The International Network on Oesophageal Atresia (INoEA) consensus guidelines on the transition of patients with oesophageal atresia-tracheoesophageal fistula.

Oesophageal atresia-tracheoesophageal fistula (EA-TEF) is a common congenital digestive disease. Patients with EA-TEF face gastrointestinal, surgical, respiratory, otolaryngological, nutritional, psychological and quality of life issues in childhood, adolescence and adulthood. Although consensus guidelines exist for the management of gastrointestinal, nutritional, surgical and respiratory problems in childhood, a systematic approach to the care of these patients in adolescence, during transition to adulthood and in adulthood is currently lacking. The Transition Working Group of the International Network on Oesophageal Atresia (INoEA) was charged with the task of developing uniform evidence-based guidelines for the management of complications through the transition from adolescence into adulthood. Forty-two questions addressing the diagnosis, treatment and prognosis of gastrointestinal, surgical, respiratory, otolaryngological, nutritional, psychological and quality of life complications that patients with EA-TEF face during adolescence and after the transition to adulthood were formulated. A systematic literature search was performed based on which recommendations were made. All recommendations were discussed and finalized during consensus meetings, and the group members voted on each recommendation. Expert opinion was used when no randomized controlled trials were available to support the recommendation. The list of the 42 statements, all based on expert opinion, was voted on and agreed upon.

Evaluating the impact of position, volume, and consistency on high-resolution esophageal manometry outcomes.

BACKGROUND: The Chicago classification primarily utilizes ten 5 mL liquid swallows in a supine position as the standard high-resolution esophageal manometry (HRM) protocol. HRM can be performed with varying volumes and consistencies and in an upright position. We aimed to determine the impact on HRM results by (1) position, (2) swallows of differing volume and consistency, and (3) perception of bolus passage. METHODS: HRM was performed in healthy volunteers (HV) with the following protocol of swallows: liquids 10 × 5 mL, 5 × 10 mL, and 3 × 10 mL multiple rapid swallows; applesauce 5 × 5 mL and 5 × 10 mL; and bread 5 × 2 × 2 cm and 5 × 4 × 4cm. HV rated difficulty of each swallow on a 5-point Likert scale. All HVs performed the protocol in supine position first and then in "semi-upright" (sitting 70 degrees in a bed) and "upright" (sitting in a chair) in a randomized order. KEY RESULTS: Thirty-seven HVs, median age 27 years, 64% female completed this study. Median distal contractile integral (DCI) and integrated relaxation pressure 4 s (IRP4) of 5 mL liquid swallows significantly differed (all p < 0.01) between position performed. Large volume swallows resulted in higher DCI and lower IRP4. IRP4 results were significantly increased for 2 × 2 cm pieces of bread compared to 5 mL water swallows. DCI results were higher for 2 × 2 cm pieces of bread compared to 5 mL water swallows. Distal latency was shorter in more upright positions. Among this cohort of HV, perceived difficulty of bolus passage was more likely to occur with solid boluses. CONCLUSIONS AND INFERENCES: The volume and consistency of a swallow and the position it is performed in, significantly alter HRM metrics. Interpretation of HRM studies should incorporate different normative values which are specific to the position and bolus type.

Defining dysphagia - a modified multi-professional Danish Delphi study.

OBJECTIVE: To establish a generally accepted Danish definition of dysphagia to enhance collaboration across sectors and professions. METHODS: The study was initiated by a multi-professional group of experienced researchers and board members of the Danish Society for Dysphagia. We used a modified Delphi methodology to achieve consensus among experienced health care professionals from different professions and contexts. The initial stage consisted of a literature search leading to the draft of different definitions followed by two Delphi rounds between professionals and a stakeholder consultation round. RESULTS: We conducted two Delphi rounds until one definition was clearly preferred. A total of 194 participants responded in round one, and 279 in round two. Both rounds had a broad representation of sectors and geography and most participants had worked with dysphagia for more than four years. CONCLUSION: The preferred definition was 'Dysphagia is a functional impairment that either prevents or limits the intake of food and fluids, and which makes swallowing unsafe, inefficient, uncomfortable or affects quality of life'. The definition was widely accepted among different health professional groups, patients and across sectors.

