Background
Improvement in lower esophageal sphincter (LES) competency after laparoscopic Nissen fundoplication (LNF) is well established, yet esophageal body physiology data are limited. We aimed to ...describe the impact of LNF on whole esophagus physiology using standard and novel manometric characteristics.
Methods
A cohort of patients with an intact fundoplication without herniation and no postoperative dysphagia were selected and underwent esophageal manometry at one‐year after surgery. Pre‐ and post‐operative manometry files were reanalyzed using standard and novel manometric characteristics and compared.
Key Results
A total of 95 patients were included in this study. At 16.1 (8.7) months LNF increased LES overall and abdominal length and resting pressure (p < 0.0001). Outflow resistance (IRP) increased 5.8 (3–11) to 11.1 (9–15), p < 0.0001 with a 95th percentile of 20 mmHg in this cohort of dysphagia‐free patients. Distal contractile integral (DCI) also increased 1177.0 (667–2139) to 1321.1 (783–2895), p = 0.002, yet contractile amplitude was unchanged (p = 0.158). There were direct correlations between pre‐ and post‐operative DCI R: 0.727 (0.62–0.81), p < 0.0001 and postoperative DCI and postoperative IRP R: 0.347 (0.16–0.51), p = 0.0006. Contractile front velocity 3.5 (3–4) to 3.2 (3–4), p = 0.0013 was slower, while distal latency 6.7 (6–8) to 7.4 (7–9), p < 0.0001, the interval from swallow onset to proximal smooth muscle initiation 4.0 (4–5) to 4.4 (4–5), p = 0.0002, and the interval from swallow onset to point when the peristaltic wave meets the LES 9.4 (8–10) to 10.3 (9–12), p < 0.0001 were longer. Esophageal length 21.9 (19–24) to 23.2 (21–25), p < 0.0001 and transition zone (TZ) length 2.2 (1–3) to 2.5 (1–4), p = 0.004 were longer. Bolus clearance was inversely correlated with TZ length (p = 0.0002) and time from swallow onset to proximal smooth muscle initiation (p < 0.0001). Bolus clearance and UES characteristics were unchanged (p > 0.05).
Conclusions & Inferences
Increased outflow resistance after LNF required an increased DCI. However, this increased contractile vigor was achieved through sustained, not stronger, peristaltic contractions. Increased esophageal length was associated with increased TZ and delayed initiation of smooth muscle contractions.
Using standard and novel high‐resolution manometry characteristics to assess whole esophagus physiology before and after Nissen fundoplication in patients with an intact wrap and no postoperative dysphagia, this study demonstrated that surgery increased esophagogastric outflow resistance, which was compensated for by increased contractility. However, peristaltic contractions were delayed and sustained, without an increase in amplitude.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Background The manometric diagnosis of distal esophageal spasm (DES) uses “simultaneous contractions” as a defining criterion, ignoring the concept of short latency distal contractions as an ...important feature. Our aim was to apply standardized metrics of contraction velocity and latency to high-resolution esophageal pressure topography (EPT) studies to refine the diagnosis of DES. Methods Two thousand consecutive EPT studies were analyzed for contractile front velocity (CFV) and distal latency to identify patients potentially having DES. Normal limits for CFV and distal latency were established from 75 control subjects. Clinical data of patients with reduced distal latency and/or rapid CFV were reviewed. Results Of 1070 evaluable patients, 91 (8.5%) had a high CFV and/or low distal latency. Patients with only rapid contractions (n = 186 17.4% using conventional manometry criteria; n = 85 7.9% using EPT criteria) were heterogeneous in diagnosis and symptoms, with the majority ultimately categorized as weak peristalsis or normal. In contrast, 96% of patients with premature contraction had dysphagia, and all (n = 24; 2.2% overall) were ultimately managed as spastic achalasia or DES. Conclusions The current DES diagnostic paradigm focused on “simultaneous contractions” identifies a large heterogeneous set of patients, most of whom do not have a clinical syndrome suggestive of esophageal spasm. Incorporating distal latency into the diagnostic algorithm of EPT studies improves upon this by isolating disorders of homogeneous pathophysiology: DES with short latency and spastic achalasia. We hypothesize that prioritizing measurement of distal latency will refine the management of these disorders, recognizing that outcomes trials are necessary.
Background
Peroral endoscopic myotomy (POEM) is a novel endoscopic surgical procedure for the treatment of achalasia. The comparative effects of POEM and laparoscopic Heller myotomy (LHM) on ...esophagogastric junction (EGJ) physiology are unknown. A novel measurement catheter, the functional lumen imaging probe (FLIP), allows for intraoperative evaluation of EGJ compliance by measuring luminal geometry and pressure during volume-controlled distensions.
