RESUMEN
BACKGROUND: Anti-reflux operations are effective treatments for GERD. Despite standardized surgical techniques, variability in post-operative outcomes persists. Most patients with GERD possess one or more characteristics that augment their disease and may affect post-operative outcomes-a GERD "phenotype". We sought to define these phenotypes and to compare their post-operative outcomes. METHODS: We performed a retrospective review of a prospective gastroesophageal database at our institution, selecting all patients who underwent an anti-reflux procedure for GERD. Patients were grouped into different phenotypes based on the presence of four characteristics known to play a role in GERD: hiatal or paraesophageal hernia (PEH), hypotensive LES, esophageal dysmotility, delayed gastric emptying (DGE), and obesity. Patient-reported outcomes (GERD-HRQL, dysphagia, and reflux symptom index (RSI) scores) were compared across phenotypes using the Wilcoxon rank-sum test. RESULTS: 690 patients underwent an anti-reflux procedure between 2008 and 2022. Most patients underwent a Nissen fundoplication (302, 54%), followed by a Toupet or Dor fundoplication (205, 37%). Twelve distinct phenotypes emerged. Non-obese patients with normal esophageal motility, normotensive LES, no DGE, with a PEH represented the most common phenotype (134, 24%). The phenotype with the best post-operative GERD-HRQL scores at one year was defined by obesity, hypotensive LES, and PEH, while the phenotype with the worst scores was defined by obesity, ineffective motility, and PEH (1.5 ± 2.4 vs 9.8 ± 11.4, p = 0.010). There was no statistically significant difference in GERD-HRQL, dysphagia, or RSI scores between phenotypes after five years. CONCLUSIONS: We have identified distinct phenotypes based on common GERD-associated patient characteristics. With further study these phenotypes may aid surgeons in prognosticating outcomes to individual patients considering an anti-reflux procedure.
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Fundoplicación , Reflujo Gastroesofágico , Hernia Hiatal , Fenotipo , Humanos , Reflujo Gastroesofágico/cirugía , Femenino , Masculino , Fundoplicación/métodos , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del Tratamiento , Hernia Hiatal/cirugía , Hernia Hiatal/complicaciones , Adulto , Anciano , Medicina de Precisión/métodos , Trastornos de la Motilidad Esofágica/etiología , Trastornos de la Motilidad Esofágica/cirugía , Vaciamiento Gástrico , Obesidad/complicacionesRESUMEN
PURPOSE OF REVIEW: Esophagogastric junction outflow obstruction (EGJOO), defined manometrically by impaired esophagogastric junction relaxation (EGJ) with preserved peristalsis, can be artifactual, due to secondary etiologies (mechanical, medication-induced), or a true motility disorder. The purpose of this review is to go over the evolving approach to diagnosing and treating clinically relevant EGJOO. RECENT FINDINGS: Timed barium esophagram (TBE) and the functional lumen imaging probe (FLIP) are useful to identify clinically relevant EGJOO that merits lower esophageal sphincter (LES) directed therapies. There are no randomized controlled trials evaluating EJGOO treatment. Uncontrolled trials show effectiveness for pneumatic dilation and peroral endoscopic myotomy to treat confirmed EGJOO; Botox and Heller myotomy may also be considered but data for confirmed EGJOO is more limited. Diagnosis of clinically relevant idiopathic EGJOO requires symptoms, exclusion of mechanical and medication-related etiologies, and confirmation of EGJ obstruction by TBE or FLIP. Botox LES injection has limited durability, it can be used in patients who are not candidates for other treatments. PD and POEM are effective in confirmed EGJOO, Heller myotomy may also be considered but data for confirmed EGJOO is limited. Randomized controlled trials are needed to clarify optimal management of EGJOO.
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Trastornos de la Motilidad Esofágica , Unión Esofagogástrica , Manometría , Humanos , Unión Esofagogástrica/fisiopatología , Trastornos de la Motilidad Esofágica/diagnóstico , Trastornos de la Motilidad Esofágica/terapia , Trastornos de la Motilidad Esofágica/fisiopatología , Trastornos de la Motilidad Esofágica/etiología , Esfínter Esofágico Inferior/fisiopatología , Esfínter Esofágico Inferior/cirugía , Miotomía/métodosRESUMEN
OBJECTIVES: We studied high-resolution impedance manometry (HRiM) findings in dermatomyositis (DM) to detect oesophageal dysmotility, even in asymptomatic patients, and correlated the alterations to clinical and serological disease domains. METHODS: We performed a cross-sectional study of DM patients, enrolled between December 2021 and December 2022. All patients underwent rheumatological, laboratory and HRiM assessment. HRiM findings were compared with different clinical and serological profiles. RESULTS: The study population consisted of 15 DM patients (13 women and 2 men, age 54±15.2 years). The mean disease duration was 6.6 years. According to HRiM findings, three different groups of oesophageal disease severity were identified (in order of severity G0, G1 and G>1, 5 patients per group). G>1 group was significantly associated with MDA5 antibodies (80% vs. 20%, p<0.05). Interstitial lung disease (ILD) did not show any significant association with HRiM findings. However, a diffusing lung capacity for carbon oxide (DLCO) < 80% was present in 100% of G>1 (p<0.05). No associations between dysphagia, creatine kinase (CK) level, muscle weakness, skin, articular involvement and treatment were found. CONCLUSIONS: Oesophageal involvement is frequent and should be evaluated in the comprehensive work-up of DM. We used for the first time HRiM in DM, which proved to be an accurate and objective technique in assessing oesophageal disease, even in the subclinical stage. Interestingly, the MDA5-positive group had a higher burden of HRiM pathological findings, suggesting a greater severity of oesophageal involvement, often asymptomatic.
