Discussing the influence of electrode location in the result of esophageal prolonged pH monitoring.

BACKGROUND: There is a large consensus to preserve the distance of 5 cm above the proximal border of the lower esophageal sphincter (PBLES) as appropriate to the location of the electrode of the pH-metry. The main objective of this study is to determine whether placement of the electrode below the recommended location achieves a significant difference in the calculation of the DeMeester score. METHODS: The study was made up of 60 GERD patients and 20 control subjects. They were submitted to esophageal manometry and to pH-metric examination with two pH-metric catheters contained antimony electrodes - the distal was positioned 3 cm above the PBLES, leaving the other 5 cm away from it. RESULTS: LES pressure (LESP) in the GERD group was significantly lower than in the control group (P = 0.005). Normal mean DeMeester score was observed simultaneously in the control group, by both the electrodes, but abnormal DeMeester score was much more expressive when observed by the distal electrode in the GERD group. There were significant differences as for DeMeester score, of patients with GERD from that of the control group and of distal from the proximal electrode in the GERD group. CONCLUSIONS: Acid reflux is directly related to lower levels of LESP. Lower location of the catheter may strongly affect the results of prolonged esophageal pH monitoring in GERD patients.

Post-operative giant hiatal hernia: A single center experience.

To verify the results of the treatment of post-operative giant hiatal hernia (POGH).The POGH becomes each time more frequent after surgical treatment of the gastroesophageal reflux.Fifteen patients (6 females and 9 males; 43.66 ±â€Š5.05 years old; BMI 22.13 ±â€Š1.92) were referred to our Service, for surgical treatment of a type III POGH 30.4 ±â€Š1.76 months after treatment of gastroesophageal reflux disease. The need for a reoperation was determined mainly by dysphagia.Reoperation was completed laparoscopically in all patients and the mean postoperative hospital stay was 3.2 ±â€Š1.2 days (range, 1-6 days). Mortality was 0% and there were not postoperative complications. They became asymptomatic along follow-up of 2.86 ±â€Š1.40 years. Around 1 year from the procedure, patients were submitted to control exams and barium esophagogram revealed well positioned esophago-gastric junction and signs of intact fundoplicature, the same observation having been done at esophageal endoscopy. Esophageal manometry showed preserved peristaltism, increase of resting pressure and extension of the intra-abdominal LES and significant raise of amplitude of deglutition waves at distal third of the esophagus. No reflux was observed at post-operative 24-hour pH testing.The corrective surgery of POGH can often be completed laparoscopically in experienced hands. Successful results can be obtained performing reduction of the hernia, sac excision, crural repair, anti-reflux procedure and long anterior gastropexy.

Results of pneumatic dilation in treating achalasia: predictive factors.

Forced pneumatic dilatation (PD) of the cardia is one of the most consecrated therapeutic measures for esophageal achalasia. The procedure only achieved better standardization with the appearance of the Rigiflex balloon. Results and predictive factors of success and failure of PD are reviewed, right after the description of the main technical aspects of the procedure. The success rates, providing control of dysphagia for about 1 year from the procedure using the Rigiflex balloon, are quite satisfactory, with success in more than 75% of patients. It is generally observed that good responses sustained for more than 5 years appear in at least 40% of cases. However, approximately half of the patients submitted to PD require additional dilation and a subgroup of them will undergo surgical treatment to attain adequate control of dysphagia. PD is a method with a low rate of acute complications, with esophageal perforation, the most severe of them, not affecting more than 5% of the cases. The best results could be potentially obtained when predictive factors of success were considered before choosing PD as a therapeutic option, but prospective studies in this field are missing until now.

COLONOSCOPY: RANDOMIZED COMPARATIVE STUDY OF INSUFFLATION WITH CARBON DIOXIDE VERSUS AIR.

BACKGROUND: In Brazil, an increasing number of people are submitted to colonoscopy, either for screening or for therapeutic purposes. AIM: To evaluate whether there are advantages of using carbon dioxide (CO2) over air for insufflation. METHODS: Two hundred and ten of 219 patients were considered eligible for this study and were randomized into two groups according to the gas insufflation used: Air Group (n=104) and CO2 Group (n=97). The study employed a double-blind design. RESULTS: The Air and CO2 Groups were similar in respect to bowel preparation evaluated using the Boston scale, age, gender, previous surgery, maneuvers necessary for the advancement of the device, and presence of polyps, tumors or signs of diverticulitis. However, "waking up with pain" and "pain at discharge" were more prevalent in the Air Group, albeit not statistically significant, with post-exam bloating seen only in the Air Group. The responses to a questionnaire, applied to analyze the late post-exam period, showed more comfort with the use of CO2. CONCLUSIONS: The use of CO2 is better than air as it avoids post-examination bloating, thereby providing greater comfort to patients.

