Management of symptoms recurrence after myotomy for achalasia. a practical approach / Manejo da recidiva de sintomas após miotomia para acalasia. uma abordagem prática

ABSTRACT BACKGROUND: Achalasia is an esophageal motility disorder, and myotomy is one of the most used treatment techniques. However, symptom persistence or recurrence occurs in 9 to 20% of cases. AIMS: This study aims to provide a practical approach for managing the recurrence or persistence of achalasia symptoms after myotomy. METHODS: A critical review was performed to gather evidence for a rational approach for managing the recurrence or persistence of achalasia symptoms after myotomy. RESULTS: To properly manage an achalasia patient with significant symptoms after myotomy, such as dysphagia, regurgitation, thoracic pain, and weight loss, it is necessary to classify symptoms, stratify severity, perform appropriate tests, and define a treatment strategy. A systematic differential diagnosis workup is essential to cover the main etiologies of symptoms recurrence or persistence after myotomy. Upper digestive endoscopy and dynamic digital radiography are the main tests that can be applied for investigation. The treatment options include endoscopic dilation, peroral endoscopic myotomy, redo surgery, and esophagectomy, and the decision should be based on the patient's individual characteristics. CONCLUSIONS: A good clinical evaluation and the use of proper tests jointly with a rational assessment, are essential for the management of symptoms recurrence or persistence after achalasia myotomy.

RESUMO RACIONAL: A acalasia é um distúrbio da motilidade esofágica e a miotomia é uma das técnicas de tratamento mais utilizadas. No entanto, a persistência ou recorrência dos sintomas ocorre em 9 a 20%. OBJETIVOS: Este estudo visa fornecer uma abordagem prática para o manejo da recorrência ou persistência dos sintomas de acalasia após miotomia. MÉTODOS: Foi realizada uma revisão crítica para reunir evidências para uma abordagem racional no manejo da recorrência ou persistência dos sintomas de acalasia após miotomia. RESULTADOS: Para o manejo adequado de um paciente com acalásia com sintomas significativos após miotomia, como disfagia, regurgitação, dor torácica e perda de peso, é necessário classificar os sintomas, estratificar a gravidade, realizar exames adequados e definir uma estratégia de tratamento. Uma investigação diagnóstica diferencial sistemática é essencial para cobrir as principais etiologias de recorrência ou persistência dos sintomas após a miotomia. A endoscopia digestiva alta e a radiografia digital dinâmica são os principais exames que podem ser aplicados para investigação. As opções de tratamento incluem dilatação endoscópica, POEM (miotomia endoscópica oral), remiotomia e esofagectomia, e a decisão deve ser baseada nas características individuais do paciente. CONCLUSÕES: Uma boa avaliação clínica e a utilização de exames adequados, juntamente com uma avaliação racional, são essenciais para o manejo da recorrência ou persistência dos sintomas após miotomia por acalasia.

Peroral endoscopic myotomy for the treatment of achalasia in the Unified Healthcare System (SUS): results of a short-term / Miotomia endoscópica peroral para o tratamento de acalásia no Sistema Único de Saúde (SUS): resultados de seguimento no curto-prazo

ABSTRACT Introduction: achalasia is a chronic disease. Since there is no curative treatment, diagnosed patients have pharmacological and/or surgical techniques available, aimed at minimizing the condition. POEM appears as a promising new type of palliative treatment with good rates of symptom improvement. Objective: evaluate the profile of POEM at the Clinical Hospital of the Federal University of Pernambuco (HC - UFPE) and correlate it with the world scenario. Methods: data collection was performed retrospectively from September 2017 to October 2019 with all patients undergoing POEM at the HC - UFPE. Sociodemographic, clinical, and hospital variables were evaluated before and three months after the procedure. Results: of 27 patients (52.41 ± 19.24 years old) who underwent the procedure, 66.7% had idiopathic etiology and 33.3% had etiology secondary to Chagas disease. 48% patients underwent previous procedures, of which seven used some type of medication for symptom control, two underwent pneumatic endoscopic dilation, and four underwent Heller cardiomyotomy with partial fundoplication. 62.5% of the evaluated patients had type II achalasia before the procedure. Seven (25.9%) patients presented the following adverse events: four presented bleeding, two pneumoperitoneum, and one both complications, all being treated conservatively. The Eckardt score reduced from 8.37 ± 1.45 to 0.85 ± 1.06 (p-value <0.001). Conclusion: clinical improvement of symptoms and the patient profile followed the worldwide trend, with emphasis on the etiology secondary to Chagas disease, endemic in Brazil. Gastroesophageal reflux remains the main post-operative symptom.