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Dermatomiositis , Trastornos de la Motilidad Esofágica , Masculino , Humanos , Femenino , Adulto , Persona de Mediana Edad , Anciano , Dermatomiositis/complicaciones , Impedancia Eléctrica , Estudios Transversales , Trastornos de la Motilidad Esofágica/etiología , Trastornos de la Motilidad Esofágica/complicaciones , Manometría/métodos , Estudios Retrospectivos , Autoanticuerpos , Helicasa Inducida por Interferón IFIH1RESUMEN
BACKGROUND AND AIMS: Peroral endoscopic myotomy (POEM) is a minimally invasive technique used to treat esophageal motility disorders. Opioid use has been demonstrated to adversely affect esophageal dysmotility and is associated with an increased prevalence of esophageal motility disorders. Our aim was to investigate the effect of narcotic use on success rates in patients undergoing POEM. METHODS: This was a single-center, retrospective study of patients undergoing POEM between February 2017 and September 2021. Primary outcomes were post-POEM Eckardt score (ES), distensibility index, and length of procedure. Secondary outcomes included technical success, myotomy length, length of stay, adverse events, reintervention rates, and postprocedure GERD. RESULTS: During the study period, 90 patients underwent POEM for treatment of esophageal dysmotility disorders. Age, sex, race, indications for POEM, and body mass index were not significant between those with or without narcotic use. There were no differences in procedure time, preprocedure ESs, or length of stay. Postprocedure ESs were higher in the group with active narcotic use compared to the group with no prior history (2.73 vs 1.2, P = .004). Distensibility indexes measured with EndoFLIP (Medtronic, Minneapolis, Minn, USA) were not different in patients using narcotics compared with opioid-naïve patients. CONCLUSION: Active narcotic use negatively affects symptom improvement after POEM for the treatment of esophageal motility disorders.
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Acalasia del Esófago , Trastornos de la Motilidad Esofágica , Miotomía , Cirugía Endoscópica por Orificios Naturales , Humanos , Acalasia del Esófago/etiología , Estudios Retrospectivos , Analgésicos Opioides/uso terapéutico , Resultado del Tratamiento , Trastornos de la Motilidad Esofágica/cirugía , Trastornos de la Motilidad Esofágica/etiología , Miotomía/métodos , Cirugía Endoscópica por Orificios Naturales/efectos adversos , Esfínter Esofágico Inferior/cirugíaRESUMEN
INTRODUCTION: Esophagogastric junction outflow obstruction (EGJOO) is an esophageal motility disorder characterized by failure of lower esophageal sphincter (LES) relaxation with preserved peristalsis. Studies have shown that Heller myotomy with Dor fundoplication (HMD) and per oral endoscopic myotomy (POEM) are effective treatments for EGJOO. However, there is paucity of data comparing the efficacy and impact of these two procedures. Therefore, the aim of this study was to compare outcomes and impact on esophageal physiology in patients undergoing HMD or POEM for primary EGJOO. METHODS: This was a retrospective review of patients who underwent either HMD or POEM for primary EGJOO at our institution between 2013 and 2021. Favorable outcome was defined as an Eckardt score ≤ 3 at 1 year after surgery. GERD-HRQL questionnaire, endoscopy, pH monitoring, and high-resolution manometry (HRM) results at baseline and 1 year after surgery were compared pre- and post-surgery and between groups. Objective GERD was defined as DeMeester score > 14.7 or LA grade C/D esophagitis. RESULTS: The final study population consisted of 52 patients who underwent HMD (n = 35) or POEM (n = 17) for EGJOO. At a mean (SD) follow-up of 24.6 (15.3) months, favorable outcome was achieved by 30 (85.7%) patients after HMD and 14 (82.4%) after POEM (p = 0.753). After HMD, there was a decrease GERD-HRQL total score (31 (22-45) to 4 (0-19); p < 0.001), and objective reflux (54.2 to 25.9%; p = 0.033). On manometry, there was a decrease in LES resting pressure (48 (34-59) to 13 (8-17); p < 0.001) and IRP (22 (17-28) to 8 (3-11); p < 0.001), but esophageal body characteristics did not change (p > 0.05). Incomplete bolus clearance improved (70% (10-90) to 10% (0-40); p = 0.010). After POEM, there was no change in the GERD-HRQL total score (p = 0.854), but objective reflux significantly increased (0 to 62%; p < 0.001). On manometry, there was a decrease in LES resting pressure (43 (30-68) to 31 (5-34); p = 0.042) and IRP (23 (18-33) to 12 (10-32); p = 0.048), DCI (1920 (1600-5500) to 0 (0-814); p = 0.035), with increased failed swallows (0% (0-30) to 100% (10-100); p = 0.032). Bolus clearance did not improve (p = 0.539). Compared to HMD, POEM had a longer esophageal myotomy length (11 (7-15)-vs-5 (5-6); p = 0.001), more objective reflux (p = 0.041), lower DCI (0 (0-814)-vs-1695 (929-3101); p = 0.004), and intact swallows (90 (70-100)-vs-0 (0-40); p = 0.006), but more failed swallows (100 (10-100); p = 0.018) and incomplete bolus clearance (90 (90-100)-vs-10 (0-40); p = 0.004). CONCLUSION: Peroral endoscopic myotomy and Heller myotomy with Dor fundoplication are equally effective at relieving EGJOO symptoms. However, POEM causes worse reflux and near complete loss of esophageal body function.