LAPAROENDOSCOPIC TRANSGASTRIC RESECTION OF SUBEPITHELIAL JUXTACARDIAC TUMORS.

BACKGROUND: With a prevalence of 0.4-3.5%, subepithelial lesions of the upper digestive tract are discovered during endoscopic procedures. Treatment depends on etiological and pathophysiological information, ability to diagnose and the different technical resources available. AIM: To demonstrate the effectiveness of a surgical technique that combines endoscopy and videolaparoscopy in the transgastric resection of subepithelial juxtacardic lesions. METHOD: The patients were assisted with a technical combination between endoscopy and laparoscopy. After diagnosis of subepithelial tumor, intraoperative endoscopy was performed after pneumoperitoneum and placement of laparoscopic tweezers. Through endoscopy, the following steps were performed: demarcation of surgical margins, visualization of the intragastric image for the laparoscopic procedure and removal of the surgical specimen. By laparoscopy the following steps were performed: intragastric intra-abdominal access, resection of the part and closure of the gaps. RESULTS: This technique was applied in two cases in order to evaluate its initial results. There were two videolaparoendoscopic resections of juxtacardiac gastric tumors of the posterior wall. Both had their endoscopic diagnosis confirmed. After laparoendoscopic and tomographic and/or ecoendoscopic diagnostic complementation and preoperative performance, the laparoendoscopic procedure was indicated. The patients had a good recovery, with a short hospitalization time and no complications. CONCLUSION: The combined use of videolaparoscopy and endoscopy is a safe and effective technique for transgastric resection of juxtacardiac subepithelial lesions. It may be important for definitive diagnosis of the tumor.

Esophagectomy for end-stage achalasia.

End-stage achalasia is rarely effectively addressed with conservative treatments, as food must traverse a serpiginous route to reach the stomach. Botox injections in the setting of end-stage achalasia will likely provide minimal temporary palliation at best, pneumatic dilation has higher risks of perforation, and laparoscopic myotomy, while minimally invasive, has presented poor results. Under these circumstances, there are many proposed procedures to restore a viable alimentary condition to patients, from partial to subtotal resection of the esophagus; each of procedures confers both advantages and specific risks. Subtotal esophagectomy must be indicated for end-stage disease (tortuous or sigmoid esophagus) and persistent dysphagia after failed interventions. When performed by experienced hands, the procedure can be undertaken successfully, with acceptable postoperative morbidity and mortality, improvement of symptoms, and a good long-term quality of life in the majority of patients.

Simultaneous bilimetry and pHmetry in GERD and Barrett's patients.

BACKGROUND/AIMS: Despite the progressive development of technology and better knowledge of physiopathology, GERD diagnosis remains a medical problem. The aim of the study is to verify whether the measurement of bile reflux can increase the diagnostic accuracy of GERD. METHODOLOGY: 6 healthy volunteers adhered to a standard protocol, 11 Barrett's patients and 15 GERD patients (endoscopic erosive esophagitis) were fasted for 6 h before any examinations and the patients ceased acid suppression medications 72 h earlier. Manometric study was performed to localize the LES. Then The Bilitec 2000 fiberoptic probe (Synectics, Medtronics) and an antimony pH probe attached to a Digitrapper Mark III pH recorder (Synectics, Medtronics), together, were inserted through the nostril and positioned 5cm above the LES. They received an uncolored diet and after around 24 h, both Bilitec and pH data were downloaded simultaneously to a personal computer for analysis, using the Synectics software. Absorbance threshold was set at 0.14 absorbance units and acceptable esophageal pH at 4, to verify fraction of time of bile reflux (absorbance > 0.14) and DeMeester score. RESULTS: Except controls, in whom DeMeester and Johnson scoring and fraction time of absorbance were always normal, all patterns of combined results were observed in GERD and Barrett's patients, showing possibilities of "normal" pHmetry in patients with detectable bile reflux, normal fraction time of absorbance with pathologic pH recording and both normal in GERD (40%) and Barrett's patients (only 18%). CONCLUSIONS: This study showed that Bilitec measurements combined with 24-hour monitoring of intraluminal pH can offer other diagnostic and screening contributions in GERD and Barrett's patients, but cases of normal pHmetry and spectrophotometry demonstrate that none is definitive in characterization of reflux.

