Short-term results of laparoscopic anti-reflux surgery with the RefluxStop device in patients with gastro-esophageal reflux disease and ineffective esophageal motility

PURPOSE

In gastro-esophageal reflux disease (GERD) requiring surgical treatment, concomitant ineffective esophageal motility (IEM) is a decisive factor in surgical planning, due to concern regarding dysphagia. Anti-reflux surgery with the RefluxStop device is a promising technique. We assessed initial feasibility and clinical outcomes of RefluxStop surgery in patients with GERD and IEM.

METHODS

Retrospective analysis of patients with GERD, hiatal hernia (HH), and IEM, who underwent surgery with RefluxStop at our institution and achieved 12-month follow-up. Technique feasibility was assessed, in addition to symptom resolution (GERD-HRQL questionnaire), adverse events, HH recurrence, dysphagia, and patient satisfaction. Placement of the device was confirmed by video fluoroscopy on postoperative day 1, and at 3 and 12 months.

RESULTS

Between June 2020 and November 2022, 20 patients with IEM underwent surgery with RefluxStop and completed 12-month follow-up. All patients reported typical symptoms of GERD, and 12 had preoperative dysphagia. The median HH length was 4.5 cm (IQR, 3.75-5). The median operating time was 59.5 min (IQR, 50.25-64) with no implant-related intra- or postoperative complications. No HH recurrence was observed. One patient reported persistent left-sided thoracic pain at 11 months post-surgery, which required diagnostic laparoscopy and adhesiolysis. Three patients reported severe postoperative dysphagia: balloon dilatation was performed towards resolution. The mean GERD-HRQL scores improved (from 40.7 at baseline to 4.8 at 3 months and 5.7 at 12 months (p <0.001)).

CONCLUSION

RefluxStop surgery was feasible and offered effective treatment for this group of patients with GERD and IEM. All patients had complete resolution or significant improvement of GERD symptoms, and 90% of them were satisfied with their quality of life 1 year after surgery.

Chicago Classification Version 4.0 Improves Stratification of Ineffective Esophageal Motility Patients into Clinically Meaningful Subtypes: A Two-Center International Study

The 4th iteration of the Chicago Classification (CC v4.0) for esophageal motility disorders offers more restrictive criteria for the diagnosis of Ineffective Esophageal Motility (IEM) compared to version 3.0 (CC v3.0). In light of the updated criteria for IEM, we aimed to characterize and compare the patients who retained their IEM diagnosis to those who were reclassified as normal motility, and to evaluate the clinical impact of the newly introduced CC v4.0. We performed a retrospective case-control study. We included all individuals who underwent a high-resolution manometry (HRM) between 2020 and 2021 at two centers. Consecutive studies reported as IEM according to the CC v3.0 were reanalyzed according to the CC v4.0. We compared demographics, clinical, manometry, and pH-monitoring parameters. Out of 452 manometry studies, 154 (34%) met criteria for IEM as per the CC v3.0 (CC v3.0 IEM group). Of those, 39 (25%) studies were reclassified as normal studies according to the CC v4.0 (CC v4.0 normal group), while the remaining 115 studies (25% of the overall cohort) retained an IEM diagnosis (CC v4.0 IEM group). The CC v4.0 normal group had more recovered contractions during solid swallows (p = 0.01), less ineffective swallows (p = 0.04), and lower acid exposure time (p = 0.02) compared to the CC4.0 IEM group. Under CC v4.0 criteria, fewer patients are diagnosed with IEM. Those diagnosed with IEM had worse esophageal function and higher acid burden. Though further studies are needed to confirm these findings, our results indicate that CC v4.0 criteria restrict the IEM diagnosis to a more clinically meaningful population.

Comparison of Diagnosis of Esophageal Motility Disorders by Chicago Classification Versions 3.0 and 4.0

Background/Aims

We aim to investigate the diagnostic accuracy and differences between Chicago classification version 3.0 (CC v3.0) and 4.0 (CC v4.0).

