Myasthenia gravis with achalasia secondary to thymoma: a case report and literature review.

Background: Myasthenia gravis is an autoimmune neuromuscular junction disorder characterized by fatigable muscle weakness and autoantibodies. Frequent associations exist between myasthenia gravis and thymic abnormalities, including hyperplasia and thymoma. Several autoimmune illnesses have been identified to be associated with thymoma; however, a few case reports have linked thymoma and achalasia, and the underlying mechanism is unknown. Case report: A 43-year-old man with thymoma-associated myasthenia gravis presented with dysphagia that was refractory to conventional treatment of myasthenia gravis. This dysphagia was challenging to diagnose even after multiple gastroenterology consults and upper endoscopy. The diagnosis of achalasia type II was established after a comprehensive evaluation, including upper endoscopy, barium swallow, and high-resolution esophageal manometry. The patient underwent elective pneumatic balloon dilatation, which successfully alleviated his dysphagia. Conclusion: This case confirmed the association between myasthenia gravis secondary to thymoma and achalasia and showed how the diagnosis of achalasia was challenging. Awareness of this association is crucial for early diagnosis and treatment, improving affected patients' quality of life.

Esophageal Squamous Cell Carcinoma: An Unfavorable Complication of Achalasia

Introduction: Achalasia is a motility disorder of the esophagus characterized by impaired relaxation of the lower esophageal sphincter and loss of peristalsis in the distal esophagus. It is a rare condition with an annual incidence of 0.5-1.2 per 100,000 individuals. The etiology of primary achalasia is unknown, however secondary achalasia can be attributed to malignancy, infections or systemic diseases such as amyloidosis. An infrequent complication of achalasia is esophageal squamous cell carcinoma which has a prevalence of 26 in every 1,000 cases. We present a case of interval locoregionally advanced esophageal squamous cell carcinoma only 2 years after a normal upper endoscopy. Case Description/Methods: A 67-year-old female with known achalasia and previous pneumatic dilation in her 30s presented to our outpatient clinic in 2019 with complaints of worsening chronic dysphagia. EGD was performed which revealed a significantly dilated esophagus with candida esophagitis. Despite completing antifungal therapy, she continued to experience dysphagia to solids and liquids. Barium swallow demonstrated absent peristalsis with pooling of contrast within the esophagus. High-Resolution Manometry testing demonstrated absent peristalsis. She opted for surgical myotomy, however due to COVID restrictions, the procedure was delayed. Repeat EGD was performed in 2022 for pre-surgical evaluation and showed a large obstructing friable esophageal mass in the lower third of the esophagus. Pathology was consistent with invasive poorly differentiated squamous cell carcinoma. PET scan showed locoregional disease with FDG-avid esophageal and gastrohepatic node lesions. She was started on chemoradiation with Paclitaxel and Carboplatin (Figure). Discussion(s): The risk of esophageal squamous cell carcinoma in achalasia has significantly increased with incidence of approximately 1 in 300 patients. The presumed mechanism of malignancy in achalasia is poor emptying resulting in food stasis, bacterial overgrowth and inflammation leading to dysplasia and development of carcinoma. Given the relatively low incidence, there are currently no guidelines on routine endoscopic screening to assess for malignancy in patients with achalasia. Survival rates are poor as patients are often diagnosed at advanced stages. This case aims to illustrate the importance and need for interval screening in individuals with long standing achalasia to improve outcomes.

