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Capogreco A, de Sire R, Massimi D, Alfarone L, Maselli R, Hassan C, Repici A. Underwater coagulation using hybrid knife in peroral endoscopic myotomy for achalasia. Endoscopy 2024; 56:E197-E198. [PMID: 38388954 PMCID: PMC10883876 DOI: 10.1055/a-2258-8371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Affiliation(s)
- Antonio Capogreco
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Roberto de Sire
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Davide Massimi
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Ludovico Alfarone
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Roberta Maselli
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Cesare Hassan
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Alessandro Repici
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
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Nagl S, Ebigbo A, Barthet M, Messmann H. Impedance planimetry-guided peroral endoscopic myotomy of the fundoplication valve. Endoscopy 2024; 56:E326. [PMID: 38594003 PMCID: PMC11003803 DOI: 10.1055/a-2291-9572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Affiliation(s)
- Sandra Nagl
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Alanna Ebigbo
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Marc Barthet
- Department of Hepatogastroenterology, Assistance Publique des Hôpitaux de Marseille Aix-Marseille, Université Hôpital Nord Marseille, Marseille, France
| | - Helmut Messmann
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
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Ikeda H, Ihara E, Takeya K, Mukai K, Onimaru M, Ouchida K, Hata Y, Bai X, Tanaka Y, Sasaki T, Saito F, Eto M, Nakayama J, Oda Y, Nakamura M, Inoue H, Ogawa Y. The interplay between alterations in esophageal microbiota associated with Th17 immune response and impaired LC20 phosphorylation in achalasia. J Gastroenterol 2024; 59:361-375. [PMID: 38472375 DOI: 10.1007/s00535-024-02088-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 02/04/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND Achalasia is an esophageal motility disorder with an unknown etiology. We aimed to determine the pathogenesis of achalasia by studying alterations in esophageal smooth muscle contraction and the associated inflammatory response, and evaluate the role of esophageal microbiota in achalasia development. METHODS We analyzed esophageal mucosa and lower esophageal sphincter (LES) samples, obtained from patients with type II achalasia who underwent peroral endoscopic myotomy. Esophageal conditioned media obtained from patients were transferred into the mouse esophagus to determine whether the esophageal intraluminal environment is associated with achalasia. RESULTS Approximately 30% of 20-kDa myosin light chains (LC20) was phosphorylated in LES from the control group under resting and stimulated conditions, whereas less than 10% of LC20 phosphorylation was detected in achalasia under all conditions. The hypophosphorylation of LC20 in achalasia was associated with the downregulation of the myosin phosphatase-inhibitor protein CPI-17. Th17-related cytokines, including IL-17A, IL-17F, IL-22, and IL-23A, were significantly upregulated in achalasia. α-Diversity index of esophageal microbiota and the proportion of several microbes, including Actinomyces and Dialister, increased in achalasia. Actinomyces levels positively correlated with IL-23A levels, whereas Dialister levels were positively associated with IL-17A, IL-17F, and IL-22 levels. Esophageal IL-17F levels increased in mice after oral administration of the conditioned media. CONCLUSIONS In LES of patients with achalasia, hypophosphorylation of LC20, a possible cause of impaired contractility, was associated with CPI-17 downregulation and an increased Th17-related immune response. The esophageal intraluminal environment, represented by the esophageal microbiota, could be associated with the development and exacerbation of achalasia.
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Affiliation(s)
- Hiroko Ikeda
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka, 812-8582, Japan
| | - Eikichi Ihara
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka, 812-8582, Japan.
| | - Kosuke Takeya
- Faculty of Veterinary Medicine, Okayama University of Science, Ehime, Japan
| | - Koji Mukai
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka, 812-8582, Japan
| | - Manabu Onimaru
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Kenoki Ouchida
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshitaka Hata
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka, 812-8582, Japan
| | - Xiaopeng Bai
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka, 812-8582, Japan
| | - Yoshimasa Tanaka
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka, 812-8582, Japan
| | - Taisuke Sasaki
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Fumiyo Saito
- Faculty of Veterinary Medicine, Okayama University of Science, Ehime, Japan
| | - Masumi Eto
- Faculty of Veterinary Medicine, Okayama University of Science, Ehime, Japan
| | - Jiro Nakayama
- Laboratory of Microbial Technology, Division of Systems Bioengineering, Department of Bioscience and Biotechnology, Faculty of Agriculture, Graduate School, Kyushu University, Fukuoka, Japan
| | - Yoshinao Oda
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Yoshihiro Ogawa
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka, 812-8582, Japan
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Ugwuegbu O, Shibli F, Kim Y, Rangan V, Kurin M, Ayoub F, Ganocy S, Kavitt R, Fass R. The Impact of Chronic Cannabis Use on Esophageal Motility in Patients Referred for Esophageal Manometry. J Clin Gastroenterol 2024; 58:342-348. [PMID: 37436840 DOI: 10.1097/mcg.0000000000001887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 05/21/2023] [Indexed: 07/14/2023]
Abstract
BACKGROUND Tetrahydrocannabinol, the main psychoactive compound in cannabis, binds with high affinity to the cannabinoid 1 receptor. Small randomized controlled studies using conventional manometry have shown that the cannabinoid 1 receptor can modulate esophageal function, namely transient lower esophageal sphincter relaxation frequency and lower esophageal sphincter tone. The effect of cannabinoids on esophageal motility in patients referred for esophageal manometry has not been fully elucidated using high-resolution esophageal manometry (HREM). We aimed to characterize the clinical effect of chronic cannabis use on esophageal motility utilizing HREM. METHODS Patients who underwent HREM from 2009 to 2019 were identified at 4 academic medical centers. The study group consisted of patients with a noted history of chronic cannabis use, a diagnosis of cannabis-related disorder, or a positive urine toxicology screen. Age and gender-matched patients with no history of cannabis use were selected to form the control group. Data on HREM metrics based on the Chicago classification V3, and the prevalence of esophageal motility disorders were compared. Confounding effects of BMI and medications on esophageal motility were adjusted for. RESULTS Chronic cannabis use was found to be an independent negative predictor of weak swallows (β=-8.02, P =0.0109), but not a predictor of failed swallows ( P =0.6890). The prevalence of ineffective esophageal motility was significantly lower in chronic cannabis users compared with nonusers (OR=0.44, 95% CI 0.19-0.93, P =0.0384). There was no significant difference in the prevalence of other esophageal motility disorders between the 2 cohorts. In patients with dysphagia as their primary indication for HREM, chronic cannabis use was found to be independently associated with increased median integrated relaxation pressure (β=6.638, P =0.0153) and increased mean lower esophageal sphincter resting pressure (β=10.38, P =0.0084). CONCLUSIONS Chronic cannabis use is associated with decreased weak swallows and reduced prevalence of ineffective esophageal motility in patients referred for esophageal manometry. In patients referred for dysphagia, chronic cannabis use is associated with increased integrated relaxation pressure and lower esophageal sphincter resting pressure, though not to levels above the normal range.
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Affiliation(s)
- Obinna Ugwuegbu
- Case Western Reserve University, School of Medicine, Cleveland, OH
- Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
| | - Fahmi Shibli
- Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
| | - Yeseong Kim
- Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
| | - Vikram Rangan
- Beth Israel Deaconess Medical Center. Digestive Disease Center, Harvard University, Boston, MA
| | - Michael Kurin
- Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
- University Hospitals Cleveland Medical Center Department of Gastroenterology and Hepatology, Case Western Reserve University, Cleveland, OH
| | - Fares Ayoub
- Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago Medicine, Chicago, IL
| | - Stephen Ganocy
- Center for Health Care Research and Policy, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH
| | - Robert Kavitt
- Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago Medicine, Chicago, IL
| | - Ronnie Fass
- Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
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Boris L, Eriksson SE, Sarici IS, Zheng P, Kuzy J, Scott S, Jobe BA, Ayazi S. Esophageal body adaptation to Nissen fundoplication: Increased esophagogastric outflow resistance yields delayed and sustained peristaltic contractions without increased amplitude. Neurogastroenterol Motil 2024; 36:e14740. [PMID: 38251459 DOI: 10.1111/nmo.14740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 12/11/2023] [Accepted: 01/01/2024] [Indexed: 01/23/2024]
Abstract
BACKGROUND Improvement in lower esophageal sphincter (LES) competency after laparoscopic Nissen fundoplication (LNF) is well established, yet esophageal body physiology data are limited. We aimed to describe the impact of LNF on whole esophagus physiology using standard and novel manometric characteristics. METHODS A cohort of patients with an intact fundoplication without herniation and no postoperative dysphagia were selected and underwent esophageal manometry at one-year after surgery. Pre- and post-operative manometry files were reanalyzed using standard and novel manometric characteristics and compared. KEY RESULTS A total of 95 patients were included in this study. At 16.1 (8.7) months LNF increased LES overall and abdominal length and resting pressure (p < 0.0001). Outflow resistance (IRP) increased [5.8 (3-11) to 11.1 (9-15), p < 0.0001] with a 95th percentile of 20 mmHg in this cohort of dysphagia-free patients. Distal contractile integral (DCI) also increased [1177.0 (667-2139) to 1321.1 (783-2895), p = 0.002], yet contractile amplitude was unchanged (p = 0.158). There were direct correlations between pre- and post-operative DCI [R: 0.727 (0.62-0.81), p < 0.0001] and postoperative DCI and postoperative IRP [R: 0.347 (0.16-0.51), p = 0.0006]. Contractile front velocity [3.5 (3-4) to 3.2 (3-4), p = 0.0013] was slower, while distal latency [6.7 (6-8) to 7.4 (7-9), p < 0.0001], the interval from swallow onset to proximal smooth muscle initiation [4.0 (4-5) to 4.4 (4-5), p = 0.0002], and the interval from swallow onset to point when the peristaltic wave meets the LES [9.4 (8-10) to 10.3 (9-12), p < 0.0001] were longer. Esophageal length [21.9 (19-24) to 23.2 (21-25), p < 0.0001] and transition zone (TZ) length [2.2 (1-3) to 2.5 (1-4), p = 0.004] were longer. Bolus clearance was inversely correlated with TZ length (p = 0.0002) and time from swallow onset to proximal smooth muscle initiation (p < 0.0001). Bolus clearance and UES characteristics were unchanged (p > 0.05). CONCLUSIONS & INFERENCES Increased outflow resistance after LNF required an increased DCI. However, this increased contractile vigor was achieved through sustained, not stronger, peristaltic contractions. Increased esophageal length was associated with increased TZ and delayed initiation of smooth muscle contractions.
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Affiliation(s)
- Lubomyr Boris
- Foregut Division, Surgical Institute, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Sven E Eriksson
- Foregut Division, Surgical Institute, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
- Chevalier Jackson Research Foundation, Esophageal Institute, Western Pennsylvania Hospital, Pittsburgh, Pennsylvania, USA
| | - Inanc S Sarici
- Foregut Division, Surgical Institute, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
- Chevalier Jackson Research Foundation, Esophageal Institute, Western Pennsylvania Hospital, Pittsburgh, Pennsylvania, USA
| | - Ping Zheng
- Foregut Division, Surgical Institute, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
- Chevalier Jackson Research Foundation, Esophageal Institute, Western Pennsylvania Hospital, Pittsburgh, Pennsylvania, USA
| | - Jacob Kuzy
- Foregut Division, Surgical Institute, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Sarah Scott
- Foregut Division, Surgical Institute, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Blair A Jobe
- Foregut Division, Surgical Institute, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
- Chevalier Jackson Research Foundation, Esophageal Institute, Western Pennsylvania Hospital, Pittsburgh, Pennsylvania, USA
- Department of Surgery, Drexel University, Philadelphia, Pennsylvania, USA
| | - Shahin Ayazi
- Foregut Division, Surgical Institute, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
- Chevalier Jackson Research Foundation, Esophageal Institute, Western Pennsylvania Hospital, Pittsburgh, Pennsylvania, USA
- Department of Surgery, Drexel University, Philadelphia, Pennsylvania, USA
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Ioannou A, Koumentakis C, Torresan F. Butterfly Wings Effect on High Resolution Manometry in A Patient with Esophageal Achalasia. J Gastrointestin Liver Dis 2024; 33:15. [PMID: 38554412 DOI: 10.15403/jgld-5393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 01/30/2024] [Indexed: 04/01/2024]
Abstract
A 57-year-old man presented with dysphagia in solids and liquids deteriorating in the last months and weight loss of 3 kg. A thoracic CT revealed a limit dilatation of the lower esophagus with food residue. An upper endoscopy was performed revealing bubble content and a contraction of the Lower Esophageal Sphincter (LES). A barium esophagogram demonstrated deceleration of esophageal emptying and a bird beak sign indicative of esophageal achalasia (Figure A). High resolution esophageal manometry was performed to evaluate the subtype of achalasia. The catheter could not be intubated into the stomach because of LES spasticity, it folded back cephalad at this level, producing a mirror image, the characteristic "butterfly wings" appearance of a folded manometry catheter (Figure B).