RESUMO Introdução: a acalasia é uma doença crônica. Por não haver tratamento curativo, os pacientes diagnosticados dispõem de técnicas farmacológicas e/ou cirúrgicas, visando minimizar o quadro. A POEM surge como um novo tipo de tratamento paliativo promissor com boas taxas de melhora dos sintomas. Objetivo: avaliar o perfil das POEM realizadas no Hospital das Clínicas da Universidade Federal de Pernambuco (HC - UFPE) e correlacioná-lo com o cenário mundial. Métodos: a coleta de dados foi realizada retrospectivamente no período de setembro de 2017 a outubro de 2019 com todos os pacientes submetidos a POEM no HC - UFPE. Variáveis sociodemográficas, clínicas e hospitalares foram avaliadas antes e três meses após o procedimento. Resultados: total de 27 pacientes (52,41 ± 19,24 anos) que realizaram o procedimento, 66,7% com etiologia idiopática e 33,3% com etiologia secundária à doença de Chagas. 48% tinham sido submetidos a procedimentos prévios, dos quais sete usaram algum tipo de medicamento para controle dos sintomas, dois foram submetidos à dilatação endoscópica pneumática e quatro à cardiomiotomia a Heller com fundoplicatura parcial. 62,5% dos pacientes avaliados tinham acalasia tipo ii antes do procedimento. Sete (25,9%) apresentaram eventos adversos: quatro sangramentos, dois pneumoperitônio e um ambas as complicações, todos foram tratados de forma conservadora. O escore de Eckardt reduziu de 8,37 ± 1,45 para 0,85 ± 1,06 (valor de p<0,001). Conclusão: melhora clínica e o perfil dos pacientes acompanhou a tendência mundial, destaque para a etiologia secundária à doença de Chagas, endêmica no Brasil. O refluxo gastroesofágico continua sendo o principal sintoma pós-operatório.

Therapeutic efficacy observation of acupuncture plus medicine for laryngopharyngeal reflux due to liver-qi stagnation and spleen deficiency / 针灸推拿医学（英文版）

Objective: To observe the clinical efficacy of acupuncture plus medicine in treating laryngopharyngeal reflux due to liver-qi stagnation and spleen deficiency. Methods: A total of 70 patients were divided into a control group and an observation group by the random number table method, with 35 cases in each group. Both groups were treated with conventional medications, and the observation group was treated with additional acupuncture therapy. The reflux symptom index (RSI) and reflux finding score (RFS) were evaluated. Esophageal motility indicators such as lower esophageal sphincter pressure (LESP) and upper esophageal sphincter pressure (UESP), and salivary pepsin level were measured. The clinical efficacy was also compared. Results: The total effective rate of the observation group was higher than that of the control group (P<0.05). After treatment, the RSI and RFS scores in both groups decreased significantly (all P<0.05), and the RSI and RFS scores in the observation group were significantly lower than those in the control group (both P<0.05). There were no significant changes in the LESP and UESP in the control group (both P>0.05), while LESP and UESP in the observation group increased significantly (both P<0.05), and higher than those in the control group (both P<0.05). The salivary pepsin levels in both groups decreased (both P<0.05), and the salivary pepsin level in the observation group was significantly lower than that in the control group (P<0.05). Conclusion: Acupuncture plus medicine can improve symptoms and signs in patients with laryngopharyngeal reflux due to liver-qi stagnation and spleen deficiency, and regulate esophageal motility and salivary pepsin level. Its efficacy is more significant compared with medicine alone.

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

Study of etiology and esophageal motility characteristics of esophagogastric junction outlet obstruction patients / 北京大学学报(医学版)

OBJECTIVE@#To analyze the causes of the esophagogastric junction outlet obstruction (EGJOO) patients, to discuss the differences of the clinical manifestation and esophageal motility characteristics between the anatomic EGJOO (A-EGJOO) and functional EGJOO (F-EGJOO) subgroups, and to search the diagnostic values of the specific metrics for differentiating the subgroups of EGJOO patients.@*METHODS@#For the current retrospective study, all the patients who underwent the esophageal high resonance manometry test were retrospectively analyzed from Jan 2012 to Oct 2018 in Peking University Third Hospital. The EGJOO patients were enrolled in the following research. The clinical characteristics, such as symptoms and causes of the patients were studied. Then the patients were divided into two subgroups as A-EGJOO subgroup and F-EGJOO subgroup. The clinical symptoms and the main manometry metrics were compared between these two subgroups. The significant different metrics between the two groups were selected to draw receiver operating characteristic (ROC) curves and the diagnostic values were analyzed in differentiating the A-EGJOO and F-EGJOO subgroups.@*RESULTS@#The most common symptom of EGJOO was chest pain or chest discomfort (30.63%), then the dysphagia (29.73%), and acid regurgitation/heartburn (27.03%). Non-erosive reflux disease (36.04%) was the most popular cause for EGJOO, then the reflux esophagitis (17.12%). Besides the intra-EGJOO and extra-EGJOO lesions, the connective tissue disease (6.31%) and central nervous diseases (2.70%) were found to be the etiology of EGJOO. The causes of the rest 19 EGJOO were unknown. A-EGJOO patients presented significantly higher intra bolus pressure (IBP) than that of F-EGJOO [6.80 (5.20, 9.20) mmHg vs. 5.10 (3.10, 7.60) mmHg, P=0.016]. The area under curve of IBP was 0.637. When IBP≥5.15 mmHg, the sensitivity was 78.60% and specificity 50.70% to differentiate A- or F-EGJOO.@*CONCLUSION@#Chest pain or chest discomfort was the most common symptom in EGJOO patients. Besides the intraluminal structural disorders, the extra-luminal causes were found in EGJOO patients. A-EGJOO presented higher IBP than that of F-EGJOO patients. The cutoff value of IBP to differentiate A-EGJOO from EGJOO was 5.15 mmHg with sensitivity 78.06% and specificity 50.70%. However for the low area under curve, the diagnostic value of IBP was limited.

