Normal values for water-perfused esophageal high-resolution manometry.

BACKGROUND: Normal values for water-perfused esophageal high-resolution manometry have still not been established in our environment, despite its generalized use and the recommendation to determine reference values for each Motility Unit based on their equipment. Normal values established with solid-state highresolution manometry are currently being used as reference values for water-perfused high-resolution manometry. OBJECTIVES: To obtain normal values for water-perfused esophageal high-resolution manometry, based on the esophageal motility analysis of healthy subjects. METHODS: 16 healthy volunteers without history of digestive complaints or esophageal symptoms were included. 22-channel water-perfused high-resolution manometry was performed. RESULTS: Normal values were calculated as 5th-95th percentile ranges for the following parameters; upper esophageal sphincter resting pressure (UESRP) (40-195 mmHg); upper esophageal sphincter residual pressure (UESResP) (30-115 mmHg), contractile front velocity (CFV) (2.4-7.1 cm/s), distal contractile integral (DCI) (285-2820 mmHg.s.cm), distal contraction latency (DL) (6.1-10.9 s), intrabolus pressure (IBP) (7-19 mmHg), integrated relaxation pressure (IRP 4s) (2-20 mmHg), lower esophageal sphincter resting pressure(LESRP) (5-54 mmHg), esophageal shortening (Es) (0.3-1.3 cm) and lower esophageal sphincter lift (LESL) (0,1-1,2 cm). CONCLUSION: Normal values for the most important parameters (such as IRP 4s, DL and CFV), obtained using a 22-channel waterperfused system resemble previously published data from other perfusion devices. However, there exist small but significant variations compared with values established with solid-state highresolution manometry. Thus, when using water-perfused catheters, caution is required when normative values are used that were established with solid-state catheters.

Esófago hipercontráctil: contexto clínico y hallazgos motores en la manometría de alta resolución / Hypercontractile esophagus: Clinical context and motors findings in high resolution manometry

INTRODUCCIÓN: el esófago hipercontráctil (EH) es un trastorno de hipercontractilidad primario del músculo esofágico poco frecuente. La manometría esofágica lo define como al menos una contracción de muy elevada amplitud y duración (ICD > 8.000 mmHg/s/cm) en pacientes con síntomas esofágicos. El objetivo de nuestro estudio fue valorar el contexto clínico y las variables manométricas de pacientes con diagnóstico de EH utilizando manometría de alta resolución (MAR). MÉTODOS: se revisaron 720 estudios de MAR realizadas desde junio de 2011 hasta junio de 2013 y se estudiaron las características clínicas y manométricas de los pacientes con EH. RESULTADOS: se encontraron siete pacientes con criterios de EH según la Clasificación de Chicago. El 100% fueron mujeres, con edad media de 64 años. Los síntomas principales fueron dolor torácico, disfagia y pirosis. En seis (86%) no hubo patología asociada y en un paciente (14%) se asoció a enfermedad por reflujo gastroesofágico (ERGE) y obstrucción al flujo de la unión esófago-gástrica (UEG). Tres pacientes (43%) presentaron más de una onda hipercontráctil. Cuatro (57%) tenía patrón multipico (esófago de Jackhammer) y en dos de ellos las contracciones estuvieron sincronizadas con la respiración. Dos pacientes (29%) fueron diagnosticados de hernia de hiato. La presión integrada de relajación (PIR) no fue mayor en las contracciones hipercontráctiles, en comparación con las contracciones normales; sólo un paciente presentó alteración leve de la relajación (PIR-4s = 15 mmHg) con peristalsis conservada, obstrucción al flujo de la UEG y patrón no multipico. Un paciente presentó una exposición ácida patológica (EAP) en la pHmetría de 24 horas. CONCLUSIONES: el EH es un trastorno de muy baja frecuencia. La MAR es indispensable para su diagnóstico y caracterización. El tratamiento del EH debe estar orientado a resolver o mejorar la sintomatología de los pacientes y evitar la realización de estudios innecesarios