Biofeedback Treatment Can Improve Clinical Condition and Quality of Life in Patients with Pelvic Floor Dyssynergy with Irritable Bowel Syndrome: A Prospective Cohort Study

Background: Chronic constipation is a common health concern. Defecatory disorders are considered one of the mechanisms of chronic idiopathic constipation. This study aimed to evaluate the effect of concurrent irritable bowel syndrome (IBS) on the success rate and response to biofeedback therapy in patients with chronic constipation and pelvic floor dyssynergia (PFD). Method(s): This prospective cohort study was performed at the Imam Khomeini Hospital Complex in Tehran from October 2020 to July 2021. Patients aged 18-70 years with chronic constipation and PFD confirmed by clinical examination, anorectal manometry, balloon expulsion test, and/or defecography were included. All patients failed to respond to treatment with lifestyle modifications and laxative use. The diagnosis of IBS was based on the ROME IV criteria. Biofeedback was educated and recommended to all patients. We used three different metrics to assess the patient's response to biofeedback: 1) constipation score (questionnaire), 2) lifestyle score (questionnaire), and 3) manometry findings (gastroenterologist report). Result(s): Forty patients were included in the final analysis, of which 7 men (17.5%) and 21 (52.2%) had IBS. The mean age of the study population was 37.7 +/- 11.4. The average resting pressure decreased in response to treatment;however, this decrease was statistically significant only in non-IBS patients (P = 0.007). Patients with and without IBS showed an increase in the percentage of anal sphincter relaxation in response to treatment, but this difference was not statistically significant. Although the first sensation decreased in both groups, this decrease was not statistically significant. Overall, the clinical response was the same across IBS and non-IBS patients, but constipation and lifestyle scores decreased significantly in both groups of patients with and without IBS (P < 0.001). Conclusion(s): Biofeedback treatment appears to improve the clinical condition and quality of life of patients with PFD. Considering that a better effect of biofeedback in correcting some manometric parameters has been seen in patients with IBS, it seems that paying attention to the association between these two diseases can be helpful in deciding on treatment.Copyright © 2023 The Author(s).

Incidence of barotrauma in patients with COVID-19 (alpha- and beta-predominant period) requiring mechanical ventilation: Single-center retrospective study.

Objective: We sought to determine predictors, incidence, and interventions required for patients who developed barotrauma. Pneumothorax, subcutaneous emphysema, and pneumomediastinum have all been reported as complications related to COVID-19-positive patients requiring invasive mechanical ventilation. Methods: In this retrospective study, clinical and imaging data from COVID-19 patients were collected and reviewed by two independent intensivists between January 4, 2020 and January 10, 2020. Data were used to identify COVID-19-positive patients requiring invasive mechanical ventilation and the incidence of barotrauma. Two separate cohorts were created as non-injured (no barotrauma) and injured (barotrauma present). We then sought to identify the risk factors for barotrauma in the non-injured cohort on Days 0, 7, 10, and 14 after intubation and day of injury in the injured cohort. Results: Of the 264 patients with COVID-19, 55.8% were African American. The non-injured group was older (60 ± 15 versus 49 ± 16, p = 0.006), with male predominance in the injured group versus non-injured group (75% versus 55%). A total of 16 (6.5%) patients developed one or more complications of barotrauma, defined as subcutaneous emphysema, pneumothorax, or pneumomediastinum. Length of stay was longer for the injured group versus non-injured group (47 versus 25 days). Plateau pressure (p = 0.024), fraction of inspired oxygen (p < 0.001), and driving pressure (p = 0.001) were statistically significant in injured cohort. Mortality rate in non-injured versus injured was 49.4% versus 69%. Using random effect model, fraction of inspired oxygen (p = 0.003) and mean airway pressure (p = 0.010) were significant at the time of injury. When comparing alive versus deceased in the injured cohort, thoracostomy placement in alive versus deceased was 80% versus 54.5%. Conclusion: COVID acute respiratory distress syndrome patients requiring invasive mechanical ventilation had a higher rate of barotrauma and were younger than those who did not develop barotrauma. Possible interventions to be considered to decrease barotrauma are decreased driving pressure goal and universal use of esophageal balloon manometry.

Optimal positive end-expiratory pressure reduces right ventricular dysfunction in COVID-19 patients on venovenous extracorporeal membrane oxygenation: A retrospective single-center study.