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Affiliation(s)
| | | | - Francesco Torresan
- Gastroenterology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna Policlinico di Sant'Orsola-Malpighi, Bologna, Italy.
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Reddy CA, Ellison A, Cipher DJ, Mendoza R, Souza RF, Spechler SJ, Konda VJA, Nguyen AD. Frequent discrepancies among diagnostic tests for detecting lower esophageal sphincter-related obstruction. Neurogastroenterol Motil 2024; 36:e14729. [PMID: 38129627 DOI: 10.1111/nmo.14729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 11/19/2023] [Accepted: 12/02/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND There are frequent discrepancies among high-resolution manometry (HRM), functional lumen imaging probe (FLIP), and esophagram in identifying lower esophageal sphincter (LES)-related obstruction. We aimed to determine the frequency of those discrepancies and how they influenced clinical treatment/outcomes. METHODS We identified patients who had all three tests (HRM, FLIP, and esophagram) and endoscopy performed for evaluation of esophageal symptoms in our Center for Esophageal Diseases. Discrepancies among the tests for the presence of LES obstruction were noted, and the performance of individual tests was compared against a consensus opinion rendered by a panel of esophagologists. Binary logistical regression was performed, and ROC curves were generated for prediction of the consensus clinical diagnosis of LES obstruction. KEY RESULTS A total of 126 patients (mean age 57.9 ± 17.0 years; 67% female) met inclusion criteria. All three tests agreed on the presence or absence of LES obstruction in only 72 (57%) patients [no LES obstruction in 57 (45%), LES obstruction in 15 (12%)]. Thirteen patients (10%) had a change in management based on additional findings on FLIP +/- esophagram not seen on HRM with 69% having symptomatic improvement after LES-directed intervention. FLIP was the strongest predictor of a consensus diagnosis of LES obstruction by logistic regression and ROC (OR 23.36, AUC 0.796), followed by HRM (OR 15.41, AUC 0.764). CONCLUSIONS & INFERENCE High-resolution manometry, functional lumen imaging probe, and esophagram each have considerable limitations for identifying LES obstruction, and discrepancies among these tests occur frequently. Multimodal testing is often required for adequate evaluation of LES-related obstruction.
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Affiliation(s)
- Chanakyaram A Reddy
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Ashton Ellison
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Daisha J Cipher
- College of Nursing and Health Innovation, The University of Texas at Arlington, Arlington, Texas, USA
| | - Roseann Mendoza
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Rhonda F Souza
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Stuart J Spechler
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Vani J A Konda
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Anh D Nguyen
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
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Vespa E, Farina DA, Pandolfino JE, Kahrilas PJ, Koop AH, Carlson DA. Presence of esophageal contractility after achalasia treatment is associated with improved esophageal emptying. Neurogastroenterol Motil 2024; 36:e14732. [PMID: 38155413 PMCID: PMC10922458 DOI: 10.1111/nmo.14732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 10/19/2023] [Accepted: 12/14/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND AND AIMS Some achalasia patients exhibit esophageal contractile activity on follow-up after treatment, yet its importance remains unclear. We aimed to identify factors associated with presence of contractility after treatment and to assess its impact on timed barium esophagram (TBE) and clinical outcomes. METHODS Patients with type I or II achalasia on baseline high-resolution manometry (HRM) who completed HRM, TBE, and functional lumen imaging probe (FLIP) after treatment were retrospectively identified. Contractility was defined on post-treatment HRM as presence of at least 1 supine swallow with DCI ≥100 mmHg s cm. KEY RESULTS One hundred twenty-two patients were included (mean age 48 ± 17 years, 50% female). At follow-up evaluation after treatment (54% peroral endoscopic myotomy, 24% pneumatic dilation, 22% laparoscopic Heller myotomy), 61 (50%) patients had contractility on HRM. Patients with contractility (compared to those without) more frequently had type II achalasia (84% vs 57%, p = 0.001) and a post-treatment normal EGJ opening classification on FLIP (69% vs 49%; p < 0.001). In the subgroup of patients with post-treatment integrated relaxation pressure <15 mmHg and normal EGJ opening on FLIP (n = 53), those with contractility had a lower median column height on TBE at 1 min (4 vs 7 cm, p = 0.002) and 5 min (0 vs 5 cm, p = 0.001). In patients with "abnormal" EGJ metrics, patients with contractility showed lower symptom scores (median Eckardt score 2 vs 3, p = 0.03). CONCLUSIONS & INFERENCES Occurring more frequently in type II achalasia, and if adequate EGJ opening is achieved after treatment, esophageal contractility may contribute to improved esophageal emptying and improved symptoms in non-spastic achalasia. Preservation of esophageal body muscle could improve outcomes in these patients.
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Affiliation(s)
- Edoardo Vespa
- Division of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Domenico A. Farina
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - John E. Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Peter J. Kahrilas
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Andree H. Koop
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Dustin A. Carlson
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Barron JO, Raja S. Endoscopic Fundoplication for Type I Achalasia? The Jury Is Still Out. Ann Thorac Surg 2024; 117:666-667. [PMID: 37804909 DOI: 10.1016/j.athoracsur.2023.09.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 09/17/2023] [Indexed: 10/09/2023]
Affiliation(s)
- John O Barron
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Ave, J4-1, Cleveland, OH 44195
| | - Siva Raja
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Ave, J4-1, Cleveland, OH 44195.
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Chuah KH, Ramasami N, Mahendran HA, Shanmuganathan G, Koleth GG, Voon K, Gew LT, Jahit MS, Lau PC, Muthukaruppan R, Said RHM, Mahadeva S, Ho SH, Lim SY, Tee SC, Siow SL, Ooi WK, Lee YY. Malaysian joint societies' consensus recommendations on diagnosis and management of disorders of esophagogastric junction outflow. J Gastroenterol Hepatol 2024; 39:431-445. [PMID: 38087846 DOI: 10.1111/jgh.16403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 09/13/2023] [Accepted: 10/18/2023] [Indexed: 03/05/2024]
Abstract
Disorders of esophagogastric junction (EGJ) outflow, including achalasia and EGJ outflow obstruction, are motility disorders characterized by inadequate relaxation of lower esophageal sphincter with or without impaired esophageal peristalsis. Current guidelines are technical and less practical in the Asia-Pacific region, and there are still massive challenges in timely diagnosis and managing these disorders effectively. Therefore, a Malaysian joint societies' task force has developed a consensus on disorders of EGJ outflow based on the latest evidence, while taking into consideration the practical relevance of local and regional context and resources. Twenty-one statements were established after a series of meetings and extensive review of literatures. The Delphi method was used in the consensus voting process. This consensus focuses on the definition, diagnostic investigations, the aims of treatment outcome, non-surgical or surgical treatment options, management of treatment failure or relapse, and the management of complications. This consensus advocates the use of high-resolution esophageal manometry for diagnosis of disorders of EGJ outflow. Myotomy, via either endoscopy or laparoscopy, is the preferred treatment option, while pneumatic dilatation can serve as a secondary option. Evaluation and management of complications including post-procedural reflux and cancer surveillance are recommended.
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Affiliation(s)
- Kee Huat Chuah
- Gastroenterology and Hepatology Unit, Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Naveen Ramasami
- Gastroenterology and Hepatology Unit, Department of Medicine, Sultanah Bahiyah Hospital, Alor Setar, Kedah, Malaysia
| | | | | | - Glenn George Koleth
- Gastroenterology and Hepatology Unit, Department of Medicine, Sultan Ismail Hospital, Johor Bahru, Johor, Malaysia
| | - Kelvin Voon
- Department of General Surgery, Penang General Hospital, George Town, Penang, Malaysia
| | - Lai Teck Gew
- Gastroenterology and Hepatology Unit, Department of Medicine, Kuala Lumpur General Hospital, Kuala Lumpur, Malaysia
| | | | - Peng Choong Lau
- Pantai Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
- Department of Surgery, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Raman Muthukaruppan
- Gastroenterology and Hepatology Unit, Department of Medicine, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia
| | - Rosaida Hj Md Said
- Gastroenterology and Hepatology Unit, Department of Medicine, Serdang Hospital, Serdang, Selangor, Malaysia
| | - Sanjiv Mahadeva
- Gastroenterology and Hepatology Unit, Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Shiaw-Hooi Ho
- Gastroenterology and Hepatology Unit, Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Shyang Yee Lim
- Department of General Surgery, Penang General Hospital, George Town, Penang, Malaysia
| | - Sze Chee Tee
- Department of Surgery, National Cancer Institute, Putrajaya, Malaysia
| | - Sze Li Siow
- Department of General Surgery, Sarawak General Hospital, Kuching, Sarawak, Malaysia
| | - Wei Keat Ooi
- Department of Surgery, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia
| | - Yeong Yeh Lee
- School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia
- GI Function and Motility Unit, Universiti Sains Malaysia Hospital, Kota Bharu, Kelantan, Malaysia
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11
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Li S, Chen X, Zhang L, Jin H, Wang B, Liu C, Ru S, Liu X, Zhao W. Early-onset esophageal squamous cell carcinoma with achalasia: A case report. Medicine (Baltimore) 2024; 103:e37140. [PMID: 38306510 PMCID: PMC10843513 DOI: 10.1097/md.0000000000037140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 01/11/2024] [Indexed: 02/04/2024] Open
Abstract
RATIONALE Individuals afflicted with achalasia of the cardia (AC) are more susceptible to the development of esophageal cancer (EC). However, the presence of esophageal retention obscured observation, making it difficult to detect EC early, which leads to misdiagnosis and poor prognosis in AC patients with EC. Besides, the persistence of high-risk factors may have contributed to the rapid progression of EC shortly after per-oral endoscopic myotomy (POEM). Therefore, it is imperative to alert clinicians to this extremely rare and instructive early-onset cancer. PATIENT CONCERNS The patient was a 67-year-old male who developed dysphagia 3 years ago without obvious causes, with intermittent onset and aggravating trend, accompanied by weight loss. He usually eats high-temperature foods and pickled foods, and has a family history of esophageal squamous cell carcinoma. DIAGNOSIS AND INTERVENTIONS The patient was initially diagnosed with AC 2 years ago and subsequently underwent POEM surgery. One year after surgery, he was found to have mid-upper EC during follow-up and underwent partial esophagectomy in time. OUTCOMES The patient's symptoms have significantly improved with weight gain, and he is still adhering to regular follow-up and endoscopic examination. LESSONS In rare cases, EC develops early in patients with achalasia after POEM surgery. To avoid missed diagnosis, a comprehensive examination to improve the accuracy to diagnose achalasia and identify possible early-onset cancer is very important in clinical practice. Especially for patients with AC who have a family history of EC or other high-risk factors may develop EC early after POEM surgery. Therefore, regular endoscopic follow-up after POEM surgery is essential.
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Affiliation(s)
- Shujin Li
- Department of Gastroenterology and Hepatology, General Hospital of Tianjin Medical University, Tianjin, China
| | - Xin Chen
- Department of Gastroenterology and Hepatology, General Hospital of Tianjin Medical University, Tianjin, China
| | - Lili Zhang
- Department of Gastroenterology and Hepatology, General Hospital of Tianjin Medical University, Tianjin, China
| | - Hong Jin
- Department of Gastroenterology and Hepatology, General Hospital of Tianjin Medical University, Tianjin, China
| | - Bin Wang
- Department of Gastroenterology and Hepatology, General Hospital of Tianjin Medical University, Tianjin, China
| | - Cong Liu
- Department of Gastroenterology and Hepatology, General Hospital of Tianjin Medical University, Tianjin, China
| | - Shiwei Ru
- Department of Gastroenterology and Hepatology, General Hospital of Tianjin Medical University, Tianjin, China
| | - Xuechai Liu
- Department of Gastroenterology and Hepatology, General Hospital of Tianjin Medical University, Tianjin, China
| | - Wei Zhao
- Department of Gastroenterology and Hepatology, General Hospital of Tianjin Medical University, Tianjin, China
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12
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Yang D, Draganov PV, Pohl H, Aihara H, Jeyalingam T, Khashab M, Liu N, Hasan MK, Jawaid S, Othman M, Al-Haddad M, DeWitt JM, Triggs JR, Wang AY, Bechara R, Sethi A, Law R, Aadam AA, Kumta N, Sharma N, Hayat M, Zhang Y, Yi F, Elmunzer BJ. Development and initial validation of a video-based peroral endoscopic myotomy assessment tool. Gastrointest Endosc 2024; 99:177-185. [PMID: 37500019 DOI: 10.1016/j.gie.2023.07.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/18/2023] [Accepted: 07/19/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND AND AIMS Video analysis has emerged as a potential strategy for performance assessment and improvement. We aimed to develop a video-based skill assessment tool for peroral endoscopic myotomy (POEM). METHODS POEM was deconstructed into basic procedural components through video analysis by an expert panel. A modified Delphi approach and 2 validation exercises were conducted to refine the POEM assessment tool (POEMAT). Twelve assessors used the final POEMAT version to grade 10 videos. Fully crossed generalizability (G) studies investigated the contributions of assessors, endoscopists' performance, and technical elements to reliability. G coefficients below .5 were considered unreliable, between .5 and .7 as modestly reliable, and above .7 as indicative of satisfactory reliability. RESULTS After task deconstruction, discussions, and the modified Delphi process, the final POEMAT comprised 9 technical elements. G analysis showed low variance for endoscopist performance (.8%-24.9%) and high interrater variability (range, 63.2%-90.1%). The G score was moderately reliable (≥.60) for "submucosal tunneling" and "myotomy" and satisfactorily reliable (≥.70) for "active hemostasis" and "mucosal closure." CONCLUSIONS We developed and established initial content and response process validity evidence for the POEMAT. Future steps include appraisal of the tool using a wider range of POEM videos to establish and improve the discriminative validity of this tool.