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.

Alteração da motilidade do esôfago durante percepção do trânsito do bolo em voluntários saudáveis / Altered esophageal motility during perception of bolus transit in healthy volunteers

ABSTRACT BACKGROUND: The perception of bolus transit through the thoracic esophagus may be caused by altered esophageal anatomy and function. OBJECTIVE: To evaluate the hypothesis that, in healthy volunteers, swallows followed by perception of esophageal bolus transit are associated with changes in esophageal motility. METHODS: Simultaneous evaluation of motility and perception of esophageal bolus transit was performed in 22 healthy volunteers. Esophageal motility was evaluated by high-resolution manometry with a 32-channel solid state catheter. Each volunteer performed, in the sitting position, 10 swallows of a 5 mL bolus of saline and 10 swallows of pieces of 1 cm3 of bread, with an interval of at least 30 seconds between swallows. After each swallow the volunteers were asked about the perception of bolus transit through the esophagus. RESULTS: Perception of bolus transit occurred in 11.7% of liquid swallows and in 48.1% of solid swallows. In liquid swallows the perception was associated with higher distal contractile integral and shorter proximal contraction length. Perception of solid bolus transit was associated with a longer distal latency, longer proximal contraction length, lower proximal contractile integral and shorter proximal contraction duration. CONCLUSION: The perception of swallowed bolus transit through the esophagus in healthy individuals is more frequent with solid than liquid swallows and is associated with changes in proximal esophageal contractions.

RESUMO CONTEXTO: A percepção do trânsito de bolo deglutido através do esôfago torácico pode ser consequência de alterações anatômicas ou funcionais do esôfago. OBJETIVO: Avaliar, em voluntários saudáveis, se a deglutição com percepção do trânsito do bolo pelo esôfago está associada a alteração da motilidade esofágica. MÉTODO: Avaliação simultânea da percepção do trânsito pelo esôfago e motilidade foi realizada em 22 voluntários saudáveis. A motilidade esofágica foi avaliada por manometria de alta resolução. Cada voluntário realizou, na posição sentada, 10 deglutições de 5 mL de soro fisiológico e 10 deglutições de pedaços de 1 cm3 de pão, com um intervalo de pelo menos 30 segundos entre as deglutições. Após cada deglutição, os voluntários foram questionados sobre a percepção do trânsito do bolo através do esôfago. RESULTADOS: A percepção do trânsito ocorreu em 11,7% das deglutições do bolo líquido e em 48,1% das deglutições do bolo sólido. A percepção do bolo líquido foi associada com menor extensão de contração proximal e maior integral da contração distal, comparadas com deglutições sem percepção. A percepção do trânsito de bolus sólido foi associada a maior latência distal, menor extensão de contração proximal, menor integral da contração proximal e menor duração da contração proximal. CONCLUSÃO: A percepção do trânsito do bolo deglutido pelo esôfago torácico ocorreu mais frequentemente com bolo sólido e foi associada a alteração das contrações esofágicas proximais.

Síndrome de Boerhaave: uma complicação rara em pós-operatório de cirurgia estética / Boerhaave syndrome: a rare complication of cosmetic surgery

