Esophagogastric Junction Contractile Integral (EGJ-CI) in Various Phenotypes of Gastroesophageal Reflux Disease (GERD)

Introduction: Two parameters of high-resolution esophageal manometry are used to observe the function of the esophagogastric junction (EGJ): the anatomical morphology of the EGJ and contractile vigor, which is evaluated with the esophagogastric junction contractile integral (EGJ-CI). To date, how these parameters behave in different gastroesophageal reflux disease (GERD) phenotypes has not been evaluated. Materials and methods: An analytical observational study evaluated patients with GERD confirmed by pH-impedance testing and endoscopy undergoing high-resolution esophageal manometry. The anatomical morphology of the EGJ and EGJ-CI was assessed and compared between reflux phenotypes: acid, non-acid, erosive, and non-erosive. Results: 72 patients were included (63% women, mean age: 54.9 years), 81.9% with acid reflux and 25% with erosive esophagitis. In the latter, a decrease in EGJ-CI (median: 15.1 vs. 23, p = 0.04) and a more significant proportion of patients with type IIIa and IIIb EGJ (83.3% vs 37.1%, p < 0.01) were found. No significant differences existed in the manometric parameters of patients with and without acid and non-acid reflux. Conclusion: In our population, EGJ-CI significantly decreased in patients with erosive GERD, suggesting that it could be used to predict this condition in patients with GERD. This finding is also related to a higher proportion of type III EGJ and lower pressure at end-inspiration of the lower esophageal sphincter in this reflux type.

Introducción: Para observar la función de la unión esofagogástrica (UEG) se utilizan dos parámetros de la manometría esofágica de alta resolución: la morfología anatómica de la UEG y el vigor contráctil, el cual se evalúa con la integral de contractilidad distal de la unión esofagogástrica (IC-UEG). Hasta el momento, no se ha evaluado cómo se comportan estos parámetros en los diferentes fenotipos de enfermedad por reflujo gastroesofágico (ERGE). Metodología: Estudio observacional analítico en el que se evaluaron pacientes con ERGE confirmado por pH-impedanciometría y endoscopia, llevados a manometría esofágica de alta resolución. Se evaluó la morfología anatómica de la UEG y la IC-UEG, y se comparó entre los diferentes fenotipos de reflujo: ácido, no ácido, erosivo y no erosivo. Resultados: Se incluyó a 72 pacientes (63% mujeres, edad media: 54,9 años), 81,9% con reflujo ácido y 25% con esofagitis erosiva. En este último grupo se encontró una disminución de la IC-UEG (mediana: 15,1 frente a 23, p = 0,04) y una mayor proporción de pacientes con UEG tipo IIIa y IIIb (83,3% frente a 37,1%, p < 0,01). No se encontraron diferencias significativas en los parámetros manométricos de los pacientes con y sin reflujo ácido y no ácido. Conclusión: En nuestra población, la IC-UEG estuvo significativamente disminuida en los pacientes con ERGE erosivo, lo que sugiere que podría ser utilizada como un predictor de esta condición en pacientes con ERGE. Este hallazgo también se relaciona con mayor proporción de UGE tipo III y menor presión al final de la inspiración del esfínter esofágico inferior en este tipo de reflujo.

Impacto de la cardiomiotomía laparoscópica de Heller en la función del esfínter esofágico inferior y el diámetro del esófago / Impact of laparoscopic Heller cardiomyotomy on lower esophageal sphincter function and esophageal diameter

Introducción. La acalasia es un trastorno motor del esófago caracterizado por la ausencia de peristalsis y la alteración en la relajación del esfínter esofágico inferior. La cardiomiotomía laparoscópica de Heller más funduplicatura parcial es el tratamiento estándar. La mejoría sintomática ha sido bien documentada, pero no hay suficiente información objetiva respecto a los cambios fisiológicos y radiográficos luego del procedimiento. Métodos. Estudio de cohorte bidireccional de pacientes llevados a cardiomiotomía laparoscópica de Heller, entre los años 2018 y 2021, en el Hospital Universitario San Vicente Fundación de Medellín, Colombia. Se describen variables demográficas y clínicas. Se realizaron puntaje sintomático de Eckardt, manometría esofágica y radiografía de esófago en el pre y postoperatorio. Se hizo comparación de síntomas, presión basal del esfínter esofágico inferior, presión de relajación integrada y diámetro del esófago antes y después de la intervención. Resultados. Se incluyeron 24 pacientes. El 63 % fueron mujeres y la edad promedio fue de 44 años. Los valores promedio preoperatorios vs postoperatorios fueron: puntaje de Eckardt 10,6 vs 1,4 puntos (p<0,001), presión basal de 41,4 vs 18,1 mmHg (p=0,004) y presión de relajación integrada de 28,6 vs 12,5 mmHg (p=0,001). El diámetro del esófago no presentó cambios. No hubo correlación de síntomas con los cambios de presión del esfínter esofágico inferior. El tiempo de seguimiento fue de 20 meses. Conclusiones. La cardiomiotomía de Heller es un procedimiento altamente efectivo para el tratamiento definitivo de la acalasia, logrando una mejoría subjetiva y objetiva basada en síntomas y en parámetros de manometría, respectivamente

