Characterization of obstructive defecation from a structural and a functional perspective.

BACKGROUND/AIMS: Defecation disorders can occur as a consequence of functional or structural anorectal dysfunctions during voiding. The aims of this study is to assess the prevalence of structural (SDD) vs functional (FDD) defecation disorders among patients with clinical complaints of obstructive defecation (OD) and their relationship with patients' expulsive capacity. PATIENTS AND METHODS: Retrospective study of 588 patients with OD studied between 2012 and 2020 with evacuation defecography (ED), and anorectal manometry (ARM) in a subgroup of 294. RESULTS: 90.3% patients were women, age was 58.5±12.4 years. Most (83.7%) had SDD (43.7% rectocele, 45.3% prolapse, 19.3% enterocele, and 8.5% megarectum), all SDD being more prevalent in women except for megarectum. Functional assessments showed: (a) absence of rectification of anorectal angle in 51% of patients and poor pelvic descent in 31.6% at ED and (b) dyssynergic defecation in 89.9%, hypertonic IAS in 44%, and 33.3% rectal hyposensitivity, at ARM. Overall, 46.4% of patients were categorized as pure SDD, 37.3% a combination of SDD+FDD, and 16.3% as having pure FDD. Rectal emptying was impaired in 66.2% of SDD, 71.3% of FDD and in 78% of patients with both (p=0.017). CONCLUSIONS: There was a high prevalence of SDD in middle-aged women with complaints of OD. Incomplete rectal emptying was more prevalent in FDD than in SDD although FDD and SDD frequently coexist. We recommend a stepwise therapeutic approach always starting with therapy directed to improve FDD and relaxation of striated pelvic floor muscles.

The evolution of the treatment of esophageal achalasia. Chronicle of a 35-year journey.

Over the last few decades, significant improvement has been made in both the evaluation and treatment of esophageal achalasia. The Chicago classification, today in version 4.0, is now the standard for diagnosis of achalasia, providing a classification into 3 subtypes with important therapeutic and prognostic implications. Therapy, which was at first mostly limited to pneumatic dilatation, today includes minimally invasive surgery and peroral endoscopic myotomy, allowing for a more tailored approach to patients and better treatment of recurrent symptoms. This review chronicles my personal experience with achalasia over the last 35 years, describing the progress made in the treatment of patients with achalasia.

Manometría de alta resolución con impedancia para el estudio de la motilidad faríngea y del esfínter esofágico superior: claves para su utilización en el estudio de la fisiopatología de la disfagia orofaríngea / High-resolution manometry with impedance for the study of pharyngeal motility and the upper esophageal sphincter: Keys for its use in the study of the pathophysiology of oropharyngeal dysphagia

La disfagia orofaríngea (DO) es una enfermedad con una alta prevalencia en diferentes fenotipos de pacientes. La manometría de alta resolución faringoesofágica (MARFE) con impedancia (MARFE-I) se ha convertido en los últimos años en una técnica fundamental para el mejor entendimiento de la fisiopatología de las disfunciones de la faringe y del esfínter esofágico superior (EES) en pacientes con DO. Diversos grupos de expertos han propuesto una metodología para la práctica de la MARFE-I y para la estandarización de las diferentes métricas para el estudio de las disfunciones de la motilidad faríngea y del EES basadas en el la cuantificación de 3fenómenos principales: la relajación del EES, la resistencia al flujo a través del EES y la propulsión del bolo a través de la faringe hacia el esófago. De acuerdo a las alteraciones de estas métricas, se proponen 3patrones de disfunción que permiten un abordaje terapéutico específico: a) restricción al flujo del EES con propulsión faríngea normal; b) restricción al flujo del EES con propulsión faríngea inefectiva, y c) contracción faríngea inefectiva con normal relajación del EES. Presentamos una revisión práctica de la metodología y la métrica que emplean los principales grupos de trabajo junto con la descripción de los principales patrones de disfunción de acuerdo con nuestra experiencia para poner de relevancia la utilidad de la MARFE-I en el estudio de la fisiopatología y selección de un tratamiento específico en pacientes con DO. (AU)

Oropharyngeal dysphagia (OD) is a pathology with a high prevalence in different patient phenotypes. High-resolution pharyngoesophageal manometry (HRPM) with impedance (HRPM-I) has become in recent years a fundamental technique for better understanding the pathophysiology of pharynx and upper oesophageal sphincter (UES) dysfunctions in patients with OD. Various groups of experts have proposed a methodology for the practice of the HRPM-I and for the standardization of the different metrics for the study of pharyngeal motility and UES dysfunctions based on the quantification of 3main phenomena: relaxation of the UES, resistance to flow through the UES and propulsion of the bolo through the pharynx into the oesophagus. According to the alterations of these metrics, 3patterns of dysfunction are proposed that allow a specific therapeutic approach: (a) UES flow restriction with normal pharyngeal propulsión; (b) UES flow restriction with ineffective pharyngeal propulsion, and (c) ineffective pharyngeal contraction with normal relaxation of the UES. We present a practical review of the methodology and metrics used by the main working groups together with the description of the main patterns of dysfunction according to our experience to highlight the usefulness of the HRPM-I in the study of the pathophysiology and selection of a specific treatment in patients with OD. (AU)

Clinical and manometric results of peroral endoscopic myotomy in patients with achalasia: experience in a latin american reference center. / Resultados clínicos y manométricos de la miotomía endoscópica peroral en pacientes con acalasia: experiencia en un centro de referencia latinoamericano.