Methods

Patients who underwent high-resolution esophageal manometry (HRM) for suspected esophageal motility disorders were prospectively recruited between May 2020 and February 2021. The protocol of HRM studies included additional positional change and provocative testing designed by CC v4.0.

Results

Two hundred forty-four patients were included. The median age was 59 (interquartile range, 45-66) years, and 46.7% were males. Of these, 53.3% (n = 130) and 61.9% (n = 151) were categorized as normalcy by CC v3.0 and CC v4.0, respectively. The 15 patients diagnosed of esophagogastric junction outflow obstruction (EGJOO) by CC v3.0 was changed to normalcy by position (n = 2) and symptom (n = 13) by CC v4.0. In seven patients, the ineffective esophageal motility (IEM) diagnosis by CC v3.0 was changed to normalcy by CC v4.0. The diagnostic rate of achalasia increased from 11.1% (n = 27) to 13.9% (n = 34) by CC v4.0. Of patients diagnosed IEM by CC v3.0, 4 was changed to achalasia based on the functional lumen imaging probe (FLIP) results by CC v4.0. Three patients (2 with absent contractility and 1 with IEM in CC v3.0) were newly diagnosed with achalasia using a provocative test and barium esophagography by CC v4.0.

Conclusions

CC v4.0 is more rigorous than CC v3.0 for the diagnosis of EGJOO and IEM and diagnoses achalasia more accurately by using provocative tests and FLIP. Further studies on the treatment outcomes following diagnosis with CC v4.0 are needed.

Ineffective esophageal motility is associated with acute rejection after lung transplantation independent of gastroesophageal reflux

BACKGROUND

Gastroesophageal reflux is associated with poorer outcomes after lung transplant, likely through recurrent aspiration and allograft injury. Although prior studies have demonstrated a relationship between impedance-pH results and transplant outcomes, the role of esophageal manometry in the assessment of lung transplant patients remains debated, and the impact of esophageal dysmotility on transplant outcomes is unclear. Of particular interest is ineffective esophageal motility (IEM) and its associated impact on esophageal clearance.

AIM

To assess the relationship between pre-transplant IEM diagnosis and acute rejection after lung transplantation.

METHODS

This was a retrospective cohort study of lung transplant recipients at a tertiary care center between 2007 and 2018. Patients with pre-transplant anti-reflux surgery were excluded. Manometric and reflux diagnoses were recorded from pre-transplant esophageal function testing. Time-to-event analysis using Cox proportional hazards model was applied to evaluate outcome of first episode of acute cellular rejection, defined histologically per International Society of Heart and Lung Transplantation guidelines. Subjects not meeting this endpoint were censored at time of post-transplant anti-reflux surgery, last clinic visit, or death. Fisher’s exact test for binary variables and student’s t-test for continuous variables were performed to assess for differences between groups.

RESULTS

Of 184 subjects (54% men, mean age: 58, follow-up: 443 person-years) met criteria for inclusion. Interstitial pulmonary fibrosis represented the predominant pulmonary diagnosis (41%). During the follow-up period, 60 subjects (33.5%) developed acute rejection. The all-cause mortality was 16.3%. Time-to-event univariate analyses demonstrated significant association between IEM and acute rejection [hazard ratio (HR): 1.984, 95%CI: 1.03-3.30, P = 0.04], confirmed on Kaplan-Meier curve. On multivariable analysis, IEM remained independently associated with acute rejection, even after controlling for potential confounders such as the presence of acid and nonacid reflux (HR: 2.20, 95%CI: 1.18-4.11, P = 0.01). Nonacid reflux was also independently associated with acute rejection on both univariate (HR: 2.16, 95%CI: 1.26-3.72, P = 0.005) and multivariable analyses (HR: 2.10, 95%CI: 1.21-3.64, P = 0.009), adjusting for the presence of IEM.