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Acalasia del Esófago , Trastornos de la Motilidad Esofágica , Reflujo Gastroesofágico , Miotomía de Heller , Cirugía Endoscópica por Orificios Naturales , Gastropatías , Humanos , Acalasia del Esófago/diagnóstico , Fundoplicación/métodos , Trastornos de la Motilidad Esofágica/etiología , Trastornos de la Motilidad Esofágica/cirugía , Esfínter Esofágico Inferior/cirugía , Reflujo Gastroesofágico/etiología , Manometría , Resultado del Tratamiento , Gastropatías/etiología , Cirugía Endoscópica por Orificios Naturales/efectos adversos , Cirugía Endoscópica por Orificios Naturales/métodos , Unión Esofagogástrica/cirugíaRESUMEN
BACKGROUND: It is thought the therapeutic benefit of per-oral endoscopic myotomy (POEM) in the treatment of esophageal dysmotility disorders is from longitudinal myotomy creation, but it is unknown if the submucosa contributes to the pathophysiology. This study investigates if submucosal tunnel (SMT) dissection alone contributes to POEM's luminal changes as measured by EndoFLIP. METHODS: A single-center, retrospective review of consecutive POEM cases from June 1, 2011 to September 1, 2022 with intraoperative luminal diameter and distensibility index (DI) data as measured by EndoFLIP. Patients with diagnoses of achalasia or esophagogastric junction outflow obstruction were grouped by those with pre-SMT and post-myotomy measurements (Group 1) and those with a third measurement post-SMT dissection (Group 2). Outcomes and EndoFLIP data were analyzed using descriptive and univariate statistics. RESULTS: There were 66 patients identified, of whom 57 (86.4%) had achalasia, 32 (48.5%) were female, and median pre-POEM Eckardt score was 7 [IQR: 6-9]. There were 42 (64%) patients in Group 1, and 24 (36%) patients in Group 2, with no differences in baseline characteristics. In Group 2, SMT dissection changed luminal diameter by 2.15 [IQR: 1.75-3.28]cm, which comprised 38% of the median 5.6 [IQR: 4.25-6.3]cm diameter of complete POEM change. Similarly, the median post-SMT change in DI of 1 [IQR: 0.5-1.2]units comprised 30% of the median 3.35 [2.4-3.98]units overall change in DI. Post-SMT diameters and DI were both significantly lower than the full POEM. CONCLUSIONS: Esophageal diameter and DI are significantly affected by SMT dissection alone, though not equaling the magnitude of diameter or DI changes from full POEM. This suggests that the submucosa does play a role in achalasia, presenting a future target for refining POEM and developing alternative treatment strategies.
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Acalasia del Esófago , Trastornos de la Motilidad Esofágica , Cirugía Endoscópica por Orificios Naturales , Humanos , Femenino , Masculino , Acalasia del Esófago/diagnóstico , Unión Esofagogástrica/cirugía , Impedancia Eléctrica , Trastornos de la Motilidad Esofágica/diagnóstico , Trastornos de la Motilidad Esofágica/etiología , Trastornos de la Motilidad Esofágica/cirugía , Resultado del Tratamiento , Esfínter Esofágico Inferior/cirugíaRESUMEN
BACKGROUND: Gastroesophageal reflux is associated with poorer outcomes after lung transplant, likely through recurrent aspiration and allograft injury. Although prior studies have demonstrated a relationship between impedance-pH results and transplant outcomes, the role of esophageal manometry in the assessment of lung transplant patients remains debated, and the impact of esophageal dysmotility on transplant outcomes is unclear. Of particular interest is ineffective esophageal motility (IEM) and its associated impact on esophageal clearance. AIM: To assess the relationship between pre-transplant IEM diagnosis and acute rejection after lung transplantation. METHODS: This was a retrospective cohort study of lung transplant recipients at a tertiary care center between 2007 and 2018. Patients with pre-transplant anti-reflux surgery were excluded. Manometric and reflux diagnoses were recorded from pre-transplant esophageal function testing. Time-to-event analysis using Cox proportional hazards model was applied to evaluate outcome of first episode of acute cellular rejection, defined histologically per International Society of Heart and Lung Transplantation guidelines. Subjects not meeting this endpoint were censored at time of post-transplant anti-reflux surgery, last clinic visit, or death. Fisher's exact test for binary variables and student's t-test for continuous variables were performed to assess for differences between groups. RESULTS: Of 184 subjects (54% men, mean age: 58, follow-up: 443 person-years) met criteria for inclusion. Interstitial pulmonary fibrosis represented the predominant pulmonary diagnosis (41%). During the follow-up period, 60 subjects (33.5%) developed acute rejection. The all-cause mortality was 16.3%. Time-to-event univariate analyses demonstrated significant association between IEM and acute rejection [hazard ratio (HR): 1.984, 95%CI: 1.03-3.30, P = 0.04], confirmed on Kaplan-Meier curve. On multivariable analysis, IEM remained independently associated with acute rejection, even after controlling for potential confounders such as the presence of acid and nonacid reflux (HR: 2.20, 95%CI: 1.18-4.11, P = 0.01). Nonacid reflux was also independently associated with acute rejection on both univariate (HR: 2.16, 95%CI: 1.26-3.72, P = 0.005) and multivariable analyses (HR: 2.10, 95%CI: 1.21-3.64, P = 0.009), adjusting for the presence of IEM. CONCLUSION: Pre-transplant IEM was associated with acute rejection after transplantation, even after controlling for acid and nonacid reflux. Esophageal motility testing may be considered in lung transplant to predict outcomes.