Using high resolution manometry impedance to diagnose upper esophageal sphincter and pharyngeal motor disorders.

BACKGROUND: Oro-pharyngeal pathophysiology, including upper esophageal sphincter (UES) and pharyngeal disorders, can be assessed by pharyngeal high-resolution manometry impedance (P-HRM-I). We aimed to establish methodology to diagnose disorders utilizing P-HRM-I, hypothesizing that the objective measures could be used to diagnose disordered deglutition evidenced by greater aspiration scores. METHODS: Patients (n = 509, 18-91 years) were compared to controls (n = 120, 20-94 years). Variables measuring UES relaxation, UES opening extent, intrabolus pressure, and pharyngeal contractile strength were derived for 10 ml liquid swallows. Three associated pharyngeal pressurization patterns, which may be indicative of obstructed flow, were characterized: pan-pressurization (Type 1), distal compartmentalized pressurization (Type 2), and transient pressurization (Type 3). Deglutitive aspiration was determined from video fluoroscopy. RESULTS: UES relaxation pressure was best able to differentiate patients from controls (T 6.528, p < 0.0001). Patients with abnormal relaxation pressure (>8 mmHg) more frequently exhibited pharyngeal pressurization patterns and had adjunct evidence of reduced luminal distensibility (high intrabolus pressure and/or reduced UES opening). Utilizing this information, a diagnostic scheme was devised identifying 138 patients with UES disorder. A further 96 patients without evidence of UES disorder had abnormally weak pharyngeal pressures, confirming propulsive disorder. Amongst a sub-sample of 320 patients undergoing video fluoroscopy, those with pharyngeal pressurizations and adjunct evidence of reduced UES relaxation and/or distensibility had higher aspiration scores (Chi-square 60.169, p < 0.0001). CONCLUSION: P-HRM-I can provide evidence for UES disorder based on pharyngeal pressurization patterns and abnormal findings for UES relaxation pressure, UES opening, and intrabolus pressure. Measuring pharyngeal contractility requires further optimization.

Characterizing Esophageal Motility in Neonatal Intensive Care Unit Patients Using High Resolution Manometry.

OBJECTIVE: To characterize esophageal motility and esophago-gastric junction (EGJ) function during feeding in neonatal intensive care unit (NICU) patients. PATIENTS AND METHODS: High resolution manometry with impedance (HRIM) was used to investigate esophageal motility and EGJ function in patients admitted to the NICU. Twenty-eight preterm born infants with bronchopulmonary dysplasia (BPD), 12 born with isolated congenital diaphragmatic hernia (iCDH), and 10 with esophageal atresia (EA) were included. Thirteen healthy infants were included as controls. Esophageal motility and EGJ function were analyzed using objective esophageal bolus transport parameters. RESULTS: Normal esophageal peristaltic wave patterns were observed in all investigated infants without EA. Nine of 10 patients with EA presented with abnormal esophageal motor wave patterns. A total of 224 nutritive swallows were analyzed (controls, n = 48; BPD, n = 96; iCDH, n = 60; EA, n = 20). Infants with BPD and iCDH had similar distal contractile strength (DCI) compared to healthy controls, while in patients with EA, DCI was significantly lower (Kruskal-Wallis test, p = 0.001). In most infants, EGJ relaxation after swallowing was unaffected. EGJ barrier function, in terms of EGJ-contractile integral, also appeared well-developed and did not differ significantly among patient groups. CONCLUSIONS: We conclude that esophageal motility studies using pressure-impedance analysis are feasible in young infants. Bolus transport mechanisms following nutritive swallows appeared well-established in all investigated infants with the exception of those with EA. EGJ relaxation was also functional after deglutition and EGJ function as an anti-reflux barrier appeared well-developed in all investigated NICU groups.