[Recommended diet for reflux spectrophotometry]. / Orientação de dieta para realização da espectrofotometria do refluxo.

BACKGROUND: The spectrophotometric probe, which uses bilirubin as a marker for the detection of duodenoesophagic reflux is subject to interference from strongly colored foods, which can cause erroneously high bilirubin absorbance readings. To overcome this problem it is necessary to ingest a diet that is free from such substances. OBJECTIVE: To test the absorbance of 48 different food substances in an in vitro environment. MATERIAL AND METHOD: Dry foods were blended with water or milk and non-dry solid foods were blended undiluted. It was utilized the proper calibration recipient to test them. RESULTS: The absorbance of weakly colored foods was usually lesser than the commonly accepted threshold of 0.14, and the absorbance of strongly colored foods was usually above this. Thirty-two from the 48 substances tested are suitable when the absorbance threshold is set at 0.14, but scrambled eggs, lacteous flour mush, green beans, beetroot, carrot, chayote, squash, "baroa" potato, boiled corn, orange, cashew, purple grape, avocado, mango, papaya and peach can alter the results and must be avoided. CONCLUSION: From the foods evaluated, enough are suitable at the 0.14 threshold to enable a suitable diet to be constructed for most patients during Bilitec studies.

Surgical treatment of the non-complicated gastroesophageal reflux: fundoplication without division of the short gastric vessels.

BACKGROUND: There is today a significant greater number of laparoscopic antireflux procedures for the surgical treatment of gastroesophageal reflux disease and there are yet controversies about the necessity of division of the short gastric vessels and full mobilization of the gastric fundus to perform an adequate fundoplication. AIM: To verify the results of the surgical treatment of non-complicated gastroesophageal reflux disease performing Rossetti modification of the Nissen fundoplication. Patients and Methods - Fourteen patients were operated consecutively and prospectively (mean age 44.07 years); all had erosive esophagitis without Barrett's endoscopic signals (grade 3, Savary-Miller) and they were submitted to the Rossetti modification of the Nissen fundoplication. Endoscopy, esophageal manometry and pHmetry were performed before the procedure and around 18 months postoperatively. RESULTS: There was no morbidity, transient dysphagia average was 18.42 days; there was no register of dehiscence or displacement of the fundoplication and only one patient revealed a light esophagitis at postoperative endoscopy; the others presented a normal endoscopic view of the distal esophagus. All noticed a marked improvement of preoperative symptoms. Lower esophageal sphincter pressure changed from 5.82 mm Hg (preoperative mean) to 12 mm Hg (postoperative mean); lower esophageal sphincter relaxing pressure, from 0.38 mm Hg to 5.24 mm Hg and DeMeester score, from 16.75 to 0.8. CONCLUSION: Rossetti procedure (fundoplication without division of the short gastric vessels) is an effective surgical method to treat gastroesophageal reflux disease.

Surgical treatments for esophageal cancers.

The following, from the 12th OESO World Conference: Cancers of the Esophagus, includes commentaries on the role of the nurse in preparation of esophageal resection (ER); the management of patients who develop high-grade dysplasia after having undergone Nissen fundoplication; the trajectory of care for the patient with esophageal cancer; the influence of the site of tumor in the choice of treatment; the best location for esophagogastrostomy; management of chylous leak after esophagectomy; the optimal approach to manage thoracic esophageal leak after esophagectomy; the choice for operational approach in surgery of cardioesophageal crossing; the advantages of robot esophagectomy; the place of open esophagectomy; the advantages of esophagectomy compared to definitive chemoradiotherapy; the pathologist report in the resected specimen; the best way to manage patients with unsuspected positive microscopic margin after ER; enhanced recovery after surgery for ER: expedited care protocols; and long-term quality of life in patients following esophagectomy.

Causes and treatments of achalasia, and primary disorders of the esophageal body.

