Gamma-aminobutyric acid receptor type B agonist baclofen inhibits acid-induced excitation of secondary peristalsis but not heartburn sensation.

BACKGROUND AND AIM: Acute esophageal acid infusion promotes distension-induced secondary peristalsis. The gamma-aminobutyric acid receptor type B (GABA-B) receptors activation inhibits secondary peristalsis. This study aimed to test the hypothesis whether acid excitation of secondary peristalsis can be influenced by baclofen. METHODS: Secondary peristalsis was performed with intra-esophageal slow and rapid air injections in 13 healthy subjects. Direct esophageal infusion of 0.1 N HCl following pretreatment with placebo or baclofen was randomly performed at least 1 week apart. Symptom intensity, distension thresholds, and peristaltic parameters were determined and compared between each study protocol. RESULTS: The intensity of heartburn symptom in response to esophageal acid infusion was significantly greater with baclofen than the placebo (P = 0.002). The threshold volume of secondary peristalsis during slow air injections in response to acid infusion was significantly greater with baclofen than the placebo (P = 0.001). Baclofen significantly increased the threshold volume of secondary peristalsis during rapid air injections in response to acid infusion (P = 0.001). The frequency of secondary peristalsis in response to acid infusion was significantly decreased by baclofen as compared with the placebo (P = 0.001). Baclofen significantly decreased peristaltic amplitudes in response to acid infusion during rapid air injections (P = 0.007). CONCLUSIONS: Gamma-aminobutyric acid receptor type B agonist baclofen inhibits acid excitation of secondary peristalsis in human esophagus, which is probably mediated by both muscular and mucosal mechanoreceptors. This work supports the evidence of potential involvement of GABA-B receptors in negative modulation of acid excitation of esophageal perception as well as secondary peristalsis.

Characterization of esophageal motility following esophageal atresia repair using high-resolution esophageal manometry.

BACKGROUND: Esophageal dysmotility, a considerable issue following esophageal atresia (EA) repair, has been reported but has not been precisely described and characterized. Using high-resolution esophageal manometry (HREM), we characterized the esophageal motility patterns in children with repaired EA and compared these patterns of dysmotility with symptomatology. METHODS: HREM was performed as an outpatient procedure in patients with repaired EA. The tracings were analyzed using the software provided by the company and were then reviewed visually. Charts were reviewed for medical/surgical histories and symptoms were assessed by a standardized questionnaire. RESULTS: Forty patients (25 boys, 15 girls) with a median age of 8 years (11 months-18 years) underwent an HREM. Thirty-five patients had type C EA and 5 had type A EA. Only 7 patients were asymptomatic at the time of the examination. HREM results were abnormal in all of the patients. Three different esophageal motility patterns were derived from HREM tracing analysis: aperistalsis (15 patients, 38%), pressurization (6 patients, 15%), and distal contractions (19 patients, 47%). Distal contractions pattern was found exclusively in type C EA. Dysphagia was encountered in the 3 groups. Gastroesophageal reflux disease-related symptoms predominated in the aperistalsis group. CONCLUSIONS: HREM improves our understanding and allows precise characterization of esophageal dysmotility in patients who have undergone EA repair.

[The effect of Nissen-Rossetti fundoplication on the motor function of swallowing in patients with reflux diseases]. / Wplyw fundoplikacji Nissena-Rossettiego na czynnosc motoryczna przelyku u chorych z choroba refluksowa.

This prospective study was undertaken to assess the motility of the middle and lower esophagus and LES resting pressure changes following the N-R fundoplication for GER. The study was carried out in 53 consecutive patients (37 women, 16 men, median age 49.1 +/- 6.2 years), operated due to antireflux mechanism insufficiency. Threefold solid state for manometry and double channel for pH metry catheters in the body of the esophagus were used before and after the operation (median follow up time was 18 months). The LES length and resting pressure were evaluated with Synectics On-line interface. The objective results obtained during 24-h pH metry and manometry were shown as median and standard deviation, with statistical significances determined using the SPSS/PC+ packet (p < 0.05 considered as significant). The individual patients' data were analyzed by Synectics software. 24-h pH metry confirmed that Nissen-Rossetti fundoplication efficaciously reduced pathological GER (significant decrease of DeMeester score from 105.6 +/- 12.2 to 5.2 +/- 3.4, p < 0.0002). Manometry proved the increase of the LES resting pressure from 7.6 +/- 3.2 to 18.2 +/- 4.2, p < 0.0005, and its total length from 3.1 +/- 0.8 to 4.2 +/- 1.0, p < 0.01. The improvement of the esophageal body peristalsis was found first of all in total period. Motility changes following N-R fundoplication during the reflux period were unsatisfactory. The frequency of peristalic contractions with higher amplitude and longer duration significantly increased after the operation in total period in all levels. The increase of the complete peristaltic contractions following N-R fundoplication was high significant from 22.15% to 60.21%, p < 0.0001. Although significant improvement of the efficacy of esophageal peristalis was observed, however it was still under 50% of normal level all the time (15.4% v. 41.7%, p < 0.002). The most impressive improvement of esophageal peristalis was noticed in the lower part of the esophagus. The increase of the complete peristaltic contractions during the reflux period was observed only in upright position. Least profitable changes in esophageal body motility were noticed during the reflux period in supine position. In comparison with the total period manometry results the efficacy of the esophageal perystalsis during the reflux period was defected before as well as after the operation, (11.2% v. 22.5%, p = NS).