Accuracy of High-Resolution Pharyngeal Manometry Metrics for Predicting Aspiration and Residue in Oropharyngeal Dysphagia Patients with Poor Pharyngeal Contractility.

Several physiological metrics can be derived from pharyngeal high-resolution impedance manometry (HRPM), but their clinical relevance has not been well established. We investigated the diagnostic performance of these metrics in relation to videofluoroscopic (VFS) assessment of aspiration and residue in patients with oropharyngeal dysphagia. We analyzed 263 swallows from 72 adult patients (22-91 years) with diverse medical conditions. Metrics of contractility, upper esophageal sphincter (UES) opening and relaxation, flow timing, intrabolus distension pressure, and a global Swallow Risk Index (SRI) were derived from pressure-impedance recordings using pressure-flow analysis. VFS data were independently scored for airway invasion and pharyngeal residue using the Penetration-Aspiration Scale and the Normalized Residue Ratio Scale, respectively. We performed multivariate logistic regression analyses to determine the relationship of HRPM metrics with radiological outcomes and receiver-operating characteristic (ROC) analysis to evaluate their diagnostic accuracy. We identified aspiration in 25% and pharyngeal residue in 84% of the swallows. Aspiration was independently associated with hypopharyngeal peak pressure < 65 mmHg (HypoPeakP) [adjusted odds ratio (OR) 5.27; 95% Confidence Interval (CI) (0.99-28.1); p = 0.051], SRI > 15 [OR 4.37; 95% CI (1.87-10.2); p < 0.001] and proximal esophageal contractile integral (PCI) < 55 mmHg·cm·s [OR 2.30; 95% CI (1.07-4.96); p = 0.034]. Pyriform sinus residue was independently predicted by HypoPeakP < 65 mmHg [OR 7.32; 95% CI (1.93-27.7); p = 0.003], UES integrated relaxation pressure (UES-IRP) > 3 mmHg [OR 2.96; 95% CI (1.49-5.88); p = 0.002], and SRI > 15 [OR 2.17; 95% CI (1.04-4.51); p = 0.039]. Area under ROC curve (AUC) values for individual HRPM metrics ranged from 0.59 to 0.74. Optimal cut-off values were identified. This study demonstrates the diagnostic value of certain proposed and adjunct HRPM metrics for identifying signs of unsafe and inefficient bolus transport in patients with oropharyngeal dysphagia.

Transient hypopharyngeal intrabolus pressurization patterns: Clinically relevant or normal variant?

INTRODUCTION: In oropharyngeal dysphagia, impaired pharyngoesophageal junction (PEJ) opening is reflected by an elevated hypopharyngeal intrabolus pressure (IBP), quantifiable using pharyngeal high-resolution manometry with impedance (P-HRM-I). Transient intrabolus pressurization (TP) phenomena are not sustained and last for only a brief period. We hypothesized that TP patterns reflect impaired coordination between timing of hypopharyngeal bolus arrival and PEJ relaxation. METHODS: A retrospective audit was conducted of P-HRM-I datasets; 93 asymptomatic Controls and 214 Patients with differing etiological/clinical backgrounds were included. TP patterns were examined during 10ml liquid swallows. TP was defined by a simultaneous, non-sustained, pressurization wave spanning from the velo-/meso-pharynx to PEJ. The coordination between deglutitive pharyngeal bolus distension and PEJ relaxation timing was assessed using timing variables; (i) Distention-Contraction Latency (DCL, s) and (ii) PEJ Relaxation Time (RT, s). Resultant flow resistance was quantified (IBP, mmHg). RESULTS: TP swallows were observed in 87 (28%) cases. DCL was not significantly different in relation to TP, while PEJ relaxation time was shorter, and IBP was higher during TP swallows. In Patients RT-DCL time difference correlated with IBP (r -0.368, p < 0.01). CONCLUSION: Bolus distension and PEJ relaxation were miss-timed during TP swallows, impeding bolus flow and leading to a brief period of pressurization of the pharyngeal chamber by muscular propulsive forces. While TP swallows were identified in both Controls and Patients, increased IBPs were most apparent for Patient swallows indicating that the extent of IBP increase may differentiate pathological TP swallows.