The following on achalasia and disorders of the esophageal body includes commentaries on controversies regarding whether patients with complete lower esophageal sphincter (LES) relaxation can be considered to exhibit early achalasia; the roles of different mucle components of the LES in achalasia; sensory neural pathways impaired in achalasia; indications for peroral endoscopic myotomy and advantages of the technique over laparoscopic and thorascopic myotomy; factors contributing to the success of surgical therapy for achalasia; modifications to the classification of esophageal body primary motility disorders in the advent of high-resolution manometry (HRM); analysis of the LES in differentiating between achalasia and diffuse esophageal spasm (DES); and appropriate treatment for DES, nutcracker esophagus (NE), and hypertensive LES (HTLES).

Stents for benign and malignant esophageal strictures.

This paper presents commentaries on endotherapy for esophageal perforation/leaks; treatment of esophageal perforation; whether esophageal stents should be used for treating benign esophageal strictures; what determines the optimal stenting period in benign esophageal strictures/leaks; how to choose an esophageal stent; how a new fistula secondary to an esophageal stent should be treated; which strategy should be adopted when a fistula of a cervical anastomosis occurs; intralesional steroids for refractory esophageal strictures; balloon and bougie dilators for esophageal strictures and predictors of response to dilation; whether refractory strictures from different etiologies respond differently to endotherapy; surgical therapy of benign esophageal strictures; and whether stenoses following severe esophageal burns should be treated by esophageal resection or esophageal bypass.

New therapeutic strategies for squamous cell cancer and adenocarcinoma.

This paper presents commentaries on neoadjuvant treatment esophagectomy; the prognostic and predictive effects of single nucleotide polymorphisms (SNP) in the multimodality therapy of esophageal cancer; optimal preoperative treatment prior to surgery for esophageal cancer; a possible role for trastuzumab in treating esophageal adenocarcinoma or any esophageal dysplasia/intra-epithelial neoplasia; surgery after chemoradiation in resectable esophageal cancer; whether para-aortic lymph node dissection should be performed in esophagogastric junction (EGJ) tumors; and transhiatal esophagectomy in treatment of the esophageal cancer.

Colonoscopy: randomized comparative study of insufflation with carbon dioxide versus air / Colonoscopia: estudo comparativo randomizado deinsuflação com co 2 e ar

ABSTRACT Background: In Brazil, an increasing number of people are submitted to colonoscopy, either for screening or for therapeutic purposes. Aim: To evaluate whether there are advantages of using carbon dioxide (CO2) over air for insufflation. Methods: Two hundred and ten of 219 patients were considered eligible for this study and were randomized into two groups according to the gas insufflation used: Air Group (n=104) and CO2 Group (n=97). The study employed a double-blind design. Results: The Air and CO2 Groups were similar in respect to bowel preparation evaluated using the Boston scale, age, gender, previous surgery, maneuvers necessary for the advancement of the device, and presence of polyps, tumors or signs of diverticulitis. However, "waking up with pain" and "pain at discharge" were more prevalent in the Air Group, albeit not statistically significant, with post-exam bloating seen only in the Air Group. The responses to a questionnaire, applied to analyze the late post-exam period, showed more comfort with the use of CO2. Conclusions: The use of CO2 is better than air as it avoids post-examination bloating, thereby providing greater comfort to patients.

RESUMO Racional: No Brasil, estima-se crescente aumento da população submetida à colonoscopia, apesar do desconforto do exame, decorrente sobretudo da insuflação colônica. Objetivo: Verificar se há vantagens do uso de CO2 sobre o ar como elemento de insuflação. Métodos: Um total de 219 participantes foram submetidos à análise de elegibilidade e dele extraíram-se 210 eleitos, que foram randomizados em dois grupos, de acordo com o elemento utilizado: ar, n=104 e CO2, n=97. O ensaio seguiu o modelo duplo-cego. Resultados: Os grupos demonstraram-se similares quando cotejados preparo intestinal avaliado pela Escala de Boston, idade, gênero, operação prévia, manobras necessárias para progressão do aparelho, presença de pólipo, tumor ou sinais de diverticulite, valorizando a comparação entre eles quanto ao elemento de insuflação. Então, observou-se que "acordar com dor" e a presença de dor na ocasião da alta foram bem mais prevalentes no "Grupo Ar", embora sem diferença estatisticamente significante, sendo a distensão pós-exame observada apenas no "Grupo Ar". De acordo com o questionário clínico aplicado para análise do período tardio pós-exame, as respostas apontaram muito mais conforto com o uso do CO2. Os elementos de insuflação não pareceram modificar substancialmente os aspectos técnicos do exame nem provocar índices expressivos de enantema da mucosa. Conclusão: O uso do dióxido de carbono é superior ao ar, pois evita a distensão abdominal pós-exame conferindo maior conforto aos pacientes no período pós-exame.