Introdução: Este estudo se trata de um relato de caso que tem por objetivo alertar os cirurgiões para uma possível complicação em pós-operatório de cirurgias estéticas longas sob anestesia geral. A Síndrome de Boerhaave é uma doença grave que ameaça a vida do paciente e merece um diagnóstico precoce até 12hs e um tratamento adequado. Relato de caso: A paciente no pós-operatório de cirurgia plástica abdominal e mastopexia apresentou, após anestesia geral, crises de vômito e náuseas. Resultados: Paciente com 58 anos do sexo feminino submetida à dermolipectomia abdominal e mastopexia pela a técnica de pedículo inferior sob raquianestesia, onde após um período de quatro horas do término da cirurgia apresentou vários episódios de vômitos. Após 10 horas do ato cirúrgico apresentou queixa de algia ao deglutir, seguida de algia intensa generalizada, dispneia intensa, sudorese, palidez, PA 90x50mmhg. Com a piora do quadro a paciente foi encaminhada para a unidade de terapia intensiva onde foi entubada. Foram realizados exames laboratoriais, toracocentese e exames radiológicos. Atualmente, a paciente encontra-se com prótese esofágica. Conclusões: Fazendo a correlação com a bibliografia, no caso em tela sugere-se evitar cirurgias prolongadas, principalmente sob anestesia geral onde pode ocorrer a retenção de gás carbônico, que pode levar a crise emética no pós-operatório em pacientes com antecedentes de doença esofagiana e estar atentos aos sintomas, não descartando a possibilidade da ocorrência da Síndrome Boerhaave.

Introduction: The objective of this case report is to alert surgeons to a possible postoperative complication of long cosmetic surgery under general anesthesia. Boerhaave syndrome is a serious life-threatening disease that requires diagnosis within 12 hours and proper treatment. Case report: A 58-year-old female patient presented with vomiting and nausea after abdominoplasty and mastopexy under general anesthesia. Results: The patient underwent dermolipectomy and mastopexy using the inferior pedicle technique under spinal anesthesia. Four hours after the operation, she presented several episodes of vomiting. Ten hours after the operation, she reported painful swallowing followed by generalized severe pain and presented severe dyspnea, sweating, pallor, and a 90/50 mmHg blood pressure. As the condition worsened, the patient was referred to the intensive care unit where she was intubated and underwent laboratory tests, thoracentesis, and radiological examinations. The patient currently uses an esophageal prosthesis. Conclusions: The literature suggests avoiding prolonged surgery, especially under general anesthesia, because of the risk of carbon dioxide retention, which may lead to postoperative emetic crisis in patients with a history of esophageal disease. It also suggests paying attention to symptoms, not excluding the possibility of Boerhaave syndrome.

Acalasia, una visión actual / Achalasia, a current view

La palabra 'acalasia' es un neologismo de origen griego, acuñado por el médico inglés Sir Edwin Cooper en 1913, y significa: sin calidad de relajación. La acalasia es una enfermedad que se manifiesta clínicamente por disfagia para sólidos y para líquidos, regurgitación esofágica, dolor retroesternal, tos, broncoaspiración, neumonía, acidez estomacal y pérdida de peso. Su fisiopatología corresponde a la ausencia de peristalsis esofágica e insuficiente relajación del esfínter esofágico inferior. Estas anormalidades motoras se deben a la pérdida de las neuronas mientéricas que coordinan la peristalsis esofágica y la relajación del esfínter esofágico inferior. Fue descrita por primera vez por Sir Thomas Willis en 1674. Aunque actualmente se considera idiopática, se han comenzado a considerar como posibles causas las alteraciones autoinmunitarias y la predisposición genética; además, las infecciones por virus herpes y por virus herpes zóster se han implicado como causas probables. Su incidencia anual oscila entre 0,3 y 1,63 por 100.000 personas en adultos, con una prevalencia anual de 10 en 100.000 habitantes. Afecta por igual a los dos sexos, y el grupo etario más afectado es el de 30 a 60 años. El diagnóstico se sospecha por los síntomas que presenta el paciente, de los cuales la disfagia es el más importante. Se confirma por medio de la endoscopia de las vías digestivas altas, el esofagograma y la manometría de alta resolución. El tratamiento sigue siendo paliativo y se puede orientar por el subtipo de acalasia, según la clasificación de Chicago. Los mejores resultados se obtienen mediante las técnicas de dilatación neumática, miotomía laparoscópica de Heller y, más recientemente, mediante la miotomía endoscópica peroral (Per-Oral Endoscopic Myotomy, POEM), descrita por Haruhiro Inoue en Japón en el año 2008. Aún faltan estudios prospectivos aleatorizados con seguimiento a largo plazo para determinar cuál es la mejor técnica. Se presenta una revisión actualizada del tema

The word achalasia is a neologism of Greek origin, coined by the English physician Sir Edwin Cooper in 1913, and means no quality of relaxation. Achalasia is a disease clinically manifested by dysphagia with both solids and liquids, esophageal regurgitation, retrosternal pain, cough, bronchial aspiration, pneumonia, heartburn and weight loss. Physiopathologically it corresponds to the loss of esophageal peristalsis and to an insufficient relaxation of the lower esophageal sphincter (LES). These motor abnormalities are due to the loss of myenteric neurons that coordinate esophageal peristalsis and relaxation of the LES. First described by Sir Thomas Willis in 1674, and although it is currently considered idiopathic, it has begun to be considered as possible causes autoimmune components and genetic predisposition; viral infections by herpes and chickenpox zoster have also been implicated as probable causes. Its incidence ranges from 0.3 to 1.63 per 100,000 adults, with a prevalence of 10 in 100,000 inhabitants per year. It affects equally any gender, and the age group between 30 and 60 years is the most affected. The diagnosis is suspected based on the symptomatology, with dysphagia being the most important symptom. It is confirmed with the performance of endoscopy of the upper digestive tract, esophagogram and high resolution manometry. The treatment remains palliative, and may be guided by the subtype of achalasia, according to the Chicago classification. The best results are obtained by the techniques of pneumatic dilation, Heller's laparoscopic myotomy, and more recently by the POEM technique (per oral endoscopic myotomy), described in 2008 in Japan by Haruhiro Inoue. There is still a lack of prospective randomized studies with long-term follow-up that determine which is the best technique. An updated review of the subject is presented