While mechanical ventilation practices on venovenous extracorporeal membrane oxygenation (VV ECMO) are variable, most institutions utilize a lung rest strategy utilizing relatively low positive end-expiratory pressure (PEEP). The effect of PEEP titration using esophageal manometry during VV ECMO on pulmonary and cardiac function is unknown. This was a retrospective study of 69 patients initiated on VV ECMO between March 2020 through November 2021. Patients underwent standard PEEP (typically 10 cm H2O) or optimal PEEP (PEEP titrated to an end-expiratory transpulmonary pressure 0-3 cm H2O) throughout the ECMO run. The optimal PEEP strategy had higher levels of applied PEEP (17.9 vs. 10.8 cm H2O on day 2 of ECMO), decreased incidence of hemodynamically significant RV dysfunction (4.55% vs. 44.0%, p = 0.0001), and higher survival to decannulation (72.7% vs. 44.0%, p = 0.022). Survival to discharge did not reach statistical significance (61.4% vs. 44.0%, p = 0.211). In univariate logistic regression analysis, optimal PEEP was associated with less hemodynamically significant RV dysfunction with an odds ratio (OR) of 0.06 (95% confidence interval [CI] = 0.01-0.27, p = 0.0008) and increased survival to decannulation with an OR of 3.39 (95% CI 1.23-9.79), p = 0.02), though other confounding factors may have contributed.

Laparoscopic Paraoesophageal Hernia, Gastric Bypass and Peroral Endoscopic Myotomy in a patient with Achalasia and Gastroesophageal reflux after Sleeve Gastrectomy

Daniel Slack Charlotte NC1, Paul Colavita Charlotte NC1, Abdelrahman Nimeri Charlotte NC1 Carolinas Medical Center, Atrium Health1 We present a 55-year-old female with class II obesity and a previous history of sleeve gastrectomy who developed significant gastroesophageal reflux disease refractory to medical management. After a covid infection in fall of 2020 she began to report new symptoms of dysphagia that progressed from solids to liquids. She underwent extensive workup including upper endoscopy, upper GI barium swallow, manometry, pH impedence and EndoFlip leading to a diagnosis of Achalasia type II as well as a paraesophageal hernia. Given these findings she underwent a combined paraesophageal hernia repair with conversion of sleeve gastrectomy to Roux-en-Y gastric diversion and an intra-operative Peroral Endoscopic Myotomy. Intra-operatively she was noted to have significant lower abdominal adhesions leading to performing the Roux-en-Y reconstruction through a supramesocolic defect in a retrocolic fashion. The patient tolerated the procedure well and recovered with improvement of both her reflux and achalasia.

IMPACT OF GERD ON PATIENTS UNDERGOING LUNG TRANSPLANTION FOR COVID-19: A SINGLE INSTITUTION RETROSPECTIVE STUDY

Background: Optimizing management of gastroesophageal reflux disease (GERD) is important to preserve graft function after lung transplantation as patients with GERD are at higher risk of rejection. Patients with COVID-19 associated respiratory failure undergoing lung transplantation is an emerging subset of patients in which GERD pre- or post-transplant is not well characterized. Aim: To evaluate the prevalence and adverse effects of GERD both pre- and post-transplant in patients undergoing lung transplantation for severe COVID-19 infection. Methods: A retrospective review was conducted at a single academic medical center with a large multi-organ transplant program. All patients undergoing lung transplant due to COVID-19 from 2020-2021 were included in the study, with attention to pre- and post-operative physiological testing for GERD. Results: Seventeen patients were identified who had undergone lung transplant for COVID-19. All patients were male;52.9% (9/17) were Hispanic, 35.3% (6/17) Caucasian and 11.8% (2/17) Black. Median age was 50 (24- 70 years) with median time to transplant from documented infection of 131 days. A prehospitalization GERD diagnosis was found in 29.4% (5/17) patients, and two patients (11.8%) were taking prescribed proton-pump inhibitor (PPI) prior to their COVID-19 associated hospitalization. No patient underwent pre-transplant GERD testing, although three patients did undergo upper endoscopy for GI bleeding prior to transplant. Post-transplant, all patients were immediately treated with PPI per institutional protocol. 70.5% (12/17) patients reported post-transplant foregut symptoms including heartburn, regurgitation, dysphagia, early satiety, abdominal bloating/cramping, nausea and vomiting. All 17 patients had at least one symptomdriven foregut study such as a gastric emptying study, barium esophagram, upper endoscopy, esophageal manometry or pH testing. Three patients were referred for anti-reflux surgery (ARS) based on results of testing, including delayed gastric emptying, abnormal pH testing and bronchoscopy findings concerning for aspiration pneumonia. All three underwent Toupet fundoplication with or without hiatal hernia repair;one was performed early (< 3 mo) posttransplant, two occurred late (> 6 mo), and none had complications or symptom-based recurrence of reflux. Discussion: In this large single-center series of COVID-19 associated respiratory failure and lung transplant, pre-operative reflux testing could not be performed;however, post-transplant GERD symptoms were still routinely assessed and evaluated, prompting management with ARS in a small subset of patients, both early and late posttransplant, with resolution of GERD symptoms. Long-term outcomes of this unique group and comparison with others requiring transplant will necessitate further investigation to assess impact of GERD on allograft dysfunction.