INTRODUCTION: Currently there is little information in Latin America on the clinical outcome and manometric evolution of patients with Achalasia undergoing peroral endoscopic myotomy (POEM). PRIMARY OUTCOME: Evaluate the manometric and clinical changes in adult patients with achalasia after peroral endoscopic myotomy at a referral center in Bogotá, Colombia. METHODS: Observational, analytical, longitudinal study. Adult patients with achalasia according to the Chicago 4.0 criteria were included. Sociodemographic, clinical and manometric variables were described. To compare the pre- and post-surgical variables, the Student's or Wilcoxon's t test was used for the quantitative variables according to their normality, and McNemar's chi-square for the qualitative variables. RESULTS: 29 patients were included, 55.17% (n=16) women, with a mean age at the time of surgery of 48.2 years (±11.33). The mean post-procedure evaluation time was 1.88±0.81 years. After the procedure, there was a significant decrease in the proportion of patients with weight loss (37.93% vs 21.43% p 0.0063), chest pain (48.28% vs 21.43, p 0.0225) and the median Eckardt score (8 (IQR 8 -9) vs 2(IQR 1-2), p <0.0001). In addition, in fourteen patients with post-surgical manometry, significant differences were found between IRP values (23.05±14.83mmHg vs 7.69±6.06mmHg, p 0.026) and in the mean lower esophageal sphincter tone (9.63±7.2mmHg vs 28.8±18.60mmHg, p 0.0238). CONCLUSION: Peroral endoscopic myotomy has a positive impact on the improvement of symptoms and of some manometric variables (IRP and LES tone) in patients with achalasia.

Brief guidelines for beginners on how to perform and analyze esophageal high-resolution manometry.

High-resolution manometry (HRM) is a diagnostic tool for surgeons, gastroenterologists and other healthcare professionals to evaluate esophageal physiology. The Chicago Classification (CC) system is based on a consensus of worldwide experts to minimize ambiguity in HRM data acquisition and diagnosis of esophageal motility disorders. The most updated version, CCv4.0, was published in 2021; however, it does not provide step-by-step guidelines (i.e., for beginners) on how to assess the most important HRM metrics. This paper aims to summarize the basic guidelines for conducting a high-quality HRM study including data acquisition and interpretation, based on CCv4.0, using Manoview ESO analysis software, version 3.3 (Medtronic, Minneapolis, MN).

High-resolution manometry with impedance for the study of pharyngeal motility and the upper esophageal sphincter: Keys for its use in the study of the pathophysiology of oropharyngeal dysphagia. / Manometría de alta resolución con impedancia para el estudio de la motilidad faríngea y del esfínter esofágico superior: claves para su utilización en el estudio de la fisiopatología de la disfagia orofaríngea.

Oropharyngeal dysphagia (OD) is a pathology with a high prevalence in different patient phenotypes. High-resolution pharyngoesophageal manometry (HRPM) with impedance (HRPM-I) has become in recent years a fundamental technique for better understanding the pathophysiology of pharynx and upper oesophageal sphincter (UES) dysfunctions in patients with OD. Various groups of experts have proposed a methodology for the practice of the HRPM-I and for the standardization of the different metrics for the study of pharyngeal motility and UES dysfunctions based on the quantification of 3main phenomena: relaxation of the UES, resistance to flow through the UES and propulsion of the bolo through the pharynx into the oesophagus. According to the alterations of these metrics, 3patterns of dysfunction are proposed that allow a specific therapeutic approach: (a) UES flow restriction with normal pharyngeal propulsión; (b) UES flow restriction with ineffective pharyngeal propulsion, and (c) ineffective pharyngeal contraction with normal relaxation of the UES. We present a practical review of the methodology and metrics used by the main working groups together with the description of the main patterns of dysfunction according to our experience to highlight the usefulness of the HRPM-I in the study of the pathophysiology and selection of a specific treatment in patients with OD.

Dyssynergic Defecation Concerning Proctalgia Fugax: An Observational Study

Introduction: There is no clarity about manometric findings in patients with proctalgia fugax; evidence shows different results. This study aims to evaluate dyssynergic defecation through anorectal manometry in Colombian patients in two gastroenterology centers in Bogotá, Colombia. Materials and methods: A cross-sectional descriptive observational study in adult patients with proctalgia fugax undergoing anorectal manometry and treated in two gastroenterology centers in Bogotá between 2018 and 2020. Results: 316 patients were included, predominantly women (65%), with a median age of 45.2 (range: 18-78; standard deviation [SD]: 28.3). Four percent of patients had hypertonicity, 50% were normotonic, and 46% were hypotonic. Regarding manometric parameters, 50% had normal pressure, and 46% had anal sphincter hypotonia; 76% had a normal voluntary contraction test. Dyssynergic defecation was documented in 5% of patients, and the most frequent was type I, followed by type III. A rectoanal inhibitory reflex was identified in all patients, 42% with altered sensory threshold and 70% with abnormal balloon expulsion. There was an agreement between the results of the anorectal manometry and the subjective report of the digital rectal exam by the head nurse who performed the procedure. Conclusions: The data obtained in the present study suggest that proctalgia is not related to the elevated and sustained basal contracture of the sphincter but neither to the alteration in voluntary contraction since most patients have typical values.