Repair of complete longitudinal esophageal rupture with preservation of esophageal motility.

There is no consensus on the ideal treatment for esophageal perforation and on the maximal extent of esophageal disruption amenable to primary repair. The effect of extensive esophageal injury on postoperative esophageal motility is also unknown. We report the case of a longitudinal iatrogenic esophageal laceration extending from the hypopharynx to the cardia in a morbidly obese patient treated with primary repair. The patient exhibited no postoperative esophageal leak or stricture and maintained a preserved esophageal peristalsis on manometry at 3 months. An extensively lacerated esophagus can be repaired primarily while maintaining a normal postoperative function.

Custom dynamic stent for esophageal strictures in children.

BACKGROUND: Esophageal stenting represents a new strategy to avoid multiple dilations owing to stenosis relapse. Our custom stent improves esophageal motility unlike the widespread self-expandable plastic esophageal stents. The aim of the study was to confirm the efficacy of treatment with silicone custom stents in esophageal stenosis (ES) in pediatric patients. METHODS: A silicone stent of 7-, 9-, or 12.7-mm external diameter is built coaxially on a nasogastric tube that guarantees the correct position. The 2 ends are tailored to allow food passage between stent and esophageal wall. All patients received dexamethasone (2 mg/kg per day) for 3 days and ranitidine/proton-pump inhibitors. Study approval was obtained from our ethical board. RESULTS: From 1988 to 2010, 79 patients with ES, mean age 35.4 months (3-125 months), underwent esophageal hydrostatic/Savary dilations and custom-stent placement, left in place for at least 40 days. Stenting was effective in 70 (88.6%) of 79 patients. Fifty percent of the patients with effective treatment received only one dilation for stent placement. Fourteen patients received more stents successfully. There was one stent-related major complication. CONCLUSION: Our custom stent improves treatment in ES. In caustic injuries, ES stenting represents the first option. In postsurgical ES, we stent after at least 5 dilations.

Motility differences in free colon and free jejunum flaps for reconstruction of the cervical esophagus.

BACKGROUND: Free colon and jejunal flaps have been described as reliable and safe conduits for pharyngoesophageal reconstruction. Compared with free colon flaps, free jejunum flaps have a smaller diameter and intrinsic peristaltic movement, both of which are considered possible causes of dysphagia. In this investigation, the authors evaluated motility differences in free jejunum and colon flaps using radionuclide esophageal scintigraphy. METHODS: Patients who received free jejunum flaps (n = 12) or free colon (n = 1) or ileocolon flaps (n = 13) for reconstruction after pharyngoesophagectomy for cancer were included. Radionuclide esophageal scintigraphy was performed using technetium-99m-labeled sulfur colloid. Transit rate was evaluated at 1 second (pharyngeal or initial clearance) and 10 seconds (esophageal or clearance throughout). Clinical progression of swallowing was recorded postoperatively. Statistical analysis was performed using the t test. RESULTS: Mean pharyngeal clearance was 61 +/- 20 percent for free colon and ileocolon flaps and 70 +/- 16 percent for free jejunum flaps. Mean esophageal clearance was 50 +/- 27 percent for free colon and ileocolon flaps and 69 +/- 17 percent for free jejunum flaps. Esophageal transit rate was significantly shorter in patients who underwent reconstruction with free jejunum flaps (p = 0.04). At 1 year, 10 of 12 free jejunum patients and eight of 14 patients were tolerating solid foods. CONCLUSIONS: Although neither flap showed normal swallowing characteristics, free jejunum flaps displayed greater esophageal clearance and should represent the first choice in hypopharyngeal reconstruction. Free colon and ileocolon flaps should be reserved for very proximal oropharyngeal defects and when simultaneous voice reconstruction is desired.

Naturally occurring fruit juices dislodge meat bolus obstruction in vitro.