CONCLUSION

Pre-transplant IEM was associated with acute rejection after transplantation, even after controlling for acid and nonacid reflux. Esophageal motility testing may be considered in lung transplant to predict outcomes.

The Relationship Between Vocal Fold Mobility Disorders and Ineffective Esophageal Motility

OBJECTIVE

Deglutition, speech production, and airway protection are extraordinarily complex, interrelated functions that are coordinated, in large part, by the motor and sensory innervation of CN X. Previous studies assessing the relationship between neurogenic voice disorders and dysphagia have focused on the risk of aspiration due to glottic insufficiency and the association of vocal fold hypomobility (VFH) with systemic neurologic disease. The purpose of this study was to investigate the relationship between VFH disorders and ineffective esophageal motility (IEM).

METHODS

Adult voice patients who underwent laryngeal electromyography (LEMG) and dual 24-hour pH impedance with high-resolution manometry (HRM) testing were included in the study. Subjects were assigned to one of two groups based on the presence or absence of moderate-to-severe RLN and/or SLN VFH (Mo-SLNH/RLNH) using results from six muscle LEMG tests. In subjects with Mo-SLNH/RLNH, there was 0-60% muscle recruitment on LEMG, whereas control subjects in the non-Mo-SLNH/RLNH group demonstrated 61-100% muscle recruitment. Analysis of mild-to-severe VFH (80% muscle recruitment or less) was also performed in a similar manner. The prevalence of IEM, defined using Chicago Classification Version 4.0 (CCv4.0), was compared between groups, as were HRM parameters.

RESULTS

One hundred sixty-two subjects were included (37.7% male/62.3% female, mean age of 43.88 ± 17.285). No differences in IEM prevalence were found when stratifying for cases of mild-to-severe VFH. However, there was significantly higher percentage of IEM in those with Mo-SLNH/RLNH. Mo-SLNH/RLNH subjects demonstrated higher rates of weak swallows and inefficient swallows, as well as lower IBP and UES residual pressures on HRM.

CONCLUSIONS

Patients with Mo-SLNH/RLNH demonstrated a significantly higher prevalence of IEM. Those with mild-to-severe VFH did not. Higher rates of ineffective and weak swallows, and lower IBP and UES residual pressures among Mo-SLNH/RLNH subjects suggest a possible connection between Mo-SLNH/RLNH and IEM disorders. These manometric differences were more prominent with sub-stratification of the Mo-SLNH/RLNH group by IEM. Additional research is advised.

The Supportive Role of Provocative Maneuvers and Impedance Clearance in Detecting Ineffective Esophageal Motility

BACKGROUND

Ineffective esophageal motility (IEM) is one of the most common esophageal motility disorders. However, the definition of IEM has evolved. Chicago classification version 4.0 (CCv4.0) made IEM parameters more stringent with greater than 70% of ineffective wet swallows (WS) necessary to diagnose conclusive IEM. Of the ineffective swallows, 50-70% are deemed "inconclusive cases". This study sought to determine whether provocative maneuvers, including multiple rapid swallows (MRS) and apple viscous swallows (AVS), and impedance clearance can provide supportive information for inconclusive IEM disorders based on CCv4.0.

METHODS

Esophageal motility data on 100 patients were analyzed. All patients completed WS and at least one additional swallow test (MRS and/or AVS). Patients were classified as having conclusive IEM, inconclusive IEM, or normal motility. IEM features detected on MRS/AVS and incomplete bolus clearance were recorded. Percentage of agreement between IEM features and incomplete bolus clearance was calculated for each motility group.

RESULTS

Ten patients had conclusive IEM, nine had inconclusive IEM, and 32 had normal motility. There was 70% agreement between IEM features and incomplete bolus clearance with conclusive IEM, 33% agreement with inconclusive IEM, and 9% agreement with normal motility. There was significantly more agreement in the conclusive and inconclusive IEM groups than in the normal motility group (P = 0.0003).