Introducción: Actualmente, no hay claridad acerca de los hallazgos manométricos en pacientes con proctalgia fugaz, y la evidencia muestra diferentes resultados. Se plantea como objetivo en el presente estudio evaluar la presencia de disinergia defecatoria con manometría anorrectal en pacientes colombianos en dos centros de gastroenterología en Bogotá, Colombia. Metodología: Estudio observacional descriptivo de corte transversal en pacientes adultos sometidos a manometría anorrectal con proctalgia fugaz y atendidos en dos centros de gastroenterología de la ciudad de Bogotá entre el 2018 y el 2020. Resultados: Se incluyó a 316 pacientes, predominantemente mujeres (65%), con mediana de edad 45,2 (rango: 18-78; desviación estándar [DE]: 28,3). El 4% de los pacientes presentaban hipertonicidad, el 50% eran normotónicos y el 46%, hipotónicos. En cuanto a parámetros manométricos, el 50% tenía presión normal y el 46%, hipotonía de esfínter anal. El 76% tuvo una prueba de contracción voluntaria normal. En 5% pacientes se documentó disinergia defecatoria, y la más frecuente fue el tipo I, seguido del tipo III. En todos los pacientes se identificó reflejo recto anal inhibitorio, 42% con alteración en umbral sensitivo y 70% con expulsión de balón anormal, y hubo concordancia entre los resultados de la manometría anorrectal y el reporte subjetivo del tacto rectal de la jefe de enfermería que realizó el procedimiento. Conclusiones: Los datos obtenidos en el presente estudio sugieren que la proctalgia no está relacionada con la contractura basal elevada y sostenida del esfínter, pero tampoco con la alteración en la contracción voluntaria, ya que la mayoría de los pacientes presentan valores normales.

High-Resolution Manometry Contributions to the Physiology of Phonation

High-resolution manometry (HRM) is a motility diagnostic system that measures intraluminal pressure of the gastrointestinal tract using a series of closely spaced pressure sensors. The topographic plot generated by HRM software makes it possible to visualize phonation pressures at the pharynx, UES, and body of the esophagus in real time, indicating pressure intensity by color, which permits easy data interpretation. It has been largely used for swallowing study and dysphagia diagnosis. Due to the proximity of the pharyngoesophageal and laryngeal structures, this technology instigated voice researchers. Despite the few studies published so far, high-resolution manometry has yet proven to be an extremely useful tool in obtaining entire pharyngoesophageal segment pressure measurements during phonation. It also allows natural voice production not interfering with the mouth area. HRM data already brought light to subglottic pressure, vertical laryngeal excursion, cricopharyngeal muscle activation, air flow, muscle tension associated with vocalization and pressure variations associated with different phonatory stimuli.

La manometría de alta resolución (HRM, por sus siglas en inglés) es un sistema de diagnóstico de motilidad que mide la presión intraluminal del tracto gastrointestinal mediante una serie de sensores de presión dispuestos de manera cercana. El gráfico topográfico generado por el software de HRM permite visualizar las presiones de fonación en la faringe, el EEI y el cuerpo del esófago en tiempo real, indicando la intensidad de la presión mediante colores que facilitan la interpretación de los datos. Ha sido ampliamente utilizado para el estudio de la deglución y el diagnóstico de la disfagia. Debido a la proximidad de las estructuras faringoesofágicas y laríngeas, esta tecnología ha despertado el interés de los investigadores en voz. A pesar de los pocos estudios publicados hasta ahora, la manometría de alta resolución ha demostrado ser una herramienta extremadamente útil para obtener mediciones de presión de todo el segmento faringoesofágico durante la fonación. Además, permite la producción natural de la voz sin interferir en el área de la boca. Los datos de HRM ya han arrojado luz sobre la presión subglótica, la excursión laríngea vertical, la activación del músculo cricofaríngeo, el flujo de aire, la tensión muscular asociada con la vocalización y las variaciones de presión asociadas con diferentes estímulos fonatorios.

The Mexican consensus on fecal incontinence.

Fecal incontinence is the involuntary passage or the incapacity to control the release of fecal matter through the anus. It is a condition that significantly impairs quality of life in those that suffer from it, given that it affects body image, self-esteem, and interferes with everyday activities, in turn, favoring social isolation. There are no guidelines or consensus in Mexico on the topic, and so the Asociación Mexicana de Gastroenterología brought together a multidisciplinary group (gastroenterologists, neurogastroenterologists, and surgeons) to carry out the «Mexican consensus on fecal incontinence¼ and establish useful recommendations for the medical community. The present document presents the formulated recommendations in 35 statements. Fecal incontinence is known to be a frequent entity whose incidence increases as individuals age, but one that is under-recognized. The pathophysiology of incontinence is complex and multifactorial, and in most cases, there is more than one associated risk factor. Even though there is no diagnostic gold standard, the combination of tests that evaluate structure (endoanal ultrasound) and function (anorectal manometry) should be recommended in all cases. Treatment should also be multidisciplinary and general measures and drugs (lidamidine, loperamide) are recommended, as well as non-pharmacologic interventions, such as biofeedback therapy, in selected cases. Likewise, surgical treatment should be offered to selected patients and performed by experts.