Introduction. Achalasia is a motor disorder of the esophagus characterized by the absence of peristalsis and impaired relaxation of the lower esophageal sphincter. Laparoscopic Heller ́s cardiomyotomy plus partial fundoplication is the standard treatment. Symptomatic improvement has been well documented, but there is insufficient objective information regarding physiologic and radiographic changes after the procedure. Methods. Bidirectional cohort study of patients underwent laparoscopic Heller ́s cardiomyotomy between 2018 and 2021 at the San Vicente Fundación University Hospital in Medellín, Colombia. Demographic and clinical variables are described. Eckardt symptom score, esophageal manometry, and esophageal radiography were performed pre and postoperatively. A comparison of symptoms, baseline lower esophageal sphincter pressure, integrated relaxation pressure, and esophageal diameter before and after intervention were performed.Results. 24 patients were included. 63% were women and the average age was 44 years. The preoperative vs. postoperative mean values were: Eckardt score 10.6 vs. 1.4 points (p<0.001), basal pressure of 41.4 vs. 18.1 mmHg (p=0.004) and integrated relaxation pressure of 28.6 vs. 12.5 mmHg (p=0.001). The diameter of the esophagus did not present changes. There was no correlation of symptoms with lower esophageal sphincter pressure changes. The follow-up time was 20 months. Conclusions. Heller cardiomyotomy is a highly effective procedure for the definitive treatment of achalasia, achieving subjective and objective improvements, based on symptoms and manometry parameters, respectively

Z-POEM: ¿Procedimiento ideal para el tratamiento del divertículo de Zenker? / Z-POEM: Ideal procedure for the treatment of Zenker's diverticulum?

Introducción. El divertículo de Zenker es una patología poco frecuente, caracterizada por la presencia de disfagia, halitosis, tos y pérdida de peso, que afectan la calidad de vida de los pacientes. El tratamiento es quirúrgico y las técnicas han evolucionado de forma permanente. El objetivo de este estudio fue evaluar la mejoría de la disfagia en pacientes a quienes se les realizó la técnica de miotomía endoscópica peroral (Z-POEM). Métodos. Estudio descriptivo de una serie de 23 pacientes con divertículo de Zenker diagnosticado por endoscopia y esofagograma, tratados entre mayo de 2018 y noviembre de 2021 en diferentes instituciones de la ciudad de Bogotá, D.C., Colombia, mediante una miotomía endoscópica del cricofaríngeo con la técnica de Z-POEM. Resultados. La mayoría de los pacientes fueron adultos mayores, de sexo masculino. Los síntomas más frecuentes correspondieron a disfagia y regurgitación. El tamaño promedio del divertículo fue de tres centímetros. La estancia hospitalaria fue de un día. Un paciente presentó disfagia postoperatoria en relación con los clips y otro presentó un absceso mediastinal, el cual fue resuelto de manera endoscópica. Actualmente, todos los pacientes se encuentran asintomáticos y no han presentado recurrencia. Conclusiones. El tratamiento endoscópico mínimamente invasivo mediante la miotomía endoscópica peroral (Z-POEM) en el paciente con divertículo de Zenker es una alternativa segura y eficaz, con buenos resultados y poca morbilidad

Introduction. Zenker's diverticulum is a rare pathology characterized by the presence of dysphagia, halitosis, cough, and weight loss, which affect the patients' quality of life. The treatment is surgical and the techniques have evolved permanently. The objective of this study was to evaluate the improvement of dysphagia in patients who underwent peroral endoscopic myotomy technique (Z-POEM). Methods. Descriptive study of a series of 23 patients with Zenker's diverticulum diagnosed by endoscopy and esophagram, treated between May 2018 and November 2021 at different institutions in Bogotá, Colombia, by means of an endoscopic cricopharyngeal myotomy with the Z-POEM technique. Results. Most of patients were older males. The most frequent symptoms corresponded to dysphagia and regurgitation. The average size of the diverticulum was three centimeters. The hospital stay was one day. One patient presented postoperative dysphagia related to the clips and another presented a mediastinal abscess which was resolved endoscopically. Currently, all patients are asymptomatic and have not presented recurrence. Conclusions. Minimally invasive endoscopic treatment by peroral endoscopic myotomy (Z-POEM) in patients with Zenker's diverticulum is a safe and effective alternative, with good results and low morbidity

Functional Changes of the Upper Esophageal Sphincter in Gastroesophageal Reflux

Abstract Introduction The upper esophageal sphincter (UES) is a muscular structure located at the transition from the pharynx to the esophagus, with the cricopharyngeal muscle as the most important component. During gastroesophageal reflux, the pressure in the UES elevates, which is apparently a protective mechanism to prevent esophagopharyngeal reflux and airway aspiration. In gastroesophageal reflux disease (GERD), there may be functional changes in the UES. Objective The objective of the present review was to determine UES functional changes in GERD. Data Synthesis In healthy individuals, gastroesophageal reflux causes an increase in the UES pressure. This response of the sphincter is at least partially impaired in patients with GERD. In the disease, the UES has a reduced length and decreased resting pressure. However, other publications found that in chronic gastroesophageal reflux the basal sphincter pressure increase, differences which may be consequent to the measurement method or to disease severity. The UES opening during swallowing has a smaller diameter, and the bolus transit time through the sphincter is longer. Conclusion The UES of patients with GERD does not open as expected and the bolus flow through the sphincter is longer. This behavior may be associated with dysphagia, a frequent complaint in patients with GERD.