High-resolution colonic manometry interobserver analysis trial.

INTRODUCTION: Colonic high-resolution manometry (HRM) is a novel, not widely used diagnostic method used in the final workup of chronic constipation before surgery. Since its introduction, different motor patterns have been defined. However, it remains to be established whether these patterns are easily and reproducibly identified by different investigators. METHODS: The primary aim of this study was to determine agreement for motor pattern identification with HRM. To calculate the interobserver agreement (IOA), the Fleiss's kappa statistic for multiple observers was used. Seven participants analyzed 106 one-min time frames, derived from five measurements in healthy volunteers and five in patients with chronic constipation. The time frames were chosen to show a variety and combination of motor patterns consisting of short antegrade, short retrograde, cyclic anterograde, cyclic retrograde, long antegrade, long retrograde, slow retrograde motor pattern, high-amplitude propagating motor patterns, and pancolonic pressurizations. All of the measurements were performed with a solid-state colonic HRM catheter, comprising 40 pressure sensors spaced 2.5 cm apart. RESULTS: A median of 10.25 h (range 6-20) were required to analyze all time frames. High-amplitude propagating contractions achieved an almost perfect level of agreement (k = 0.91). Several motor patterns achieved substantial agreement; these included the short antegrade (k = 0.63), long antegrade (k = 0.68), cyclic retrograde (k = 0.70), slow retrograde motor pattern (k = 0.80), and abdominal pressure or movement artifacts (k = 0.67). Moderate agreement was found for short retrograde (k = 0.57), cyclic anterograde (k = 0.59), long retrograde motor patterns (k = 0.59) and simultaneous pressure waves (k = 0.59). CONCLUSION: For the majority of motor patterns, the overall IOA for colonic manometry was substantial or high. This high level of agreement supports the use of colonic manometry application in clinical and research settings. Harmonization has the potential to improve agreement for long anterograde motor patterns with high amplitudes and for mixed direction patterns.

Spontaneous Swallowing Frequency, Dysphagia, and Drooling in Children With Cerebral Palsy.

OBJECTIVE: To evaluate relationships between spontaneous swallowing frequency, dysphagia, and drooling in children with cerebral palsy. Spontaneous swallowing frequency was predicted to be inversely related to both dysphagia and drooling among children with cerebral palsy. A secondary objective compared patterns among spontaneous swallowing frequency, drooling, and age in healthy children vs children presenting with cerebral palsy. DESIGN: Cross sectional study. SETTING: Children with cerebral palsy were tested at a Cerebral Palsy Reference Center in a university hospital. Healthy children were tested in their home setting. PARTICIPANTS: Twenty children with cerebral palsy were recruited from the local registry for cerebral palsy children and purposive sampling among parents. A group of 30 healthy children was recruited by purposive sampling among family, friends, and the local community. Children below 1 year of age up to 5 years of age were included in the healthy group. This age range was targeted to maximize the potential for drooling in this group. MAIN OUTCOME MEASURES: Both groups provided data on spontaneous swallowing frequency (swallows per minute, or SPM), dysphagia, and drooling. Motor impairment was documented in the children with cerebral palsy. RESULTS: SPM was significantly lower in children with cerebral palsy. Among children with cerebral palsy, SPM correlated significantly with dysphagia severity and trended toward a significant correlation with drooling at rest. In this subgroup, SPM was not correlated with age or degree of motor impairment. Dysphagia was significantly correlated with drooling at rest and both dysphagia and drooling at rest were correlated with degree of motor impairment. The 2 groups did not differ in the degree of drooling at rest. Among healthy children, age but not SPM demonstrated a significant inverse correlation with drooling quotient at rest. CONCLUSIONS: Spontaneous swallowing frequency is related to dysphagia and drooling in children with cerebral palsy. The pattern of relationships among spontaneous swallowing frequency and drooling is different between children with cerebral palsy and younger healthy children.