Utilizing Machine Learning and Esophageal Pressure to Detect Ventilator Dyssynchrony and Delineate the Potential for Ventilator Induced Lung Injury

Rationale: It is recognized that ventilator dyssynchrony (VD) may propagate ventilator induced lung injury (VILI). Yet some VD cannot be detected without advanced monitoring like measuring esophageal pressure (Pes) and it is unknown which types of VD propagate VILI. We describe the automated detection of VD using machine learning (ML) in patients with esophageal manometry to quantify the frequency and association between VD, tidal volume (VT) and transpulmonary driving pressure (ΔPdyn.tp). Methods: We enrolled 42 patients with ARDS or ARDS risk factors, including COVID-19. XGBoost, a ML algorithm, was trained to identify 7 types of breaths using a one-vs-all strategy, from a training set of 3500 random breaths. We compared the models' sensitivity and specificity with and without features derived from Pes. Finally, the association between each VD type and VT or ΔPdyn.tp was calculated using separate linear mixed-effect models. Temporally related breaths were nested by patient and modeled as random effects, accounting for repeat measures and changing pulmonary mechanics in each patient. Breaths without an adequate Pes signal were excluded from analysis Results: Patients were 37.5% female, 52±15 years old, had an initial P:F ratio of 140±64, and 24.2% of the 480, 976 breaths were dyssynchronous. Normal passive (Nlp), normal spontaneous (Nls), late reverse triggered (RTl), reverse triggered double triggered (DTr), mild flow limited (FLm), severe flow limited (FLs), and early ventilator terminated (EVT) account for 47.0%, 28.7%, 4.8%, 3.7%, 8.9%, 4.2%, and 2.5% of all breaths, respectively. ML training, VT and ΔPdyn.tp results are show in the table (∗p<0.001). Conclusion: ML algorithms can be trained using Pes to identify types of VD that traditionally need Pes measurements, although without Pes sensitivity may decrease. VD is frequent and DTr is associated with an increase in VT, while FLm and FLs are associated with an increased in ΔPdyn.tp. These data suggest that double triggered breaths and flow limited breaths have the potential to propagate VILI, while other types of VD may not be as deleterious. (Table Presented).

Risk Factors for Pulmonary Air Leak and Clinical Prognosis in Patients With COVID-19 Related Acute Respiratory Failure: A Retrospective Matched Control Study.