BACKGROUND: Hypercontractile esophagus (HE) is a primary hypercontractile disorder of the esophageal musculature not frequently seen in the general population. It is characterized by the presence of at least one contraction with a very high amplitude and duration (DCI > 8,000 mmHg/s/cm) in patients with esophageal symptoms. The aim of our study was to assess the clinical context and manometric characteristics in patients with HE using high-resolution manometry (HRM). METHODS: We thoroughly reviewed the clinical features and manometric findings of a total of 720 patients with esophageal symptoms that were attended in the Department of Gastroenterology of our hospital between June 2011 and June 2013. RESULTS: We found seven patients that met criteria for HE according to the Chicago Classification (2012). All of the patients were women (100%). Mean age was 64 years old. Most frequent symptoms were: Chest pain, dysphagia and heartburn. In one patient (14%) the HE was related to a gastroesophageal reflux disease (GERD) and gastroesophageal junction (GEJ) outflow obstruction. Three patients (43%) had more than one hypercontractile contraction in the study. Four patient (57%) hade multipeaked pattern (Jackhammer esophagus) and y two of them were synchronized with respiration. Two patients (29%) were diagnosed with hiatus hernias. Integrated relaxation pressure (IRP) was not higher in hypercontractile contractions than in normal contractions. Only one patient presented a slight alteration of the relaxation (IRP-4s = 15 mmHg) with normal peristalsis, GEJ outflow obstruction and not multipeakeded pattern. One patient presented pathological acid exposure (PAE) in 24-hours pH-metry. CONCLUSIONS: HE is a rare disorder and HRM is essential for its correct diagnosis and characterization. The treatment of HE should achieve the disappearance or at least improvement of the patient's symptoms and avoid unnecessary diagnostic testing

Valores de referencia de manometría esofágica de alta resolución mediante sistema de perfusión / Normal values for water-perfused esophageal high-resolution manometry

ANTECEDENTES: los valores de referencia de la manometría esofágica de alta resolución mediante sistema de perfusión aún no han sido establecidos en nuestro medio, a pesar de su empleo generalizado en múltiples Unidades de Motilidad y la recomendación de determinar valores de referencia propios de cada Unidad en función de sus equipos. Actualmente se utilizan como referencia los valores de normalidad de la manometría de alta resolución en estado sólido. OBJETIVOS: el objetivo de este estudio es establecer los valores de normalidad para la manometría de alta resolución de perfusión de 22 canales a partir del análisis de la motilidad esofágica de individuos sanos. MÉTODOS: se incluyeron 16 voluntarios sanos, sin patología digestiva ni síntomas esofágicos, a los que se realizó una manometría de alta resolución mediante sistema de perfusión de 22 canales. RESULTADOS: los datos vienen referidos como la media y el rango comprendido entre los percentiles 5 y 95. Los percentiles 5 y 95 de cada uno de los parámetros fueron de 40-195 mmHg para la presión de reposo del esfínter esofágico superior (PRESS), 30-115 mmHg para la presión residual del esfínter esofágico superior (PResEES), 2,4-7,1 cm/s para la velocidad de frente contráctil (VFC), 285-2.820 mmHg.s.cm para la integral contráctil distal (ICD), 6,1-10,9 s para la latencia distal (LD), 7-19 mmHg para la presión intrabolo (PIB), 2-20 mmHg para la presión de relajación integrada a los 4 segundos (PRI4s) y 5-54 mmHg para la presión de reposo del esfínter esofágico inferior (PREEI). Los percentiles 5 y 95 del acortamiento esofágico (aE) fueron 0,3-1,3 cm y del ascenso del esfínter esofágico inferior (aEEI) 0,1-1,2 cm. CONCLUSIÓN: los rangos de normalidad obtenidos mediante sistema de perfusión de 22 canales para los parámetros manométricos más importantes (PRI4s, LD, VFC) son similares a los previamente publicados con equipos de perfusión, existiendo variaciones pequeñas, pero significativas, respecto a los valores establecidos por equipos de estado sólido