Rare Case of Bilateral Diffuse Uveal Melanocytic Proliferation with Dermal and Mucosal Hyperpigmentations.

PURPOSE: The demonstration of a rare case of bilateral diffuse uveal melanocytic proliferation (BDUMP) due to a lung carcinoma with unusual dermal lesions. CASE DESCRIPTION: A 76-year-old man with painless bilateral vision loss revealed leopard or giraffe spot chorioretinopathy and bilateral serous retinal detachment. Ultrasound biomicroscopy revealed uveal swelling expanding into the anterior chamber angle. Dermal and mucosal lesions were present on the lip, breast, groin, scrotum, and penis. Screening analyses revealed a non-small cell lung carcinoma. CONCLUSIONS: The diagnosis of BDUMP, a rare paraneoplastic syndrome, was made. The ophthalmological diagnosis led to screening investigations and revealed the underlying malignant disease. Uncommonly, multiple dermal and mucosal lesions could be detected and were analyzed histopathologically.

Management of Ineffective Esophageal Hypomotility.

Esophageal hypomotility in general and especially ineffective esophageal motility according to the Chicago criteria of primary motility disorders of the esophagus, is one of the most frequently diagnosed motility disorders on high resolution manometry and results in a large number of patients visiting gastroenterologists. Most patients with esophageal hypomotility present with gastroesophageal reflux symptoms or dysphagia. The clinical relevance of the motility pattern, however, is not well established but seems to be correlated with disease severity in reflux patients. The correlation with dysphagia is less clear. Prokinetic agents are commonly prescribed as first line pharmacologic intervention to target esophageal smooth muscle contractility and improve esophageal motor functions. However, the beneficial effects of these medications are limited and only confined to some specific drugs. Serotonergic agents, including buspirone, mosapride and prucalopride have been shown to improve parameters of esophageal motility although the effect on symptoms is less clear. Understanding on the complex correlation between esophageal hypomotility and esophageal symptoms as well as the limited evidence of prokinetic agents is necessary for physicians to appropriately manage patients with Ineffective Esophageal Motility (IEM).

Appropriateness for SARS-CoV-2 vaccination for otolaryngologist and head and neck surgeons in case of pregnancy, breastfeeding, or childbearing potential: Yo-IFOS and CEORL-HNS joint clinical consensus statement.

PURPOSE: SARS-CoV-2 vaccines are a key step in fighting the pandemic. Nevertheless, their rapid development did not allow for testing among specific population subgroups such as pregnant and breastfeeding women, or elaborating specific guidelines for healthcare personnel working in high infection risk specialties, such as otolaryngology (ORL). This clinical consensus statement (CCS) aims to offer guidance for SARS-CoV-2 vaccination to this high-risk population based on the best evidence available. METHODS: A multidisciplinary international panel of 33 specialists judged statements through a two-round modified Delphi method survey. Statements were designed to encompass the following topics: risk of SARS-Cov-2 infection and use of protective equipment in ORL; SARS-Cov-2 infection and vaccines and respective risks for the mother/child dyad; and counseling for SARS-CoV-2 vaccination in pregnant, breastfeeding, or fertile healthcare workers (PBFHW). All ORL PBFHW were considered as the target audience. RESULTS: Of the 13 statements, 7 reached consensus or strong consensus, 2 reached no consensus, and 2 reached near-consensus. According to the statements with strong consensus otorhinolaryngologists-head and neck surgeons who are pregnant, breastfeeding, or with childbearing potential should have the opportunity to receive SARS-Cov-2 vaccination. Moreover, personal protective equipment (PPE) should still be used even after the vaccination. CONCLUSION: Until prospective evaluations on these topics are available, ORL-HNS must be considered a high infection risk specialty. While the use of PPE remains pivotal, ORL PBFHW should be allowed access to SARS-CoV-2 vaccination provided they receive up-to-date information.