Background: The role of excessive inspiratory effort in promoting alveolar and pleural rupture resulting in air leak (AL) in patients with SARS-CoV-2 induced acute respiratory failure (ARF) while on spontaneous breathing is undetermined. Methods: Among all patients with COVID-19 related ARF admitted to a respiratory intensive care unit (RICU) and receiving non-invasive respiratory support, those developing an AL were and matched 1:1 [by means of PaO2/FiO2 ratio, age, body mass index-BMI and subsequent organ failure assessment (SOFA)] with a comparable population who did not (NAL group). Esophageal pressure (ΔPes) and dynamic transpulmonary pressure (ΔPL) swings were compared between groups. Risk factors affecting AL onset were evaluated. The composite outcome of ventilator-free-days (VFD) at day 28 (including ETI, mortality, tracheostomy) was compared between groups. Results: Air leak and NAL groups (n = 28) showed similar ΔPes, whereas AL had higher ΔPL (20 [16-21] and 17 [11-20], p = 0.01, respectively). Higher ΔPL (OR = 1.5 95%CI[1-1.8], p = 0.01), positive end-expiratory pressure (OR = 2.4 95%CI[1.2-5.9], p = 0.04) and pressure support (OR = 1.8 95%CI[1.1-3.5], p = 0.03), D-dimer on admission (OR = 2.1 95%CI[1.3-9.8], p = 0.03), and features suggestive of consolidation on computed tomography scan (OR = 3.8 95%CI[1.1-15], p = 0.04) were all significantly associated with AL. A lower VFD score resulted in a higher risk (HR = 3.7 95%CI [1.2-11.3], p = 0.01) in the AL group compared with NAL. RICU stay and 90-day mortality were also higher in the AL group compared with NAL. Conclusion: In spontaneously breathing patients with COVID-19 related ARF, higher levels of ΔPL, blood D-dimer, NIV delivery pressures and a consolidative lung pattern were associated with AL onset.

Severe Acute Respiratory Distress Syndrome (ARDS) or Severely Increased Chest Wall Elastance?

Esophageal manometry can be used to calculate transpulmonary pressures and optimize ventilator settings accordingly. We present the case of a 31-year-old male patient with ataxia-telangiectasia (Louis-Bar syndrome) and a BMI of 20 kg/m2, admitted to our intensive care unit for coronavirus disease 2019 (COVID-19) pneumonia. The patient soon required mechanical ventilation; however, there was very poor respiratory system compliance. Cholecystitis complicated the clinical course, and veno-venous extracorporeal membrane oxygenation (ECMO) was initiated as gas exchange deteriorated. Esophageal manometry was introduced and revealed severely increased intrathoracic pressure and chest wall elastance.

Prevalence Of Covid-19 Among Outpatients Presenting For Non-Urgent Endoscopy In A Large Healthcare Network