Esclerodermia y alteraciones esofágicas documentadas por manometría / Scleroderma and Esophageal Alterations Documented by Manometry

Introducción: Las manifestaciones gastrointestinales y en especial la disfunción esofágica son frecuentes en pacientes con diagnóstico de esclerosis sistémica. Objetivos: Determinar los hallazgos manométricos en el esófago de pacientes con esclerosis sistémica. Métodos: Se realizó un estudio descriptivo de corte transversal, en 86 pacientes con diagnóstico de esclerosis sistémica que fueron atendidos en el Servicio de Reumatología del Hospital Hermanos Ameijeiras, en el período comprendido de enero de 2020 a diciembre de 2021. Resultados: La edad media fue de 49,5 ± 15,3 años, (94,3 por ciento) en el sexo femenino. El (90,7 por ciento) tenía trastornos de la motilidad esofágica, principalmente los trastornos mayores (58,1por ciento) y el esfínter esofágico corto (62,8 por ciento). La presencia de síntomas como la regurgitación, la pirosis y la disfagia se relacionaron de forma significativa en la mayoría de los parámetros manométricos. De igual forma, el tiempo de evolución de la enfermedad (10,1 ± 9,1 frente a 5,9 ± 5,9 años), el fenómeno de Raynaud (93,9 por ciento frente a 25,0 por ciento) y la esclerosis sistémica difusa (96,2 por ciento frente a 82,4 por ciento) fueron significativamente mayores en pacientes con trastornos de la motilidad esofágica. La edad y el sexo no mostraron una asociación significativa con las alteraciones manométricas. Conclusiones: Se concluye que los pacientes con esclerosis sistémica difusa, fenómeno de Raynaud, a partir de la presencia de los síntomas y de la evolución de la enfermedad tienen una elevada probabilidad de padecer trastornos de la motilidad esofágica(AU)

Introduction: Gastrointestinal manifestations, and especially esophageal dysfunction, are common in patients diagnosed with systemic sclerosis. Objectives: To determine the manometric findings in the esophagus of patients with systemic sclerosis. Methods: A descriptive cross-sectional study was carried out on 86 patients with a diagnosis of systemic sclerosis who were treated in the Rheumatology Service of Hermanos Ameijeiras Hospital from January 2020 to December 2021. Results: The mean age was 49.5 ± 15.3 years, (94.3percent) in females. 90.7percent had esophageal motility disorders, mainly major disorders (58.1percent) and 62.8percent had short esophageal sphincter. The presence of symptoms such as regurgitation, heartburn and dysphagia were significantly related to most manometric parameters. Similarly, the duration of the disease (10.1 ± 9.1 versus 5.9 ± 5.9 years), Raynaud's phenomenon (93.9percent versus 25.0percent) and sclerosis diffuse systemic (96.2percent vs. 82.4percent) were significantly higher in patients with esophageal motility disorders. Age and sex did not show significant association with manometric alterations. Conclusions: It is concluded that patients with diffuse systemic sclerosis, Raynaud's phenomenon, based on the presence of symptoms, and the evolution of the disease, have high probability of suffering from esophageal motility disorders(AU)

Patrón de motilidad de la enfermedad por reflujo gastroesofágico en la manometría de alta resolución

Introducción: La manometría esofágica es la prueba de referencia para el diagnóstico de los trastornos motores esofágicos; diagnostica elementos conocidos en la fisiopatología de la enfermedad por reflujo gastroesofágico, como la hipotonía del esfínter esofágico inferior y sus relajaciones transitorias. La manometría se utiliza para evaluar la función peristáltica en pacientes considerados para cirugía antirreflujo, particularmente si el diagnóstico es incierto. No debe emplearse para hacer o confirmar el diagnóstico de enfermedad por reflujo gastroesofágico. Objetivo: Profundizar en los conocimientos relacionados con el patrón de motilidad de la enfermedad por reflujo gastroesofágico en la manometría de alta resolución. Desarrollo: La manometría esofágica de alta resolución permite caracterizar la actividad contráctil del esófago. Registra de manera simultánea la actividad de los esfínteres esofágicos superior e inferior; también la motilidad del cuerpo esofágico. Sus indicaciones, aunque precisas, resultan de interés en determinados pacientes con enfermedad por reflujo gastroesofágico, sobre todo en quienes se sospecha un trastorno de la motilidad. El patrón manométrico más aceptado para la enfermedad por reflujo gastroesofágico describe un fallo de los siguientes factores: la presión del esfínter esofágico inferior, longitud, inestabilidad, la presencia de hernia hiatal y los trastornos de la peristalsis esofágica. Conclusiones: La manometría de alta resolución permite caracterizar el patrón de motilidad de la enfermedad por reflujo gastroesofágico. Los elementos primarios del reflujo son la hipotonía del esfínter esofágico inferior, sus relajaciones transitorias y la distorsión anatómica de la unión esofagogástrica.