Chicago classification version 4.0© technical review: Update on standard high-resolution manometry protocol for the assessment of esophageal motility.

The Chicago Classification v4.0 (CCv4.0) is the updated classification scheme for esophageal motility disorders using metrics from high-resolution manometry (HRM). A key feature of CCv.4.0 is the more rigorous and expansive protocol that incorporates single wet swallows acquired in different positions (supine, upright) and provocative testing, including multiple rapid swallows and rapid drink challenge. Additionally, solid bolus swallows, solid test meal, and/or pharmacologic provocation can be used to identify clinically relevant motility disorders and other conditions (eg, rumination) that occur during and after meals. The acquisition and analysis for performing these tests and the evidence supporting their inclusion in the Chicago Classification protocol is detailed in this technical review. Provocative tests are designed to increase the diagnostic sensitivity and specificity of HRM studies for disorders of esophageal motility. These changes attempt to minimize ambiguity in prior iterations of Chicago Classification, decrease the proportion of HRM studies that deliver inconclusive diagnoses and increase the number of patients with a clinically relevant diagnosis that can direct effective therapy. Another aim in establishing a standard manometry protocol for motility laboratories around the world is to facilitate procedural consistency, improve diagnostic reliability, and promote collaborative research.

ESSD Commentary on Dysphagia Management During COVID Pandemia.

Since the World Health Organization declared the COVID-19 pandemic a Global Public Health Emergency, experts in swallowing are seeking guidance on service delivery and clinical procedures. The European Society for Swallowing Disorders provides considerations to support experts in swallowing disorders in clinical practice. During the COVID-19 pandemic, assessment and treatment of patients with oropharyngeal dysphagia should be provided, while at the same time balancing risk of oropharyngeal complications with that of infection of patients and healthcare professionals involved in their management. Elective, non-urgent assessment may be temporarily postponed and patients are triaged to decide whether dysphagia assessment is necessary; instrumental assessment of swallowing is performed only if processing of the instruments can be guaranteed and clinical assessment has not provided enough diagnostic information for treatment prescription. Assessment and management of oropharyngeal dysphagia is a high-risk situation as it must be considered an aerosol-generating procedure. Personal protective equipment (PPE) should be used. Telepractice is encouraged and compensatory treatments are recommended.

Modulation of pharyngeal swallowing by bolus volume and viscosity.

Oropharyngeal swallowing involves complex neuromodulation to accommodate changing bolus characteristics. The pressure events during deglutitive pharyngeal reconfiguration and bolus flow can be assessed quantitatively using high-resolution pharyngeal manometry with impedance. An 8-French solid-state unidirectional catheter (32 pressure sensors, 16 impedance segments) was used to acquire triplicate swallows of 3 to 20 ml across three viscosity levels using a Standardized Bolus Medium (SBMkit) product (Trisco, Pty. Ltd., Australia). An online platform (https://swallowgateway.com/; Flinders University, South Australia) was used to semiautomate swallow analysis. Fifty healthy adults (29 females, 21 males; mean age 46 yr; age range 19-78 yr old) were studied. Hypopharyngeal intrabolus pressure, upper esophageal sphincter (UES) maximum admittance, UES relaxation pressure, and UES relaxation time revealed the most significant modulation effects to bolus volume and viscosity. Pharyngeal contractility and UES postswallow pressures elevated as bolus volumes increased. Bolus viscosity augmented UES preopening pressure only. We describe the swallow modulatory effects with quantitative methods in line with a core outcome set of metrics and a unified analysis system for broad reference that contributes to diagnostic frameworks for oropharyngeal dysphagia.NEW & NOTEWORTHY The neuromodulation of the healthy oropharyngeal swallow response was described in relation to bolus volume and viscosity challenges, using intraluminal pressure and impedance topography methods. Among a wide range of physiological measures, those indicative of distension pressure, luminal opening, and flow timing were most significantly altered by bolus condition, and therefore can be considered to be potential markers of swallow neuromodulation. The study methods and associated findings inform a diagnostic framework for swallow assessment in patients with oropharyngeal dysphagia.