Residue localization and risk for aspiration in partial laryngectomy: the relevance of assertive therapeutic strategies and resources

ABSTRACT Objective: To describe the correlation between the residues, their anatomical location and the presence of laryngotracheal penetration and aspiration in patients after supracricoid laryngectomy undergoing cricohyoidoepiglotopexy reconstruction. Methods: This study included 70 patients treated by supracricoid laryngectomy with cricohyoidoepiglotopexy reconstruction in a referral national cancer hospital. The patients were submitted to swallowing videofluoroscopy, and the findings were classified by the penetration and aspiration scale. The images were described observing the presence or absence of residues and their anatomical location. Results: The prevalence of penetration in this study was 68.6% and aspiration was 34.3%. An association was found between the presence of residue on the tongue (p=0.005), posterior pharyngeal wall (p=0.013), pyriform recesses (p=0.002), valecula (p=0.061), and laryngeal penetration. The residue in the upper esophageal sphincter (p=0.039) was associated with the occurrence of laryngotracheal aspiration. Conclusion: Patients undergoing supracricoid laryngectomy with cricohioidoepiglotopexy reconstruction have food residues in different anatomical regions after swallowing. Penetration was associated with the presence of residues on the base of the tongue and posterior pharyngeal wall. Aspiration was associated with the presence of residues in the upper esophageal sphincter.

Clinical factors influencing the effect of anti-reflux surgery for gastroesophageal reflux disease / 中华普通外科杂志

Objective:to analyze the risk factors for the side effect of anti-reflux surgery for gastroesophageal reflux disease (GERD) with regards to relief of reflux symptom, dysphagia and postoperative satisfaction.Method:The incidence of disappointing chief complaint among 192 patients who underwent anti-reflux surgery was analyzed. The related independent risk factors were identified by multivariate analysis.Results:The incidence of non-relief of reflux symptom was approximately 21.8% (42 cases), of which the risk factors were identified as preoperative depression and long-term PPI administration. The incidence of persistent dysphagia was 7.3% (14 cases), of which the risk factors were identified as preoperative depression and weak peristalsis of esophageal body. The incidence of postoperative dissatisfaction was 26.0% (50 cases), of which the risk factors were identified as long-term PPI administration and moderate-severe depression. The GERD patients with hiatal hernia and low pressure of lower esophageal sphincter were more likely benefit from anti-reflux surgery and had a higher postoperative satisfaction rate.Conclusion:Hiatal hernia and low pressure of lower esophageal sphincter are the favorable factors predicting good result of anti-reflux surgery. Long-term PPI administration and preoperative depression is an indication for poor result of anti-reflux surgery.

Adequate Number of Swallows for Pharyngeal Pressure Measurement of a Subject using High-resolution Manometry

Abstract Introduction The number of pressure measurements that need to be recorded using high-resolution manometry (HRM) for the accurate evaluation of pharyngeal function is not well established. Objective The purpose of this study is to clarify the number of swallows required to obtain an accurate pharyngeal manometric profile of a person. Methods Forty healthy adults performed a dry swallow and bolus swallows using 3-, 5-, or 10 ml of water and underwent measurements using the Starlet HRM system. Each subject underwent 10 swallows for each of the four bolus volume conditions. Results The mean of up to seven measurements of maximum pre-swallow upper esophageal sphincter pressure with 10 ml of swallow was close to the mean of up to eight measurements in 95% of the subjects. Similarly, the rate of change of the average for the eighth and ninth measurements and the rate of change for the average of the ninth and tenth measurements were less than 5 %. When the other parameters were similarly measured up to the sixth measurement, no major change in the average value was observed even if more measurements were taken. Conclusion A minimum of six measurements are required, and seven swallows are sufficient for evaluating the pharyngeal manometric profile of a single person. This number of measurements can be a useful criterion when performing HRM measurements on individual subjects.

Reflux symptom index, reflux finding score, esophageal motility and their correlation with laryngopharyngeal reflux in patients with vocal cord polyps / 中国基层医药