Oesophageal meat bolus obstruction is often removed endoscopically/surgically with attendant morbidity and mortality. Anecdotal evidence suggests that fruit juices' enzymes may dissolve meat boluses. To assess this, an in vitro study was carried out. Cooked chicken was tightly packed between 10 and 8 mL markers of 80, 10 mL syringes. Two millilitres of fresh juice from lemons, papaya, kiwi fruits, pineapples, frozen and then thawed pineapple juice, processed pineapple juice, Coca-Cola and saliva were added to 10 syringes each. By 4 h, the meat boluses significantly moved in the pineapple juice both fresh and frozen and kiwi juice groups (P < 0.001), little movement in the Coca-Cola group (P < 0.05), and no movement in the saliva, processed pineapple juice, lemon juice and papaya groups. In conclusion, pineapples and kiwi fruits contain enzymes which can dislodge meat boluses. Freezing does not denature the enzyme and provides a convenient way of storing the juice.

Hot water swallows improve symptoms and accelerate esophageal clearance in esophageal motility disorders.

Cold liquid ingestion may precipitate episodes of dysphagia and chest pain in patients with spastic esophageal motility disorders. The effect of hot liquids on esophageal symptoms, esophageal peristalsis, and clearance and any potential therapeutic benefit in such patients has not been examined. Using esophageal scintigraphy and manometry, we have investigated the effects of hot water swallows on dysphagia, chest pain, and esophageal motility and clearance in patients with esophageal motility disorders. We studied 48 men and women with intermittent dysphagia to both solids and liquids, chest pain, and/or regurgitation. All patients underwent upper endoscopy, barium swallow, and esophageal manometry using standard techniques. Esophageal scintigraphy assessed esophageal transit time (ETT) and retrograde intraesophageal movement of bolus at baseline (22 degrees C) and after hot (60 degrees C) water swallows. Esophageal manometry assessed the amplitude and duration of esophageal contractions in response to baseline and hot water swallows. Patients were followed clinically for as long as 6 months to assess symptomatic response. We found that baseline esophageal scintigraphy revealed a mean ETT of 48.5 seconds; after hot water swallow, mean ETT was 27.8 seconds (p < 0.001). The number of secondary peaks at baseline was 3.5; after hot water swallow, it was 2.1 (p < 0.001). Baseline esophageal manometry showed a mean esophageal body contraction amplitude of 188 mm Hg (mean duration, 11.8 seconds) in response to wet swallows and 125 mm Hg (mean duration, 5.7 seconds) with hot water swallows (p < 0.001). Clinically, 28 (58%) of 48 patients noted significant (>50%) improvement of their symptoms and have been ingesting hot water or other hot liquids regularly with their meals. We conclude that hot water accelerates esophageal clearance, decreases the amplitude and duration of esophageal body contractions, and improves symptoms in patients with esophageal motility disorders. Because of its safety and simplicity, it may have an important role in the management of these chronic conditions.

De-epithelialization for esophageal cyst by video-assisted thoracoscopic surgery monitored by esophagoscopy.

In a 26-year-old male a congenital esophageal cyst was de-epithelialized using electro-cauterization via video-assisted thoracoscopic surgery (VATS) together with esophagoscopy. As the cyst adhered firmly to the esophageal muscle layer and mucosa, partial excision of the cyst and burning up of the cystic mucosa by electro-cauterization was performed to prevent esophageal mucosal perforation and postoperative esophageal dysmotility. Intraoperative video esophagoscopic monitoring enabled esophageal mucosal perforation to be avoided. Postoperative barium esophagography revealed good esophageal motility, and the patient showed no symptoms of esophageal dysmotility. We conclude that de-epithelialization for congenital esophageal cysts using VATS together with esophagoscopy is a minimally damaging and reasonable curative procedure without postoperative complications.

Medical treatment of gastroesophageal reflux disease does not prevent the development of Barrett's metaplasia and poor esophageal body motility.

OBJECTIVE: Duodenal contents refluxing into the esophagus may be involved in the pathophysiology of gastroesophageal reflux disease (GERD). This study was performed to investigate whether medical treatment of GERD aimed at suppression of gastric acid production can prevent the development of complications, such as Barrett's metaplasia or poor esophageal body motility. DESIGN: Retrospective study. SETTING: University hospital. PATIENTS: 138 GERD patients were analyzed regarding the development of Barrett's metaplasia or poor esophageal body motility, despite intermittent or continuous treatment with H2 blockers or omeprazole. MAIN OUTCOME MEASURES: The rate of patients with Barrett's metaplasia or poor esophageal body motility with or without effective medical treatment. RESULTS: Barrett's metaplasia was found in 33.8% of patients receiving medical treatment, although it was not present when treatment was induced. This rate was 21.9% among patients who were not receiving therapy (not significant). In all, 41.9% of patients with medication had impaired esophageal body motility compared with 59.3% of patients not receiving treatment (P < 0.05), but these patients had a significantly shorter history of GERD. CONCLUSIONS: Medical treatment with H2 blockers or omeprazole does not prevent the development of Barrett's metaplasia or poor esophageal body motility.