European white paper: oropharyngeal dysphagia in head and neck cancer.

PURPOSE: To develop a European White Paper document on oropharyngeal dysphagia (OD) in head and neck cancer (HNC). There are wide variations in the management of OD associated with HNC across Europe. METHODS: Experts in the management of specific aspects of OD in HNC across Europe were delegated by their professional medical and multidisciplinary societies to contribute to this document. Evidence is based on systematic reviews, consensus-based position statements, and expert opinion. RESULTS: Twenty-four sections on HNC-specific OD topics. CONCLUSION: This European White Paper summarizes current best practice on management of OD in HNC, providing recommendations to support patients and health professionals. The body of literature and its level of evidence on diagnostics and treatment for OD in HNC remain poor. This is in the context of an expected increase in the prevalence of OD due to HNC in the near future. Contributing factors to increased prevalence include aging of our European population (including HNC patients) and an increase in human papillomavirus (HPV) related cancer, despite the introduction of HPV vaccination in various countries. We recommend timely implementation of OD screening in HNC patients while emphasizing the need for robust scientific research on the treatment of OD in HNC. Meanwhile, its management remains a challenge for European professional associations and policymakers.

Esophageal motility disorders on high-resolution manometry: Chicago classification version 4.0©.

Chicago Classification v4.0 (CCv4.0) is the updated classification scheme for esophageal motility disorders using metrics from high-resolution manometry (HRM). Fifty-two diverse international experts separated into seven working subgroups utilized formal validated methodologies over two-years to develop CCv4.0. Key updates in CCv.4.0 consist of a more rigorous and expansive HRM protocol that incorporates supine and upright test positions as well as provocative testing, a refined definition of esophagogastric junction (EGJ) outflow obstruction (EGJOO), more stringent diagnostic criteria for ineffective esophageal motility and description of baseline EGJ metrics. Further, the CCv4.0 sought to define motility disorder diagnoses as conclusive and inconclusive based on associated symptoms, and findings on provocative testing as well as supportive testing with barium esophagram with tablet and/or functional lumen imaging probe. These changes attempt to minimize ambiguity in prior iterations of Chicago Classification and provide more standardized and rigorous criteria for patterns of disorders of peristalsis and obstruction at the EGJ.

Codeine induces increased resistance at the esophagogastric junction but has no effect on motility and bolus flow in the pharynx and upper esophageal sphincter in healthy volunteers: A randomized, double-blind, placebo-controlled, cross-over trial.

BACKGROUND: Chronic opioid use can induce esophageal dysfunction with symptoms resembling achalasia and a manometric pattern of esophagogastric junction-outflow obstruction (EGJ-OO). However, the effect of opioids in acute setting on pharyngeal function and esophageal body contractility has not been investigated. METHODS: After positioning the high-resolution impedance manometry (HRiM) catheter, codeine (60 mg) or placebo (glucose syrup) was infused intragastrically. Forty-five minutes post-infusion, participants received liquid, semi-solid, and solid boluses to assess esophageal and pharyngeal function. HRiM analysis was performed adhering to the Chicago classification v3.0. (CC v3.0). Pressure flow analysis (PFA) for the esophageal body and the pharynx was performed using the SwallowGateway™ online platform. KEY RESULTS: Nineteen healthy volunteers (HV) [5 male; age 38.3] were included. After codeine administration, higher integrated relaxation pressure 4 s values resulted in significantly reduced deglutitive EGJ relaxation and distal latency was significantly shorter. Distal contractility was similar in both conditions. Bolus flow resistance at the EGJ and distention pressures increased significantly after codeine infusion. Based on CC v3.0, acute infusion of codeine induced EGJ-OO in six HV (p = 0.0003 vs. placebo). Codeine administration induced no significant alterations in any of the pharyngeal PFA metrics. CONCLUSIONS & INFERENCES: In HV, acute administration of codeine increased bolus resistance at the EGJ secondary to induced incomplete EGJ relaxation leading to major motility disorders in a subset of subjects including EGJ-OO. However, an acute single dose of codeine did not affect motility or bolus flow in pharynx and UES. ClinicalTrials.gov number, NCT03784105.