Objective:To investigate reflux symptom index (RSI), reflux finding score (RFS), esophageal motility and to correlate them with laryngopharyngeal reflux in patients with vocal cord polyps, providing guidance for clinical study.Methods:A total of 100 patients with vocal cord polyps who received treatment from January 2018 to January 2020 in Jiangshan People's Hospital were included in the observation group. A total of 100 healthy controls who concurrently received physical examination were included in the control group. RSI and RFS were used to preliminarily evaluate laryngopharyngeal reflux. The characteristics of esophageal motility and the pressure of upper and lower sphincter were monitored. The correlation between RSI, RFS, esophageal motility and laryngopharyngeal reflux was analyzed.Results:In the observation group, 35.00% of patients had RSI > 13 points, and 30.00% of patients had RFS > 7 points. The RSI and RFS in the observation group were significantly higher than those in the control group [RSI: (24.17 ± 1.14) points vs. (7.28 ± 12) points; RFS: (17.59 ± 1.52) points vs. (4.28 ± 0.21) points, t = 147.344, 86.742, both P < 0.05)]. The time to upper sphincter relaxation recovery and the duration of upper sphincter relaxation in the observation group were significantly shorter than those in the control group ( t = 5.373, 4.660, both P < 0.05). The intra pellet pressure in the observation group was significantly greater than that in the control group ( t = 2.186, P < 0.05). The length of the lower sphincter in the observation group was significantly shorter than that in the control group ( t = 4.977, P < 0.05). Correlation analysis showed that RSI was positively correlated with foreign body sensation in the throat, continuous throat clearing, nasal reflux or phlegm ( r = 0.640, 0.649, 0.507, all P < 0.05). RFS was positively correlated with disappearance of laryngeal chamber, posterior commissure hyperplasia and vocal cord edema ( r = 0.742, 0.516, 0.547, all P < 0.05). Conclusion:RSI and RFS of patients with vocal cord polyps are positively correlated with laryngopharyngeal reflux. Some patients with vocal cord polyps have dysfunction and abnormal structure of upper and lower esophageal sphincter as well as laryngopharyngeal reflux. Therefore, reflux symptom index, reflux finding score and esophageal motility can be used together to diagnose laryngopharyngeal reflux and increase the diagnosis accuracy

Danos anatômicos ao esfíncter esofágico inferior após gastrectomia subtotal / Anatomic damage of the lower esophageal sphincter after subtotal gastrectomy

RESUMO - RACIONAL: Disfunção do esfíncter esofágico inferior (EEI), doença do refluxo gastroesofágico e esofagite erosiva em pacientes submetidos à gastrectomia subtotal são ocorrências comumente reconhecidas, mas até agora as causas permanecem obscuras. OBJETIVO: A hipótese deste estudo é que a gastrectomia subtotal provoque alterações na pressão de repouso do EEI e na sua competência, devido ao dano anatômico desta, visto que as fibras oblíquas "Sling", um dos componentes musculares do EEI, são seccionadas durante este procedimento cirúrgico. MÉTODOS: Sete cães adultos sem raça definida (18-30 kg) foram anestesiados e submetidos à transecção do estômago proximal. Em seguida, o remanescente gástrico proximal foi fechado por sutura. No intraoperatório, manometria lenta foi realizada em cada cão, em condições basais (com estômago intacto) e no remanescente gástrico proximal fechado. A média dessas medidas é apresentada, com cada cão servindo como seu próprio controle. RESULTADOS: A pressão média do EEI medida no remanescente gástrico proximal, em comparação com a pressão do EEI no estômago intacto, foi diminuída em cinco cães, aumentada em um cão e sem alterações no outro cão. CONCLUSÃO: A secção transversa superior do estômago e o fechamento do remanescente do estômago por sutura provocam alterações na pressão do EEI. Sugerimos que essas mudanças na pressão do EEI são secundárias à secção das fibras oblíquas "Sling" do esfíncter, um de seus componentes musculares. A sutura e o fechamento do remanescente gástrico proximal, reancora essas fibras com mais, menos ou a mesma tensão, modificando ou não a pressão do EEI.

ABSTRACT - BACKGROUND: Dysfunction of the lower esophageal sphincter (LES), gastroesophageal reflux disease, and erosive esophagitis in patients undergoing subtotal gastrectomy are commonly recognized occurrences, but until now the causes remain unclear. AIM: The hypothesis of this study is that subtotal gastrectomy provokes changes on the LES resting pressure and its competence, due to the anatomical damage of it, given that the oblique "Sling" fibers, one of the muscular components of the LES, are transected during this surgical procedure. METHODS: Seven adult mongrel dogs (18-30 kg) were anesthetized and admitted for transection of the proximal stomach. Later, the proximal gastric remnant was closed by a suture. Intraoperatively, slow pull-through LES manometries were performed on each dog, under basal conditions (with the intact stomach), and in the closed proximal gastric remnant. The mean of these measurements is presented, with each dog serving as its control. RESULTS: The mean LES pressure (LESP) measured in the proximal gastric remnant, compared with the LESP in the intact stomach, was decreased in five dogs, increased in one dog, and remained unchanged in other dogs. CONCLUSION: The upper transverse transection of the stomach and closing the stomach remnant by suture provoke changes in the LESP. We suggested that these changes in the LESP are secondary to transecting the oblique "Sling" fibers of the LES, one of its muscular components. The suture and closing of the proximal gastric remnant reanchor these fibers with more, less, or the same tension, whether or not modifying the LESP.

