Affiliation(s)
- Yeong Yeh Lee
- School of Medical Sciences, Universiti Sains Malaysia Kubang Kerian, Kelantan, Malaysia
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Pathophysiology of gastroesophageal reflux disease. Best Pract Res Clin Gastroenterol 2013; 27:339-51. [PMID: 23998973 DOI: 10.1016/j.bpg.2013.06.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Accepted: 06/23/2013] [Indexed: 01/31/2023]
Abstract
The gastroesophageal junction is structurally complex and functionally designed to ensure the acid secreted by the most proximal gastric mucosa flows towards the stomach and not up onto the oesophageal squamous mucosa. The pattern and mechanism of reflux vary with the severity of reflux disease and this probably represents different ends of a spectrum rather than distinct pathophysiological mechanisms. Nearly all patients with severe reflux disease have hiatus hernia, however, a substantial proportion of patients with mild reflux disease do not, and this may be a result of intermittent or partial hiatus hernia undetectable by current available tools. The acid pocket is an area of post-prandial unbuffered gastric acidity immediately distal to the gastroesophageal junction and which is enlarged in patients with hiatus hernia. The acid pocket provides a reservoir of acid available to reflux when the intrinsic sphincter fails. Central obesity is an important factor in the aetiology of reflux and does this by the increased abdomino-thoracic pressure gradient inducing hiatus hernia and increasing the rate of flow of reflux when sphincter opens. Central obesity also induces short segment intrasphincteric reflux and thereby columnar metaplasia of the most distal oesophagus.
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Mittal RK, Hong SJ, Bhargava V. Longitudinal muscle dysfunction in achalasia esophagus and its relevance. J Neurogastroenterol Motil 2013; 19:126-36. [PMID: 23667744 PMCID: PMC3644649 DOI: 10.5056/jnm.2013.19.2.126] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Revised: 03/09/2013] [Accepted: 03/10/2013] [Indexed: 12/19/2022] Open
Abstract
Muscularis propria of the esophagus is organized into circular and longitudinal muscle layers. Goal of this review is to summarize the role of longitudinal muscle in physiology and pathophysiology of esophageal sensory and motor function. Simultaneous manometry and ultrasound imaging that measure circular and longitudinal muscle contraction respectively reveal that during peristalsis 2 layers of the esophagus contract in perfect synchrony. On the other hand, during transient relaxation of the lower esophageal sphincter (LES), longitudinal muscle contracts independently of circular muscle. Recent studies provide novel insights, i.e., longitudinal muscle contraction of the esophagus induces LES relaxation and possibly descending relaxation of the esophagus. In achalasia esophagus and other motility disorders there is discoordination between the 2 muscle layers. Longitudinal muscle contraction patterns are different in the recently described three types of achalasia identified by high-resolution manometry. Robust contraction of the longitudinal muscle in type II achalasia causes pan-esophageal pressurization and is the mechanism of whatever little esophageal emptying that take place in the absence of peristalsis and impaired LES relaxation. It may be that preserved longitudinal muscle contraction is also the reason for superior outcome to medical/surgical therapy in type II achalasia esophagus. Prolonged contractions of longitudinal muscles of the esophagus is a possible mechanism of heartburn and "angina like" pain seen in esophageal motility disorders and possibly achalasia esophagus. Novel techniques to record longitudinal muscle contraction are on the horizon. Neuro-pharmacologic control of circular and longitudinal muscles is different, which provides an important opportunity for the development of novel pharmacological therapies to treat sensory and motor disorders of the esophagus.
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Affiliation(s)
- Ravinder K Mittal
- Division of Gastroenterology, Department of Medicine, San Diego VA Health Care System and University of California, San Diego, CA, USA
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