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Affiliation(s)
- Dennis Yang
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida, USA.
| | - Peter V Draganov
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
| | - Heiko Pohl
- Veterans Affairs Medical Center, White River Junction, Vermont; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Hiroyuki Aihara
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Thurarshen Jeyalingam
- Division of Gastroenterology and Hepatology, University of Toronto, Toronto, Ontario, Canada
| | - Mouen Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Nanlong Liu
- Division of Gastroenterology, University of Louisville, Louisville, Kentucky, USA
| | - Muhammad K Hasan
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida, USA
| | - Salmaan Jawaid
- Division of Gastroenterology, Baylor College of Medicine, Houston, Texas, USA
| | - Mohamed Othman
- Division of Gastroenterology, Baylor College of Medicine, Houston, Texas, USA
| | - Mohamed Al-Haddad
- Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - John M DeWitt
- Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Joseph R Triggs
- Division of Gastroenterology, Fox Chase Cancer Center, Temple Health, Philadelphia, Pennsylvania, USA
| | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, USA
| | - Robert Bechara
- Division of Gastroenterology and GI Diseases Research Unit, Queen's University, Kingston, Ontario, Canada
| | - Amrita Sethi
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, Presbyterian Hospital, New York, New York, USA
| | - Ryan Law
- Division of Gastroenterology and Hepatology, Mayo Clinic, Minneapolis, Minnesota, USA
| | - Aziz A Aadam
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Nikhil Kumta
- Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Neil Sharma
- Division of Interventional Oncology and Surgical Endoscopy (IOSE), Parkview Cancer Institute, Fort Wayne, Indiana, USA
| | - Maham Hayat
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida, USA
| | - YiYang Zhang
- Center for Collaborative Research, AdventHealth Research Institute, Orlando, Florida, USA
| | - Fanchao Yi
- Center for Collaborative Research, AdventHealth Research Institute, Orlando, Florida, USA
| | - B Joseph Elmunzer
- Department of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
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13
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Leahy PF. A Novel Therapeutic Method in Gastro-esophageal Reflux Disease. Surg Innov 2024; 31:71-74. [PMID: 38116630 DOI: 10.1177/15533506231223913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
BACKGROUND Gastro-esophageal reflux disease (GERD/GORD) is a chronic condition in which gastric acid flows backwards up into the esophagus, causing heart burn and a higher disposition to esophageal cancer. The reflux is caused by impairment of the lower esophageal sphincter (LES). Over the past century gastro-esophageal reflux has become the principal gastrointestinal condition of our time. The proton pump inhibitor class of drugs is effective in ameliorating the symptoms of reflux. The cost of investigation of patients in Europe is €100 billion per annum. The cost in days lost from work is €100 billion per annum in Europe. The global cost is 3 times this amount. METHODOLOGY The proposed device for treating gastro-esophageal reflux is a biodegradable valve that is placed non surgically in the esophago-gastric junction to prevent reflux from the stomach to the esophagus. EXPERIMENT RESULTS 50 simulator studies were performed with the patented device to elucidate the most consistent method of insertion and fixation in a human like simulator. The simulator was designed to replicate the normal human gastro-esophageal anatomy and characteristics. Four animal insertions were performed under ethical regulation at Amsterdam Medical Centre, Netherlands. Three cadaveric experiments were performed at Hackensack University Hospital, New Jersey, USA, to verify the positive outcomes of the simulator studies. CONCLUSION Successful outcomes of simulator studies and cadaveric experiments allowed the design freeze of a NoReflux device for treating gastro-esophageal reflux disease.
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14
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Josefsson A, Simrén M, Smolak A, Sabbagh N, Törnblom H. Natural history of symptoms and prognostic information of the rapid drink challenge and solid bolus swallows in esophagogastric junction outflow obstruction defined by manometry. Neurogastroenterol Motil 2024; 36:e14720. [PMID: 38073000 DOI: 10.1111/nmo.14720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 11/15/2023] [Accepted: 11/22/2023] [Indexed: 01/25/2024]
Abstract
BACKGROUND/INTRODUCTION Esophagogastric junction outflow obstruction (EGJOO) is a condition characterized by poor relaxation of the lower esophageal sphincter (LES), which can manifest as dysphagia and chest pain. The best treatment of EGJOO is unknown as some patients improve without any specific therapy, whereas some patients undergo invasive therapy. Currently, prognostic factors are lacking. We aimed to assess the long-term prognosis and predictors of dysphagia and chest pain by the rapid drink challenge and solid bolus swallows in EGJOO. METHODS We retrospectively assessed high-resolution esophageal manometries (HRM) performed at our center between 2015 and 2018. The patients completed a dysphagia and chest pain questionnaire a median of 34 months after the HRM/baseline assessment, including the Impaction dysphagia questionnaire-10 (IDQ-10) complemented with questions regarding chest pain and esophageal treatments. Symptoms were compared with HRM findings. RESULTS In all, 980 HRMs were analyzed and 66 (6.5%) were identified as having HRM findings compatible with EGJOO. Of these, 27 patients with EGJOO (41%) completed the follow-up questionnaires and had no exclusion criteria, and 70% of these patients had dysphagia and 44% chest pain at least once a week. Dysphagia at follow-up was more common in patients with elevated integrated relaxation pressure (IRP) on all three HRM metrics (water swallows, solid bolus swallows, and rapid drink challenge) (p = 0.03, odds ratio: 8.4 (95% CI: 1.2-56.0)), but this was not seen for chest pain (p = 0.45). Abnormal motility patterns on rapid drink challenge or solid bolus swallows were not associated with dysphagia or chest pain at follow-up. CONCLUSIONS Having a high IRP on three HRM metrics-water swallows, solid bolus swallows, and rapid drink challenge-is associated with a worse prognosis in patients with EGJOO and could potentially be used to select candidates suitable for invasive procedures.
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Affiliation(s)
- Axel Josefsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Magnus Simrén
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Center for Functional GI and Motility Disorders, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, USA
| | - Adam Smolak
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Nour Sabbagh
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Hans Törnblom
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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15
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Drury AM, Albunni H, Al-Haddad M, Powelson JA, Lutz A, Fridell JA. Role of gastric peroral endoscopic myotomy (GPOEM) in chronic gastroparesis management after pancreas transplantation. Clin Transplant 2024; 38:e15176. [PMID: 37922244 DOI: 10.1111/ctr.15176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/11/2023] [Accepted: 10/20/2023] [Indexed: 11/05/2023]
Abstract
Gastroparesis is a common complaint among patients with diabetes. Symptoms tend to improve following successful pancreas transplantation (PTx), but persist despite euglycemia in a subset of patients. We aimed to assess the benefit of gastric peroral endoscopic myotomy (G-POEM) in persistent gastroparesis following PTx. This was a single center retrospective review of all patients who underwent G-POEM for persistent gastroparesis following PTx. Patient demographics, pre and post procedure perception of symptom severity according to the patient assessment of upper gastrointestinal symptoms severity index (PAGI-SYM), gastroparesis cardinal symptom index (GCSI) score, and 36-item short form survey (SF36) score along with gastric emptying scintigraphy (GES) were analyzed. Seven PTx recipients underwent G-POEM for persistent gastroparesis symptoms. The majority were female. All reported nausea/vomiting, abdominal pain, bloating, and post prandial fullness prior to G-POEM. The post procedure survey scores improved in all patients although this was not significant. The improvement in gastric emptying on GES was statistically significant. G-POEM is a relatively new treatment option for gastroparesis. While it requires specialized proceduralist and training, we have documented improvement in the management of symptoms. With increasing experience, we anticipate more significant benefit in post PTx patients with persistent symptoms of gastroparesis undergoing G-POEM.
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Affiliation(s)
- Allison M Drury
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Hashem Albunni
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Mohammad Al-Haddad
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - John A Powelson
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Andrew Lutz
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jonathan A Fridell
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
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16
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Chen SF, Jia XY, Hou X, Tang MM, Tan ND, Zhang MY, Xiao YL, Wang JH. High-resolution manometry evaluation and endoscopic myotomy for pediatric cricopharyngeal achalasia: A case report and literature review. J Dig Dis 2024; 25:70-74. [PMID: 38375998 DOI: 10.1111/1751-2980.13253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 09/11/2023] [Accepted: 01/25/2024] [Indexed: 02/21/2024]
Affiliation(s)
- Song Feng Chen
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Xing Yu Jia
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Xun Hou
- Gastrointestinal Surgery Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Mi Mi Tang
- Department of Radiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Nian Di Tan
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Meng Yu Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Ying Lian Xiao
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Jin Hui Wang
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
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17
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Mubashir M, Andrus V, Okuampa D, Neice M, Armstrong E, Canezaro H, Dies R, Deville A, Kawji L, Rashid S, Raza SM, Hafiz N, Faisal ASM, Bhuiyan MAN, Cai Q. Short-term Outcome of Peroral Endoscopic Myotomy Performed by the Same Endoscopist on Achalasia and Nonachalasia Esophageal Motility Disorders. Surg Laparosc Endosc Percutan Tech 2023; 33:577-582. [PMID: 37852237 DOI: 10.1097/sle.0000000000001240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 07/31/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) is a relatively new but increasingly therapeutic option for achalasia. In recent years, POEM has been used for nonachalasia esophageal motility disorders (NAEMDs), such as diffuse esophageal spasm, esophagogastric junction outlet obstruction, and hypercontractile disorder, with some clinical success. No studies thus far compare the outcomes of these two groups. We perform the first head-to-head comparison of outcomes after POEM in patients with achalasia and NAEMD. PATIENTS AND METHODS A retrospective analysis of all patients undergoing POEM at one university hospital by a single expert endoscopist from July 2021 to December 2022 was performed. All patients were symptomatic, and the presence of esophageal motility disorders was confirmed using multiple diagnostic modalities. These patients were then divided into 2 groups, achalasia and NAEMD, based on the underlying diagnosis. Statistical analysis of different clinical outcomes, including effectiveness and safety, was performed. RESULTS Thirty-seven patients (mean age: 59.55, females: 22) underwent POEM in the study period. Twenty patients had achalasia and 17 patients had NAEMD. The median myotomy length was 5.5 cm for the achalasia group and 10 cm for the NAEMD group. This excluded patients with esophagogastric junction outlet obstruction in which the median myotomy length was 3 cm. The procedure time, the duration of hospital stays, the rates of same-day discharge, and complications were similar between the two. Short-term outcomes of POEM for the two groups were similar with improvement in 94% of patients in the achalasia group and 93.75% in the NAEMD group. CONCLUSION Contrary to prior observations, our study highlights that POEM is equally effective in achieving clinical improvement in patients with NAEMD as achalasia over 6 months of follow-up. In addition, POEM has a comparable safety profile in both patient groups making it a feasible therapeutic option for these debilitating and challenging disorders.
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Affiliation(s)
- Maryam Mubashir
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
| | - Victoria Andrus
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
| | - David Okuampa
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
| | - Michelle Neice
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
| | - Elizabeth Armstrong
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
| | - Hailey Canezaro
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
| | - Ross Dies
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
| | - Ashely Deville
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
| | - Lena Kawji
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
| | - Shazia Rashid
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
| | - Syed Musa Raza
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
| | - Nazar Hafiz
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
| | - Abu Saleh Mosa Faisal
- Department of Internal Medicine, Division of Clinical Informatics, Louisiana State University Health Science Center at Shreveport, Shreveport, LA
| | - Mohammad Alfrad Nobel Bhuiyan
- Department of Internal Medicine, Division of Clinical Informatics, Louisiana State University Health Science Center at Shreveport, Shreveport, LA
| | - Qiang Cai
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
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18
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Lee MH, Jung K, Kim JH, Kim SE, Moon W, Park MI, Park SJ. Case of Concomitant Endoscopic Treatment of Achalasia with Superficial Esophageal Cancer. Korean J Gastroenterol 2023; 82:248-253. [PMID: 37997221 DOI: 10.4166/kjg.2023.099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 09/25/2023] [Accepted: 10/09/2023] [Indexed: 11/25/2023]
Abstract
Achalasia, a rare motility disorder of the esophagus, is generally accepted as a premalignant disorder. This paper presents the case of a 72-year-old male with achalasia and synchronous superficial esophageal cancer who experienced dysphagia symptoms for five years. As achalasia is associated with an increased risk of esophageal cancer, both can be treated simultaneously if detected at the time of diagnosis. Achalasia and synchronous esophageal cancer are rarely detected and treated endoscopically. This paper reports a case of concurrent successful treatment.