Trânsitos oral e faríngeo na pirose funcional / Oral and pharyngeal transit in functional heartburn

ABSTRACT BACKGROUND: Gastroesophageal reflux disease is associated with slower transit of the bolus through the pharynx and upper esophageal sphincter. Functional heartburn has similar symptoms to gastroesophageal reflux disease, however, the symptoms are not caused by reflux. OBJECTIVE: The aim of this investigation was to evaluate oral and pharyngeal transit in patients with functional heartburn, with the hypothesis that, similar to patients with gastroesophageal reflux disease, they have changes in pharyngeal and upper esophageal sphincter transit time. METHODS: Oral and pharyngeal transit was evaluated by videofluoroscopy in eight women with functional heartburn, five with mild dysphagia for solid foods, and 12 female controls. Controls and patients swallowed in duplicate 5 mL and 10 mL of liquid and paste boluses. RESULTS: No difference in the oral or pharyngeal transit time was found between patients and controls. No aspiration of bolus into the airways was detected in any individual. Pharyngeal residues were detected in the same proportion of swallows, in patients (12.5%) and controls (15.0%), after swallows of 10 mL paste bolus. CONCLUSION: Oral, pharyngeal and upper esophageal sphincter transit time are similar in patients with functional heartburn to healthy controls.

RESUMO CONTEXTO: A doença do refluxo gastroesofágico está associada ao trânsito mais lento do bolo deglutido pela faringe e esfíncter superior do esôfago. Pirose funcional tem sintomas similares aos de doença do refluxo gastroesofágico, entretanto eles não são consequência de refluxo. OBJETIVO: Como na pirose funcional os sintomas são semelhantes aos da doença do refluxo gastroesofágico, o objetivo desta investigação foi avaliar a duração do trânsito do bolo deglutido pela boca, faringe e esfíncter superior do esôfago em pacientes com pirose funcional, com a hipótese de que esses pacientes também apresentem alteração no trânsito. MÉTODOS: Pelo método videofluoroscópico foi avaliado o trânsito oral e faríngeo de oito pacientes do sexo feminino com pirose funcional, cinco com disfagia leve para alimentos sólidos, e 12 indivíduos controles do sexo feminino. Controles e pacientes deglutiram em duplicata 5 mL e 10 mL de bolos com a consistências líquida e pastosa. RESULTADOS: Com bolo líquido e pastoso não houve diferença na duração do trânsito oral, faríngeo e pelo esfíncter superior do esôfago entre controles e pacientes. Não houve aspiração do bolo para as vias aéreas em nenhum indivíduo. Os resíduos faríngeos foram observados na mesma proporção das deglutições em pacientes (12,5%) e controles (15%), com a deglutição de 10 mL de bolo pastoso. CONCLUSÃO: A duração do trânsito oral, faríngeo e pelo esfíncter superior do esôfago foi semelhante nos pacientes com pirose funcional e controles.

Validation of a new water-perfused high-resolution manometry system / Validação de um novo sistema de manometria de alta resolução por perfusão de água

ABSTRACT Background: High-resolution manometry is more costly but clinically superior to conventional manometry. Water-perfused systems may decrease costs, but it is unclear if they are as reliable as solid-state systems, and reference values are interchangeable. Aim: To validate normal values for a new water-perfusion high-resolution manometry system. Methods: Normative values for a 24-sensors water perfused high-resolution manometry system were validated by studying 225 individuals who underwent high resolution manometry for clinical complaints. Patients were divided in four groups: group 1 - gastroesophageal reflux disease; group 2 - achalasia; group 3 - systemic diseases with possible esophageal manifestation; and group 4 - dysphagia. Results: In group 1, a hypotonic lower esophageal sphincter was found in 49% of individuals with positive 24 h pH monitoring, and in 28% in pH-negative individuals. In groups 2 and 3, aperistalsis was found in all individuals. In group 4, only one patient (14%) had normal high-resolution manometry. Conclusions: The normal values determined for this low-cost water-perfused HRM system with unique peristaltic pump and helicoidal sensor distribution are discriminatory of most abnormalities of esophageal motility seen in clinical practice.

RESUMO Racional: A manometria de alta resolução é mais custosa, porém clinicamente superior à manometria convencional. Sistemas por perfusão de água podem ter custo diminuído, mas não é certo se são tão eficazes quanto aos sistemas de estado sólido e se os valores de referência são intercambiáveis. Objetivo: Este estudo visa validar valores de normalidade para um novo sistema por perfusão de água. Método: Valores de normalidade para um sistema de manometria de alta resolução de 24 sensores por perfusão de água foram validados estudando 225 indivíduos submetidos à manometria de alta resolução por queixas clínicas. Pacientes foram divididos em quatro grupos: grupo 1 - doença do refluxo gastroesofágico; grupo 2 - acalasia; grupo 3 - doenças sistêmicas com possível doenças sistêmicas com comprometimento esofágico; e grupo 4 - pacientes com disfagia. Resultado: No grupo 1, esfíncter esofagiano inferior hipotônico foi encontrado em 49% dos indivíduos com pHmetria positiva e 28% daqueles com pHmetria negativa. Nos grupos 2 e 3, aperistalse foi encontrada em todos indivíduos. No grupo 4, somente um paciente (14%) tinha manometria normal. Conclusão: Os valores de normalidade definidos para este sistema de manometria de alta resolução por perfusão de água são discriminatórios da maioria das anormalidades da motilidade esofágica vistas na prática clínica.

