Recorded Lower Esophageal Pressures as a Function of Electronic Sleeve Placement and Location of Gastric Pressure Measurement in Patients With Hiatal Hernia

BACKGROUND/AIMS: In high-resolution manometry lower esophageal sphincter pressure (LESP) is measured relative to intragastric pressure, however Gastric Marker(TM) (GM) location used to determine resting LESP is not well established with hiatal hernia (HH). We test the hypothesis that measured resting LESP varies with HH based on GM location. METHODS: Subjects with HH > or = 2 cm were included. The eSleeve(TM) was adjusted to span only the LES, excluding the crural diaphragm (CD). Resting LESP was determined by placing the GM below and above the CD (in the position yielding the highest resting LESP). Resting pressure across the lower esophageal sphincter (LES) to CD and pressure in the HH relative to subdiaphragmatic intragastric pressure were also measured. RESULTS: HH > or = 2 cm was present in 98 patients (mean length 2.7 cm). LESP decreased when GM was moved from below the CD into the HH: respiratory minimum LESP 7.5 +/- 1.1 to 3.6 +/- 0.9 mmHg; P < 0.001, mean LESP 17.7 +/- 1.3 to 13.7 +/- 1.1 mmHg; P < 0.001. When the eSleeve encompassed the LES and CD, the respiratory minimum pressure was 12.2 +/- 0.9 mmHg and mean pressure was 23.9 +/- 1.0 mmHg pressure (P < 0.001 for both). Pressure in the hernia pouch was greater than intragastric pressure: respiratory minimum 3.0 +/- 0.7 mmHg and mean 9.0 +/- 0.8 mmHg (P < 0.001 for both). pH studies showed a trend toward an association between abnormal distal esophagus acid exposure and lower resting LESP. CONCLUSIONS: GM placement in the HH produces lower resting LESPs. This may provide a more physiologic representation of LESP in HH.

Gastric Electrical Stimulation for Gastroparesis

Gastric electrical stimulation (GES) for gastroparesis has been in use for more than a decade. Multiple publications, consisting almost entirely of open label single center studies, reported a beneficial effect on symptoms, quality of life and nutritional status. Some predictors of better response to GES have been lately identified, primarily diabetic etiology and nausea and vomiting as the predominant symptoms. However, individual response to GES remains difficult to predict. The mechanism of action of GES remains poorly understood. Stimulation parameters approved in clinical practice do not regulate gastric slow wave activity and have inconsistent effect on gastric emptying. Despite such limitations, gastric electrical stimulation remains a helpful intervention in some patients with severe gastroparesis who fail to respond to medical therapy.