A New Method to Evaluate Lower Esophageal Distension Capacity in Eosinophilic Esophagitis by Using Functional Lumen Imaging Probe (EndoFLIP™).

Endoluminal functional lumen impedance planimetry (EndoFLIPTM) has become the gold standard to evaluate esophageal distensibility, although the study itself and its analysis present challenges. We propose here a new method to assess lower esophageal distension capacity that overcomes several limitations of prior approaches, including incomplete and corrupted EndoFLIPTM recordings. Esophageal distension capacity was evaluated with a 16-channel EndoFLIPTM in 10 controls and 14 patients with eosinophilic esophagitis (EoE). Controls were evaluated once. EoE patients were evaluated at baseline and after at least six weeks of treatment with orodispersible budesonide tablets, 1 mg bd. Balloon volumes were increased by 5 mL stepwise, either reaching a maximum volume of 60 mL or a maximum balloon pressure of 60 mmHg. Recordings were analyzed with a homemade R script. The mean esophageal diameter at 60 mL, D (60 mL), was calculated or extrapolated depending on whether the 60 mL volume was reached. By fitting a Michaelis-Menten curve across all measured diameters throughout all constant volume steps, the mean D (60 mL) was estimated. For control subjects, the mean ± SD value of D (60 mL) was 17.08 ± 1.69 mm, and for EoE patients at baseline, D (60 mL) was 14.51 ± 2.68 mm. After six weeks of treatment of EoE patients, D (60 mL) significantly increased to 16.22 ± 1.86 mm (paired Wilcoxon signed test: p = 0.0052), although the values for control subjects were not reached. The estimated mean esophageal diameter at 60 mL is a good proxy for esophageal distension capacity, which correlates with clinical outcomes in EoE. The method presented in this study overcomes difficulties encountered during the standard measurement protocol, allowing the analysis of recordings from incomplete and corrupted registries.

Implementation of a peroral endoscopic myotomy program.

INTRODUCTION: the aim of our study was to develop a peroral endoscopic myotomy (POEM) program in our Unit following a two-step sequence: training on animal models and supervision by an experienced endoscopist during the first human cases. METHODS: a single endoscopist experienced in advanced endoscopy was trained in POEM. After observing POEM in referral centers, training was implemented on swine models (preclinical phase). Technical aspects and adverse events were prospectively recorded. A first subset of cases (group A) was compared to a second one (group B) to assess our progression. Finally, POEM was implemented in humans under the supervision of an experienced endoscopist (clinical phase). The outcomes and adverse events were prospectively recorded. RESULTS: during the preclinical phase, 15 POEM procedures were performed on live pigs. Severe adverse events (AE) were less frequent in group B than in group A (12 % vs 57 %, p = 0.07). After nine cases, a plateau of adverse events was reached. During the clinical phase, eleven POEM procedures were performed in patients under expert supervision. Technical and clinical (Eckardt score ≤ 3) success were 100 % and 91 %, respectively (follow-up 3-21 months). In two cases, intervention of an experienced endoscopist was required (cases 2 and 3) because of a difficult orientation at the esophagogastric junction. One mild pneumoperitoneum occurred, with no severe adverse events reported. CONCLUSIONS: training in animal models and supervision by an experienced endoscopist during the first cases could provide the necessary skills to perform POEM safely and effectively.

Role of high resolution manometry in the diagnostic and therapeutic approach of post fundoplication dysphagia / Papel de la manometría de alta resolución en el abordaje diagnóstico y terapéutico de la disfagia posterior a la fundoplicatura

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Normal values for water-perfused esophageal high-resolution manometry.

BACKGROUND: Normal values for water-perfused esophageal high-resolution manometry have still not been established in our environment, despite its generalized use and the recommendation to determine reference values for each Motility Unit based on their equipment. Normal values established with solid-state highresolution manometry are currently being used as reference values for water-perfused high-resolution manometry. OBJECTIVES: To obtain normal values for water-perfused esophageal high-resolution manometry, based on the esophageal motility analysis of healthy subjects. METHODS: 16 healthy volunteers without history of digestive complaints or esophageal symptoms were included. 22-channel water-perfused high-resolution manometry was performed. RESULTS: Normal values were calculated as 5th-95th percentile ranges for the following parameters; upper esophageal sphincter resting pressure (UESRP) (40-195 mmHg); upper esophageal sphincter residual pressure (UESResP) (30-115 mmHg), contractile front velocity (CFV) (2.4-7.1 cm/s), distal contractile integral (DCI) (285-2820 mmHg.s.cm), distal contraction latency (DL) (6.1-10.9 s), intrabolus pressure (IBP) (7-19 mmHg), integrated relaxation pressure (IRP 4s) (2-20 mmHg), lower esophageal sphincter resting pressure(LESRP) (5-54 mmHg), esophageal shortening (Es) (0.3-1.3 cm) and lower esophageal sphincter lift (LESL) (0,1-1,2 cm). CONCLUSION: Normal values for the most important parameters (such as IRP 4s, DL and CFV), obtained using a 22-channel waterperfused system resemble previously published data from other perfusion devices. However, there exist small but significant variations compared with values established with solid-state highresolution manometry. Thus, when using water-perfused catheters, caution is required when normative values are used that were established with solid-state catheters.