Analysis of clinical features and motility characteristics of ineffective esophageal motility / 中华消化杂志

Objective@#To clarify the correlation between the clinical characteristics, esophageal motility features and esophageal acid exposure in patients with ineffective esophageal motility (IEM).@*Methods@#From January 2016 to March 2018, at Peking University First Hospital, 22 IEM patients diagnosed by esophagus high-resolution manometry (HRM) and 24 individuals with normal HRM results were enrolled. Clinical features, parameters of esophageal HRM and results of esophageal 24-hour pH monitoring of IEM patients and the individuals with normal HRM results were compared. According to the median distal contraction integral (DCI) of ten swallows, the IEM patients were divided into mild-IEM group (DCI 250-450 mmHg·s·cm (1 mmHg=0.133 kPa)) (14 cases) and severe-IEM group (DCI<250 mmHg·s·cm) (eight cases). The clinical features and esophageal motility were compared between normal HRM group, mild-IEM group and severe-IEM group. T test, chi-square test and one-way analysis of various were used for statistical analysis.@*Results@#The age of IEM group was older than that of normal HRM group ((64.5±11.2) years vs. (50.3±18.2) years), and the difference was statistically significant (t=-3.135, P=0.003). The lower esophageal sphincter pressure (LESP) of IEM group was lower than that of normal HRM group ((17.0±6.8) mmHg vs. (22.3±7.2) mmHg), and the difference was statistically significant (t=2.516, P=0.016). There were 15 cases in normal HRM group and 14 patients in IEM group who underwent esophageal 24-hour pH monitoring and there were five and two patients with abnormal acid exposure time (AET) in normal HRM group and IEM group, respectively. The length of proximal esophageal body (PEB) pressure zone of severe-IEM group was shorter than those of normal HRM group and mild-IEM group ((2.8±1.5) cm vs.(4.2±0.7) cm and (4.6±0.9) cm), and the differences were statistically significant (t=2.397 and 3.432, P=0.044 and 0.003). The integrated relaxation pressure (IRP) and LESP of normal HRM group were both higher than those of mild-IEM group ((9.3±2.9) mmHg vs. (7.2±3.3) mmHg, (22.3±7.2) mmHg vs. (15.4±7.1) mmHg), and the differences were statistically significant (t=2.148 and 2.843, P=0.038 and 0.007). There were six and eight patients in mild-IEM group and severe-IEM group who underwent esophageal 24-hour pH monitoring, respectively, and two patients in mild-IEM had abnormal AET.@*Conclusions@#The LESP of IEM patients is low. The clinical features and AET of IEM patients are not associated with the severity of IEM. In patients with severe IEM, the proximal and distal esophageal contractility is weakened, and the length of PEB pressure zone is shortened.

Analysis of clinical features and motility characteristics of ineffective esophageal motility / 中华消化杂志

Objective To clarify the correlation between the clinical characteristics,esophageal motility features and esophageal acid exposure in patients with ineffective esophageal motility (IEM). Methods From January 2016 to March 2018,at Peking University First Hospital,22 IEM patients diagnosed by esophagus high-resolution manometry (HRM ) and 24 individuals with normal HRM results were enrolled. Clinical features,parameters of esophageal HRM and results of esophageal 24-hour pH monitoring of IEM patients and the individuals with normal HRM results were compared. According to the median distal contraction integral (DCI)of ten swallows,the IEM patients were divided into mild-IEM group (DCI 250 - 450 mmHg · s · cm (1 mmHg = 0. 133 kPa))(14 cases)and severe-IEM group (DCI < 250 mmHg·s·cm)(eight cases). The clinical features and esophageal motility were compared between normal HRM group,mild-IEM group and severe-IEM group. T test,chi-square test and one-way analysis of various were used for statistical analysis. Results The age of IEM group was older than that of normal HRM group ((64. 5 ± 11. 2)years vs. (50. 3 ± 18. 2)years),and the difference was statistically significant (t = - 3. 135,P = 0. 003). The lower esophageal sphincter pressure (LESP)of IEM group was lower than that of normal HRM group ((17. 0 ± 6. 8)mmHg vs. (22. 3 ± 7. 2)mmHg),and the difference was statistically significant (t = 2. 516,P = 0. 016). There were 15 cases in normal HRM group and 14 patients in IEM group who underwent esophageal 24-hour pH monitoring and there were five and two patients with abnormal acid exposure time (AET)in normal HRM group and IEM group,respectively. The length of proximal esophageal body (PEB)pressure zone of severe-IEM group was shorter than those of normal HRM group and mild-IEM group ((2. 8 ± 1. 5 )cm vs. (4. 2 ± 0. 7 )cm and (4. 6 ± 0. 9)cm),and the differences were statistically significant (t = 2. 397 and 3. 432,P = 0. 044 and 0. 003). The integrated relaxation pressure (IRP)and LESP of normal HRM group were both higher than those of mild-IEM group ((9. 3 ± 2. 9 )mmHg vs. (7. 2 ± 3. 3 )mmHg,(22. 3 ± 7. 2 )mmHg vs. (15. 4 ± 7. 1)mmHg),and the differences were statistically significant (t = 2. 148 and 2. 843,P = 0. 038 and 0. 007). There were six and eight patients in mild-IEM group and severe-IEM group who underwent esophageal 24-hour pH monitoring,respectively,and two patients in mild-IEM had abnormal AET. Conclusions The LESP of IEM patients is low. The clinical features and AET of IEM patients are not associated with the severity of IEM. In patients with severe IEM,the proximal and distal esophageal contractility is weakened,and the length of PEB pressure zone is shortened.