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Trastornos de la Motilidad Esofágica , Esofagitis Péptica , Reflujo Gastroesofágico , Trasplante de Pulmón , Masculino , Humanos , Persona de Mediana Edad , Femenino , Estudios Retrospectivos , Reflujo Gastroesofágico/complicaciones , Esofagitis Péptica/complicaciones , Trastornos de la Motilidad Esofágica/diagnóstico , Trastornos de la Motilidad Esofágica/etiología , Trasplante de Pulmón/efectos adversos , Trasplante de Pulmón/métodos , Manometría/métodos , Monitorización del pH Esofágico/efectos adversos , Monitorización del pH Esofágico/métodosAsunto(s)
Terapia por Acupuntura , Acalasia del Esófago , Trastornos de la Motilidad Esofágica , Humanos , Acalasia del Esófago/terapia , Manometría , Terapia por Acupuntura/efectos adversos , Trastornos de la Motilidad Esofágica/diagnóstico , Trastornos de la Motilidad Esofágica/etiología , Trastornos de la Motilidad Esofágica/terapiaRESUMEN
BACKGROUND: Lung transplantation (LTx) remains controversial in patients with absent peristalsis (AP) given the increased risk for gastroesophageal reflux (GER), and chronic lung allograft dysfunction. Furthermore, specific treatments to facilitate LTx in those with AP have not been widely described. Transcutaneous Electrical Stimulation (TES) has been reported to improve foregut contractility in LTx patients and therefore we hypothesize that TES may augment the esophageal motility of patients with ineffective esophageal motility (IEM). METHODS: We included 49 patients, 14 with IEM, 5 with AP, and 30 with normal motility. All subjects underwent standard high-resolution manometry and intraluminal impedance (HRIM) with additional swallows as TES was delivered. RESULTS: TES induced a universal impedance change observable in real-time by a characteristic spike activity. TES significantly augmented the contractile vigor of the esophagus measured by the distal contractile integral (DCI) in patients with IEM [median DCI (IQR) 0 (238) mmHg-cm-s off TES vs. 333 (858) mmHg-cm-s on TES; p = .01] and normal peristalsis [median DCI (IQR) 1545 (1840) mmHg-cm-s off TES vs. 2109 (2082) mmHg-cm-s on TES; p = .01]. Interestingly, TES induced measurable contractile activity (DCI > 100 mmHg-cm-s) in three out of five patients with AP [median DCI (IQR) 0 (0) mmHg-cm-s off TES vs. 0 (182) mmHg-cm-s on TES; p < .001]. CONCLUSION: TES acutely augmented contractile vigor in patients with normal and weak/ AP. The use of TES may positively impact LTx candidacy, and outcomes for patients with IEM/AP. Nevertheless, further studies are needed to determine the long-term effects of TES in this patient population.
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Trastornos de la Motilidad Esofágica , Reflujo Gastroesofágico , Estimulación Eléctrica Transcutánea del Nervio , Humanos , Trastornos de la Motilidad Esofágica/etiología , Peristaltismo/fisiología , Estimulación Eléctrica Transcutánea del Nervio/efectos adversosRESUMEN
BACKGROUND: Studies have demonstrated that non-acid reflux (NAR) is associated with esophageal squamous cell carcinoma (ESCC). Esophageal dysmotility is associated with NAR but few studies have focused on the esophageal motility of ESCC patients. We explored the relationship between ESCC, NAR and esophageal dysmotility with the aid of multichannel intraluminal impedance and pH (MII-pH) and high-resolution manometry (HRM). METHODS: From Jan 2021 to Oct 2022, 20 patients with superficial ESCC were enrolled as the ESCC group, while 20 age and gender matched individuals without gastroesophageal reflux disease (GERD) symptoms and 20 age and gender matched patients with GERD symptoms were recruited as the control groups. Patients received 24 h MII-pH and HRM procedure before endoscopic submucosal dissection (ESD), and the data were then collected to identify the type of reflux and esophageal dysmotility. RESULTS: Prevalence of esophageal dysmotility was significantly different among the three groups, 75.0% in the ESCC group, 35.0% in the non-GERD group and 70.0% in the GERD group (P = 0.029). NAR episodes at 15 cm above the lower esophageal sphincter (LES) in the ESCC group were significantly higher than that in the non-GERD group (6.5 (3.5-9.3) vs 1.0 (0.8-4.0), P = 0.001) and were similar with that in the GERD group (6.5 (3.5-9.3) vs 5.5 (3.0-10.5), P > 0.05). NAR episodes at 5 cm above LES was significantly higher in the ESCC group than that in the non-GERD group (38.0 (27.0-60.0) vs 18.0 (11.8-25.8), P = 0.001) and was significantly higher than that in the GERD group (38.0 (27.0-60.0) vs 20.0 (9.8-30.5)), P = 0.010). Prevalence of pathologic non-acid reflux was significantly different among the three groups, 30.0% in the ESCC group, 0.0% in the non-GERD group and 10.0% in the GERD group (P < 0.001). CONCLUSION: Our study found NAR and esophageal dysfunction frequently occur in ESCC patients. NAR and esophageal dysmotility may be associated with ESCC. CLINICAL TRIAL REGISTRATION NUMBER: ChiCTR2200061456.