Background In Response To The Covid-19 Pandemic And National Professional Gastroenterology Society Guidelines, Ucla Health Implemented System-Wide Policies For Safe Non-Urgent Endoscopy On 4/13/2020. These Policies Included Mandatory Nasopharyngeal Covid-19 Testing 48 Hours Prior To All Outpatient Procedures. We Aimed To Determine The Covid-19 Positive Rate Among Outpatients Presenting For Elective Gastrointestinal (Gi) Procedures And To Characterize Patients Who Tested Positive For Covid-19. Methods Ucla Health Is A Large, Integrated Healthcare System With 5 Outpatient Endoscopy Units Across Southern California. Our Study Cohort Included All Patients Scheduled For One Or More Outpatient Procedures (Colonoscopy, Egd, Sigmoidoscopy, Manometry, Ph Study, Small Bowel Enteroscopy, Manometry, Eus, Ercp) Who Underwent Pre-Procedure Covid-19 Testing From 4/13/2020 To 11/5/2020. We Developed An Electronic Dashboard To Track Procedure Date, Type, And Completion Status, Pre-Procedure Covid-19 Test Results 48 Hours Prior To Procedure, And Post-Procedure Covid-19 Test Results Up To 14 Days After A Procedure. We Queried The Electronic Health Record For Patient Data, Performed Manual Chart Review To Identify Covid-19 Symptoms, And Used Administrative Data To Determine Covid-19 Exposures To Gastroenterology Providers And Staff. Our Primary Outcome Was The Preprocedure Covid-19 Positive Rate. We Also Determined Covid-19 Symptom Prevalence And Cases Of New Covid-19 Positivity Post-Procedure. We Used Univariate And Multivariable Logistic Regression To Determine Factors Associated With A Positive Pre-Procedure Covid-19 Test, Controlling For Age, Sex, Race/Ethnicity, And Bmi. Results The Study Cohort Included 9,645 Patients, Representing 10,056 Total Outpatient Scheduled Gi Procedures (Table 1). The Cumulative Pre-Procedure Positive Rate Was 0.3% (N=28), And The Inconclusive Rate Was <0.1% (N=7, Figure 1). One Patient Had A New Positive Covid-19 Result Post-Procedure (Day 4), Associated With New Cough. There Were No Known Covid-19 Exposures Among Gastroenterology Faculty And Staff. Of Patients With A Preprocedure Positive Covid-19 Result, 13 (46.4%) Were Asymptomatic And 10 (35.7%) Had Symptoms Possibly Consistent With Covid-19 (25% Cough, 14.3% Fevers/Chills, 7.1% Diarrhea, 3.6% Myalgias, 3.6% Dyspnea). No Factors Were Significantly Associated With A Positive Pre-Procedure Covid-19 Result In The Multivariable Model. The Covid-19 Testing Positivity Rate Was 3-13% In Los Angeles County During The Study Period. Discussion Implementation Of Mandatory Covid-19 Testing Before Outpatient Gi Procedures Was Successful, And The Positive Rate Was Low. Common Symptoms Among Patients With A Positive Pre-Procedure Covid-19 Result Were Cough, Fevers, And Chills. Although They Were Not Mandated, Post-Procedure Positive Covid-19 Results Were Rare (Table Presented) Patient Characteristics Overall And By Pre-Procedure Covid-19 Test Result (Figure Presented) Pre-Procedure Covid-19 Testing By Result (Per Month And Overall).

MULTIDISCIPLINARY SPECIALTY CLINIC DECREASES HEALTHCARE UTILIZATION IN CHILDREN WITH FUNCTIONAL GASTROINTESTINAL DISORDERS

Introduction: The biopsychosocial model has been used to describe the complex pathophysiology of functional gastrointestinal disorders (FGIDs), and the literature is clear that conventional medical treatment alone is often inadequate and should be supplemented with behavioral and/or dietary treatment. We hypothesized that the implementation of a multidisciplinary clinic for children with FGIDs would lead to decreased healthcare utilization. Our objective was to compare healthcare utilization before and after the initial visit in a pediatric multidisciplinary FGID clinic. Methods: We performed a retrospective review of children seen in the FGID clinic at our institution for their initial visit from March 2018-November 2019 (to avoid any impact of the COVID-19 pandemic). Our FGID clinic sees patients referred from other gastroenterologists. The initial visit is a 60-minute visit with a pediatric gastroenterologist, psychologist, and at times a dietitian. We recorded baseline characteristics and clinic visit information. To evaluate impact on healthcare utilization, we compared phone calls, electronic messages, additional outpatient GI visits, emergency department (ED) or urgent care (UC) visits, and hospitalizations for GI symptoms three months before and after a patient's initial FGID clinic visit. Results: We included 49 patients (76% female, median age 16 years, range 5-19). Primary FGID diagnoses were functional abdominal pain (45%), irritable bowel syndrome (22%), functional dyspepsia (20%), rumination syndrome (6%), functional constipation (4%), and abdominal migraine (2%). Other diagnoses included anxiety (73%), depression (33%), and inflammatory bowel disease (2%). Prior testing included blood tests (86%), imaging (82%), esophagogastroduodenoscopy (78%), colonoscopy (35%), and manometry testing (31%). At the initial visit, 71% were on a medication for their GI symptoms, 76% were on a supplement or probiotic, and 35% were on a psychiatric medication. During their initial visit, 96% met with a psychologist and 18% met with a dietitian. Recommendations at the initial visit included new medications (76%), follow up with a GI psychologist (45%), dietary treatment (22%), imaging studies (16%), manometry testing (10%), psychiatry referral (10%), blood tests (8%), esophagogastroduodenoscopy (4%), and colonoscopy (2%). As shown in Table 1, total phone calls, electronic messages, and ED/UC visits for GI symptoms decreased after the FGID clinic visit (p<0.001, p<0.001, and p=0.02 respectively). Conclusion: Healthcare utilization decreased significantly after children with FGIDs were seen in a multidisciplinary FGID clinic. Our findings imply that establishing a multidisciplinary FGID clinic improves the care of children with these disorders and may also reduce the time and financial costs of caring for these disorders.(Table Presented)