Methods
Distensibility index (DI) (defined as the minimum cross-sectional area at the EGJ divided by pressure) was measured with FLIP intraoperatively in patients undergoing LHM and POEM. Separate measurements were taken after each operative step. During LHM, measurements were performed after: (1) induction of anesthesia, (2) insufflation of pneumoperitoneum, (3) hiatal dissection and esophageal mobilization, (4) myotomy, (5) partial fundoplication, and (6) deinsufflation. During POEM, they were performed after: (1) induction of anesthesia, (2) submucosal tunnel creation, and (3) myotomy.
Results
Eleven LHM and 14 POEM patients underwent intraoperative FLIP. Baseline DI was similar between groups. LHM resulted in an overall increase in mean DI (pre 1.4 vs. post 7.6 mm
2
/mmHg, using a 40-ml distension volume;
p
< 0.001). Insufflation of pneumoperitoneum and hiatal dissection did not affect DI. Myotomy caused an increase in DI. Partial fundoplication (6 Toupet, 5 Dor) caused a decrease in DI, and deinsufflation caused an increase in DI. POEM also resulted in an overall increase in mean DI (pre 1.4 vs. post 7.9 mm
2
/mmHg;
p
< 0.001). Measured individually, both submucosal tunnel creation and myotomy caused increases in DI. When overall changes were compared, there were no differences in the amount of DI increase between LHM and POEM.
Conclusions
POEM and LHM result in a similar improvement in EGJ distensibility intraoperatively. Further study is needed to correlate intraoperative FLIP measurements with postoperative symptomatic and physiologic outcomes.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background & Aims Radiofrequency ablation (RFA) is a safe alternative to esophagectomy for patients with dysplastic Barrett's esophagus (BE). Although some studies have indicated that RFA is ...effective at eradicating dysplasia, most have found that RFA is not as effective in eradicating intestinal metaplasia. We investigated whether uncontrolled reflux is associated with persistent intestinal metaplasia after RFA. Methods Thirty-seven patients with BE underwent RFA, high-resolution manometry, and 24-hour impedance-pH testing; they received proton pump inhibitors twice daily. Patients returned every 2 months for repeat treatment or standard surveillance. Patients were classified as complete responders (CRs) if all intestinal metaplasia was eradicated in fewer than 3 ablation sessions. We analyzed clinical parameters to identify factors associated with a CR or incomplete responder (ICR). Results Among the 37 patients, 22 had a CR and 15 had an ICR. Mann–Whitney U tests revealed that length of BE, size of hiatal hernia, and frequency of reflux, but not acid reflux, differed between CRs and ICRs. CRs had fewer weakly acidic events than ICRs (29.5 vs 52; P < .05) and total reflux events (33.5 vs 60; P < .05), and a trend toward fewer weakly alkaline events (1.0 vs 5.0; P = .06). No other clinical or manometric features differed between groups. Conclusions Uncontrolled, predominantly weakly acidic reflux despite twice-daily proton pump inhibitor therapy before RFA increases the incidence of persistent intestinal metaplasia after ablation in patients with BE. Length of BE and size of hiatal hernia also were associated with persistent intestinal metaplasia after RFA.
Background
The functional lumen imaging probe (FLIP) is a novel diagnostic tool that can be used to measure esophagogastric junction (EGJ) distensibility. In this study, we performed intraoperative ...FLIP measurements during laparoscopic Heller myotomy (LHM) and peroral esophageal myotomy (POEM) for treatment of achalasia and evaluated the relationship between EGJ distensibility and postoperative symptoms.
Methods
Distensibility index (DI) (defined as the minimum cross-sectional area at the EGJ divided by distensive pressure) was measured with FLIP at two time points during LHM and POEM: (1) at baseline after induction of anesthesia, and (2) after operation completion.