Laparoendoscopic transgastric resection of subepithelial juxtacardiac tumors / Laparoendoscopia e ressecção transgástrica de tumores subepiteliais justacárdicos

ABSTRACT Background: With a prevalence of 0.4-3.5%, subepithelial lesions of the upper digestive tract are discovered during endoscopic procedures. Treatment depends on etiological and pathophysiological information, ability to diagnose and the different technical resources available. Aim: To demonstrate the effectiveness of a surgical technique that combines endoscopy and videolaparoscopy in the transgastric resection of subepithelial juxtacardic lesions. Method: The patients were assisted with a technical combination between endoscopy and laparoscopy. After diagnosis of subepithelial tumor, intraoperative endoscopy was performed after pneumoperitoneum and placement of laparoscopic tweezers. Through endoscopy, the following steps were performed: demarcation of surgical margins, visualization of the intragastric image for the laparoscopic procedure and removal of the surgical specimen. By laparoscopy the following steps were performed: intragastric intra-abdominal access, resection of the part and closure of the gaps. Results: This technique was applied in two cases in order to evaluate its initial results. There were two videolaparoendoscopic resections of juxtacardiac gastric tumors of the posterior wall. Both had their endoscopic diagnosis confirmed. After laparoendoscopic and tomographic and/or ecoendoscopic diagnostic complementation and preoperative performance, the laparoendoscopic procedure was indicated. The patients had a good recovery, with a short hospitalization time and no complications. Conclusion: The combined use of videolaparoscopy and endoscopy is a safe and effective technique for transgastric resection of juxtacardiac subepithelial lesions. It may be important for definitive diagnosis of the tumor.

RESUMO Racional: Lesões subepiteliais do trato digestivo superior são descobertas durante procedimentos endoscópicos com prevalência de 0,40-3,5%. Seu tratamento parte de conhecimento etiológico, fisiopatológico, capacidade diagnóstica e recursos técnicos variados. Objetivo: Demonstrar a eficácia de técnica cirúrgica que combina videolaparoscopia e endoscopia para ressecção transgástrica de lesões subepiteliais justacárdicas e seus resultados preliminares. Método: Os pacientes foram assistidos com uma combinação técnica entre endoscopia e laparoscopia. Após o diagnóstico de tumor sub-epitelial justacárdico endoscopia intra-operatória foi realizada após confecção do pneumoperitônio e colocação das pinças laparoscópicas. Através da endoscopia realizou-se os seguintes passos: demarcação de margens cirúrgicas, visualização da imagem intragastrica para o procedimento laparoscópico e retirada de peça cirúrgica; pela laparoscopia realizou-se os seguintes passos: acesso intragástrico por via intra-abdominal, ressecção da peça e fechamento das brechas. Resultados: Esta técnica foi aplicada em dois casos afim de serem avaliados seus resultados inicias. Foram duas ressecções videolaparoendoscópica de tumores gástricos justacárdicos, de parede posterior. Ambos tiveram seu diagnóstico endoscópico de tumores subepiteliais justacárdicos. Após complementação diagnóstica tomográfica e/ou ecoendoscópica e realização de pré operatório foi indicado o procedimento laparoendoscópico. Os pacientes tiveram recuperação muito satisfatória, com pequeno tempo de internação e sem complicações. Conclusão: O uso combinado de videolaparoscopia e endoscopia constitui técnica segura e eficaz para a ressecção transgástrica de lesões subepiteliais justacárdicas. Pode ser importante para diagnóstico definitivo da tumoração.

Barrett's esophagus: surveillance and reversal.

The following on surveillance and reversal of Barrett's esophagus (BE) includes commentaries on criteria for surveillance even when squamous epithelium stains normally with a variety of biomarkers; the long-term follow-up of surgery versus endoscopic ablation of BE; the recommended surveillance intervals in patients without dysplasia; the sampling problems related to anatomic changes following fundoplication; the value of tissue spectroscopy and optical coherence tomography; the cost-effectiveness of biopsy protocols for surveillance; the quality of life of Barrett's patients; and risk stratification and surveillance strategies.