CONCLUSIONS

Combinational follow-up testing with provocative maneuvers and impedance clearance may assist with risk stratification of IEM patients and assist in further management of inconclusive IEM. MRS and AVS can detect unique IEM features that may help with preoperative management of inconclusive IEM.

Making Sense of Nonachalasia Esophageal Motor Disorders

Achalasia is the prototypical obstructive motor disorder diagnosed using HRM, but non-achalasia motor disorders are often identified in symptomatic patients. The clinical relevance of these disorders are assessed using ancillary HRM maneuvers (multiple rapid swallows, rapid drink challenge, solid swallows) that augment the standard supine HRM evaluation by challenging peristaltic function. Finding obstructive motor physiology in non-achalasia motor disorders may raise the option of invasive management akin to achalasia. Certain non-achalasia disorders, particularly hypermotility disorders, may manifest as epiphenomena seen with esophageal hypersensitivity. Symptomatic management is offered for superimposed reflux disease, psychological disorders, functional esophageal disorders, and behavioral disorders.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Ineffective esophageal motility is not a contraindication to total fundoplication

INTRODUCTION

Ineffective esophageal motility (IEM) is a physiologic diagnosis and is a component of the Chicago Classification. It has a strong association with gastroesophageal reflux and may be found during work-up for anti-reflux surgery. IEM implies a higher risk of post-op dysphagia if a total fundoplication is done. We hypothesized that IEM is not predictive of dysphagia following fundoplication and that it is safe to perform total fundoplication in appropriately selected patients.

METHODS

Retrospective chart review of patients who underwent total fundoplication between September 2012 and December 2018 in a single foregut surgery center and who had IEM on preoperative manometry. We excluded patients who had partial fundoplication, previous foregut surgery, other causes of dysphagia or an esophageal lengthening procedure. Dysphagia was assessed using standardized Dakkak score ≤ 40 and GERD-HRQL question 7 ≥ 3.

RESULTS

Two hundred patients were diagnosed with IEM and 31 met the inclusion criteria. Median follow-up: 706 days (IQR 278-1348 days). No preoperative factors, including subjective dysphagia, transit on barium swallow, or individual components of manometry showed statistical correlation with postoperative dysphagia. Of 9 patients with preoperative dysphagia, 2 (22%) had persistent postoperative dysphagia and 7 had resolution. Of 22 patients without preoperative dysphagia, 3 (14%) developed postoperative dysphagia; for a combined rate of 16%. No patient needed re-intervention beyond early recovery or required reoperation for dysphagia during the follow-up period.

CONCLUSION

In appropriately selected patients, when total fundoplication is performed in the presence of preoperative IEM, the rate of long-term postoperative dysphagia is similar to the reported rate of dysphagia without IEM. With appropriate patient selection, total fundoplication may be performed in patients with IEM without a disproportionate increase in postoperative dysphagia. The presence of preoperative IEM should not be rigidly applied as a contraindication to a total fundoplication.

Ineffective Esophageal Motility Is Associated with Impaired Bolus Clearance but Does Not Correlate with Severity of Dysphagia

BACKGROUND

Ineffective esophageal motility (IEM) is defined as a distal contractile integral < 450 mmHg/s/cm in at least 50% of ten liquid swallows on high-resolution esophageal manometry (HREM). Whether this latest definition correlates with degree of symptoms has not been studied.

METHODS

Patients presenting for HREM prospectively rated their symptoms using the Eckardt score. Topography plots were retrospectively reviewed and classified according to the latest Chicago Classification. Patients with non-obstructive dysphagia and an Eckardt score of at least 1 were included. Patients with major motility disorders were excluded. Scores between patients with IEM (group A) and patients with normal classification (group B) were compared using two-tailed t-tests. Spearman's correlation coefficient was calculated to determine correlation between symptoms and percent bolus clearance.