Introduction: Esophageal manometry is the reference test for the diagnosis of esophageal motor disorders; diagnoses known elements in the pathophysiology of gastroesophageal reflux disease, such as hypotony of the lower esophageal sphincter and its transient relaxations. Manometry is used to evaluate peristaltic function in patients considered for anti-reflux surgery, particularly if the diagnosis is uncertain. It should not be used to make or confirm the diagnosis of gastroesophageal reflux disease. Objective: To deepen the knowledge related to the motility pattern of gastroesophageal reflux disease in high-resolution manometry. Development: High-resolution esophageal manometry allows characterizing the contractile activity of the esophagus. Simultaneously records the activity of the upper and lower esophageal sphincters; also, the motility of the esophageal body. Its indications, although precise, are of interest in certain patients with gastroesophageal reflux disease, especially in those who suspect a motility disorder. The most accepted manometric pattern for gastroesophageal reflux disease describes a failure of the following factors: lower esophageal sphincter pressure, length, instability, the presence of hiatal hernia, and disorders of esophageal peristalsis. Conclusions: High-resolution manometry allows us to characterize the motility pattern of gastroesophageal reflux disease. The primary elements of reflux are hypotonia of the lower esophageal sphincter, its transient relaxations, and anatomical distortion of the esophagogastric junction.

Study of gastroesophageal reflux. Interpretation of functional tests in the obese patient.

Overweight and obesity are a public health problem and in 1997 obesity was recognized as a global epidemic by the World Health Organization (WHO). Overweight and obesity affect almost 60% of adults and one in three children in Europe according to the most recent WHO report. Objectively, gastroesophageal reflux disease (GERD) is defined as the presence of characteristic esophageal mucosal damage assessed by endoscopy and/or the demonstra-tion of pathological acid exposure by reflux monitoring studies. The prevalence of GERD is increased in obese patients In overweight and obese patients, the clinical symptoms of GERD are especially present in the supine position and this correlates with more frequent episodes of nocturnal reflux in the 24-h pH monitoring, there is also an increase in the number of refluxes with content acid. In the population with symptoms, digestive endoscopy detects data of erosive esophagitis in 50% of patients, while 24-h pH-impedanciometry diagnoses 92% of patients with non-erosive reflux disease (NERD) The presence of persistent GERD in the mucosa affects esophageal motility and patients may develop ineffective esophageal motility-type disorders, so we will review the interpre-tation of the functional tests that determine motility, which is esophageal manometry, and those that determine reflux gastroesophageal, acid and non-acid, which is the pH measure-ment with or without 24-h impedanciometry.

Possible technical aspects involved in the development of GERD after sleeve gastrectomy: Surgical technique considerations.

Sleeve gastrectomy (SG) is the most common bariatric surgery worldwide and has shown to cause de novo or worsen symptoms of gastroesophageal reflux disease (GERD). Esophageal motility and physiology studies are mandatory in bariatric and foregut centers. The predisposing factors in post-SG patients are disruption of His angle, resection of gastric fold and gastric fundus, increased gastric pressure, resection of the gastric antrum, cutting of the sling fibers and pyloric spasm. There are symptomatic complications due to sleeve morphology as torsion, incisura angularis stenosis, kinking and dilated fundus. In this article, we present recommendations, surgical technique and patient selection flow diagram for SG and avoid de novo or worsening GERD.

Impacto de la cardiomiotomía laparoscópica de Heller en la función del esfínter esofágico inferior y el diámetro del esófago / Impact of laparoscopic Heller cardiomyotomy on lower esophageal sphincter function and esophageal diameter

Introducción. La acalasia es un trastorno motor del esófago caracterizado por la ausencia de peristalsis y la alteración en la relajación del esfínter esofágico inferior. La cardiomiotomía laparoscópica de Heller más funduplicatura parcial es el tratamiento estándar. La mejoría sintomática ha sido bien documentada, pero no hay suficiente información objetiva respecto a los cambios fisiológicos y radiográficos luego del procedimiento. Métodos. Estudio de cohorte bidireccional de pacientes llevados a cardiomiotomía laparoscópica de Heller, entre los años 2018 y 2021, en el Hospital Universitario San Vicente Fundación de Medellín, Colombia. Se describen variables demográficas y clínicas. Se realizaron puntaje sintomático de Eckardt, manometría esofágica y radiografía de esófago en el pre y postoperatorio. Se hizo comparación de síntomas, presión basal del esfínter esofágico inferior, presión de relajación integrada y diámetro del esófago antes y después de la intervención. Resultados. Se incluyeron 24 pacientes. El 63 % fueron mujeres y la edad promedio fue de 44 años. Los valores promedio preoperatorios vs postoperatorios fueron: puntaje de Eckardt 10,6 vs 1,4 puntos (p<0,001), presión basal de 41,4 vs 18,1 mmHg (p=0,004) y presión de relajación integrada de 28,6 vs 12,5 mmHg (p=0,001). El diámetro del esófago no presentó cambios. No hubo correlación de síntomas con los cambios de presión del esfínter esofágico inferior. El tiempo de seguimiento fue de 20 meses. Conclusiones. La cardiomiotomía de Heller es un procedimiento altamente efectivo para el tratamiento definitivo de la acalasia, logrando una mejoría subjetiva y objetiva basada en síntomas y en parámetros de manometría, respectivamente