Same day barium esophagography and high-resolution manometry during the COVID-19 pandemic.

PURPOSE: Double contrast barium esophagography (BAS) and high-resolution manometry (HRM) are traditionally performed on separate days to allow for pre-procedural fasting. In an effort to minimize COVID-19 exposure and improve appointment efficiency with required pre-procedure testing, we permitted same day HRM prior to BAS. Our study aimed to evaluate the adequacy of barium mucosal coating with same day HRM prior to BAS compared to BAS alone. METHODS: We performed a retrospective pilot cohort study including 14 patients undergoing same day HRM prior to BAS and 20 patients undergoing BAS alone over an 8-month interval during the COVID-19 pandemic. Three abdominal imaging subspecialty-trained radiologists blindly reviewed the images and graded adequacy of esophageal coating on a 4-point scale with a score of 1 representing inadequate coating and 4 representing optimal coating. RESULTS: For the cohort studied thus far, the mean grade of the HRM and BAS group was 3.17 with a standard deviation of 0.66. The mean grade of the BAS alone group was 3.13 with a standard deviation of 0.79. There was no statistical difference in the adequacy of esophageal coating between the two groups (p-value 0.97). CONCLUSION: Same day HRM prior to BAS has no detrimental effect on barium mucosal coating compared to BAS alone. Though created to limit patient exposures during the COVID pandemic, same day BAS and HRM may prevent delays in care and improve convenience towards improved patient-centered care beyond the pandemic.

Impact of the COVID-19 pandemic on high-resolution manometry and peroral endoscopic myotomy for esophageal motility disorder in Japan.

AIM: To elucidate the impact of the coronavirus disease 2019 (COVID-19) on the practice of high-resolution manometry (HRM) and peroral endoscopic myotomy (POEM) in Japan. METHODS: We utilized a large-scale database involving 14 high-volume centers in Japan to investigate changes in the numbers of HRM and POEM procedures performed and outcomes of POEM between 2019 and 2020. A questionnaire survey was also conducted to analyze pandemic-associated changes in the HRM and POEM protocols. RESULTS: Compared to that in 2019, the number of HRM and POEM procedures decreased by 17.2% (1587-1314) and 20.9% (630-498), respectively. These declines were prominent during the state of emergency from April to May 2020, particularly in pandemic areas. HRM and POEM in nonpandemic areas were relatively unaffected. From 2019 to 2020, there was a 0.4% (254-248) decrease in POEM cases within the prefecture, but the number outside the prefecture decreased by 33.6% (372-247). During the pandemic, the safety and efficacy of POEM were maintained. The implementation of personal protective equipment (PPE) measures varied among facilities, and PPE for POEM was relatively insufficient compared to that for HRM. CONCLUSION: The COVID-19 pandemic influenced HRM and POEM practices in Japan. It is necessary to establish a sufficient system for HRM and POEM in each hospital as well as countrywide to overcome the effects of the pandemic.

Recommendations for the reopening and activity resumption of the neurogastroenterology units in the face of the COVID-19 pandemic. Position of the Sociedad Latinoamericana de Neurogastroenterología. / Recomendaciones para la reapertura y reinicio de actividades de las Unidades de Neurogastroenterología ante la pandemia por COVID-19. Posicionamiento de la Sociedad Latinoamericana de Neurogastroenterología.