The gastro-sphincteric pressure gradient: A new parameter to diagnose a rumination episode.

BACKGROUND: Rumination is defined as the repetitive, effortless regurgitation of recently ingested food into the mouth. These episodes are preceded by a rise in intragastric pressure (IGP) and mainly occur postprandially. IGP peaks >30 mmHg have been proposed as a cutoff to differentiate rumination from reflux events. In clinical practice, we observed that this cutoff, which does not consider esophagogastric junction (EGJ) resistance, is not always reached. METHODS: We studied 27 patients with rumination syndrome [age: 43.6, 59% female] and 28 gastro-esophageal reflux disease patients [age: 45.9, 54% female]. For each rumination episode, reflux event, transient lower esophageal sphincter relaxation (TLESR), or straining without regurgitation, the following parameters were registered: maximal IGP, IGP, and EGJ pressure preceding the respective episodes. We also quantified the gastro-sphincteric pressure gradient (GSPG) prior to the respective episodes. KEY RESULTS: Five reflux episodes were characterized by a maximal IGP >30 mmHg. In 28% of the rumination episodes, the IGP peak did not exceed 30 mmHg. Median GSPG was positive for rumination episodes and significantly higher compared with TLESRs, reflux episodes, and straining without regurgitation (7 [3-13] vs. 0 [-1-0] vs. 0 [-1-0] vs. -9 [-13--2]; p < 0.0001). CONCLUSIONS & INTERFERENCES: Applying the proposed cutoff of 30 mmHg, 28% of the rumination episodes were missed. We found that the GSPG differentiates between rumination (positive GSPG), TLESRs and reflux events (GSPG around 0), and straining without regurgitation (negative GSPG). We propose a GSPG value ≥2 mmHg to distinguish rumination from reflux episodes, TLESRs, and straining without regurgitation.

A survey on the impact of the COVID-19 pandemic on motility and functional investigations in Europe and considerations for recommencing activities in the early recovery phase.

BACKGROUND: The COVID-19 pandemic, declared by WHO on March 13, 2020, had a major global impact on the healthcare system and services. In the acute phase, the presence of the SARS-CoV-2 virus in the aerodigestive tract limited activities in the gastroenterology clinic and procedures to emergencies only. Motility and function testing was interrupted and as we enter the recovery phase, restarting these procedures requires a safety-focused approach with adequate infection prevention for patients and healthcare professionals. METHODS: We summarized knowledge on the presence of the SARS-CoV-2 virus in the aerodigestive tract and the risk of spread with motility and functional testing. We surveyed 39 European centers documenting how the pandemic affected activities and which measures they are considering for restarting these measurements. We propose recommendations based on current knowledge as applied in our center. RESULTS: Positioning of catheters for gastrointestinal motility tests carries a concern for aerosol-borne infection of healthcare workers. The risk is low with breath tests. The surveyed centers stopped almost all motility and function tests from the second half of March. The speed of restarting and the safety measures taken varied highly. CONCLUSIONS AND INFERENCES: Based on these findings, we provided recommendations and practical relevant information for motility and function test procedures in the COVID-19 pandemic era, to guarantee a high-quality patient care with adequate infection prevention.