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Affiliation(s)
- Myung-Hun Lee
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Kyoungwon Jung
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Jae Hyun Kim
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Sung Eun Kim
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Won Moon
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Moo In Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Seun Ja Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
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19
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Inoue H, Shimamura Y. Functional Endoscopy. Digestion 2023; 105:58-61. [PMID: 38008079 PMCID: PMC10777710 DOI: 10.1159/000534831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 10/24/2023] [Indexed: 11/28/2023]
Abstract
BACKGROUND Functional endoscopy signifies a significant advancement in gastrointestinal examination, integrating motor function assessments alongside routine endoscopy findings. Traditional gastrointestinal endoscopy primarily focuses on the detection of early-stage cancer by identifying morphological changes within the gastrointestinal tract. These alterations include modifications in lumen structure, color tone, and surface patterns, which can be diagnosed using endoscopic images that assess these morphological changes. In contrast, functional endoscopy aims to dynamically evaluate the peristaltic movements of the digestive tract and the presence or movement of reflux of digestive fluids during the endoscopic procedure. It also seeks to identify morphological changes such as hiatal hernias, as observed in conventional endoscopy. Consequently, relying solely on endoscopic images proves inadequate for diagnosis, necessitating continuous observation of these dynamic movements. SUMMARY The endoscopic pressure study integrated system (EPSIS) serves as an exemplar of functional endoscopy. It incorporates a stress test to assess the functionality of the lower esophageal sphincter (LES) through intragastric insufflation. A crucial element of EPSIS evaluation is the identification of the scope holding sign (SHS), which signifies LES contraction. EPSIS also encompasses the observation of esophageal peristaltic waves and the auditory detection of burping, providing a comprehensive diagnostic approach while observing the sphincter from a retroflex view on the stomach side. By integrating these dynamic findings, functional endoscopy offers an efficient method for diagnosing functional gastrointestinal diseases, such as gastroesophageal reflux disease (GERD). KEY MESSAGES Functional endoscopy combines motor function assessments with traditional endoscopy, enhancing the diagnostic capabilities of gastrointestinal examinations. Traditional endoscopy focuses on identifying morphological changes, while functional endoscopy evaluates dynamic movements, reflux, and sphincter functionality. EPSIS exemplifies functional endoscopy, featuring a stress test and the SHS for LES contraction assessment. EPSIS provides a comprehensive approach to diagnose GERD by integrating dynamic observations.
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Affiliation(s)
- Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Yuto Shimamura
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
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20
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Wakim El-Khoury J, Pandolfino JE, Kahrilas PJ, Godo B, Farina DA, Kou W, Carlson DA. Relaxation of the lower esophageal sphincter in response to reduced volume distension during FLIP Panometry. Neurogastroenterol Motil 2023; 35:e14663. [PMID: 37691556 DOI: 10.1111/nmo.14663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/29/2023] [Accepted: 07/31/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND The esophageal response to stepwise distension during the functional lumen imaging probe (FLIP) Panometry study often parallels high-resolution manometry (HRM) motility diagnoses. This study aimed to describe the changes in FLIP metrics during FLIP emptying, that is, reduced volume distension. METHODS Adult patients who completed FLIP and HRM for esophageal motility evaluation were included. Esophagogastric junction (EGJ) opening parameters were assessed during stepwise FLIP filling to volumes of 60 mL ("filling 60 mL"), then 70 mL, and then back to 60 mL ("emptying 60 mL"). HRM studies were analyzed per Chicago classification version 4.0 (CCv4.0). KEY RESULTS Among 265 patients included, HRM/CCv4.0 diagnoses included achalasia in 80 patients (30%), normal motility in 70 (26%), and ineffective esophageal motility (IEM) in 43 (16%). EGJ-distensibility index (DI) and EGJ diameter were greater during emptying 60 mL than filling 60 mL in achalasia, normal motility, and IEM (p values <0.002). If applying the emptying 60 mL EGJ-DI (vs. filling 60 mL EGJ-DI), EGJ opening classification changed from reduced EGJ opening to borderline EGJ opening in 31% of achalasia patients and in 2% of patients with normal motility or IEM. EGJ opening classification was unchanged in 69% achalasia and 96% of normal motility/IEM. CONCLUSIONS AND INFERENCES This study suggests that isotonic or auxotonic relaxation of the lower esophageal sphincter occurs with reduced volume distension in patients with achalasia and normal motility. The study also supports the importance of utilizing a standardized FLIP motility study protocol (i.e., controlled, stepwise filling to 50 mL, 60 mL, then 70 mL) to provide reliable and generalizable FLIP metrics to facilitate diagnosis of esophageal motility disorders.
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Affiliation(s)
- Jeanine Wakim El-Khoury
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
- Division of Gastroenterology and Hepatology, Department of Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - John E Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Peter J Kahrilas
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Bidemi Godo
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Domenico A Farina
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Wenjun Kou
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Dustin A Carlson
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
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Low EE, Fehmi SA, Yadlapati R. Tailored myotomy for the treatment of type 3 achalasia: Is there a role for the functional lumen imaging probe? Neurogastroenterol Motil 2023; 35:e14670. [PMID: 37691561 PMCID: PMC10759927 DOI: 10.1111/nmo.14670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 08/21/2023] [Indexed: 09/12/2023]
Affiliation(s)
- Eric E Low
- Division of Gastroenterology, University of California, San Diego, San Diego, California, USA
| | - Syed A Fehmi
- Division of Gastroenterology, University of California, San Diego, San Diego, California, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California, San Diego, San Diego, California, USA
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22
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Zou K, Xu H, Peng Y, Tang X. Tailored myotomy length in peroral endoscopic myotomy for achalasia: Combination of high-resolution esophageal manometry and endoluminal functional lumen imaging probe. Neurogastroenterol Motil 2023; 35:e14650. [PMID: 37496279 DOI: 10.1111/nmo.14650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 07/16/2023] [Indexed: 07/28/2023]
Affiliation(s)
- Kang Zou
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Huan Xu
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yan Peng
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xiaowei Tang
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, The Affiliated Hospital of Southwest Medical University, Luzhou, China
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23
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Xu JQ, Geng ZH, Liu ZQ, Yao L, Zhang ZC, Zhong YS, Zhang YQ, Hu JW, Cai MY, Yao LQ, Li QL, Zhou PH. Landscape of Psychological Profiles in Patients With Esophageal Achalasia. Clin Transl Gastroenterol 2023; 14:e00613. [PMID: 37440756 PMCID: PMC10684233 DOI: 10.14309/ctg.0000000000000613] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 05/19/2023] [Indexed: 07/15/2023] Open
Abstract
INTRODUCTION Esophageal achalasia (EA) is a chronic esophageal dysmotility disease, of which psychological distress was poorly understood. This study aims to assess the status of psychosocial characteristics in EA and to determine the relationship between psychological distress and EA. METHODS Seventy pairs of age and gender-matched patients with EA and healthy control individuals were prospectively enrolled from December 2019 to April 2020 at our hospital. Demographic, psychosocial, and clinical data were obtained. Psychosocial assessments contained psychological distress (Symptom Checklist-90 Revised), perceived stress (Perceived Stress Scale-14), and stressful life events (Life Events Scale). Comparison for psychological parameters was made between patients with EA and controls as well as for EA before/after per oral endoscopic myotomy (POEM). Spearman rank correlation coefficients were used to testify the association between psychological distress and achalasia symptoms. RESULTS The mean course and Eckardt score of patients with EA were 4.26 ± 5.11 years and 6.63 ± 2.21, respectively. There was a significant difference between patients with EA and healthy individuals in Global Severity Index ( P = 0.039) and Positive Symptoms Total ( P = 0.041) for Symptom Checklist-90 Revised as well as positive intensity ( P = 0.011) for the Life Events Scale. Somatization ( P < 0.001), anxiety ( P = 0.021), anger-hostility ( P = 0.009), and others (appetite and sleep, P = 0.010) accounted for the most difference. Somatization was positively associated with chest pain ( P = 0.045). Two patients with EA developed recurrence and showed no relationship with psychological status. Psychological status was significantly improved after POEM. DISCUSSION Psychological distress, especially somatization, was more prevalent in patients with EA than healthy controls. POEM seemed able to improve psychological distress.
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Affiliation(s)
- Jia-Qi Xu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zi-Han Geng
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zu-Qiang Liu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Lu Yao
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhao-Chao Zhang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yun-Shi Zhong
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yi-Qun Zhang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jian-Wei Hu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ming-Yan Cai
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Li-Qing Yao
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Quan-Lin Li
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Ping-Hong Zhou
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
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Luther J, Zarro S, Sagaram M, Eiswerth M, Ganguli S, Rogers B, Gyawali CP. Intermittent Hiatus Hernia on High-Resolution Manometry Associates With Abnormal Reflux Burden Similar to Persistent Hiatus Hernia. Am J Gastroenterol 2023; 118:2071-2074. [PMID: 37307572 DOI: 10.14309/ajg.0000000000002353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 05/25/2023] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Hiatus hernia is characterized by axial separation between the lower esophageal sphincter and the crural diaphragm, and higher reflux burden. Impact on reflux is unclear if such separation is intermittent rather than persistent. METHODS Reflux burden off antisecretory therapy was compared between no hernia (n = 357), intermittent hernia (n = 42), and persistent hernia (n = 155) after review of consecutive high-resolution manometry and reflux monitoring studies. RESULTS Proportions with pathologic acid exposure was similar between intermittent and persistent hernia (45.2% vs 46.5%, respectively), and both were significantly different from no hernia (28.7%, P ≤ 0.002). DISCUSSION Intermittent hiatus hernias are clinically relevant in gastroesophageal reflux pathophysiology.
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Affiliation(s)
- Janki Luther
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Samantha Zarro
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Manasa Sagaram
- Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Michael Eiswerth
- Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Surosree Ganguli
- Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Benjamin Rogers
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
- Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
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Trabelsi NO, Marchut K, Campos SRU, Maggio D, Rakovich G. A Road Less Traveled: Endoscopic Retrograde Cholangiopancreatography in a Patient with Long-standing Achalasia and Sigmoid Esophagus. Korean J Gastroenterol 2023; 82:190-193. [PMID: 37876258 DOI: 10.4166/kjg.2023.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 10/03/2023] [Accepted: 10/03/2023] [Indexed: 10/26/2023]
Abstract
Endoscopic retrograde cholangiopancreatography in a patient with achalasia and sigmoid esophagus poses a unique technical challenge, as one must safely guide the side viewing duodenoscope across a severely distorted distal esophagus and non-relaxing lower esophageal sphincter. In such patients, the use of an overtube is a simple solution that allows the safe passage of a duodenoscope and the removal of common bile duct stones.
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Affiliation(s)
- Nadia O Trabelsi
- Section for Thoracic Surgery, Hôpital Maisonneuve-Rosemont, University of Montreal Faculty of Medicine, Montreal, QC, Canada
| | - Katherine Marchut
- Section for Gastroenterology, Hôpital Maisonneuve-Rosemont, University of Montreal Faculty of Medicine, Montreal, QC, Canada
| | - Sally Romina Urena Campos
- Section for Gastroenterology, Hôpital Maisonneuve-Rosemont, University of Montreal Faculty of Medicine, Montreal, QC, Canada
| | - Davide Maggio
- Section for Gastroenterology, Hôpital Maisonneuve-Rosemont, University of Montreal Faculty of Medicine, Montreal, QC, Canada
| | - George Rakovich
- Section for Thoracic Surgery, Hôpital Maisonneuve-Rosemont, University of Montreal Faculty of Medicine, Montreal, QC, Canada
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26
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Kolb JM, Pessorrusso F, Pisipati S, Han S, Menard-Katcher P, Yadlapati R, Wagh MS. Role of short interval FLIP panometry in predicting long-term outcomes after per-oral endoscopic myotomy. Surg Endosc 2023; 37:7767-7773. [PMID: 37580583 PMCID: PMC10771858 DOI: 10.1007/s00464-023-10319-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 07/19/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND The Eckardt score (ES) is used to assess symptom response to Per-Oral Endoscopic Myotomy (POEM), but reliable methods to assess physiologic success are needed. Functional lumen imaging probe (FLIP) panometry has a potential role in post-POEM follow-up to predict long-term outcomes. The aim of this study was to assess the correlation between clinical success and FLIP parameters following POEM to determine if short interval FLIP could predict long-term outcomes. METHODS This was a prospective study of adult patients who underwent POEM with short interval follow-up FLIP between 11/2017 and 3/2020. Clinical success was defined as post-procedure ES ≤ 3. Physiologic success was based on an esophago-gastric junction distensibility index (EGJ-DI) > 2.8 mm2/mmHg on FLIP. RESULTS 47 patients (55% female, mean age 55 years) were included in the study. Clinical success after POEM was seen in 45 (96%) patients (mean ES 6.5 ± 2.2 pre and 0.83 ± 1.0 post-POEM, p < 0.001). Physiologic success was noted in 43 (91.5%) patients (mean EGJ-DI 6.1 mm2/mmHg ± 2.5). Among 4 patients not meeting criteria for physiologic success, EGJ-DI was 2.5-2.6. There was no correlation between post-POEM EGJ-DI and ES in the short term or long term. Significant reflux esophagitis was seen in 6 (12.8%) patients with no difference in mean EGJ-DI with vs without esophagitis (5.9 vs 6.1, p = 0.44). CONCLUSION Post-POEM endoscopy with FLIP is useful to both assess EGJ physiology and to examine for reflux esophagitis. Short interval FLIP has limited utility to predict long-term patient outcomes or risk of acid reflux.