BACKGROUND: Normal values for water-perfused esophageal high-resolution manometry have still not been established in our environment, despite its generalized use and the recommendation to determine reference values for each Motility Unit based on their equipment. Normal values established with solid-state highresolution manometry are currently being used as reference values for water-perfused high-resolution manometry. OBJECTIVES: To obtain normal values for water-perfused esophageal high-resolution manometry, based on the esophageal motility analysis of healthy subjects. METHODS: 16 healthy volunteers without history of digestive complaints or esophageal symptoms were included. 22-channel water-perfused high-resolution manometry was performed. RESULTS: Normal values were calculated as 5th-95th percentile ranges for the following parameters; upper esophageal sphincter resting pressure (UESRP) (40-195 mmHg); upper esophageal sphincter residual pressure (UESResP) (30-115 mmHg), contractile front velocity (CFV) (2.4-7.1 cm/s), distal contractile integral (DCI) (285-2820 mmHg.s.cm), distal contraction latency (DL) (6.1-10.9 s), intrabolus pressure (IBP) (7-19 mmHg), integrated relaxation pressure (IRP 4s) (2-20 mmHg), lower esophageal sphincter resting pressure (LESRP) (5-54 mmHg), esophageal shortening (Es) (0.3-1.3 cm) and lower esophageal sphincter lift (LESL) (0,1-1,2 cm). CONCLUSION: Normal values for the most important parameters (such as IRP 4s, DL and CFV), obtained using a 22-channel waterperfused system resemble previously published data from other perfusion devices. However, there exist small but significant variations compared with values established with solid-state highresolution manometry. Thus, when using water-perfused catheters, caution is required when normative values are used that were established with solid-state catheters

Hypercontractile esophagus: Clinical context and motors findings in high resolution manometry.

BACKGROUND: Hypercontractile esophagus (HE) is a primary hypercontractile disorder of the esophageal musculature not frequently seen in the general population. It is characterized by the presence of at least one contraction with a very high amplitude and duration (DCI > 8,000 mmHg/s/cm) in patients with esophageal symptoms. The aim of our study was to assess the clinical context and manometric characteristics in patients with HE using highresolution manometry (HRM). METHODS: We thoroughly reviewed the clinical features and manometric findings of a total of 720 patients with esophageal symptoms that were attended in the Department of Gastroenterology of our hospital between June 2011 and June 2013. RESULTS: We found seven patients that met criteria for HE according to the Chicago Classification (2012). All of the patients were women (100%). Mean age was 64 years old. Most frequent symptoms were: Chest pain, dysphagia and heartburn.In one patient (14%) the HE was related to a gastroesophageal reflux disease (GERD) and gastroesophageal junction (GEJ) outflow obstruction. Three patients (43%) had more than one hypercontractile contraction in the study. Four patient (57%) hade multipeaked pattern (Jackhammer esophagus) and y two of them were synchronized with respiration. Two patients (29%) were diagnosed with hiatus hernias. Integrated relaxation pressure (IRP) was not higher in hypercontractile contractions than in normal contractions. Only one patient presented a slight alteration of the relaxation (IRP-4s = 15 mmHg) with normal peristalsis, GEJ outflow obstruction and not multipeakeded pattern. One patient presented pathological acid exposure (PAE) in 24-hours pH-metry. CONCLUSIONS: HE is a rare disorder and HRM is essential for its correct diagnosis and characterization. The treatment of HE should achieve the disappearance or at least improvement of the patient´s symptoms and avoid unnecessary diagnostic testing.

Aortic injury during laparoscopic esophageal hiatoplasty.

A 75-year-old female patient with a type III hiatal hernia was submitted to laparoscopic mesh hiatoplasty. Soon after the last suture fixed the mesh to the left crura, a hemorrhage was observed. Conversion to open surgery was not performed. The most common sources of bleeding (liver, phrenic arteries, crura, spleen, and short gastric vessels) were discarded as the cause of the hemorrhage. The mesh was set free in order to explore the lower mediastinum. The source of the hemorrhage was identified: it was the last suture fixing the mesh to the left crura, which was found passing through the aortic wall. The hemorrhage stopped as soon as the suture was removed. When facing a hemorrhage during this kind of surgery, it is essential to be methodical to discover the source of the bleeding. First of all, the most common sources of bleeding must be checked out. Injury of the inferior vena cava must also be ruled out, because it is an uncommon but potentially lethal complication. Afterwards, the lower mediastinum must be explored. Conversion to an open approach is needed if the patient becomes unstable or the surgeon does not have enough laparoscopic skills to find and solve the bleeding. Most of the reported cases of aortic injury during laparoscopic hiatoplasty are secondary to vascular injuries during port insertion. When a suture is the cause of bleeding, the removal of the stitch should be enough to stop the bleeding. If there is a tear of the aortic wall, a patch should be employed for the repair. In conclusion, left crura and thoracic aorta are very close to one another. The surgeon must be very careful when working near the left crura, mostly in old patients with a dilated and aneurysmatic aorta.