RESULTS

A total of 241 patients were screened; 33 patients met criteria for group A and 44 patients for group B. There was no difference between the two groups in mean symptom severity for dysphagia (1.63 vs. 1.61, P = 0.89), chest pain (0.67 vs. 0.75, P = 0.64), regurgitation (1.06 vs. 0.85, P = 0.32), or weight loss (0.85 vs. 0.49, P = 0.11). The percent bolus clearance was significantly lower in group A (46.5% vs. 76.7%, P > 0.01). There was a moderate inverse correlation between dysphagia and percent bolus clearance (R = - 0.37) in group A, but none in group B (R = 0.09).

CONCLUSION

The classification of IEM did not discriminate from normal studies for symptom severity in our cohort. However, patients with IEM did have an inverse correlation between dysphagia score and bolus clearance, but those without IEM did not. Adding impedance information to the motor pattern classification should be considered in the symptom assessment in minor motility disorders.

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

Background

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

Methods

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

Results

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

Conclusions

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

Multiple rapid swallow testing in patients with gastroesophageal reflux disease

Patients with gastroesophageal reflux disease are commonly referred to a gastrointestinal motility unit for assessment of esophageal physiology tests prior to an anti-reflux procedure. On esophageal manometry, most patients have normal peristalsis; however, minor disorders of motility such as ineffective esophageal motility and fragmented peristalsis are not uncommon. Multiple rapid swallow (MRS) test is a provocative method for assessing peristaltic reserve in such patients. We report our single-center experience on MRS testing. ᅟ ᅟ.

The Effect of Ineffective Esophageal Motility on Gastroesophageal Reflux Disease

BACKGROUND/AIMS

Ineffective esophageal motility (IEM) is the most common gastrointestinal motility disorder. Studies have reported that IEM is related to gastroesophageal reflux disease (GERD). However, the relationship between IEM and GERD remains uncertain. This study aims to clarify this relationship retrospectively.

METHODS

We analyzed 195 subjects who underwent high-resolution manometry between January 2011 and September 2016. Of these subjects, 72 had normal esophageal motility (NEM) and 26 had IEM. We investigated differences in the clinical characteristics, severity and duration of GERD symptoms, and comorbid extra-esophageal symptoms of the subjects. Comorbid extra-esophageal symptoms were assessed with the Gastrointestinal Symptom Rating Scale questionnaire. Investigation-defined GERD was diagnosed when erosive esophagitis or abnormal multichannel intraluminal impedance was present.

RESULTS

We found no significant difference in the prevalence of IEM between patients with and without GERD (37.5 and 21.1%, respectively; p = 0.174). There were no differences in age, gender, body mass index, presence of hiatal hernia, or duration of GERD between the groups. Compared to patients with NEM, those with IEM were significantly less likely to have comorbid extra-esophageal symptoms (p < 0.05).

CONCLUSION

There is no association between IEM and GERD.

Role of Mixed Reflux and Hypomotility with Delayed Reflux Clearance in Patients with Non-cardiac Chest Pain

Background/Aims

Gastroesophageal reflux disease (GERD) is the most common cause of non-cardiac chest pain (NCCP). Currently available data reveal a weak relationship between NCCP and dysmotility. Moreover, it is unclear why some refluxes are perceived as heartburn and others as NCCP. We aimed to evaluate the role of the reflux pattern and the esophageal motility in patients with NCCP.

Methods

Forty-eight patients with NCCP (Group 1) and 50 only typical GERD symptoms (Group 2) were included and underwent high-resolution manometry (HRM) and multichannel intraluminal impedance-pH monitoring.