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Affiliation(s)
- Jennifer M Kolb
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Greater Los Angeles VA Healthcare System, Los Angeles, CA, USA
| | - Fernanda Pessorrusso
- Division of Gastroenterology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sailaja Pisipati
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ, USA
| | - Samuel Han
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Paul Menard-Katcher
- Division of Gastroenterology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California San Diego, San Diego, CA, USA
| | - Mihir S Wagh
- Division of Gastroenterology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
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García Ruiz de Gordejuela A, Ibarzabal Olano A, Petrola Chacón CG, González López Ó. Obesity related pathophysiological aspects favouring Gastroesophageal Reflux Disease. Cir Esp 2023; 101 Suppl 4:S3-S7. [PMID: 37979938 DOI: 10.1016/j.cireng.2022.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 12/11/2022] [Indexed: 11/20/2023]
Abstract
Gastroesophageal reflux disease (GERD) is a complex entity and one of the most frequents in general population. Association of GERD with obesity is clearly defined from an epidemiological point of view, where up to 40% of patients with overweight and obesity present reflux. Most of the risk factors associated to GERD are shared and especially frequent in patients with obesity. The pathophysiology that explain this correlation is complex and multifactorial, and includes both aspects related to physiology of motility, and anatomic changes. The malfunction of the lower esophageal sphincter, the greater transdiaphragmatic pressure gradient, pathological accumulation of fat and the high rate of hiatal hernia that comes with overweight will be the main factors that explain this correlation. Other factor like pathological eating habits or obesity related diseases have also an important role. In summary, it is the sum of the factors more than just one of them what would explain the pathophysiology of GERD in obese population.
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Affiliation(s)
- Amador García Ruiz de Gordejuela
- Unidad de Cirugía Endocrina, Bariátrica y Metabólica, Servicio de Cirugía General, Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain.
| | - Ainitze Ibarzabal Olano
- Servicio de Cirugía Gastrointestinal, Hospital Clínic Barcelona, Universidad de Barcelona, Barcelona, Spain
| | - Carlos Gustavo Petrola Chacón
- Unidad de Cirugía Endocrina, Bariátrica y Metabólica, Servicio de Cirugía General, Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Óscar González López
- Unidad de Cirugía Endocrina, Bariátrica y Metabólica, Servicio de Cirugía General, Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
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Ichkhanian Y, Al-Haddad MA, Jacobs CC, Schlachterman A, Yang J, Canakis A, Kim R, Guerson-Gil A, D'Souza LS, Alsheik E, Ginnebaugh BD, Khashab MA, Zuchelli T, McFarlin K, Piraka C. Gastric peroral endoscopic myotomy for management of refractory gastroparesis in patients with gastric neurostimulator devices: a multicenter retrospective case control study. Gastrointest Endosc 2023; 98:559-566.e1. [PMID: 37121364 DOI: 10.1016/j.gie.2023.04.2079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/28/2023] [Accepted: 04/19/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND AND AIMS Gastric neurostimulation (GNS) and gastric peroral myotomy (G-POEM), therapies for refractory gastroparesis, are associated with suboptimal outcomes. We studied the role of G-POEM as a salvage therapy in patients with refractory symptoms after GNS implantation. METHODS This was a multicenter, retrospective, matched case-control study. Consecutive patients with a GNS device and who underwent G-POEM as a salvage therapy for clinical failure (cases) and patients without GNS implantation and who underwent G-POEM for refractory gastroparesis (control) between October 2018 and August 2021 were included. The primary outcome was clinical success after G-POEM. RESULTS A total of 123 patients (mean age 45.7 ± 14.7 years; 88 female subjects [72%]) underwent G-POEM therapy during the study: 41 cases and 82 controls. Clinical success was achieved in 66% in the case group and 65% in the control group (P = .311), during a median total clinical follow-up time of 11.8 (interquartile range, 2.4-6.3) months. In the case group, the mean Gastroparesis Cardinal Symptom Index score decreased from 2.8 ± 1.8 to 1.5 ± 1.9 (P = .024), and gastric retention at 4 hours improved from 45% ± 25.8% to 16.6% ± 13.1% (P = .06). The mean delta improvement in the subscales of nausea/vomiting (1.3 ± .6 vs .9 ± 1.1, P = .044) and bloating (1.6 ± 1.3 vs 1.2 ± 1.4, P = .041) were significantly higher in cases than in controls. CONCLUSIONS Among patients with refractory symptoms after GNS, G-POEM can be a reasonable salvage therapy to provide further symptomatic relief with evidence of a potential additive effect of both G-POEM and GNS.
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Affiliation(s)
| | - Mohammad A Al-Haddad
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Chelsea C Jacobs
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Alexander Schlachterman
- Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Juliana Yang
- Division of Gastroenterology and Hepatology, Vanderbilt University, Nashville, Tennessee, USA
| | - Andrew Canakis
- Division of Gastroenterology and Hepatology, University of Maryland, Baltimore, Maryland, USA
| | - Raymond Kim
- Division of Gastroenterology and Hepatology, University of Maryland, Baltimore, Maryland, USA
| | - Arcelia Guerson-Gil
- Division of Gastroenterology and Hepatology, Stony Brook University Hospital, Stony Brook, New York, USA
| | - Lionel S D'Souza
- Division of Gastroenterology and Hepatology, Stony Brook University Hospital, Stony Brook, New York, USA
| | | | | | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA (10)Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador
| | | | - Kellie McFarlin
- Department of Surgery, Henry Ford Hospital, Detroit, Michigan, USA
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Zhu Q, Zhang H, Huang S, Gan P, Wang R, Peng Y, Lü M, Tang X. Research hotspots and trend of a emerging novel endoscopic technique of peroral endoscopic myotomy from 2010 to 2022: A bibliometric analysis. Medicine (Baltimore) 2023; 102:e35009. [PMID: 37682198 PMCID: PMC10489447 DOI: 10.1097/md.0000000000035009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 08/08/2023] [Indexed: 09/09/2023] Open
Abstract
Peroral endoscopic myotomy (POEM), which has been used to treat achalasia and other esophageal motility disorders for the past 10 years, has proven to be secure and efficient. Every year, more and more essays on this subject are published. We sought to investigate the global scientific outputs and hotspots of POEM produced by various nations, organizations, and authors. From 2010 to October 2022, there were 875 papers on POEM that were found in the Web of Science Core database. The bibliometric visualization analyses of nations/regions, institutions, authors, journals, references, and keywords were conducted by CiteSpace V.5.8.R3. Eight hundred seventy-five publications were included in this analysis. With 68 publications, Inoue H had the highest output. While Showa University in Japan was the most productive institution, the United States was the most productive nation. Among the journals, Surgical Endoscopy published the highest number of articles, followed by Gastrointestinal Endoscopy and Endoscopy. The top 10 keywords that appeared most frequently were achalasia, peroral endoscopic myotomy, POEM, myotomy, esophageal achalasia, dysphagia, heller myotomy, endoscopy, gastroparesis and peroral endoscopic myotomy. Seven frontiers, including meta-analysis, high-resolution esophageal manometry, geriatric patient, third space endoscopy, adverse event, endoscopic submucosal dissection, and gastric peroral endoscopic myotomy, had an impact on future research on POEM. The previous 10 years have seen a considerable rise in POEM research, and this trend will continue. The most recent research frontiers, which require more attention, are meta-analysis, high-resolution esophageal manometry, geriatric patient, third space endoscopy, adverse event, and gastric peroral endoscopic myotomy.
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Affiliation(s)
- Qingliang Zhu
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Han Zhang
- Department of Gastroenterology, Zigong First People’s Hospital, Zigong, China
| | - Shu Huang
- Department of Gastroenterology, Lianshui County People’ Hospital, Huaian, China
| | - Peiling Gan
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Ruiyu Wang
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yan Peng
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Muhan Lü
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xiaowei Tang
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
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30
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Wang Y, Zhang C, Zhao D. Achalasia Combined with Idiopathic Gastroparesis Treated with Peroral Endoscopic Myotomy and Gastric Peroral Endoscopic Myotomy in a Single Procedure. Turk J Gastroenterol 2023; 34:982-983. [PMID: 37674441 PMCID: PMC10544314 DOI: 10.5152/tjg.2023.23276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 07/19/2023] [Indexed: 09/08/2023]
Affiliation(s)
- Yating Wang
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Chunxi Zhang
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Dongqiang Zhao
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
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31
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Hoshikawa Y, Iwakiri K. Esophageal Motility Disorders: Diagnosis and Treatment Strategies. Digestion 2023; 105:11-17. [PMID: 37634495 DOI: 10.1159/000533347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 07/25/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Esophageal motility disorders (EMDs) are caused by the impaired relaxation of the upper/lower esophageal sphincter and/or defective esophageal peristaltic contractions, resulting in dysphagia and noncardiac chest pain. High-resolution manometry (HRM) is essential for the diagnosis of primary EMD; however, the recognition of EMD and HRM by general practitioners in Japan is limited. This review summarizes the diagnosis of and treatment strategies for EMD. SUMMARY HRM is a specific test for the diagnosis of EMD, whereas endoscopy and barium swallow as screening tests provide characteristic findings (i.e., esophageal rosette and bird's beak sign) in some cases. It is important to note that manometric diagnoses apart from achalasia are often clinically irrelevant; therefore, the recently updated guidelines suggest additional manometric maneuvers, such as the rapid drink challenge, and further testing, including functional lumen imaging, for a more accurate diagnosis before invasive treatment. Endoscopic/surgical myotomy, pneumatic dilation, and botulinum toxin injections need to be considered for patients with achalasia and clinically relevant esophagogastric junction outflow obstruction. KEY MESSAGE Since the detailed pathophysiology of EMD remains unclear, their diagnosis needs to be cautiously established prior to the initiation of invasive treatment.
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Affiliation(s)
- Yoshimasa Hoshikawa
- Department of Gastroenterology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Katsuhiko Iwakiri
- Department of Gastroenterology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
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Liu ZQ, Dai H, Yao L, Chen WF, Wang Y, Ma LY, Li XQ, Lin SL, He MJ, Gao PT, Liu XY, Xu JX, Xu XY, Wang KH, Wang L, Chen L, Zhou PH, Li QL. A single-cell transcriptional landscape of immune cells shows disease-specific changes of T cell and macrophage populations in human achalasia. Nat Commun 2023; 14:4685. [PMID: 37542039 PMCID: PMC10403544 DOI: 10.1038/s41467-023-39750-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 06/28/2023] [Indexed: 08/06/2023] Open
Abstract
Achalasia is a rare motility disorder of the esophagus caused by the gradual degeneration of myenteric neurons. Immune-mediated ganglionitis has been proposed to underlie the loss of myenteric neurons. Here, we measure the immune cell transcriptional profile of paired lower esophageal sphincter (LES) tissue and blood samples in achalasia and controls using single-cell RNA sequencing (scRNA-seq). In achalasia, we identify a pattern of expanded immune cells and a specific transcriptional phenotype, especially in LES tissue. We show C1QC+ macrophages and tissue-resident memory T cells (TRM), especially ZNF683+ CD8+ TRM and XCL1+ CD4+ TRM, are significantly expanded and localized surrounding the myenteric plexus in the LES tissue of achalasia. C1QC+ macrophages are transcriptionally similar to microglia of the central nervous system and have a neurodegenerative dysfunctional phenotype in achalasia. TRM also expresses transcripts of dysregulated immune responses in achalasia. Moreover, inflammation increases with disease progression since immune cells are more activated in type I compared with type II achalasia. Thus, we profile the immune cell transcriptional landscape and identify C1QC+ macrophages and TRM as disease-associated immune cell subsets in achalasia.
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Affiliation(s)
- Zu-Qiang Liu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Hao Dai
- Key Laboratory of Systems Biology, Shanghai Institute of Biochemistry and Cell Biology, Center for Excellence in Molecular Cell Science, Chinese Academy of Sciences, Shanghai, China
| | - Lu Yao
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Wei-Feng Chen
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Yun Wang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Li-Yun Ma
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Xiao-Qing Li
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Sheng-Li Lin
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Meng-Jiang He
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Ping-Ting Gao
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Xin-Yang Liu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Jia-Xin Xu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Xiao-Yue Xu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Ke-Hao Wang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Li Wang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Luonan Chen
- Key Laboratory of Systems Biology, Shanghai Institute of Biochemistry and Cell Biology, Center for Excellence in Molecular Cell Science, Chinese Academy of Sciences, Shanghai, China.