Herniorrafia hiatal y fundoplicatura laparoscópica de Toupet en un paciente con esófago corto / Hiatal herniorrhaphy and Toupet laparoscopic fundoplication in a patient with short esophagus

El esófago corto es una complicación infrecuente del reflujo gastroesofágico, polémico para algunos autores. Su diagnóstico se hace de manera intraoperatoria, ante la imposibilidad de conservar un esófago intrabdominal mayor a tres centímetros desde el hiato diafragmático. Algunos expertos niegan la existencia de esta entidad, argumentando que se debe a una mala disección del esófago. En este artículo, se presenta el caso de un paciente sometido a herniorrafia hiatal con colocación de malla, con gran dificultad para conservar una adecuada longitud del esófago abdominal, y que no requirió gastroplastia (AU)

Short esophagus is an uncommon complication of gastroesophageal reflux, controversial for some authors. The diagnosis is made intraoperatively when , the impossibility of leaving an intra-abdominal esophagus longer than 3 cm becomes patent. Some experts, however, doubt about the existence of this entity, arguing that it is due to a bad dissection of the esophagus. In this article, we present the case of a patient where a hiatal herniorraphy was performed with great difficulty to conserve an adequate length of the abdominal esophagus, without requiring gastroplasty (AU)

Advances in Study on Esophageal Motility Abnormalities in Gastroesophageal Reflux Disease / 胃肠病学

The role of esophageal motility abnormalities in gastroesophageal reflux disease (GERD) has drawed more and more attention. In recent years, the rapid development in examining techniques of esophageal motility can identify esophageal motility abnormalities early, accurately and effectively, especially for helping the diagnosis of atypical GERD. This article reviewed the advances in study on role of esophageal motility abnormalities in GERD.

Esophageal Motor Dysfunctions in Gastroesophageal Reflux Disease and Therapeutic Perspectives

Gastroesophageal reflux disease (GERD) is a very common disease, and the prevalence in the general population has recently increased. GERD is a chronic relapsing disease associated with motility disorders of the upper gastrointestinal tract. Several factors are implicated in GERD, including hypotensive lower esophageal sphincter, frequent transient lower esophageal sphincter relaxation, esophageal hypersensitivity, reduced resistance of the esophageal mucosa against the refluxed contents, ineffective esophageal motility, abnormal bolus transport, deficits initiating secondary peristalsis, abnormal response to multiple rapid swallowing, and hiatal hernia. One or more of these mechanisms result in the reflux of stomach contents into the esophagus, delayed clearance of the refluxate, and the development of symptoms and/or complications. New techniques, such as 24-hour pH and multichannel intraluminal impedance monitoring, multichannel intraluminal impedance and esophageal manometry, high-resolution manometry, 3-dimensional high-resolution manometry, enoscopic functional luminal imaging probe, and 24-hour dynamic esophageal manometry, provide more information on esophageal motility and have clarified the pathophysiology of GERD. Proton pump inhibitors remain the preferred pharmaceutical option to treat GERD. The ideal target of GERD treatment is to restore esophageal motility and reconstruct the anti-reflux mechanism. This review focuses on current advances in esophageal motor dysfunction in patients with GERD and the influence of these developments on GERD treatment.

Elevated Intrabolus Pressure Predicts Abnormal Timed Barium Esophagram in Esophagogastric Junction Outflow Obstruction

BACKGROUND/AIMS: Timed barium esophagram (TBE) is used the classification of esophageal motility disorders and assessing esophageal function. Currently, there are no published studies examining the relationship between high-resolution manometry and TBE in patients with esophagogastric junction outflow obstruction (EGJOO). This study seeks to evaluate this relationship and identify manometric variables that may indicate further evaluation using TBE. METHODS: Retrospective review of medical records identified patients with a diagnosis of EGJOO per the Chicago classification version 3.0. TBE was performed using standard protocol. Patients were divided into 2 groups based on complete emptying or persistence of standing barium column at 5 minutes. RESULTS: Eleven patients were identified with EGJOO who underwent both high-resolution manometry and TBE within 3 months. Five patients had no standing barium column at 5 minutes, while 6 patients had a persistent barium column. Mean age of each group was 54.0 years and 57.8 years, respectively. Patients with abnormal TBE were found to have significantly elevated intrabolus pressure (IBP) compared with patients who had a normal TBE. CONCLUSIONS: In our study, we found significant differences in IBP between these patient groups. These findings suggest that patients with EGJOO and elevated IBP may prompt further clinical evaluation with TBE in order to clarify clinical diagnosis and guide therapeutic intervention.