Valores de referencia de manometría esofágica de alta resolución mediante sistema de perfusión / Normal values for water-perfused esophageal high-resolution manometry

ANTECEDENTES: los valores de referencia de la manometría esofágica de alta resolución mediante sistema de perfusión aún no han sido establecidos en nuestro medio, a pesar de su empleo generalizado en múltiples Unidades de Motilidad y la recomendación de determinar valores de referencia propios de cada Unidad en función de sus equipos. Actualmente se utilizan como referencia los valores de normalidad de la manometría de alta resolución en estado sólido. OBJETIVOS: el objetivo de este estudio es establecer los valores de normalidad para la manometría de alta resolución de perfusión de 22 canales a partir del análisis de la motilidad esofágica de individuos sanos. MÉTODOS: se incluyeron 16 voluntarios sanos, sin patología digestiva ni síntomas esofágicos, a los que se realizó una manometría de alta resolución mediante sistema de perfusión de 22 canales. RESULTADOS: los datos vienen referidos como la media y el rango comprendido entre los percentiles 5 y 95. Los percentiles 5 y 95 de cada uno de los parámetros fueron de 40-195 mmHg para la presión de reposo del esfínter esofágico superior (PRESS), 30-115 mmHg para la presión residual del esfínter esofágico superior (PResEES), 2,4-7,1 cm/s para la velocidad de frente contráctil (VFC), 285-2.820 mmHg.s.cm para la integral contráctil distal (ICD), 6,1-10,9 s para la latencia distal (LD), 7-19 mmHg para la presión intrabolo (PIB), 2-20 mmHg para la presión de relajación integrada a los 4 segundos (PRI4s) y 5-54 mmHg para la presión de reposo del esfínter esofágico inferior (PREEI). Los percentiles 5 y 95 del acortamiento esofágico (aE) fueron 0,3-1,3 cm y del ascenso del esfínter esofágico inferior (aEEI) 0,1-1,2 cm. CONCLUSIÓN: los rangos de normalidad obtenidos mediante sistema de perfusión de 22 canales para los parámetros manométricos más importantes (PRI4s, LD, VFC) son similares a los previamente publicados con equipos de perfusión, existiendo variaciones pequeñas, pero significativas, respecto a los valores establecidos por equipos de estado sólido

BACKGROUND: Normal values for water-perfused esophageal high-resolution manometry have still not been established in our environment, despite its generalized use and the recommendation to determine reference values for each Motility Unit based on their equipment. Normal values established with solid-state highresolution manometry are currently being used as reference values for water-perfused high-resolution manometry. OBJECTIVES: To obtain normal values for water-perfused esophageal high-resolution manometry, based on the esophageal motility analysis of healthy subjects. METHODS: 16 healthy volunteers without history of digestive complaints or esophageal symptoms were included. 22-channel water-perfused high-resolution manometry was performed. RESULTS: Normal values were calculated as 5th-95th percentile ranges for the following parameters; upper esophageal sphincter resting pressure (UESRP) (40-195 mmHg); upper esophageal sphincter residual pressure (UESResP) (30-115 mmHg), contractile front velocity (CFV) (2.4-7.1 cm/s), distal contractile integral (DCI) (285-2820 mmHg.s.cm), distal contraction latency (DL) (6.1-10.9 s), intrabolus pressure (IBP) (7-19 mmHg), integrated relaxation pressure (IRP 4s) (2-20 mmHg), lower esophageal sphincter resting pressure (LESRP) (5-54 mmHg), esophageal shortening (Es) (0.3-1.3 cm) and lower esophageal sphincter lift (LESL) (0,1-1,2 cm). CONCLUSION: Normal values for the most important parameters (such as IRP 4s, DL and CFV), obtained using a 22-channel waterperfused system resemble previously published data from other perfusion devices. However, there exist small but significant variations compared with values established with solid-state highresolution manometry. Thus, when using water-perfused catheters, caution is required when normative values are used that were established with solid-state catheters

Effect of aspirin and antiplatelet drugs on the outcome of the fecal immunochemical test.

OBJECTIVE: To evaluate the effect of aspirin and nonaspirin antiplatelet agents (NAAAs) on the performance of the fecal immunochemical test (FIT). PARTICIPANTS AND METHODS: We performed a post hoc analysis of results from a clinical trial that involved 28,696 asymptomatic average-risk men and women aged 50 to 69 years invited to participate in a colorectal cancer screening program with FIT between November 1, 2008, and June 31, 2011. RESULTS: The test was returned by 6390 individuals (22.3%), of whom 5821 (91.1%) reported not using antiplatelet drugs (nonusers group) and 569 (8.9%) reported using these drugs at the time of testing (users group). The FIT result was positive in 48 of 569 users (8.4%) and 365 of 5821 nonusers (6.3%) (P=.05). A positive FIT result was found in 7.3% (28/384) of aspirin users, 7.1% (10/140) of NAAA users, and 22.2% (10/45) of those undergoing dual antiplatelet therapy (DAPT) (aspirin plus an NAAA). The DAPT subgroup had a significantly higher positive FIT rate than the nonuser group (odds ratio, 3.5; 95% CI, 1.7-7.3; P<.05). The positive predictive value (PPV) for advanced neoplasia (AN) in nonusers was 50.4% vs 50.0% in users (P = .40). The PPV for AN was 57.0% in aspirin users, 30.0% in NAAA users, and 50.0% in DAPT users, without statistically significant differences between the user and nonuser groups. CONCLUSION: The use of DAPT increased the rate of positive FIT results. Use of aspirin, NAAAs, or both did not modify the PPV for AN in this population-based colorectal screening program.