Weight loss in achalasia is determined by its phenotype.

Patients with achalasia present with dysphagia, regurgitation, and varying degrees of weight loss. However, despite it being a disorder of the lower esophageal sphincter with functional obstruction in all patients, it is unclear why certain patients lose significantly more weight compared to others. The aims of this study are to assess demographic, clinical, and manometric characteristics of a large cohort of patients with achalasia to determine potential correlates of weight loss in this population. Patients with diagnosis of achalasia referred to our center between 2009 and 2016 were evaluated. Demographic and physiologic tests between those with and without weight loss were compared. The cohort of patients with initial self-reported weight loss were studied to determine change in weight after intervention (pneumatic dilation or myotomy). The Kruskal-Wallis test was used for comparison of continuous variables between groups and Pearson's χ2 test was used for comparison of categorical variables between groups. 138 patients with achalasia were evaluated. 35 patients were excluded due to lack of manometric data and 3 from lack of documented weight resulting in the study population of 100 patients with achalasia [51% male, median age: 56 years]. Weight loss was reported in 51/100 (51%) patients. BMI was lower in patients who reported weight loss (25 vs. 31, P < 0.001) with a median weight loss of 28 lbs (14-40 lbs). There were no significant differences in age at diagnosis, gender, or symptom presentation (dysphagia, regurgitation, or chest pain) between the groups. However, more patients with type II achalasia (63%) reported weight loss as compared to other sub-types (P = 0.013). 73% of type III achalasia denied having weight loss. Patients who denied weight loss had symptoms for longer duration (24 vs. 12 months, P < 0.001) and had lower mean residual LES pressure (20 vs. 30 mmHg, P = 0.006). Postintervention 42% of patients reported no weight regain despite appropriate therapy for achalasia with median follow-up of 22 months (range: 6-90 months). Type II achalasia patients are most likely and type III achalasia are least likely to have weight loss compared to type I achalasia. Given that no other demographic/physiologic parameters predicted weight loss, the role of underlying inflammatory cascade in achalasia phenotypes deserves special attention.

Symptom association probability does not reliably distinguish functional heartburn from reflux hypersensitivity.

BACKGROUND: Symptom association probability (SAP) is thought to distinguish reflux hypersensitivity from functional disorders. A diagnosis of hypersensitive oesophagus (SAP-positive) indicates that gastro-oesophageal reflux disease (GERD) is the cause of continued symptoms. AIM: To conduct an analysis of pH and symptom criteria that lead to a diagnosis of SAP-positivity METHODS: We calculated SAP for 205 patients with GERD symptoms refractory to proton pump inhibitor (PPI) therapy who underwent endoscopy with wireless pH monitoring from 2007 to 2014. Patients were divided into three groups: pH-negative with no oesophagitis (n = 45), pH-positive with no oesophagitis (n = 130), and patients with oesophagitis (n = 30). We constructed a 2 × 2 table of symptom and reflux event association and quantified the number of 2-minute intervals for each of the 2 × 2 variables that distinguished SAP-positive from SAP-negative. In a separate cohort of 58 patients who had undergone anti-reflux surgery, we evaluated the effects of pre-surgery SAP. RESULTS: The difference in symptom association parameters that led to a diagnosis of an SAP-positive was small (2.98% in oesophagitis-positive; 1.56% in oesophagitis-negative/pH-positive; 0.48% in oesophagitis-negative/pH-negative). In the pH-negative/oesophagitis-negative group, a difference of 0.48% led to a diagnosis of hypersensitivity. There was significant variability in SAP values between day 1 and day 2 of pH testing in all groups, with the greatest in the oesophagitis-positive group, despite objective evidence for reflux (27% in oesophagitis-positive, 19% pH-positive/oesophagitis-negative, and 7% in pH-negative/oesophagitis-negative). Pre-surgery SAP was not associated with response to anti-reflux surgery. CONCLUSION: In PPI-refractory GERD, SAP cannot accurately distinguish reflux hypersensitivity from functional oesophageal symptoms.

Randomized controlled trial comparing esophageal dilation to no dilation among adults with esophageal eosinophilia and dysphagia.

The role of esophageal dilation in patients with esophageal eosinophilia with dysphagia remains unknown. The practice of dilation is currently based on center preferences and expert opinion. The aim of this study is to determine if, and to what extent, dysphagia improves in response to initial esophageal dilation followed by standard medical therapies. We conducted a randomized, blinded, controlled trial evaluating adult patients with dysphagia and newly diagnosed esophageal eosinophilia from 2008 to 2013. Patients were randomized to dilation or no dilation at time of endoscopy and blinded to dilation status. Endoscopic features were graded as major and minor. Subsequent to randomization and endoscopy, all patients received fluticasone and dexlansoprazole for 2 months. The primary study outcome was reduction in overall dysphagia score, assessed at 30 and 60 days post-intervention. Patients with severe strictures (less than 7-mm esophageal diameter) were excluded from the study. Thirty-one patients were randomized and completed the protocol: 17 randomized to dilation and 14 to no dilation. Both groups were similar with regard to gender, age, eosinophil density, endoscopic score, and baseline dysphagia score. The population exhibited moderate to severe dysphagia and moderate esophageal stricturing at baseline. Overall, there was a significant (P < 0.001) but similar reduction in mean dysphagia score at 30 and 60 days post-randomization compared with baseline in both groups. No significant difference in dysphagia scores between treatment groups after 30 (P = 0.93) or 60 (P = 0.21) days post-intervention was observed. Esophageal dilation did not result in additional improvement in dysphagia score compared with treatment with proton pump inhibitor and fluticasone alone. In patients with symptomatic esophageal eosinophilia without severe stricture, dilation does not appear to be a necessary initial treatment strategy.

The effect of femoral prosthesis design on cement strain in cemented total hip arthroplasty.

Finite element studies show that the highest cement stresses are located at the most proximal and distal ends of the prosthesis. In vitro biomechanical and histologic analyses of autopsy-retrieved cemented femoral components show these areas to be associated with cement-prosthesis debonding. In this study, cement strains were measured in 2 geometrically different femoral stems in paired cadaver femora: A straight, collared, moderately tapered stem (Centralign) was compared with an anatomically curved, collarless, dramatically tapered stem (Scientific Hip Prosthesis [SHP]). Results showed that the maximum strain and the overall strain profile differed between the 2 stems. The Centralign had peak strains located at the most proximal gauge positions, whereas the peak strains of the SHP were located around the middle of the femoral stem. Minimization of cement strain, especially at the crucial proximal and distal areas of the stem, by altering component design may be able to reduce cement-prosthesis debonding and improve clinical results.