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Trastornos de la Motilidad Esofágica , Neoplasias Esofágicas , Carcinoma de Células Escamosas de Esófago , Reflujo Gastroesofágico , Humanos , Trastornos de la Motilidad Esofágica/etiología , Trastornos de la Motilidad Esofágica/complicaciones , Monitorización del pH Esofágico , Reflujo Gastroesofágico/complicaciones , Reflujo Gastroesofágico/epidemiología , Reflujo Gastroesofágico/diagnóstico , Masculino , FemeninoRESUMEN
BACKGROUND AND AIMS: Peroral endoscopic myotomy (POEM) can successfully treat patients with achalasia. Prior therapy with Botox (Allergan, Madison, NJ, USA) injections, pneumatic dilation (PD), and/or laparoscopic Heller myotomy (LHM) is believed to increase the difficulty of POEM procedures. We aimed to determine if prior treatment methods were associated with longer procedure times or lower clinical success. METHODS: In this single-center retrospective study, consecutive patients who underwent POEM for achalasia between February 2017 and September 2021 were studied. Collected data were patient demographics, prior treatment, pre- and postprocedure Eckardt score (ES), distensibility indices (DIs), and procedure times. Primary outcomes were clinical success and procedure difficulty. RESULTS: Of 95 patients (mean age, 55.6 years; 45% women), 25 patients underwent POEM for type I achalasia, 31 for type II achalasia, and 33 for spastic esophageal pathologies. Thirty-three patients (34.7%) were treated for achalasia before POEM with onabotulinumtoxinA injections (n = 18), PD (n = 17), and LHM (n = 3). There were no significant differences in post-treatment ESs or technical success between the 2 groups (P = .98 and P = .66, respectively). Multivariate analysis showed that prior treatment was associated with decreased case time and easier tunneling during POEM. CONCLUSIONS: Prior treatment did not impact the clinical success rate of POEM and led to decreased case times and easier tunneling difficulty, likely because of persistent lower esophageal sphincter changes and differences in diagnostic indications. POEM should be considered for patients with treatment-refractory symptoms as a safe and feasible option. Further large-scale studies are needed to validate our findings.
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Acalasia del Esófago , Trastornos de la Motilidad Esofágica , Miotomía de Heller , Cirugía Endoscópica por Orificios Naturales , Humanos , Femenino , Persona de Mediana Edad , Masculino , Acalasia del Esófago/cirugía , Acalasia del Esófago/etiología , Estudios Retrospectivos , Resultado del Tratamiento , Trastornos de la Motilidad Esofágica/etiología , Trastornos de la Motilidad Esofágica/cirugía , Esfínter Esofágico Inferior/cirugía , Miotomía de Heller/métodos , Cirugía Endoscópica por Orificios Naturales/efectos adversosRESUMEN
BACKGROUND AND AIMS: Chronic narcotic use may cause opioid-induced esophageal dysfunction and associated type III achalasia, hypercontractile esophagus (HE), diffuse esophageal spasm (DES), and esophagogastric junction outflow obstruction (EGJOO). The frequency of opioid use and its impact on peroral endoscopic myotomy (POEM) in these patients is unknown. METHODS: Consecutive patients between April 2017 and September 2021 who underwent POEM for type III achalasia, EGJOO, DES, or HE with ≥6 months follow-up were identified. Baseline evaluation was done with EGD, esophageal high-resolution manometry (HRM), and functional lumen impedance planimetry (FLIP) of the esophagogastric junction (EGJ). Eckardt scores (ESs) were calculated at baseline and follow-up at 6 to 12 months after POEM for opioid users and nonusers. Clinical response was defined as ES ≤3, EGJ distensibility index >2.8 mm2/mm Hg, maximum EGJ diameter >14 mm, and integrated relaxation pressure (IRP) <15 mm Hg. Opioid use before baseline HRM was assessed. RESULTS: One hundred twenty-six patients underwent POEM, and 89 had ≥6 months of follow-up. Daily opioid use was present in 18 of 89 patients (20%). Baseline demographics, FLIP metrics, IRP, distribution of motility disorders, and POEM characteristics were similar between both groups. At 6 to 12 months after POEM, clinical response and frequency of GERD, esophagitis, and proton pump inhibitor use were similar between opioid users and nonusers. Heartburn was more frequent in the opioid group (82.4% vs 38.6%, P = .002). CONCLUSIONS: In this single-center study of 89 patients with type III achalasia, EGJOO, DES, or HE treated with POEM, daily opioid use was present in 20%. Response to POEM and post-POEM GERD were similar between opioid users and nonusers. (Clinical trial registration number: NCT02770859.).