Introduction. Achalasia is a motor disorder of the esophagus characterized by the absence of peristalsis and impaired relaxation of the lower esophageal sphincter. Laparoscopic Heller ́s cardiomyotomy plus partial fundoplication is the standard treatment. Symptomatic improvement has been well documented, but there is insufficient objective information regarding physiologic and radiographic changes after the procedure. Methods. Bidirectional cohort study of patients underwent laparoscopic Heller ́s cardiomyotomy between 2018 and 2021 at the San Vicente Fundación University Hospital in Medellín, Colombia. Demographic and clinical variables are described. Eckardt symptom score, esophageal manometry, and esophageal radiography were performed pre and postoperatively. A comparison of symptoms, baseline lower esophageal sphincter pressure, integrated relaxation pressure, and esophageal diameter before and after intervention were performed.Results. 24 patients were included. 63% were women and the average age was 44 years. The preoperative vs. postoperative mean values were: Eckardt score 10.6 vs. 1.4 points (p<0.001), basal pressure of 41.4 vs. 18.1 mmHg (p=0.004) and integrated relaxation pressure of 28.6 vs. 12.5 mmHg (p=0.001). The diameter of the esophagus did not present changes. There was no correlation of symptoms with lower esophageal sphincter pressure changes. The follow-up time was 20 months. Conclusions. Heller cardiomyotomy is a highly effective procedure for the definitive treatment of achalasia, achieving subjective and objective improvements, based on symptoms and manometry parameters, respectively

Changes in pulmonary mechanics from supine to prone position measured through esophageal manometry in critically ill patients with COVID-19 severe acute respiratory distress syndrome.

OBJECTIVE: To describe changes in pulmonary mechanics when changing from supine position (SP) to prone position (PP) in mechanically ventilated (MV) patients with Acute Respiratory Distress Syndrome (ARDS) due to severe COVID-19. DESIGN: Retrospective cohort. SETTING: Intensive Care Unit of the National Institute of Respiratory Diseases (Mexico City). PATIENTS: COVID-19 patients on MV due to ARDS, with criteria for PP. INTERVENTION: Measurement of pulmonary mechanics in patients on SP to PP, using esophageal manometry. MAIN VARIABLES OF INTEREST: Changes in lung and thoracic wall mechanics in SP and PP RESULTS: Nineteen patients were included. Changes during first prone positioning were reported. Reductions in lung stress (10.6 vs 7.7, p=0.02), lung strain (0.74 vs 0.57, p=0.02), lung elastance (p=0.01), chest wall elastance (p=0.003) and relation of respiratory system elastances (p=0.001) were observed between patients when changing from SP to PP. No differences were observed in driving pressure (p=0.19) and transpulmonary pressure during inspiration (p=0.70). CONCLUSIONS: Changes in pulmonary mechanics were observed when patients were comparing values of supine position with measurements obtained 24h after prone positioning. Esophageal pressure monitoring may facilitate ventilator management despite patient positioning.

Clinical utility of the solid meal test during high-resolution esophageal manometry. A study in a Latin American population.

INTRODUCTION AND AIMS: The solid test meal (STM) is a challenge test that is done during esophageal manometry and appears to increase the diagnostic yield of the study. The aim of our analysis was to establish the normal values for STM and evaluate its clinical utility in a group of Latin American patients with esophageal disorders versus healthy controls. MATERIAL AND METHODS: A cross-sectional study was conducted on a group of healthy controls and consecutive patients that underwent high-resolution esophageal manometry, in which STM was done at the final part of the study and consisted of asking the subjects to eat 200 g of precooked rice. The results were compared during the conventional protocol and the STM. RESULTS: Twenty-five controls and 93 patients were evaluated. The majority of the controls (92%) completed the test in under 8 min. The STM changed the manometric diagnosis in 38% of the cases. The STM diagnosed 21% more major motor disorders than the conventional protocol; it doubled the cases of esophageal spasm and quadrupled the cases of jackhammer esophagus, whereas it demonstrated normal esophageal peristalsis in 43% of the cases with a previous diagnosis of ineffective esophageal motility. CONCLUSIONS: Our study confirms the fact that complementary STM during esophageal manometry adds information and enables a more physiologic assessment of esophageal motor function to be made, compared with liquid swallows, in patients with esophageal motor disorders.