Treating dysphagia with surface neuromuscular electrical stimulation of the neck / 中华物理医学与康复杂志

Objective To explore the effect of applying surface neuromuscular electrical stimulation (NMES) on the functioning of the upper esophageal sphincter (UES) using the high-resolution solid-state manometry.Methods Seventeen healthy volunteers were selected and given sham stimulation (SS),superior and inferior hyoid stimulation (SIHS),superior hyoid stimulation (SHS) or inferior hyoid stimulation (IHS) at a frequency of 80 Hz and the maximum tolerated level before swallowing.Any changes in the kinematics or biomechanics during swallowing and at rest were recorded using high-resolution solid-state manometry.One-factor repeated analysis of the measurement variance was used.Results A significant decrease in the duration of UES relaxation was observed in response to the electrical stimulation (compared with the sham stimulation).The UES's residual pressure showed a rising trend during electrical stimulation,especially in response to IHS,but the difference compared with SS was not significant.The UES's resting pressure during SIHS increased significantly compared with SS,but there was no significant difference between SHS and IHS in this respect.Conclusions Surface neuromuscular electrical stimulation applied to the neck can immediately change the functioning of the UES.NMES at the maximum tolerated intensity can reduce the duration of UES relaxation,which is important for dysphagia therapy and research.

Plummer-vinson syndrome associated with lower esophageal ring (Schatzki's Ring)

We report a case of Plummer-Vinson syndrome (PVS) and lower esophageal ring with a small sliding hiatal hernia. PVS is a rare entity formed by the combination of dysphagia, cervical esophageal web and iron deficiency anemia. It occurs mainly in middle-aged women1,2,3. A lower esophageal ring and a small sliding hiatal hernia were also observed in this case. We documented clinical manifestations of iron deficiency anemia through images and esophageal abnormalities through barium esophagogram. (AU)

O papel do gradiente pressórico transdiafragmático na fisiopatologia da doença do refluxo gastroesofágico / The role of the transdiaphragmatic pressure gradient in the pathophysiology of gastroesophageal reflux disease

ABSTRACT Gastroesophageal reflux disease (GERD) is the most common disease of the upper gastrointestinal tract in the Western world. GERD pathophysiology is multifactorial. Different mechanisms may contribute to GERD including an increase in the transdiaphragmatic pressure gradient (TPG). The pathophysiology of GERD linked to TPG is not entirely understood. This review shows that TPG is an important contributor to GERD even when an intact esophagogastric barrier is present in the setting of obesity and pulmonary diseases.

RESUMO A doença do refluxo gastroesofágico (DRGE) é a enfermidade mais comum do trato digestivo alto no mundo ocidental. A fisiopatologia da DRGE é multifatorial. Diferentes mecanismos podem contribuir para um aumento do gradiente pressórico transdiafragmático (GPT). A fisiopatologia da DRGE associada ao GPT não é totalmente compreendida. Esta revisão enfoca que o GPT é um importante contribuinte para DRGE mesmo na presença de uma barreira gastroesofágica intacta como na obesidade e doenças pulmonares crônicas.

Axial Movements and Length Changes of the Human Lower Esophageal Sphincter During Respiration and Distension-induced Secondary Peristalsis Using Functional Luminal Imaging Probe

BACKGROUND/AIMS: Efficient transport through the esophago-gastric junction (EGJ) requires synchronized circular and longitudinal muscle contraction of the esophagus including relaxation of the lower esophageal sphincter (LES). However, there is a scarcity of technology for measuring esophagus movements in the longitudinal (axial) direction. The aim of this study is to develop new analytical tools for dynamic evaluation of the length change and axial movement of the human LES based on the functional luminal imaging probe (FLIP) technology and to present normal signatures for the selected parameters. METHODS: Six healthy volunteers without hiatal hernia were included. Data were analyzed from stepwise LES distensions at 20, 30, and 40 mL bag volumes. The bag pressure and the diameter change were used for motion analysis in the LES. The cyclic bag pressure frequency was used to distinguish dynamic changes of the LES induced by respiration and secondary peristalsis. RESULTS: Cyclic fluctuations of the LES were evoked by respiration and isovolumetric distension, with phasic changes of bag pressure, diameter, length, and axial movement of the LES narrow zone. Compared to the respiration-induced LES fluctuations, peristaltic contractions increased the contraction pressure amplitude (P < 0.001), shortening (P < 0.001), axial movement (P < 0.001), and diameter change (P < 0.01) of the narrow zone. The length of the narrow zone shortened as function of the pressure increase. CONCLUSIONS: FLIP can be used for evaluation of dynamic length changes and axial movement of the human LES. The method may shed light on abnormal longitudinal muscle activity in esophageal disorders.