The COVID-19 pandemic has forced the establishment of preventive measures against contagion during the performance of diagnostic and therapeutic tests in gastroenterology. Digestive tract motility tests involve an intermediate and elevated risk for the transmission of COVID-19 infection. Given their elective or non-urgent indication in the majority of cases, we recommend postponing those tests until significant control of the infection rate in each Latin American country has been achieved during the pandemic. When the health authorities allow the return to normality, and in the absence of an effective treatment for or preventive vaccine against COVID-19 infection, we recommend a strict protocol for classifying patients according to their infectious-contagious status through the appropriate use of tests for the detection of the virus and the immune response to it, and the following of protective measures by the healthcare personnel to prevent contagion during the performance of a gastrointestinal motility test.

The Impact of COVID-19 on Gastrointestinal Motility Testing in Asia and Europe.

BACKGROUND: The new coronavirus disease (COVID-19) has high infection and mortality rates, and has become a pandemic. The infection and mortality rates are lower in Asian countries than in European countries. This study aimed to conduct a survey on the effects of COVID-19 on the capacity to perform gastrointestinal motility tests in Asian countries compared with European countries. METHODS: We used the questionnaire previously established by our team for researchers in European countries. The correlation between the decreased rate of gastrointestinal motility and function tests, and the infection/mortality rates of COVID-19 and stringency of a government's interventions in each country was analysed and protective measures were assessed. RESULTS: In total, 58 gastroenterologists/motility experts in Asian countries responded to this survey. The infection/mortality rates of COVID-19 and Stringency Index had a significant impact on the testing capacity of oesophageal manometry and catheter-based pH monitoring. In European countries, most facilities used filtering facepiece 2/3 (FFP2/3) masks during oesophageal motility studies. Meanwhile, in Asian countries, most facilities used surgical masks. CONCLUSION: The total infection and mortality rates of COVID-19 can affect the rate of gastrointestinal motility testing and the type of protective equipment that must be used.

Statements for conducting high-resolution manometry during the COVID-19 pandemic.

To ensure the safety of medical personnel is important during the new coronavirus infectious disease (COVID-19) pandemic. Although high-resolution manometry (HRM) is an essential device for diagnosis of functional gastrointestinal disorders, it contains risks of droplet infection, contact infection and aerosol-borne infection. Screening tests such as PCR, serology test to detect COVID-19 antibodies, and CT scan should be considered as well as body temperature check and anamnestic risk assessment. Moreover, the provision of protective equipment such as a mask with face shield (or goggles + mask), gloves, cap or hairnet, and a long-sleeved gown would be necessary to reduce the risk of COVID-19.

Recommendations of the Spanish Association of Neurogastroenterology and Motility (ASENEM) to restart the activity of gastrintestinal motility laboratories after the state of alarm called due to the Covid-19 pandemic. / Recomendaciones de la Asociación Española de Neurogastroenterología y Motilidad (ASENEM) para el reinicio de la actividad de los laboratorios de motilidad digestiva, tras el confinamiento por el estado de alarma decretado a raíz de la pandemia por COVID-19.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was responsible for the outbreak of the 2019 coronavirus disease (COVID-19), which is now considered as a pandemic. The prevention strategies adopted have included social distancing measures and the modification, reduction or interruption of a large proportion of routine healthcare activity. This has had a significant impact on the care provided in Gastrointestinal Motility Units. Having passed the peak, in terms of mortality and infections, a gradual reduction in transmission figures has been observed in Spain and other European countries. The risk of reactivation, however, remains high, so it is necessary to have a plan in place that allows healthcare centres to safely resume, for their patients and professionals, instrumental examinations linked to the management of motor pathology. Based on the available scientific evidence and the consensus of a panel of experts, the Spanish Association of Neurogastroenterology and Motility (ASENEM) has drawn up a series of practical recommendations, which have been adapted to the risks inherent in each activity. These include individual protection proposals, as well as organisational and structural measures, which are conceived to allow for the gradual resumption of examinations while minimising the possibility of contagion.