Characterization of Achalasia Subtypes Based on High-Resolution Manometry in Patients at a Reference Hospital in Colombia

Introduction: Limited information is available regarding the clinical and manometric characteristics of different subtypes of achalasia. This study aims to describe these characteristics in patients treated at a prominent hospital in Colombia. Methods: This descriptive observational study included patients diagnosed with achalasia using high-resolution esophageal manometry at Hospital Universitario San Ignacio in Bogotá, Colombia, between 2016 and 2020. We documented the clinical manifestations, manometric findings, treatment approaches, and response to treatment based on the subtype of achalasia. Results: A total of 87 patients were enrolled, with a median age of 51 years, and 56.4% of them were female. The majority had type II achalasia (78.1%), followed by type I (16%) and type III (5.7%). All patients presented with dysphagia, 40.2% experienced chest pain, and 27.6% had gastroesophageal reflux. The clinical parameters, including integrated relaxation pressure value (IRP; median: 24 mmHg, interquartile range [IQR]: 19-33), upper esophageal sphincter pressure (UES; median: 63 mmHg, IQR: 46-98), and lower esophageal sphincter pressure (LES; median: 34 mm Hg, IQR: 26-45), were similar across the different subtypes. Esophageal clearance was incomplete in all patients. Among the 35 patients who received intervention, Heller's myotomy was the most commonly employed procedure (68.5%), followed by esophageal dilation (28.6%). All patients experienced symptomatic improvement, with a median pre-treatment Eckardt score of 5 (IQR: 5-6) and a post-treatment score of 1 (IQR: 1-2). Conclusions: Type II achalasia is the most prevalent subtype. The clinical and manometric findings, as well as treatment response, exhibit similarities among the different subtypes of achalasia. In Colombia, the outcomes of this condition align with those reported in other parts of the world.

Introducción: existe información limitada sobre las características clínicas y manométricas de los diferentes subtipos de acalasia. Este estudio describe dichas características en pacientes manejados en un hospital de referencia en Colombia. Método: estudio descriptivo observacional que incluye a pacientes con diagnóstico de acalasia por manometría esofágica de alta resolución manejados en el Hospital Universitario San Ignacio de Bogotá, Colombia, entre 2016 y 2020. Se describen las manifestaciones clínicas, hallazgos manométricos, tratamiento utilizado y respuesta al mismo según el subtipo de acalasia. Resultados: se incluyeron a 87 pacientes (mediana de edad: 51 años, 56,4% mujeres). La mayoría de tipo II (78,1%), seguido por tipo I (16%) y tipo III (5,7%). Todos presentaron disfagia, 40,2% dolor torácico y 27,6% reflujo gastroesofágico. La clínica y los valores del integral de presión de relajación (IRP; mediana: 24 mm Hg, rango intercuartílico [RIC]: 19-33), presión del esfínter esofágico superior (EES; mediana: 63 mm Hg, RIC: 46-98) y presión del esfínter esofágico inferior (EEI; mediana: 34 mm Hg, RIC: 26-45) fueron similares en los diferentes subtipos. El aclaramiento esofágico fue incompleto en todos los pacientes. Entre 35 pacientes que recibieron manejo intervencionista, la miotomía de Heller fue la intervención más utilizada (68,5%), seguido por la dilatación esofágica (28,6%). La totalidad de estos pacientes presentó una mejoría sintomática con la mediana de Eckardt pretratamiento de 5 (RIC: 5-6) y postratamiento de 1 (RIC: 1-2). Conclusiones: la acalasia tipo II es la más común. La clínica y los hallazgos manométricos y respuesta a tratamiento son similares entre los subtipos de acalasia. En Colombia, esta entidad se comporta de forma similar a lo reportado en otras partes del mundo.

Diferencias en la duración del reflejo rectoanal inhibitorio en pacientes con constipación funcional refractaria y mielomeningocele / Differences in rectoanal inhibitory reflex duration between patients with refractory functional constipation and myelomeningocele

Introducción. Habitualmente, durante la manometría anorrectal, en lo correspondiente al reflejo rectoanal inhibitorio (RRAI) solo se pesquisa su presencia o ausencia. Estudios han reportado que su análisis detallado puede brindar datos de interés. Nuestra hipótesis es que la medición del RRAI puede dar información para reconocer causas orgánicas (médula anclada, lipoma, etc.) en pacientes en los que previamente se consideró como de causa funcional. Objetivos. Comparar la duración del reflejo rectoanal inhibitorio en la manometría anorrectal de pacientes con constipación funcional refractaria (CFR) y mielomeningocele (MMC). Población y métodos. Estudio observacional, transversal, analítico (2004-2019). Pacientes constipados crónicos con incontinencia fecal funcional y orgánica (mielomeningocele). Se les realizó manometría anorrectal con sistema de perfusión de agua y se midió la duración del RRAI con diferentes volúmenes (20, 40 y 60 cc). Grupo 1 (G1): 81 CFR. Grupo 2 (G2): 54 MMC. Se excluyeron pacientes con retraso madurativo, esfínter anal complaciente, agenesia sacra y aquellos no colaboradores. Resultados. Se incluyeron 135 sujetos (62 varones). La mediana de edad fue G1:9,57 años; G2: 9,63 años. Duración promedio G1 vs. G2 con 20 cc: 8,89 vs. 15,21 segundos; con 40 cc: 11.41 vs. 21,12 segundos; con 60 cc: 14,15 vs. 26,02 segundos. La diferencia de duración del RRAI entre ambos grupos con diferentes volúmenes fue estadísticamente significativa (p = 0,0001). Conclusión. La duración del RRAI aumenta a mayor volumen de insuflación del balón en ambas poblaciones. Pacientes con MMC tuvieron mayor duración del RRAI que aquellos con CFR. En los pacientes con RRAI prolongado, debe descartarse lesión medular.