Asunto(s)
Acalasia del Esófago , Trastornos de la Motilidad Esofágica , Reflujo Gastroesofágico , Miotomía , Cirugía Endoscópica por Orificios Naturales , Humanos , Analgésicos Opioides/uso terapéutico , Trastornos de la Motilidad Esofágica/epidemiología , Trastornos de la Motilidad Esofágica/cirugía , Trastornos de la Motilidad Esofágica/etiología , Esfínter Esofágico Inferior/cirugía , Esofagoscopía , Reflujo Gastroesofágico/epidemiología , Reflujo Gastroesofágico/etiología , Manometría , Cirugía Endoscópica por Orificios Naturales/efectos adversos , Prevalencia , Resultado del TratamientoRESUMEN
BACKGROUND/AIMS: Absent contractility is considered a disorder of peristalsis. The literature about the etiology and clinical characteristics is scarce and the evidence on systemic diseases associated with this esophageal disorder is limited. Therefore, we aimed to determine the etiology of absent contractility in our population using the clinical algorithm recently described in the literature. METHODS: We conducted a retrospective, descriptive study at a single tertiary hospital of all patients diagnosed of absent contractility between May 2018 and February 2020. Data on demographic characteristics, medication, comorbidities, and laboratory and paraclinical tests were recorded from clinical records. RESULTS: A total of 72 patients with absent contractility were included for analysis. There was a predominance of female sex (n=43, 59.7%), with a mean age of 55.4 (±15.0) years. We identified a systemic disorder associated with absent contractility in 64 (88.9%) patients. From these, 31 (43.1%) patients were diagnosed with a systemic autoimmune disease, 26 (36.1%) patients were considered to have absent contractility secondary to pathological exposure to acid-reflux and 15 (20.8%) patients were diagnosed with other non-autoimmune systemic disorders. In the remaining eight (11.1%) patients, there were no underlying systemic disorders that could justify the diagnosis of absent contractility. CONCLUSIONS: A systematic approach to search for an underlying cause in patients diagnosed with absent contractility is warranted. Up to 90% of patients with absent contractility have a systemic disorder associated with this condition.
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Trastornos de la Motilidad Esofágica , Reflujo Gastroesofágico , Humanos , Femenino , Persona de Mediana Edad , Masculino , Trastornos de la Motilidad Esofágica/diagnóstico , Trastornos de la Motilidad Esofágica/etiología , Estudios Retrospectivos , Reflujo Gastroesofágico/complicaciones , Reflujo Gastroesofágico/diagnóstico , ManometríaRESUMEN
OBJECTIVE: The gastrointestinal tract is commonly involved in patients with systemic sclerosis (SSc) with varied manifestations. As our understanding of SSc gastrointestinal disease pathogenesis and risk stratification is limited, we sought to investigate whether patterns of esophageal dysfunction associate with specific clinical phenotypes in SSc. METHODS: Patients enrolled in the Johns Hopkins Scleroderma Center Research Registry who completed high-resolution esophageal manometry (HREM) studies as part of their clinical care between 2011 and 2020 were identified. Associations between esophageal abnormalities on HREM (absent contractility [AC], ineffective esophageal motility [IEM], hypotensive lower esophageal sphincter [hypoLES]) and patient demographic information, clinical characteristics, and autoantibody profiles were examined. RESULTS: Ninety-five patients with SSc had HREM data. Sixty-five patients (68.4%) had AC (37 patients with only AC, 28 patients with AC and a hypoLES), 9 patients (9.5%) had IEM, and 11 patients (11.6%) had normal studies. AC was significantly associated with diffuse cutaneous disease (38.5% versus 10.0%; P < 0.01), more severe Raynaud's phenomenon, including digital pits, ulcers, or gangrene (56.9% versus 30.0%; P = 0.02), and reduced median diffusing capacity of lung for carbon monoxide (50.6% versus 72.2%; P = 0.03). AC was observed in most of the patients who died (13 of 14; P = 0.06). These findings were not seen in patients with IEM. CONCLUSION: Among patients with SSc, AC is associated with a significantly more severe clinical phenotype. IEM may associate with a milder phenotype. Further studies are needed to evaluate AC, IEM, and their clinical impact relative to the timing of other end-organ complications in SSc.
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Trastornos de la Motilidad Esofágica , Esclerodermia Localizada , Esclerodermia Sistémica , Enfermedades de la Piel , Humanos , Trastornos de la Motilidad Esofágica/etiología , Trastornos de la Motilidad Esofágica/complicaciones , Esclerodermia Sistémica/complicaciones , Esclerodermia Sistémica/diagnóstico , Esclerodermia Sistémica/epidemiología , Enfermedades de la Piel/complicaciones , AutoanticuerposRESUMEN
Esophageal dysmotility in esophageal atresia (EA) relates to abnormal development of esophageal innervation and musculature and to the esophageal repair. Few studies have investigated the preexisting dysmotility in EA, present prior to surgery. This systematic review aims to summarize the literature on neuronal studies in EA, to understand the causative factors for esophageal dysmotility. We performed a systematic review (PubMed, EMBASE, EBM, CINAHL databases; January 1947-February 2021) in accordance with PRISMA (PROSPERO number CRD42020171014). Fourteen studies were identified (eleven human, 187 EA patients; three animal, 64 EA rat specimens). Neural factors affecting esophageal dysmotility in human and animal studies included proteins, enzymes, growth factors, and genes, which play a role in the nervous system or neuroendocrine system, some of which have functions as neuromodulators or neurotransmitters. This systematic review has identified neural factors that affect esophageal dysmotility and contributes toward our understanding of the underlying dysmotility in patients with EA. The studies identified are important and essential for successful translation of basic science knowledge to impact clinical practice and understanding. Level of evidence: III.