Achalasia Cardia Resulting in Bronchial Obstruction: A Case Series and Literature Review / 대한소화기학회지

Achalasia is a motility disorder of the esophagus that is characterized by loss of ganglionic neurons within the myenteric plexus of the lower esophageal sphincter (LES) resulting in failure of the LES to relax. Clinically this disorder presents with simultaneous dysphagia to solids and liquids, and if left untreated, leads to esophageal dilation, which can give rise to many adverse consequences. Extrinsic compression of respiratory structures is one such consequence, and rarely, cases of tracheal compression secondary to achalasia have been reported. However, cases of extrinsic bronchial compression are yet rarer. Here, we present a case series comprised of two patients with achalasia who presented with extrinsic bronchial compression by a dilated esophagus secondary to achalasia.

Valores de normalidade de um novo sistema de manometria de alta resolução por perfusão de água / Normative values for a new water-perfused high resolution manometry system

ABSTRACT BACKGROUND: Esophageal manometry is the most reliable method to evaluate esophageal motility. High resolution manometry (HRM) provides topographic contour colored plots (Clouse Plots) with simultaneous analysis from the pharynx to the stomach. Both solid state and water-perfused systems are available. OBJECTIVE: This study aims to determinate the normative data for a new water-perfused HRM. METHODS: HRM was made in 32 healthy volunteers after 8 hours fasting. HRM system used consisted of a 24-channel water-perfused catheter (Multiplex, Alacer Biomedica, São Paulo, Brazil). The reusable catheter is made of polyvinyl chloride (PVC) with 4.7 mm of diameter. Side holes connected to pressure transducers are spaced 2 cm for the analysis from the pharynx to the lower esophageal sphincter (LES). Holes are spaced 5 mm and 120° in a spiral disposition in the LES area. The sensors encompass 34 cm in total. Upper esophageal sphincter (UES) parameters studied were basal and relaxation pressures. Esophageal body parameters were distal contractile integral (DCI), distal latency (DL) and break. LES parameters studied were basal pressure, integrated residual pressure (IRP), total and abdominal length. Variables are expressed as mean ± standard deviation, median (interquartile range) and percentiles 5-95th. RESULTS: All volunteers (17 males, aged 22-62 years) completed the study and tolerated the HRM procedure well. Percentiles 5-95th range were calculated: Upper Esophageal Sphincter (UES) basal pressure 16.7-184.37 (mmHg), DL: 6.2-9.1 (s), DCI: 82.72-3836.61 (mmHg.s.cm), break: <7.19 (cm), LES basal pressure: 4.89-37.16 (mmHg), IRP: 0.55-15.45 (mmHg). CONCLUSION: The performance and normative values obtained for this low-cost water-perfused HRM seems to be adequate for clinical use.

RESUMO CONTEXTO: Manometria esofágica é o exame mais confiável para avaliar motilidade esofágica. Manometria esofágica de alta resolução (MAER) apresenta um gráfico dinâmico e colorido (Clouse plots) com análise simultânea da faringe ao estomago. Dois tipos de manometria estão disponíveis: estado sólido e por perfusão de água. OBJETIVO: Determinar os valores de normalidade de um novo sistema de manometria de alta resolução. MÉTODOS: MAER foi realizada em 32 voluntários saudáveis após jejum de oito horas. O sistema utilizado é de perfusão de água com 24 sensores (Multiplex, Alacer Biomedica, São Paulo, Brasil). O catéter permanente é feito de cloreto de polivinil (PVC) com 4,7 mm de diâmetro. Os orifícios laterais para conexão com os transdutores de pressão são espaçados de 2 cm para análise da faringe ao esfíncter esofagiano inferior (EEI) e são esparçados em 5mm em forma espiralada com 120° entre orificios. Os sensores no total englobam 34 cm. Para o esfíncter esofágico superior (EES), os parâmetros estudados foram às pressões basal e de relaxamento. Os parâmetros do corpo esofágico foram: integral de contratilidade distal (DCI), latência distal (DL) e quebra. Os parâmetros do EEI inferior foram pressões basal e de relaxamento e pressão de relaxamento integrada (IRP). As variáveis foram expressas em medias ± desvio padrão, medianas (variação de interquartis) e percentis 5-95. RESULTADOS: Todos os voluntários (17 homens, com idade variando entre 22-62 anos) terminaram e toleraram o exame. A variação dos percentis 5-95 foi calculada: pressão basal do esfíncter esofágico superior (EES) foi 16,7-184,37 (mmHg), DL: 6,2-9,1 (s), DCI: 82,72-3836,61 (mmHg.s.cm), quebra: <7,19 (cm), pressão basal do EEI: 4,89-37,16 (mmHg), IRP: 0,55-15,45 (mmHg). CONCLUSÃO: A realização dos testes e os valores de normalidade determinados por este estudo parecem ser adequadas para a prática clínica.