- Key Laboratory of Systems Health Science of Zhejiang Province, Hangzhou Institute for Advanced Study, University of Chinese Academy of Sciences, Chinese Academy of Sciences, Hangzhou, China.
- School of Life Science and Technology, ShanghaiTech University, Shanghai, China.
| | - Ping-Hong Zhou
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China.
| | - Quan-Lin Li
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China.
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Srivastava A, Poddar U, Mathias A, Mandelia A, Sarma MS, Lal R, Yachha SK. Achalasia cardia sub-types in children: Does it affect the response to therapy? Indian J Gastroenterol 2023; 42:534-541. [PMID: 37300794 DOI: 10.1007/s12664-023-01344-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 01/26/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Achalasia sub-types affect treatment response in adults, but there is no similar data in children. We studied the differences in clinico-laboratory features and response to therapy between achalasia sub-types in children. METHODS Forty-eight children (boys:girls-25:23, 14 [0.9-18] years) with achalasia (clinical, barium, high-resolution manometry [HRM], gastroscopy) were evaluated. The sub-type was determined by Chicago classification at HRM. Pneumatic dilatation (PD) or surgery was the primary therapy. Success was defined as Eckhardt score of ≤ 3. RESULTS Dysphagia (95.8%) and regurgitation (93.8%) were the most common symptoms. Forty of 48 cases had an adequate HRM study: Type I (n-19), II (n-19) and III (n-2). Types I and II had similar clinical profile. Type II had higher basal lower esophageal sphincter (LES) pressure (30.5 [16.5-46] vs. 22.5 [13-43] mmHg; p = 0.007) and less dilated esophagus on timed barium esophagogram (TBE, 25 [13-57] vs. 34.5 [20-81] mm; p = 0.006) than type I. Both types had similar success (86.6% [13/15] vs. 92.8% [13/14]; p = 1) after first PD and need of post-PD myotomy (5/17 vs. 1/16; p = 0.1) in follow-up. Twenty-three cases had TBE before and after PD; 15 (65.2%) had good clearance. These subjects required myotomy (1/15 vs. 4/8; p = 0.03) and repeat PD (5/15 vs. 4/8; p = 0.08) less often than those with poor clearance on TBE. CONCLUSION Types I and II achalasia have similar frequency and clinical profile. Type II has higher LES pressure and less dilated esophagus than Type I. Both respond equally well to initial PD. Type I required post-PD myotomy more often, though not significantly. TBE is useful for assessing therapeutic response.
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Affiliation(s)
- Anshu Srivastava
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India.
| | - Ujjal Poddar
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Amrita Mathias
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Ankur Mandelia
- Pediatric Surgical Superspecialty, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Moinak Sen Sarma
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Richa Lal
- Pediatric Surgical Superspecialty, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Surender Kumar Yachha
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
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Draganov PV. Peroral endoscopic myotomy: A lifelong solution or another temporizing measure for achalasia and nonachalasia spastic esophageal motility disorders? Gastrointest Endosc 2023; 98:249-251. [PMID: 37004814 DOI: 10.1016/j.gie.2023.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 03/08/2023] [Accepted: 03/14/2023] [Indexed: 04/04/2023]
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Abstract
Achalasia is a rare disease of the esophagus with impaired relaxation of the lower esophageal sphincter and aperistalsis. The etiology is unknown but speculations include a viral or autoimmune etiology. All specialists dealing with swallowing and esophageal diseases should recognize the classic symptoms of dysphagia for solids/liquids, regurgitation, and choking, especially at night. High-resolution manometry is critical for the diagnosis with endoscopy and barium esophagram having a supportive role. The disease cannot be cured but most can return to near normal swallowing and a regular diet with appropriate therapy. Treatment includes smooth muscle relaxants, botulinum toxin injections to the lower sphincter, pneumatic dilation, Heller myotomy, and peroral endoscopic myotomy. One treatment does not fit all and a tailored approach through a multidiscipline team will give the best long-term outcomes.
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Affiliation(s)
- Wojciech Blonski
- Division of Gastroenterology, James A. Haley VA Hospital, Tampa, FL, USA
- Division of Gastroenterology and Nutrition, Morsani College of Medicine, University of South Florida, 12901 Bruce B. Downs Blvd, MDC 72, Tampa, FL, 33612, USA
| | - Samuel Slone
- Division of Gastroenterology and Nutrition, Morsani College of Medicine, University of South Florida, 12901 Bruce B. Downs Blvd, MDC 72, Tampa, FL, 33612, USA
| | - Joel E Richter
- Division of Gastroenterology and Nutrition, Morsani College of Medicine, University of South Florida, 12901 Bruce B. Downs Blvd, MDC 72, Tampa, FL, 33612, USA.
- Joy McCann Culverhouse Center for Esophageal Diseases, Morsani College of Medicine, University of South Florida, Tampa, FL, USA.
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Zhang C, Pan C, Chan KF, Gao J, Yang Z, Leung KKC, Jin D, Wang Y, Xia N, Ning Z, Wang X, Jiang S, Zhang Z, Wang Q, Hao B, Chiu PWY, Zhang L. Wirelessly powered deformable electronic stent for noninvasive electrical stimulation of lower esophageal sphincter. Sci Adv 2023; 9:eade8622. [PMID: 36888700 PMCID: PMC9995080 DOI: 10.1126/sciadv.ade8622] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 02/03/2023] [Indexed: 06/18/2023]
Abstract
Electrical stimulation is a promising method to modulate gastrointestinal disorders. However, conventional stimulators need invasive implantation and removal surgeries associated with risks of infection and secondary injuries. Here, we report a battery-free and deformable electronic esophageal stent for wireless stimulation of the lower esophageal sphincter in a noninvasive fashion. The stent consists of an elastic receiver antenna infilled with liquid metal (eutectic gallium-indium), a superelastic nitinol stent skeleton, and a stretchable pulse generator that jointly enables 150% axial elongation and 50% radial compression for transoral delivery through the narrow esophagus. The compliant stent adaptive to the dynamic environment of the esophagus can wirelessly harvest energy through deep tissue. Continuous electrical stimulations delivered by the stent in vivo using pig models significantly increase the pressure of the lower esophageal sphincter. The electronic stent provides a noninvasive platform for bioelectronic therapies in the gastrointestinal tract without the need for open surgery.
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Affiliation(s)
- Chong Zhang
- Department of Biomedical Engineering, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China
| | - Chengfeng Pan
- Department of Mechanical and Automation Engineering, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China
- The State Key Laboratory of Fluid Power and Mechatronic Systems, College of Mechanical Engineering, Zhejiang University, Hangzhou 310027, P. R. China
| | - Kai Fung Chan
- Department of Biomedical Engineering, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China
- Chow Yuk Ho Technology Center for Innovative Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China
- Multi-Scale Medical Robotics Center, Hong Kong Science Park, Shatin, New Territories, Hong Kong SAR, China
| | - Jinyang Gao
- Department of Mechanical and Automation Engineering, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China
| | - Zhengxin Yang
- Department of Mechanical and Automation Engineering, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China
| | - Kevin Kai Chung Leung
- Multi-Scale Medical Robotics Center, Hong Kong Science Park, Shatin, New Territories, Hong Kong SAR, China
| | - Dongdong Jin
- Department of Mechanical and Automation Engineering, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China
| | - Yuqiong Wang
- Department of Mechanical and Automation Engineering, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China
| | - Neng Xia
- Department of Mechanical and Automation Engineering, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China
| | - Zhipeng Ning
- Department of Mechanical and Automation Engineering, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China
| | - Xin Wang
- Department of Mechanical and Automation Engineering, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China
| | - Shuai Jiang
- Department of Biomedical Engineering, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China
| | - Zifeng Zhang
- Department of Mechanical and Automation Engineering, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China
| | - Qinglong Wang
- Department of Mechanical and Automation Engineering, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China
| | - Bo Hao
- Department of Mechanical and Automation Engineering, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China
| | - Philip Wai Yan Chiu
- Chow Yuk Ho Technology Center for Innovative Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China
- Multi-Scale Medical Robotics Center, Hong Kong Science Park, Shatin, New Territories, Hong Kong SAR, China
- Department of Surgery, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China
| | - Li Zhang
- Department of Biomedical Engineering, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China
- Department of Mechanical and Automation Engineering, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China
- Multi-Scale Medical Robotics Center, Hong Kong Science Park, Shatin, New Territories, Hong Kong SAR, China
- Department of Surgery, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China
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Nabi Z, Mandavdhare H, Akbar W, Talukdar R, Reddy DN. Long-term Outcome of Peroral Endoscopic Myotomy in Esophageal Motility Disorders: A Systematic Review and Meta-analysis. J Clin Gastroenterol 2023; 57:227-238. [PMID: 36227028 DOI: 10.1097/mcg.0000000000001776] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND AIM Peroral endoscopic myotomy (POEM) is an established treatment for achalasia. In this systematic review and meta-analysis, we aimed to analyze the mid and long-term outcomes of POEM in esophageal motility disorders. METHODS Literature search was performed in databases including PubMed, Embase, Cochrane databases, and Google scholar from January 2010 to May 2021. The primary objective of the study was the clinical success (Eckardt score ≤3 or <4) at mid-term (30 to 60 mo) and long-term (>60 mo) follow-up after POEM. Secondary objectives included post-POEM gastroesophageal reflux (GER) as evaluated by symptoms, increased esophageal acid exposure, and reflux esophagitis. RESULTS Seventeen studies with 3591 patients were included in the review. Subtypes of motility disorders were type I (27%), type II (54.5%), type III (10.7%), distal esophageal spasm/Jackhammer esophagus (2%), and esophagogastric junction outflow obstruction (17.5%). Pooled mean follow-up duration was 48.9 months (95% CI, 40.02-57.75). Pooled rate of clinical success at mid-term follow-up was 87% (95% CI, 81-91; I2 , 86%) and long-term was 84% (95% CI, 76-89; I2 , 47%). In nonachalasia motility disorders (esophagogastric junction outflow obstruction, distal esophageal spasm, and Jackhammer esophagus), pooled rate of clinical success was 77% (95% CI, 65-85; I2 , 0%). GER as estimated by symptoms was 23% (95% CI, 19-27; I2 , 74%), erosive esophagitis was 27% (95% CI, 18-38%; I2 , 91%), and increased esophageal acid exposure was 41% (95% CI, 30-52; I2 , 88%). CONCLUSION POEM is a durable treatment option in cases with achalasia. One-fourth of patients suffer from erosive GER in the long-term and success rates are lower in nonachalasia esophageal motility disorders.
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Affiliation(s)
- Zaheer Nabi
- Asian Institute of Gastroenterology, Hyderabad, India
| | | | - Wahid Akbar
- Asian Institute of Gastroenterology, Hyderabad, India
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Mekaroonkamol P, Tiankanon K, Rerknimitr R. A New Paradigm Shift in Gastroparesis Management. Gut Liver 2022; 16:825-839. [PMID: 35670120 PMCID: PMC9668508 DOI: 10.5009/gnl210309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 11/07/2021] [Accepted: 01/13/2022] [Indexed: 08/30/2023] Open
Abstract
Gastroparesis, once regarded as a rare disease, is difficult to diagnose and challenging to treat; there were many breakthrough advances in the 2010s, shifting the paradigm of the understanding of this complex entity and its management. Similar to diabetes, its increasing prevalence reflects increased accessibility to diagnostic modalities and suggests that gastroparesis was underacknowledged in the past. Major developments in the three main aspects of the disease include the discovery of smooth muscle cells, interstitial cells of Cajal, PDGFRα+ cells syncytium, rather than interstitial cells of Cajal alone, as the main gastric pacemaker unit; the development of validated point-of-care diagnostic modalities such as a wireless motility capsule, the carbon 13-labeled breath test, and impedance planimetry; and the introduction of novel minimally invasive therapeutic options such as newer pharmacologic agents and gastric peroral endoscopic pyloromyotomy. All aspects of these advances will be discussed further in this review.
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Affiliation(s)
- Parit Mekaroonkamol
- Division of Gastroenterology, Department of Medicine, King Chulalongkorn Memorial Hospital and Chulalongkorn University, Bangkok, Thailand
| | - Kasenee Tiankanon
- Division of Gastroenterology, Department of Medicine, King Chulalongkorn Memorial Hospital and Chulalongkorn University, Bangkok, Thailand
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, King Chulalongkorn Memorial Hospital and Chulalongkorn University, Bangkok, Thailand
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Dias NCB, Herbella FAM, Del Grande LM, Patti MG. The Transdiaphragmatic Pressure Gradient and the Lower Esophageal Sphincter in the Pathophysiology of Gastroesophageal Reflux Disease: an Analysis of 500 Esophageal Function Tests. J Gastrointest Surg 2022; 27:677-681. [PMID: 36376725 DOI: 10.1007/s11605-022-05529-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 11/04/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) pathophysiology is multifactorial. Greater importance has been attributed to a defective lower esophageal sphincter (LES) in comparison to an altered transdiaphragmatic pressure gradient (TPG). This study aims to evaluate the role of the TPG and LES disfunction in GERD pathogenesis. METHODS Five hundred consecutive esophageal function tests from patients with clinically suspected GERD were reviewed. Patients were classified according to the pH monitoring in GERD positive or GERD negative. Abdominal pressure, thoracic pressure, TPG (abdominal-thoracic pressures), LES resting pressure (mid-respiratory, expiratory, and EGJ-CI), and LES retention pressure (LES resting pressure-TPG) were determined. RESULTS GERD was present in 296 (59%) individuals. GERD-positive patients were mostly males. LES resting pressure (by all parameters) and thoracic pressure were not different between groups. Abdominal pressure and TPG were higher in GERD-positive patients. LES retention pressure (by all parameters) was lower in GERD-positive patients. DeMeester score had a positive correlation with LES resting pressure, TPG, and LES retention pressure (by all parameters) but not with abdominal pressure and thoracic pressure. CONCLUSIONS LES valvular competency as measured by absolute resting pressure was not reliable to predict GERD; however, it was associated with GERD severity. Relative LES pressure (LES retention pressure) predicted GERD presence and severity, but no parameter showed superiority. TPG plays an important role in the pathophysiology of GERD since it is related to GERD presence and severity; still TPG is altered mostly based on a higher abdominal pressure.