Results
Measurements were performed in 20 patients undergoing LHM and 36 undergoing POEM. Both operations resulted in an increase in DI, although this increase was larger with POEM (7 ± 3.1 vs. 5.1 ± 3.4 mm
2
/mmHg,
p
< .05). The two patients (both LHM) with the smallest increases in DI (1 and 1.6 mm
2
/mmHg) both had persistent symptoms postoperatively and, overall, LHM patients with larger increases in DI had lower postoperative Eckardt scores. In the POEM group, there was no correlation between change in DI and symptoms; however, all POEM patients experienced an increase in DI of >3 mm
2
/mmHg. When all patients were divided into thirds based on final DI, none in the lowest DI group (<6 mm
2
/mmHg) had symptoms suggestive of reflux (i.e., GerdQ score >7), as compared with 20 % in the middle third (6–9 mm
2
/mmHg) and 36 % in the highest third (>9 mm
2
/mmHg). Patients within an “ideal” final DI range (4.5–8.5 mm
2
/mmHg) had optimal symptomatic outcomes (i.e., Eckardt ≤ 1 and GerdQ ≤ 7) in 88 % of cases, compared with 47 % in those with a final DI above or below that range (
p
< .05).
Conclusions
Intraoperative EGJ distensibility measurements with FLIP were predictive of postoperative symptomatic outcomes. These results provide initial evidence that FLIP has the potential to act as a useful calibration tool during operations for achalasia.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
The functional lumen imaging probe (FLIP), measures esophagogastric junction (EGJ) distensibility (cross‐sectional area/luminal pressure) during volume‐controlled distension. The aim of ...this study is to apply this tool to the assessment of the EGJ in untreated and treated achalasia patients and to compare EGJ distensibility with other diagnostic tools utilized in managing achalasia.
Methods
Findings from FLIP, high‐resolution manometry (HRM), timed barium esophagram, and symptom assessment by Eckardt Score (ES) were compared in 54 achalasia patients (23 untreated, 31 treated). Twenty healthy volunteers underwent FLIP as a comparator group. The EGJ distensibility index (EGJ‐DI) was defined at the ‘waist’ of the FLIP bag during volumetric distension, expressed in mm2 mmHg−1. The ES was used to gauge treatment outcome: good response < 3 or poor response ≥ 3.
Key Results
Of the 31 treated patients, 17 had good and 14 poor treatment response. The EGJ‐DI was significantly different among groups, greatest in the control subjects and least in the untreated patients; patients with good treatment response had significantly greater EGJ‐DI than untreated or patients with poor response. The correlations between EGJ‐DI and ES and integrated relaxation pressure on HRM were significant.
Conclusions & Inferences
The FLIP provided a useful measure of EGJ distensibility in achalasia patients that correlated with symptom severity. The measurement of EGJ distensibility was complementary to existing tests suggesting a potentially important role in the clinical management of achalasia.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK
Background
For laparoscopic Heller myotomy (LHM), the optimal myotomy length proximal to the esophagogastric junction (EGJ) is unknown. In this study, we used a functional lumen imaging probe (FLIP) ...to measure EGJ distensibility changes resulting from variable proximal myotomy lengths during LHM and peroral esophageal myotomy (POEM).
Methods
Distensibility index (DI) (defined as the minimum cross-sectional area at the EGJ divided by pressure) was measured with FLIP after each operative step. During LHM and POEM, each patient’s myotomy was performed in two stages: first, a myotomy ablating only the EGJ complex was created (EGJ-M), extending from 2 cm proximal to the EGJ, to 3 cm distal to it. Next, the myotomy was lengthened 4 cm further cephalad to create an extended proximal myotomy (EP-M).
Results
Measurements were performed in 12 patients undergoing LHM and 19 undergoing POEM. LHM resulted in an overall increase in DI (1.6 ± 1 vs. 6.3 ± 3.4 mm
2
/mmHg,
p
< 0.001). Creation of an EGJ-M resulted in a small increase (1.6–2.3 mm
2
/mmHg,
p
< 0.01) and extension to an EP-M resulted in a larger increase (2.3–4.9 mm
2
/mmHg,
p
< 0.001). This effect was consistent, with 11 (92 %) patients experiencing a larger increase after EP-M than after EGJ-M. Fundoplication resulted in a decrease in DI and deinsufflation an increase. POEM resulted in an increase in DI (1.3 ± 1 vs. 9.2 ± 3.9 mm
2
/mmHg,
p
< 0.001). Both creation of the submucosal tunnel and performing an EGJ-M increased DI, whereas lengthening of the myotomy to an EP-M had no additional effect. POEM resulted in a larger overall increase from baseline than LHM (7.9 ± 3.5 vs. 4.7 ± 3.3 mm
2
/mmHg,
p
< 0.05).
Conclusions
During LHM, an EP-M was necessary to normalize distensibility, whereas during POEM, a myotomy confined to the EGJ complex was sufficient. In this cohort, POEM resulted in a larger overall increase in EGJ distensibility.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
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