Miotomía endoscópica por vía oral (POEM) para el tratamiento de acalasia: nuestras primeras experiencias / Peroral endoscopic myotomy (POEM) for treatment of achalasia: our first experiences

Resumen Introducción: la miotomía endoscópica por vía oral (POEM) se diseñó inicialmente para el manejo de la acalasia, que es un trastorno crónico y progresivo de la motilidad esofágica con hipertensión del esfínter esofágico inferior (EEI), para la cual el manejo estándar, hasta ahora, ha sido la cirugía de Heller; sin embargo, esta nueva técnica ofrece resultados muy comparables y prometedores. Materiales y métodos: se realizó una revisión retrospectiva de las historias clínicas de los pacientes con acalasia operados por POEM en una institución de Colombia por un solo cirujano endoscopista. Resultados: se encontraron 4 pacientes con acalasia, todas con Eckardt ≥10 y presión EEI ≥30 mm Hg; el tiempo quirúrgico osciló entre 81-120 minutos; en el seguimiento, la reducción en la presión del EEI fue mayor al 50% prácticamente en todos los pacientes, encontrando valores cercanos a la normalidad y con resultados de Eckardt que demuestran éxito en la terapia POEM a los 2 meses de evaluación. Las complicaciones fueron resueltas en el intraoperatorio, con mortalidad de 0%. Conclusiones: El manejo de la acalasia mediante POEM ha demostrado ser una técnica eficaz y segura. Nuestros primeros hallazgos concuerdan con los resultados descritos en la literatura. Este es el primer paso para la implementación de este novedoso abordaje en el manejo de la acalasia en la población colombiana.

Abstract Introduction: Peroral endoscopic myotomies (POEMs) were initially designed to manage achalasia, a chronic and progressive esophageal motility disorder with lower esophageal sphincter hypertension (LES). Until recently, standard treatment had been Heller's surgery, but this new technique offers very promising pressure. Materials and methods: This is a retrospective review of the clinical histories of patients with achalasia who underwent POEM performed by one endoscopic surgeon at a Colombian institution. Results: Four patients with achalasia were found. All had Eckardt scores of ten or more and lower esophageal sphincter (LES) pressure of 30mm Hg or more. Surgical times ranged between 81 and 120 minutes. Follow-up examinations found that LES pressure had decreased by more than 50% in practically all patients. Eckardt scores were close to normal. This demonstrates success of POEM therapy after two months of evaluation. Complications were resolved intraoperatively without mortality. Conclusions: Management of achalasia by POEM has proven to be a safe and effective technique. Our first findings agree with the results described in the literature. This is the first step in the implementation of this novel approach for management of achalasia in our Colombian population.

¿El reflujo gastroesofágico y la aspiración de contenido gástrico están implicados en la etiopatogenia y la progresión de la fibrosis pulmonar idiopática? / Does gastroesophageal reflux and gastric content aspiration have some role in the pathogenesis and progression of Idiopathic Pulmonary Fibrosis?

Resumen El reflujo gastroesofágico (RGE) y la aspiración oculta de contenido digestivo están probablemente implicados en la etiopatogenia y progresión de la fibrosis pulmonar idiopática (FPI). Los mecanismos patogénicos involucrados son la disminución de la distensibilidad pulmonar y el consiguiente aumento de la presión negativa intratorácica durante la inspiración, así como la disminución de los mecanismos de control de la motilidad esofágica o del tono del esfínter esofágico inferior. La prevalencia de RGE y anomalías de la motilidad esofágica están aumentadas en los pacientes con FPI comparado con la población general. Entre los pacientes con FPI, el 67-76% demostraron exposición anormal al contenido ácido en el esófago. Sin embargo, no hubo relación entre la gravedad del RGE y la gravedad de la FPI. Los estudios que han examinado el tratamiento antirreflujo en esta población han sido escasos. Incluso, algunos datos sugieren que el tratamiento antiácido puede ser perjudicial en algunos pacientes con esta condición. Después de analizar toda la evidencia relevante encontrada hasta la fecha, concluimos que no se puede establecer una relación causal entre el RGE, la aspiración del contenido gástrico y la patogénesis de la FPI. Además, existe escasa evidencia clínica que haya examinado el tratamiento antirreflujo en pacientes con fibrosis pulmonar idiopática.