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Affiliation(s)
- Natalya C B Dias
- Department of Surgery, Escola Paulista de Medicina, Federal University of São Paulo, Rua Diogo de Faria 1087 Cj 301, Sao Paulo, SP, 04037-003, Brazil
| | - Fernando A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of São Paulo, Rua Diogo de Faria 1087 Cj 301, Sao Paulo, SP, 04037-003, Brazil.
| | - Leonardo M Del Grande
- Department of Surgery, Escola Paulista de Medicina, Federal University of São Paulo, Rua Diogo de Faria 1087 Cj 301, Sao Paulo, SP, 04037-003, Brazil
| | - Marco G Patti
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
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Facciorusso A, Ramai D, Ichkhanian Y, Yadlapati R, Annese V, Wani S, Khashab MA. Peroral Endoscopic Myotomy for the Treatment of Esophageal Diverticula: A Systematic Review and Meta-analysis. J Clin Gastroenterol 2022; 56:853-862. [PMID: 34608024 PMCID: PMC8977395 DOI: 10.1097/mcg.0000000000001622] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 09/04/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND There is limited evidence on the efficacy of peroral endoscopic myotomy (POEM) in patients with esophageal diverticula. AIMS This meta-analysis aimed to assess the efficacy and safety profile of POEM in patients with Zenker (ZD) and epiphrenic diverticula. METHODS With a literature search through August 2020, we identified 12 studies (300 patients) assessing POEM in patients with esophageal diverticula. The primary outcome was treatment success. Results were expressed as pooled rates and 95% confidence intervals. RESULTS Pooled rate of technical success was 95.9% (93.4%-98.3%) in ZD patients and 95.1% (88.8%-100%) in patients with epiphrenic diverticula. Pooled rate of treatment success was similar for ZD (90.6%, 87.1%-94.1%) and epiphrenic diverticula (94.2%, 87.3%-100%). Rates of treatment success were maintained at 1 year (90%, 86.4%-97.4%) and 2 years (89.6%, 82.2%-96.9%) in ZD patients. Pooled rate of symptom recurrence was 2.6% (0.9%-4.4%) in ZD patients and 0% in patients with epiphrenic diverticula. Pooled rates of adverse events and severe adverse events were 10.6% (4.6%-16.6%) and 3.5% (0%-7.4%) in ZD and 8.4% (0%-16.8%) and 8.4% (0%-16.8%) in epiphrenic diverticula, respectively. CONCLUSION POEM represents an effective and safe therapy for the treatment of esophageal diverticula.
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Affiliation(s)
| | - Daryl Ramai
- Department of Medicine, The Brooklyn Hospital Center, Brooklyn, New York
| | - Yervant Ichkhanian
- Division of Gastroenterology and Hepatology, John Hopkins University Hospital, Baltimore
| | - Rena Yadlapati
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Vito Annese
- Valiant Clinic & American Hospital, Dubai, United Arab Emirates
| | - Sachin Wani
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, U.S.A
| | - Mouen A. Khashab
- Division of Gastroenterology and Hepatology, John Hopkins University Hospital, Baltimore
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Liu X, Zhou Y, Jiang X, Liu L, Zhao D, Ma H, Tian H, Jiang H. Superselective arterial microcoil embolization for delayed bleeding after peroral endoscopic myotomy. J Int Med Res 2022; 50:3000605221135475. [PMID: 36348613 PMCID: PMC9659941 DOI: 10.1177/03000605221135475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 10/11/2022] [Indexed: 08/30/2023] Open
Abstract
Peroral endoscopic myotomy (POEM) has been shown to be an effective treatment for achalasia and with few adverse events. Only a few cases of delayed bleeding have been described. This current case report describes a patient with delayed bleeding in the submucosal tunnel on the eighth day after POEM. The patient was a 21-year-old woman with a 4-month history of dysphagia, vomiting and excessive weight loss. Achalasia was diagnosed according to her symptoms, barium oesophagogram, oesophageal manometry and endoscopy examination. POEM was performed by an experienced operator. On the eighth day after POEM, the patient suddenly developed continuous haematemesis presented with vomiting of fresh blood and melena. An emergency exploratory esophagogastroduodenoscopy was performed. A large number of blood clots were found at the wound and a long haematoma was found along the lining of the submucosal tunnel. Re-entry into the submucosal tunnel and exposure of the haemorrhagic site was attempted but failed because of severe submucosal tissue adhesion. An emergency angiography was undertaken and haemostasis was achieved with superselective arterial microcoil embolization.
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Affiliation(s)
- Xuechen Liu
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, Hebei Clinical Research Centre for Digestive Diseases, Shijiazhuang, Hebei Province, China
| | - Yonghong Zhou
- Department of Nutrition, Shijiazhuang Maternity and Child Healthcare Hospital, Shijiazhuang, Hebei Province, China
| | - Xiaoyu Jiang
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, Hebei Clinical Research Centre for Digestive Diseases, Shijiazhuang, Hebei Province, China
| | - Li Liu
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, Hebei Clinical Research Centre for Digestive Diseases, Shijiazhuang, Hebei Province, China
| | - Dongqiang Zhao
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, Hebei Clinical Research Centre for Digestive Diseases, Shijiazhuang, Hebei Province, China
| | - Huihui Ma
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, Hebei Clinical Research Centre for Digestive Diseases, Shijiazhuang, Hebei Province, China
| | - Hui Tian
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, Hebei Clinical Research Centre for Digestive Diseases, Shijiazhuang, Hebei Province, China
| | - Huiqing Jiang
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, Hebei Clinical Research Centre for Digestive Diseases, Shijiazhuang, Hebei Province, China
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42
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Abstract
With the advent of high-resolution esophageal manometry, it is recognized that the antireflux barrier receives a contribution from both the lower esophageal sphincter (intrinsic sphincter) and the muscle of the crural diaphragm (extrinsic sphincter). Further, an increased intra-abdominal pressure is a major force responsible for an adaptive response of a competent sphincter or the disruption of the esophagogastric junction resulting in gastroesophageal reflux, especially in the presence of a hiatal hernia. This review describes how the pressure dynamics in the lower esophageal sphincter were discovered and measured over time and how this has influenced the development of antireflux surgery.
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Affiliation(s)
- Stefano Siboni
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, San Donato Milanese
| | - Luigi Bonavina
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, San Donato Milanese
| | | | - Ciara Egan
- Humanitas University, Humanitas Research Hospital, Rozzano, Milan
| | - Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padova, Padova, Italy
| | | | - Tom R. DeMeester
- Emeritus, Keck School of Medicine, University of Southern California, Montague, MI
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Dao HV, Hoang LB, Luu HTM, Nguyen HL, Goldberg RJ, Allison J, Dao ATM, Van Nguyen HT, Matsumura T, Van Dao L. Clinical symptoms, endoscopic findings, and lower esophageal sphincter characteristics in patients with absent contractility. Medicine (Baltimore) 2022; 101:e31428. [PMID: 36316894 PMCID: PMC9622690 DOI: 10.1097/md.0000000000031428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Absent contractility is a rare esophageal motility disorder defined by high-resolution manometry which remains poorly understood in pathogenesis and management. We investigated the clinical symptoms, upper gastrointestinal endoscopy findings, and lower esophageal sphincter (LES) characteristics in adult patients diagnosed with absent contractility on high resolution manometry and factors associated with erosive esophagitis that were found on endoscopy in these patients. A cross-sectional study was conducted in patients with absent contractility who were examined at the Institute of Gastroenterology and Hepatology, Vietnam between March 2018 and December 2020. Clinical symptoms, endoscopic findings, and LES metrics were collected and compared between individuals with and without erosive esophagitis. Logistic regression analysis was used to examine a variety of factors associated with erosive esophagitis. Among 7519 patients who underwent high resolution manometry, 204 (2.7%) were diagnosed with absent contractility. The mean age of the study sample was 45.9 years, 65.7% were women, and none had systemic sclerosis. The most common symptoms were regurgitation, belching, epigastric pain, and bloating. On endoscopy, 50% had erosive esophagitis, mostly Los Angeles grade A (42.9%). On manometry, 44.6% of the patients had LES hypotension and 68.1% had low integrated relaxation pressure in 4 seconds (IRP4s). Male sex (adjusted odds ratio = 2.01, 95% confidence interval: 1.04-3.89) and an IRP4s < 5 mm Hg (adjusted odds ratio = 2.21, 95% confidence interval: 1.12-4.37) were significantly associated with erosive esophagitis. Absent contractility was present in many patients without known systemic diseases. Erosive esophagitis was common and associated with male sex and low IRP4s.
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Affiliation(s)
- Hang Viet Dao
- Internal Medicine Faculty, Hanoi Medical University, Hanoi, Vietnam
- The Institute of Gastroenterology and Hepatology, Hanoi, Vietnam
- *Correspondence: Hang Viet Dao, Internal Medicine Faculty, Hanoi Medical University, Hanoi, VietnamThe Institute of Gastroenterology and Hepatology, Hanoi, Vietnam (e-mail: )
| | - Long Bao Hoang
- The Institute of Gastroenterology and Hepatology, Hanoi, Vietnam
| | - Hue Thi Minh Luu
- The Institute of Gastroenterology and Hepatology, Hanoi, Vietnam
| | - Hoa Lan Nguyen
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Robert Joel Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Jeroan Allison
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - An Thi Minh Dao
- Internal Medicine Faculty, Hanoi Medical University, Hanoi, Vietnam
| | | | - Tomoaki Matsumura
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Long Van Dao
- Internal Medicine Faculty, Hanoi Medical University, Hanoi, Vietnam
- The Institute of Gastroenterology and Hepatology, Hanoi, Vietnam
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Zheng T, Vosoughi K, Busciglio I, Tebay L, Burton D, Camilleri M. Fasting pyloric diameter and distensibility by functional endoluminal imaging probe in unsedated healthy volunteers. Neurogastroenterol Motil 2022; 34:e14386. [PMID: 35468258 PMCID: PMC9529766 DOI: 10.1111/nmo.14386] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 03/31/2022] [Accepted: 04/11/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Recent studies with functional endoluminal imaging probe (EndoFLIP® ) measure physiologic characteristics of the pylorus. EndoFLIP® has the potential to select optimal candidates for gastric peroral endoscopic myotomy (G-POEM). Normative values of the pylorus using EndoFLIP® have not been established. METHODS Twenty-four healthy volunteers (20-56 years old; 15 females) underwent unsedated, transoral EndoFLIP® measurements of the pylorus after 8 h of fasting. Measurements of diameter (DM), balloon pressure, and distensibility index (DI) of the pylorus were obtained twice over 5 min at 40, 50, and 60 ml balloon distensions. KEY RESULTS Pyloric DM at 40, 50, and 60 ml balloon distensions were 13.0 ± 2.5, 14.3 ± 1.8, and 17.2 ± 2.0 mm, respectively. DM with 60 ml distension was notably higher than with 40 and 50 ml distensions. Pyloric DI at 40, 50, and 60 ml distensions were 10.9 ± 4.8, 11.3 ± 5.8, and 11.1 ± 4.3 mm2 /mm Hg, respectively (p = 0.86). Linear regression and Bland-Altman plots showed similar distribution of the DM and DI during the second minute compared with the full 5-min measurements at 50 ml distension, as well as between two sequential measurements using 50 ml distension. With 50 ml balloon distension, intraindividual coefficients of variation (COVintra ) for DM and DI were 13.8% and 29.6%, respectively, and interindividual COV (COVinter ) were 12.6% and 51.3%, respectively. Similar reproducibility was obtained with 40 ml balloon distension. CONCLUSIONS AND INFERENCES Unsedated EndoFLIP® can be used to characterize human fasting pyloric diameter and distensibility, with best performance observed with 40 ml and 50 ml distensions and data collection during the second minute. Normative values reported serve as reference values for future studies.