Barrett's esophagus: progression to adenocarcinoma and markers.

The following on progression to adenocarcinoma and markers of Barrett's esophagus includes commentariess on the expression of claudin 4 in Barrett's adenocarcinoma; the role of acid and bile salts; the role of insulin-like growth factor; the value of reactive oxygen species; the importance of abnormal methylation; genetic alterations in stromal cells and genomic changes in the epithelial cells; the value of confocal laser endomicroscopy for the subsurface analysis of the mucosa; indications for statins as adjuvant chemotherapeutic agent; the sequence of molecular events in malignant progression in Barrett's mucosa; and the value of the macroscopic markers and of p53 mutations.

Barrett's esophagus: proton pump inhibitors and chemoprevention I.

The following on proton pump inhibitors and chemoprevention in Barrett's esophagus includes commentaries on normalization of esophageal refluxate; the effects of 5-HT(4) agonists on EGF secretion and of lubripristone on chloride channels agents; the role of Campylobacter toxin production; the deleterious effects of unconjugated bile acids; the role of baclofen in nonacid reflux; the threshold for adequate esophageal acid exposure; the effects of proton pump inhibitor (PPI) therapy on normalization of esophageal pH and on cell proliferation; the role of the phenotype of cellular proliferation on the effects of PPI therapy; and the value of Symptom Index and Symptom Association Probability in the evaluation of potential response to treatment.

Clinical evaluation of oropharyngeal dysphagia in Machado-Joseph disease.

CONTEXT: In Machado-Joseph disease, poor posture, dystonia and peripheral neuropathy are extremely predisposing to oropharyngeal dysphagia, which is more commonly associated with muscular dystrophy. OBJECTIVE: To evaluate the clinical characteristics of oropharyngeal dysphagia in Machado-Joseph disease patients. METHOD: Forty individuals participated in this study, including 20 with no clinical complaints and 20 dysphagic patients with Machado-Joseph disease of clinical type 1, who were all similar in terms of gender distribution, average age, and cognitive function. The medical history of each patient was reviewed and each subject underwent a clinical evaluation of deglutition. At the end, the profile of dysphagia in patients with Machado-Joseph disease was classified according to the Severity Scale of Dysphagia, as described by O'Neil and collaborators. RESULTS: Comparison between dysphagic patients and controls did not reveal many significant differences with respect to the clinical evaluation of the oral phase of deglutition, since afflicted patients only demonstrated deficits related to the protrusion, retraction and tonus of the tongue. However, several significant differences were observed with respect to the pharyngeal phase. Dysphagic patients presented pharyngeal stasis during deglutition of liquids and solids, accompanied by coughing and/or choking as well as penetration and/or aspiration; these signs were absent in the controls. CONCLUSIONS: Oropharyngeal dysphagia is part of the Machado-Joseph disease since the first neurological manifestations. There is greater involvement of the pharyngeal phase, in relation to oral phase of the deglutition. The dysphagia of these patients is classified between mild and moderate.

A therapeutic maneuver for oropharyngeal dysphagia in patients with Parkinson's disease.

OBJECTIVE: This study investigates resources to provide better conditions for oropharyngeal swallowing for improvement in the quality of life of Parkinson's disease patients. METHOD: Three men and one woman with an average age of 70.25 years had been afflicted with Parkinson's disease for an average of 9.25 years. The patients were submitted to a rehabilitation program for oropharyngeal dysphagia after a clinical evaluation of swallowing. The rehabilitation program consisted of daily sessions for two consecutive weeks during which a biofeedback resource adapted especially for this study was used. The patients were then reevaluated for swallowing ability at follow-up. RESULTS: The patients presenting difficulties with swallowing water displayed no such problems after rehabilitation. Only one patient exhibited slow oral transit of food and other discrete oropharyngeal food remnants when swallowing a biscuit. The sample variance was used to analyze the pressure measurements, demonstrating a numerical similarity of the results obtained with the swallowing of saliva or of biscuits (VAR = 4.41). A statistical difference was observed between the swallowing of saliva and biscuits, showing a significant pressure increase at the end of the rehabilitation program (p < 0.001). CONCLUSION: The effortful swallow maneuver reinforced by using biofeedback appears to be a therapeutic resource in the rehabilitation of oropharyngeal dysphagia in Parkinson's disease patients.