ABSTRACT Gastroesophageal reflux (GERD) and hidden aspiration of gastric contents are probably involved in the pathogenesis and progression of idiopathic pulmonary fibrosis (IPF). The pathological mechanisms involved are decreased pulmonary distensibility and consequent increase of intrathoracic negative pressure during inspiration, as well as decreased control mechanisms of esophageal motility or lower esophageal sphincter. The prevalence of GERD and oesophageal dysmotility was higher in patients with IPF as compared with general population. Among patients with IPF, 67-76% demonstrated abnormal oesophageal acid exposure. However, no relationship was demonstrated between severity of GERD and severity of IPF. Data are scant on outcomes of antireflux treatment in patients with IPF. Actually, some data suggests that antacid treatment may be deleterious in some IPF patients. After analyzing all the relevant evidence found to date, a causal relationship between GERD, gastric content aspiration and IPF pathogenesis cannot be established. There is scant evidence examining antireflux treatment in idiopathic pulmonary fibrosis patients.

A pictorial presentation of esophageal high resolution manometry current parameters / Apresentação pictórica de parâmetros atuais na manometria de alta resolução esofágica

ABSTRACT Introduction: High resolution manometry is the current technology used to the study of esophageal motility and is replacing conventional manometry in important centers for esophageal motility with parameters used on esophageal motility, following the Chicago Classification. This classification unifies high resolution manometry interpretation and classifies esophageal disorders. Objective: This review shows, in a pictorial presentation, the new parameters established by the Chicago Classification, version 3.0, aimed to allow an easy comprehension and interpretation of high resolution manometry. Methods: Esophageal manometries performed by the authors were reviewed to select illustrative tracings representing Chicago Classification parameters. Results: The parameters are: Esophagogastric Morphology, that classifies this junction according to its physiology and anatomy; Integrated Relaxation Pressure, that measures the lower esophageal sphincter relaxation; Distal Contractile Integral, that evaluates the contraction vigor of each wave; and, Distal Latency, that measures the peristalsis velocity from the beginning of the swallow to the epiphrenic ampulla. Conclusion: Clinical applications of these new concepts is still under evaluation.

RESUMO A manometria de alta resolução é, atualmente, a tecnologia mais moderna para o estudo da motilidade esofágica e vem substituindo a manometria convencional nos grandes centros de pesquisa com parâmetros que seguem a Classificação de Chicago, que busca unificar as interpretações gráficas da manometria de alta resolução e, dessa maneira, categorizar os diversos distúrbios esofágicos. Objetivo: Mostrar, de forma pictórica, os novos parâmetros compilados na versão 3.0 da Classificação de Chicago, buscando facilitar a compreensão e interpretação da manometria de alta resolução. Métodos: Foram revistas as manometrias da casuística dos autores e selecionados os traçados representativos dos parâmetros da Classificação de Chicago. Resultados: Entre os parâmetros apresentados foram considerados a Morfologia da Transição Gastroesofágica, que classifica o segmento de acordo com sua fisiologia e anatomia; a Integral da Pressão de Relaxamento, que mede o relaxamento do esfíncter esofagiano inferior; a Integral Contrátil Distal, que avalia o vigor contrátil da onda peristáltica; e, a Latência Distal, que mede o tempo da peristalse, desde o início da deglutição até a ampola epifrênica. Conclusão: A aplicabilidade clínica desses novos conceitos ainda está sendo estudada.

Cómo realizar e interpretar una manometría esofágica de alta resolución usando la clasificación de Chicago 3. 0 / How to perform and interpret a high resolution esophageal manometry using the Chicago 3.0 classification

Resumen Con la introducción de la manometría esofágica de alta resolución se revelaron patrones no identificados previamente de la función esofágica. De igual forma, este método diagnóstico adiciona patrones de presión topográfica de la presión esofágica, lo que lleva al desarrollo de nuevas herramientas para el análisis y clasificación de desórdenes motores esofágicos. En la actualidad, la clasificación de Chicago 3.0 es la herramienta de análisis de los diferentes trastornos motores esofágicos. En Colombia, cada día se ve el crecimiento en la realización de este estudio. El artículo propone hacer una revisión de cómo realizar e interpretar una manometría esofágica de alta resolución y clasificar los diferentes trastornos de la motilidad esofágica según la última actualización de la clasificación de Chicago 3.0.

Abstract The introduction of high resolution esophageal manometry has led to the revelation of previously unidentified patterns of esophageal function. Similarly, this diagnostic method has revealed topographic patterns of esophageal pressure which has led to the development of new tools for analysis and classification of esophageal motility disorders. Currently, the Chicago 3.0 classification has become a tool for analysis of the various esophageal motility disorders. In Colombia, the use of this study is spreading and growing. This article reviews of how to perform and interpret high resolution esophageal manometry and shows how to classify esophageal motility disorders according to the latest update of Chicago 3.0.