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Affiliation(s)
- Ting Zheng
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kia Vosoughi
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Irene Busciglio
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Lisa Tebay
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Duane Burton
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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45
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Xia H, Peng Y, Tang X. Is it necessary for endoscopic surveillance for achalasia patients? J Gastroenterol 2022; 57:812. [PMID: 36001160 DOI: 10.1007/s00535-022-01916-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 08/16/2022] [Indexed: 02/05/2023]
Affiliation(s)
- Huifang Xia
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan Province, China
| | - Yan Peng
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan Province, China
| | - Xiaowei Tang
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan Province, China.
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Zheng T, BouSaba J, Sannaa W, Eckert DJ, Burton DD, Camilleri M. Comprehensive characterization of antral and pyloric contractions by high resolution manometry: applied physiology in suspected gastroparesis. Am J Physiol Gastrointest Liver Physiol 2022; 323:G255-G264. [PMID: 35819155 PMCID: PMC9448275 DOI: 10.1152/ajpgi.00119.2022] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 06/30/2022] [Accepted: 06/30/2022] [Indexed: 02/03/2023]
Abstract
Delayed gastric emptying may result from diverse pathophysiological mechanisms including antral hypomotility and pylorospasm. With increasing use of gastric peroral endoscopic myotomy and preliminary evidence of efficacy, our aim was to assess the motor functions of the distal antrum and pylorus in patients with symptoms of gastroparesis using high-resolution antropyloroduodenal manometry (HR-ADM). Sixteen patients with symptoms suggestive of gastroparesis underwent HR-ADM with 13 sensors, 1 cm apart, placed across the antropyloroduodenal (APD) junction and 2 sensors, 10 cm apart, in descending and distal duodenum. The 1-h postprandial motility was quantitated as contraction frequency/minute, average amplitude, and motility index (MI). Six healthy volunteers served as controls. In the patient group, the HR-ADM identified postprandial antral hypomotility, isolated pyloric pressure waves, and tonic elevation of baseline pressure in pylorus. Patients had significantly reduced frequency of the full-hour postprandial antral contractions/minute compared with healthy volunteers [1.52 (0.97, 1.67) vs. 2.04 (1.70, 2.67), P = 0.005], as well as reduced MI [9.65 (8.29, 10.31) vs. 11.04 (10.65, 11.63), P = 0.002]. The average contraction amplitude was numerically, but not significantly reduced [51.9 (21.9, 74.9) vs. 73.0 (59.8, 82.7), P = 0.14]. Bland-Altman plots showed similar distribution of antral contraction frequency and MI during the first and second postprandial 30-min periods for both patients and controls. High-resolution ADM can characterize a variety of postprandial antral contractile and pyloric motility dysfunctions. This technique shows promise to provide guidance for the selection of optimal treatment of patients with gastroparesis.NEW & NOTEWORTHY Current selection of different treatments for patients with gastroparesis is empiric or based on trial and error, though pyloric distensibility and diameter may predict response to pyloric interventions. High-resolution antropyloroduodenal manometry (HR-ADM) can characterize a variety of postprandial antral contractile and pyloric motility dysfunctions in patients with suspected gastroparesis. HR-ADM shows promise to provide guidance for selection and individualization of treatments such as prokinetic agents or pyloric interventions for patients with gastroparesis based on documented pathophysiology.
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Affiliation(s)
- Ting Zheng
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Joelle BouSaba
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Wassel Sannaa
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Deborah J Eckert
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Duane D Burton
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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Li YY, Lu WT, Liu JX, Wu LH, Chen M, Jiao HM. Changes in the esophagogastric junction outflow obstruction manometric feature based on the Chicago Classification updates. World J Gastroenterol 2022; 28:4163-4173. [PMID: 36157106 PMCID: PMC9403428 DOI: 10.3748/wjg.v28.i30.4163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/21/2022] [Accepted: 07/18/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The critical diagnostic criteria for esophagogastric junction outflow obstruction (EGJOO) were published in the latest Chicago Classification version 4.0 (CCv4.0). In addition to the previous criterion [elevated integrated relaxation pressure (IRP) in supine position], manometric diagnosis of EGJOO requires meeting the criteria of elevated median-IRP during upright wet swallows and elevated intrabolus pressure. However, with the diagnostic criteria modification, the change in manometric features of EGJOO remained unclear.
AIM To evaluate the esophageal motility characteristics of patients with EGJOO and select valuable parameters for confirming the diagnosis of EGJOO.
METHODS We performed a retrospective analysis of 370 patients who underwent high-resolution manometry with 5 mL water swallows × 10 in supine, × 5 in upright position and the rapid drink challenge (RDC) with 200 mL water from November 2016 to November 2021 at Peking University First Hospital. Fifty-one patients with elevated integrated supine IRP and evidence of peristalsis were enrolled, with 24 patients meeting the updated manometric EGJOO diagnosis (CCv4.0) as the EGJOO group and 27 patients not meeting the updated EGJOO criteria as the isolated supine IRP elevated group (either normal median IRP in upright position or less than 20% of supine swallows with elevated IBP). Forty-six patients with normal manometric features were collected as the normal high-resolution manometry (HRM) group. Upper esophageal sphincter (UES), esophageal body, and lower esophageal sphincter (LES) parameters were compared between groups.
RESULTS Compared with the normal HRM group, patients with EGJOO (CCv4.0) had significantly lower proximal esophageal contractile integral (PECI) and proximal esophageal length (PEL), with elevated IRP on RDC (P < 0.05 for each comparison), while isolated supine IRP elevated patients had no such feature. Patients with EGJOO also had more significant abnormalities in the esophagogastric junction than isolated supine IRP elevated patients, including higher LES resting pressure (LESP), intrabolus pressure, median supine IRP, median upright IRP, and IRP on RDC (P < 0.05 for each comparison). Patients with dysphagia had significantly lower PECI and PEL than patients without dysphagia among the fifty-one with elevated supine IRP. Further multivariate analysis revealed that PEL, LESP, and IRP on RDC are factors associated with EGJOO. The receiver-operating characteristic analysis showed UES nadir pressure, PEL, PECI, LESP, and IRP on RDC are parameters supportive for confirming the diagnosis of EGJOO.
CONCLUSION Based on CCv4.0, patients with EGJOO have more severe esophagogastric junction dysfunction and are implicated in the proximal esophagus. Additionally, several parameters are supportive for confirming the diagnosis of EGJOO.
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Affiliation(s)
- Yue-Yuan Li
- Department of Geriatrics, Peking University First Hospital, Beijing 100034, China
| | - Wen-Ting Lu
- Department of Geriatrics, Peking University First Hospital, Beijing 100034, China
| | - Jian-Xiang Liu
- Department of Gastroenterology and Hepatology, Peking University First Hospital, Beijing 100034, China
| | - Li-Hong Wu
- Department of Gastroenterology and Hepatology, Peking University First Hospital, Beijing 100034, China
| | - Meng Chen
- Department of Geriatrics, Peking University First Hospital, Beijing 100034, China
| | - Hong-Mei Jiao
- Department of Geriatrics, Peking University First Hospital, Beijing 100034, China
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48
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Promdam N, Khuituan P, Panichayupakaranant P. Effects of standardized [6]-gingerol extracts and [6]-gingerol on isolated ileum and lower esophageal sphincter contractions in mice. Food Chem 2022; 378:132077. [PMID: 35042108 DOI: 10.1016/j.foodchem.2022.132077] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 01/03/2022] [Accepted: 01/04/2022] [Indexed: 02/08/2023]
Abstract
Standardized [6]-gingerol extracts were prepared by microwave-assisted extraction using 20% v/v glycerin in ethanol and 20% v/v eutectic mixture of sucrose and citric acid in ethanol as alternative green solvents. The extracts obtained from 20% v/v glycerin in ethanol (GEE) and 20% v/v eutectic mixture of sucrose and citric acid in ethanol (EMSCEE) were standardized by HPLC to contain 17.0 mg/g of [6]-gingerol. The effects of the extracts on mouse ileal contractions via M3 and 5-HT3 receptors as well as lower esophageal sphincter (LES) contraction were determined in vitro relative to the marker compound, [6]-gingerol. [6]-Gingerol, GEE and EMSCEE demonstrated significant and concentration-dependent inhibitory effects on ileal contraction in mice via M3 and 5-HT3 receptors in a noncompetitive manner. In addition, [6]-gingerol and EMSCEE tend to increase the LES tone. These results indicated the potential of GEE and EMSCEE to attenuate nausea and vomiting and might be used as nutraceuticals.
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Affiliation(s)
- Nantaporn Promdam
- Department of Pharmacognosy and Pharmaceutical Botany, Faculty of Pharmaceutical Sciences, Prince of Songkla University, Hat-Yai, Songkhla 90112, Thailand
| | - Pissared Khuituan
- Division of Health and Applied Sciences, Faculty of Science, Prince of Songkla University, Hat-Yai, Songkhla 90112, Thailand; Gut Biology and Microbiota Research Unit, Prince of Songkla University, Hat-Yai, Songkhla 90112, Thailand
| | - Pharkphoom Panichayupakaranant
- Department of Pharmacognosy and Pharmaceutical Botany, Faculty of Pharmaceutical Sciences, Prince of Songkla University, Hat-Yai, Songkhla 90112, Thailand; Phytomedicine and Pharmaceutical Biotechnology Excellence Center, Faculty of Pharmaceutical Sciences, Prince of Songkla University, Hat-Yai, Songkhla 90112, Thailand.
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49
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Calu V, Enciu O, Toma EA, Pîrîianu C, Miron A. Treatment of Achalasia in the Evidence-Based Medicine Era - A Quest in Search for a Proper Attitude by Reviewing the Present Guidelines. Chirurgia (Bucur) 2022; 117:154-163. [PMID: 35535776 DOI: 10.21614/chirurgia.2732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2022] [Indexed: 11/23/2022]
Abstract
The best way to start a paper like this is with a citation from W. Edwards Deming: Without data, you're just another person with an opinion. In the era of Evidence-Based Medicine (EBM) every surgical procedure has to be backed up by solid statistical data to offer our patients the best treatment. But is EBM always the path to truth? We decided to analyze the literature for achalasia and see if the guidelines and the data are reliable enough to justify a certain attitude. Practically, we engaged in this endeavor not because we do not trust the statements of the guidelines, but to see if a surgeon can find by themselves the proper attitude in this disease. Achalasia is a motility disorder of the esophagus characterized by deficient relaxation of the inferior esophageal sphincter that results in dysphagia. There are several methods of treatment, with various statements in the guidelines. Currently, every treatment should be sustained by data and statistics, evidence-based medicine being mandatory when a method is preferred over another. This article reviews several studies and also the available guidelines in search for an answer to the question which procedure is the best.
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50
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Reja M, Mishra A, Tyberg A, Andalib I, Martínez GM, Zamarripa F, Gaidhane M, Nieto J, Kahaleh M. Gastric Peroral Endoscopic Myotomy: A Specific Learning Curve. J Clin Gastroenterol 2022; 56:339-342. [PMID: 34009842 DOI: 10.1097/mcg.0000000000001537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 02/18/2021] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Gastric peroral endoscopic pyloromyotomy (G-POEM) is a novel option for patients with gastroparesis. It involves submucosal tunneling across the pylorus, followed by pyloromyotomy, and subsequent closure of the endoscopic tunnel. The aim of this study was to determine the learning curve for G-POEM. METHODS Consecutive patients undergoing G-POEM by a single operator were included from a prospective registry over 2 years. Demographics, procedure info, postprocedure follow-up data, and adverse events were collected. Nonlinear regression and cumulative sum control chart analyses were conducted for the learning curve. Clinical outcomes were improvement in Gastroparesis Cardinal Symptom Index score and gastric emptying scintigraphy. RESULTS Thirty-six patients were included (16.7% M, mean age 46 y). The majority had idiopathic gastroparesis (n=16, 44%), with the remaining having diabetes (n=5, 17%), postsurgical (n=10, 28%), or other (n=4, 11%). Technical success was achieved in 35 of 36 (97%). There was a significant reduction in the total Gastroparesis Cardinal Symptom Index score (2.09 units, P<0.00001) and a significant reduction in postoperative gastric emptying scintigraphy (82.44 mins, P<0.00001). Mean follow-up was 15 months (SD, 1.05). Median procedure time was 60.5 minutes (range, 35 to 136). Cumulative sum control chart shows 60-minute procedure was achieved at the 18th procedure. Procedure durations further reduced with consequent procedures with the last 3 being 45 minutes, thus demonstrating continued improvement with ongoing experience (nonlinear regression P<0.0001). CONCLUSION Endoscopists experienced in G-POEM are expected to achieve a reduction in procedure time over successive cases, with efficiency reached at 60.5 minutes and a learning rate of 18 cases with continuing improvement.
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Affiliation(s)
- Mishal Reja
- Rutgers Robert Wood Johnson Medical School, New Brunswick
| | | | - Amy Tyberg
- Rutgers Robert Wood Johnson Medical School, New Brunswick
| | - Iman Andalib
- Ichan School of Medicine, Mount Sinai, New York, NY
| | | | | | | | | | - Michel Kahaleh
- Rutgers Robert Wood Johnson Medical School, New Brunswick
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