Results

Impaired peristalsis was found in 60% of patients with NCCP and in 24% of patients with typical symptoms (P < 0.05). In patients belonging to Group 1, the majority of reflux episodes associated with chest pain were acid and mixed. The proportion of mixed refluxes was higher than that in Group 2. In Group 1, the reflux clearing time at 5, 9, and 15 cm, measured in reflux episodes associated to NCCP was longer than in reflux episodes associated to typical symptoms (mean ± 95% CI: 27.2 ± 5.6, 23.3 ± 4.4, and 14.6 ± 2.3 seconds vs 18.3 ± 3.5, 13.3 ± 2.2, and 11.1 ± 1.8 seconds; P < 0.01).

Conclusions

The presence of gas in the refluxate seems to be associated with NCCP. The impaired motility observed in NCCP patients may play a relevant role in delaying reflux clearing, hence increasing the time of contact between refluxate and esophageal mucosa.

The Chicago classification of motility disorders: an update

The Chicago Classification defines esophageal motility disorders in high resolution manometry. This is based on individual scoring of 10 swallows performed in supine position. Disorders of esophago-gastric junction (EGJ) outflow obstruction are defined by a median integrated relaxation pressure above the limit of normal and divided into 3 achalasia subtypes and EGJ outflow obstruction. Major motility disorders (aperistalsis, distal esophageal spasm, and hypercontractile esophagus) are patterns not encountered in controls in the context of normal EGJ relaxation. Finally with the latest version of the Chicago Classification, only two minor motor disorders are considered: ineffective esophageal motility and fragmented peristalsis.

Esophageal motility abnormalities in gastroesophageal reflux disease

Esophageal motility abnormalities are among the main factors implicated in the pathogenesis of gastroesophageal reflux disease. The recent introduction in clinical and research practice of novel esophageal testing has markedly improved our understanding of the mechanisms contributing to the development of gastroesophageal reflux disease, allowing a better management of patients with this disorder. In this context, the present article intends to provide an overview of the current literature about esophageal motility dysfunctions in patients with gastroesophageal reflux disease. Esophageal manometry, by recording intraluminal pressure, represents the gold standard to diagnose esophageal motility abnormalities. In particular, using novel techniques, such as high resolution manometry with or without concurrent intraluminal impedance monitoring, transient lower esophageal sphincter (LES) relaxations, hypotensive LES, ineffective esophageal peristalsis and bolus transit abnormalities have been better defined and strongly implicated in gastroesophageal reflux disease development. Overall, recent findings suggest that esophageal motility abnormalities are increasingly prevalent with increasing severity of reflux disease, from non-erosive reflux disease to erosive reflux disease and Barrett’s esophagus. Characterizing esophageal dysmotility among different subgroups of patients with reflux disease may represent a fundamental approach to properly diagnose these patients and, thus, to set up the best therapeutic management. Currently, surgery represents the only reliable way to restore the esophagogastric junction integrity and to reduce transient LES relaxations that are considered to be the predominant mechanism by which gastric contents can enter the esophagus. On that ground, more in depth future studies assessing the pathogenetic role of dysmotility in patients with reflux disease are warranted.

Influence of endoscopic submucosal dissection on esophageal motility

AIM: To assess esophageal motility after esophageal endoscopic submucosal dissection (ESD).

METHODS: Twelve patients (6 men and 6 women) aged 53-64 years (mean age, 58 years) who underwent regular examination 3-12 mo after esophageal ESD for neoplasms of the esophageal body were included in this study. The ESD procedure was performed under deep sedation using a combination of propofol and fentanyl, and involved a submucosal injection to lift the lesion and use of a dual-knife and an insulated-tip knife to create a circumferential incision around the lesion extending into the submucosa. Esophageal motility was examined using a high-resolution manometry system. Dysphagia was graded using a five-point scale according to the Mellow and Pinkas scoring system. Patient symptoms and the results of esophageal manometry were then analyzed.