Safety and Effectiveness of Reza Band in Management of Laryngopharyngeal Reflux Disease: A Preliminary Study / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The main treatment of laryngopharyngeal reflux disease (LPRD) includes life style modification and proton pump inhibitor (PPI) medication. However, LPRD is sometimes refractory to PPI medication. The Reza band has been developed to exert external pressure on the upper esophageal sphincter thus preventing gastric acid reflux to the larynx and pharynx. The aim of this study was to evaluate safety and efficacy of using the Reza band in patients with LPRD. SUBJECTS AND METHOD: We prospectively enrolled 16 LPRD patients who were refractory to PPI medication and who had agreed to wear the Reza band. Patients were treated with the Reza band and PPI medication simultaneously or only the Reza band. We studied complications related to the Reza band, analyzed Reflux Symptom Index (RSI) and Reflux Finding Score (RFS) before and after the application of the band up to 12 weeks. RESULTS: The Reza band was endured by 15 patients except one patient. One patient (6.25%) ceased wearing the band due to pain and discomfort in the neck. No major complications occurred, except one patient who reported mild neck discomfort when the band was applied. The mean value of RSI before the application of the Reza band was 12.31±6.43, which significantly improved at 8 weeks and 12 weeks (9.17±5.08, p=0.005 and 8.20±5.59, p=0.007, respectively) post-treatment. The mean value of RFS before the application of the Reza band was 13.50±2.97, which significantly improved at 2, 4, 8, and 12 weeks (p < 0.05) post-treatment. CONCLUSION: We conclude that the Reza band is safe and effective for the treatment of LPRD in properly selected patients.

Relationship between location of cerebral infarction and features of videofluoroscopic swallowing / 中华物理医学与康复杂志

Objective To explore whether the pattern of dysphagia verified using videofluoroscopic swallowing study (VFSS) was associated with the Iocation of the infarction in stroke patients.Methods Ninety-two patients with dysphagia (admitted between January 2015 and August 2016) who had first onset of cerebral infarction confirmed by magnetic resonance imaging were included in this study.They were divided into a unilateral brainstem group (n =29),a left hemisphere (cortex + white matter) group (n =37) and a right hemisphere (cortex + white matter) group (n=26) according to the location of the stroke.All subjects were evaluated using VFSS,and the oral transit time (OTT),triggering of pharyngeal swallowing (TPS),presence of residue in the vallecular and pyriform sinus,penetration,aspiration,cough reaction and upper esophageal sphincter (UES) opening were recorded and compared among the three groups.Results There were no significant differences among the three groups in OTT (X2 =0.712,P=0.918),TPS (1.564,P =0.458),penetration (X2 =5.615,P=0.060) and cough reaction (X2 =5.882,P=0.053).The unilateral brainstem group had significantly more residue in the vallecular and pyriform sinus than the left hemisphere group (X2=6.508,P=0.011).Aspiration was significantly more frequently found in the unilateral brainstem group than in the left hemisphere group (X2=7.803,P =0.005).The unilateral brainstem group was more likely to have insufficient UES opening than the left hemisphere (X2=29.555,P＜0.001) and right hemisphere groups (X2=24.630,P＜0.001).Conclusions Unilateral brainstem stroke is more likely to cause dysphagia than the unilateral cerebral hemisphere stroke,characterized by the abnormal residue in the vallecular and pyriform sinus,aspiration and the degree of UES opening.No significant differences were found in the dysphagia between stroke survivors with stroke in right and left hemispheres.

Characteristics of Cricopharyngeal Dysphagia After Ischemic Stroke

OBJECTIVE: To evaluate the characteristics of cricopharyngeal dysfunction (CPD), the frequency, and correlation with a brain lesion in patients with first-ever ischemic stroke, and to provide basic data for developing a therapeutic protocol for dysphagia management. METHODS: We retrospectively reviewed the medical records of a series of subjects post-stroke who underwent a videofluoroscopic swallowing study (VFSS) from January 2009 to December 2015. VFSS images were recorded on videotape and analyzed. CPD was defined as the retention of more than 25% of residue in the pyriform sinus after swallowing. The location of the brain lesion was assessed using magnetic resonance imaging. RESULTS: Among the 262 dysphagic patients with first-ever ischemic stroke, 15 (5.7%) showed CPD on the VFSS. Patients with an infratentorial lesion had a significantly higher proportion of CPD than those with a supratentorial lesion (p=0.003), and lateral medullary infarction was identified as the single independent predictor of CPD (multivariable analysis: odds ratio=19.417; confidence interval, 5.560–67.804; p < 0.0001). Compared to patients without CPD, those with CPD had a significantly prolonged pharyngeal transit time, lower laryngeal elevation, and a higher pharyngeal constriction ratio and functional dysphagia scale score. CONCLUSION: Overall, the results support the notion that an impaired upper esopharyngeal opening is likely related to the specific locations of brain lesions. The association of CPD with lateral medullary infarction can be explained based on the regulation of the pharyngolaryngeal motor system by the motor neurons present in the dorsal nucleus ambiguus. Overall, the results reveal the relation between CPD and the problems in the pharyngeal phase as well as the severity of dysphagia.