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Atresia Esofágica , Trastornos de la Motilidad Esofágica , Fístula Traqueoesofágica , Humanos , Ratas , Animales , Atresia Esofágica/cirugía , Trastornos de la Motilidad Esofágica/etiología , Neuronas , Fístula Traqueoesofágica/complicacionesRESUMEN
BACKGROUND: Esophageal dysmotility is a common finding in patients being evaluated for antireflux surgery, although its implication remains unclear. We aimed to evaluate outcomes of patients with esophageal dysmotility after fundoplication. METHODS: A retrospective review of a prospective quality-database was performed. All patients who underwent laparoscopic Nissen (NF) or Toupet (TF) fundoplication were included. Esophageal dysmotility was defined using the Chicago Classification v4.0 and conventional metrics, creating three sub-groups: ineffective esophageal motility (IEM), distal/diffuse esophageal spasm (DES), and hypercontractile esophagus (HE). Quality of life (QOL) outcomes were measured by the Reflux Severity Index (RSI), Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL), and Dysphagia Scores. RESULTS: Of 487 patients included, 99 (20.3%) had esophageal dysmotility (49 IEM, 40 DES, 10 HE). While a majority in the dysmotility group (81.8%) underwent TF, most patients in the normal group (76.5%) underwent NF (p < 0.001). On multivariable analysis controlling for sex, age, BMI, hiatal hernia, and surgery type, the normal group had higher Dysphagia Scores at 3 weeks (2.2 ± 0.9 vs. 1.7 ± 0.8, p < 0.001), but not at 6-month, 1-year, 2-year, or 5-year follow-up. There were no differences between normal and dysmotility groups in terms of RSI or GERD-HRQL scores at any time point. Patients with different sub-types of esophageal dysmotility had similar QOL outcomes at all time points. CONCLUSION: Patients with esophageal dysmotility had similar outcomes compared to those with normal motility after fundoplication, suggesting the tailored approach favoring partial fundoplication for patients with dysmotility as part of an appropriate treatment algorithm.
Asunto(s)
Trastornos de Deglución , Trastornos de la Motilidad Esofágica , Reflujo Gastroesofágico , Laparoscopía , Humanos , Recién Nacido , Fundoplicación/efectos adversos , Calidad de Vida , Trastornos de Deglución/etiología , Estudios Prospectivos , Manometría , Trastornos de la Motilidad Esofágica/etiología , Trastornos de la Motilidad Esofágica/cirugía , Reflujo Gastroesofágico/complicaciones , Reflujo Gastroesofágico/cirugía , Laparoscopía/efectos adversos , Resultado del TratamientoRESUMEN
BACKGROUND AND AIMS: No recommendation regarding antibiotic prophylaxis and preparation modalities are available for patients with esophageal motor disorders who benefit from Per-Oral Endoscopic Myotomy (POEM). The aim of our study was to evaluate their impact on the POEM's safety. PATIENTS AND METHODS: This study was a comparative and multicentric retrospective analysis of a database prospectively collected. Patients over 18 years old with esophageal motor disorders confirmed by prior manometry, who underwent POEM were included. The primary endpoint was the occurrence of adverse events, as classified by Cotton, based on whether or not antibiotic prophylaxis was administered. RESULTS: A total of 226 patients (median age 52.9 ± 19.12 years [18-105], 116 women [51.3%]) were included. The indication for POEM was mainly type 2 achalasia (n = 135, 60.3%). Antibiotic prophylaxis was administered to 170 patients (75.2%) during 3.93 ± 3.46 days [1-21]. The overall adverse events rate was 9.3% (n = 21). Antibiotic prophylaxis was associated with the occurrence of adverse events (p = .003), but had no impact on their severity (p = .238). Antibiotic prophylaxis didn't influence the effectiveness of POEM (1 [0-4] vs 1 [0-9], p = .231). The use of a liquid diet in the 48 h prior to the procedure was significantly associated with a lower adverse events rate (3.1% vs 6.19%, p = .0002). CONCLUSION: The antibiotic prophylaxis during POEM does not prevent adverse events, had no impact on their severity and the efficacy of the procedure. A liquid diet before the procedure should be systematically proposed.
Asunto(s)
Acalasia del Esófago , Trastornos de la Motilidad Esofágica , Trastornos Motores , Miotomía , Cirugía Endoscópica por Orificios Naturales , Humanos , Femenino , Adulto , Persona de Mediana Edad , Anciano , Adolescente , Estudios Retrospectivos , Cirugía Endoscópica por Orificios Naturales/efectos adversos , Trastornos Motores/etiología , Resultado del Tratamiento , Trastornos de la Motilidad Esofágica/cirugía , Trastornos de la Motilidad Esofágica/etiología , Miotomía/métodos , Esfínter Esofágico Inferior/cirugíaRESUMEN
OBJECTIVES: Patients with esophageal motility disorders (EMDs) including achalasia after gastric surgery have not been thoroughly characterized. Furthermore, the efficacy of peroral endoscopic myotomy (POEM) in this population should be clarified. METHODS: In this retrospective multicenter study of 3707 patients with EMDs, 31 patients (0.8%) had a history of gastric surgery. Patient characteristics and POEM efficacy were compared between patients with and without previous gastric surgery. RESULTS: In patients with EMD after gastric surgery, age at EMD diagnosis was higher (72.0 years), male sex was predominant (90.3%), and the American Society of Anesthesiologists physical status score was higher (≥II, 48.4%). High-resolution manometry (HRM) findings did not reveal significant differences. In patients who underwent gastric surgery, atrophic gastritis was common (80.6%), and gastric cancer was the primary surgical indication (32.3%). Distal gastrectomy was performed in 28 patients (90.3%). POEM was effective (3.3% adverse events; 100% treatment success). The incidence rates of reflux esophagitis (RE) and symptomatic gastroesophageal reflux disease (GERD) were 60.0% and 16.7%, respectively, without significant intergroup differences, and severe RE was not observed in the long-term follow-up. Extended gastric myotomy was a risk factor for RE. CONCLUSION: Patients with gastric surgery often present severe disease manifestations; the surgical indication is mainly gastric cancer. HRM findings can be similarly used for diagnosis in patients with and without gastric surgery. POEM maintains safety and efficacy with acceptable RE and symptomatic GERD rates. To prevent RE, extended myotomy should be avoided.