RESULTS: Of the 12 patients enrolled, 1 patient had grade 2 dysphagia, 1 patient had grade 1 dysphagia, and 3 patients complained of sporadic dysphagia. Ineffective esophageal motility was observed in 5 of 6 patients with above semi-circumference of resection extension. Of these 5 patients, 1 patient complained of grade 2 dysphagia (with esophageal stricture), one patient complained of grade 1 dysphagia, and 3 patients complained of sporadic dysphagia. Normal esophageal body manometry was observed in all 6 patients with below semi-circumference of resection extension. The 6 patients with normal esophageal motility did not complain of dysphagia.

CONCLUSION: Extensive esophageal ESD may cause esophageal dysmotility in some patients, and might also have an influence on dysphagia although without esophageal stricture.

Habitual rapid food intake and ineffective esophageal motility

AIM: To study non-cardiac chest pain (NCCP) in relation to ineffective esophageal motility (IEM) and rapid food intake.

METHODS: NCCP patients with a self-reported habit of fast eating underwent esophageal manometry for the diagnosis of IEM. Telephone interviews identified eating habits of additional IEM patients. Comparison of manometric features was done among IEM patients with and without the habit of rapid food intake and healthy controls. A case study investigated the effect of 6-mo gum chewing on restoration of esophageal motility in an IEM patient. The Valsalva maneuver was performed in IEM patients and healthy controls to assess the compliance of the esophagus in response to abdominal pressure increase.

RESULTS: Although most patients diagnosed with NCCP do not exhibit IEM, remarkably, all 12 NCCP patients who were self-reporting fast eaters with a main complaint of chest pain (75.0%) had contraction amplitudes in the mid and distal esophagus that were significantly lower compared with healthy controls [(23.45 mmHg (95%CI: 14.06-32.85) vs 58.80 mmHg (95%CI: 42.56-75.04), P < 0.01 and 28.29 mmHg (95%CI: 21.77-34.81) vs 50.75 mmHg (95%CI: 38.44-63.05), P < 0.01, respectively)]. In 7 normal-eating IEM patients with a main complaint of sensation of obstruction (42.9%), the mid amplitude was smaller than in the controls [30.09 mmHg (95%CI: 19.48-40.70) vs 58.80 mmHg (95%CI: 42.56-75.04), P < 0.05]. There was no statistically significant difference in manometric features between the fast-eating and normal-eating groups. One NCCP patient who self-reported fast eating and was subsequently diagnosed with IEM did not improve with proton-pump inhibition but restored swallow-induced contractions upon 6-mo gum-chewing. The Valsalva maneuver caused a markedly reduced pressure rise in the mid and proximal esophagus in the IEM patients.

CONCLUSION: Habitual rapid food intake may lead to IEM. A prospective study is needed to validate this hypothesis. Gum-chewing might strengthen weakened esophageal muscles.

Is ineffective esophageal motility associated with gastropharyngeal reflux disease?

AIM: To evaluate the association between ineffective esophageal motility (IEM) and gastropharyngeal reflux disease (GPRD) in patients who underwent ambulatory 24-h dual-probe pH monitoring for the evaluation of supraesophageal symptoms.

METHODS: A total of 632 patients who underwent endoscopy, esophageal manometry and ambulatory 24-h dual-pH monitoring due to supraesophageal symptoms (e.g. globus, hoarseness, or cough) were enrolled. Of them, we selected the patients who had normal esophageal motility and IEM. The endoscopy and ambulatory pH monitoring findings were compared between the two groups.

RESULTS: A total of 264 patients with normal esophageal motility and 195 patients with the diagnosis of IEM were included in this study. There was no difference in the frequency of reflux esophagitis and hiatal hernia between the two groups. All the variables showing gastroesophageal reflux and gastropharyngeal reflux were not different between the two groups. The frequency of GERD and GPRD, as defined by ambulatory pH monitoring, was not different between the two groups.

CONCLUSION: There was no association between IEM and GPRD as well as between IEM and GERD. IEM alone cannot be considered as a definitive marker for reflux disease.