Introduction. Usually, during anorectal manometry, only the presence or absence of rectoanal inhibitory reflex (RAIR) is investigated. Studies have reported that a detailed analysis may provide data of interest. Our hypothesis is that RAIR measurement may provide information to detect organic causes (tethered cord, lipoma, etc.) in patients in whom a functional cause had been previously considered. Objectives. To compare RAIR duration in anorectal manometry between patients with refractory functional constipation (RFC) and myelomeningocele (MMC). Population and methods. Observational, analytical, cross-sectional study (2004­2019). Patients with chronic constipation and functional and organic fecal incontinence (myelomeningocele). The anorectal manometry was performed with a water-perfused system, and the duration of RAIR was measured with different volumes (20, 40, and 60 cc). Group 1 (G1): 81 RFC. Group 2 (G2): 54 MMC. Patients with developmental delay, compliant anal sphincter, sacral agenesis and non-cooperative patients were excluded. Results. A total of 135 individuals were included (62 were male). Their median age was 9.57 years in G1 and 9.63 years in G2. Average duration in G1 versus G2 with 20 cc: 8.89 versus 15.21 seconds; 40 cc: 11.41 versus 21.12 seconds; 60 cc: 14.15 versus 26.02 seconds. The difference in RAIR duration with the varying volumes was statistically significant (p = 0.0001). Conclusion. RAIR duration was longer with increasing balloon inflation volumes in both populations. RAIR duration was longer in patients with MMC than in those with RFC. Spinal injury should be ruled out in patients with prolonged RAIR.

El amplio diagnóstico diferencial de los vómitos: un caso de acalasia / The broad differential diagnosis of vomiting: a case of achalasia

Los vómitos constituyen un motivo de consulta muy frecuente en Pediatría. Su abordaje requiere un amplio diagnóstico diferencial, ya que pueden ser síntoma tanto de un trastorno funcional como de patología orgánica importante. Presentamos el caso de una niña de 13 años que debuta con vómitos como síntoma guía de una acalasia. La acalasia es un trastorno motor esofágico que provoca una retención de los alimentos en el segmento distal del esófago debido a un fallo de la peristalsis y una ausencia de relajación del esfínter esofágico inferior (EEI) tras la deglución. Aunque se trata de una patología infrecuente, es necesario incluirla en el diagnóstico diferencial de síntomas gastrointestinales como los vómitos, precisando un alto grado de sospecha para su diagnóstico (AU)

Vomiting is a very frequent reason for consultation in pediatrics. Their approach requires a wide differential diagnosis since they can be a symptom of both a functional disorder and important organic pathology. We present the case of a 13-year-old girl who debuted with vomiting as a guiding symptom of achalasia. Achalasia is an esophageal motor disorder that causes retention of food in the distal segment of the esophagus due to a failure of peristalsis and a lack of relaxation of the lower esophageal sphincter after swallowing. Although it is an infrequent pathology, it is necessary to include it in the differential diagnosis of gastrointestinal symptoms such as vomiting, requiring a high degree of suspicion for its diagnosis. (AU)

Diagnóstico y manejo actual de la acalasia / Diagnosis and current management of achalasia

Introducción. La acalasia es un trastorno motor del esófago poco común, de etiología no clara, caracterizado por la pérdida de relajación del esfínter esofágico inferior, pérdida del peristaltismo normal, regurgitación y disfagia. Métodos. Se realizó una revisión narrativa de la literatura en revistas científicas y bases de datos en español e inglés, con el fin de presentar información actualizada en lo referente al diagnóstico y tratamiento de esta patología. Resultado. Se presenta la actualización de los criterios de los trastornos motores esofágicos según la clasificación de Chicago (CCv4.0) para el diagnóstico de acalasia y sus subtipos de acuerdo con los nuevos criterios, así como los tratamientos actuales. Conclusión. La acalasia es un trastorno esofágico multimodal, con manifestaciones de predominio gastrointestinal, por lo que su diagnóstico y abordaje terapéutico oportuno es esencial para mejorar la calidad de vida de los pacientes

Introduction. Achalasia is a rare motor disorder of the esophagus of unclear etiology, characterized by loss of lower esophageal sphincter relaxation, loss of normal peristalsis, regurgitation, and dysphagia. Methods. A narrative review of the literature in scientific journals and databases in Spanish and English was carried out, in order to present updated information regarding the diagnosis and treatment of this pathology. Result. The update of the Chicago esophageal motor disorders criteria (CCv4.0) is presented for the diagnosis of achalasia and its subtypes according to the new criteria, as well as current treatments. Conclusion. Achalasia is a multimodal esophageal disorder, with predominantly gastrointestinal manifestations, so its timely diagnosis and therapeutic approach is essential to improve the quality of life of patients.