Asunto(s)
Acalasia del Esófago , Trastornos de la Motilidad Esofágica , Reflujo Gastroesofágico , Miotomía , Cirugía Endoscópica por Orificios Naturales , Neoplasias Gástricas , Humanos , Masculino , Anciano , Acalasia del Esófago/cirugía , Acalasia del Esófago/complicaciones , Neoplasias Gástricas/complicaciones , Japón/epidemiología , Cirugía Endoscópica por Orificios Naturales/efectos adversos , Trastornos de la Motilidad Esofágica/etiología , Trastornos de la Motilidad Esofágica/cirugía , Reflujo Gastroesofágico/etiología , Resultado del Tratamiento , Esfínter Esofágico Inferior/cirugíaRESUMEN
BACKGROUND AND AIMS: The etiology of chest pain in achalasia-related esophageal motility disorders and the frequency and risk factors of persistent chest pain after peroral endoscopic myotomy (POEM) remain unclear. METHODS: A multicenter cohort study including 14 hospitals was conducted to elucidate the characteristics of patients with chest pain and the efficacy of POEM. RESULTS: Consecutive cases of achalasia-related esophageal motility disorders included 2294 (64.2%) and 1280 (35.8%) patients with and without chest pain, respectively. Among the 2107 patients with chest pain who underwent POEM, we observed complete remission in 1464 patients (69.5%) and nonremission in 643 patients (30.5%), including a partial response in 619 patients (29.4%) and resistance in 24 patients (1.1%). Multivariate analysis revealed that advanced age (odds ratio [OR], .28), male sex (OR, .70), prior treatment (OR, 1.39), and sigmoid type (OR, .65) were related to the prevalence of chest pain. Long disease duration (OR, .69) and esophageal dilation (OR, .79) were related to decreased severity. POEM improved patients' quality of life that was hindered by chest pain. Early onset (OR, 1.45), advanced age (OR, .58), male sex (OR, .79), prior treatment (OR, 1.37), and posterior myotomy (OR, 1.42) were associated with nonremission after POEM; high-resolution manometry (HRM) findings and myotomy length showed no statistical significance on pain etiology and persistence after POEM. CONCLUSIONS: The prevalence and severity of chest pain were dependent on age, sex, disease duration, prior treatment, and esophageal morphology rather than HRM findings. The efficacy of POEM is satisfactory; however, residual pain was often observed. Excessively long myotomy can be avoided, and anterior myotomy may be recommended.
Asunto(s)
Acalasia del Esófago , Trastornos de la Motilidad Esofágica , Miotomía , Cirugía Endoscópica por Orificios Naturales , Dolor en el Pecho/epidemiología , Dolor en el Pecho/etiología , Estudios de Cohortes , Acalasia del Esófago/etiología , Acalasia del Esófago/cirugía , Trastornos de la Motilidad Esofágica/epidemiología , Trastornos de la Motilidad Esofágica/etiología , Esfínter Esofágico Inferior/cirugía , Humanos , Japón/epidemiología , Masculino , Manometría/métodos , Miotomía/efectos adversos , Miotomía/métodos , Cirugía Endoscópica por Orificios Naturales/efectos adversos , Cirugía Endoscópica por Orificios Naturales/métodos , Calidad de Vida , Resultado del TratamientoRESUMEN
Esophageal motility disorders (EMD) may be considered primary disorders only in the absence of gastroesophageal reflux disease (GERD). If GERD is present, treatment should be directed toward correction of the abnormal reflux. The actual prevalence of GERD in manometric dysmotility patterns according to the new Chicago Classification 4.0 (CC4) is still elusive. This study aims to evaluate the prevalence of GERD in patients with esophageal motility disorders according to the CC4. We reviewed 400 consecutive patients that underwent esophageal manometry and pH monitoring. Esophageal motility was classified according to the CC4 and GERD + was defined by a DeMeester score > 14.7. Normal motility or unclassified dysmotility was present in 290 (73%) patients, with GERD+ in 184 of them (63%). There were a total of 110 patients (27%) with named esophageal motility disorders, with GERD+ in 67 (61%). The incidence of ineffective esophageal motility was 59% (n = 65) with 69% GERD +, diffuse esophageal spasm was 40% (n = 44) with 48% GERD +, and hypercontractile esophagus was 0.01% (n = 1) with 100% GERD +. There was no correlation between the presence of GERD and the number of non-peristaltic swallows. Our results show that: (i) manometry only is not enough to select patients' treatment as >60% of patients with named esophageal motility disorders have GERD; (ii) there was no correlation between the presence of GERD and the number of non-peristaltic swallows.