Upper esophageal sphincter abnormalities on high-resolution esophageal manometry and treatment response of type Ⅱ achalasia

BACKGROUND Little is known about the clinical significance of upper esophageal sphincter(UES)motility disorders and their association with the treatment response of typeⅡachalasia.None of the three versions of the Chicago Classification of Esophageal Motility Disorders has defined UES abnormality metrics or their function.UES abnormalities exist in some patients and indicate a clinically significant problem in patients with achalasia.AIM To demonstrate the manometric differentiation on high-resolution esophageal manometry between subjects with abnormal UES and normal UES,and the association between UES type and the treatment response of typeⅡachalasia.METHODS In total,498 consecutive patients referred for high-resolution esophageal manometry were analyzed retrospectively.The patients were divided into two groups,those with normal and abnormal UES function.UES parameters were analyzed after determining lower esophageal sphincter(LES)function.Patients with typeⅡachalasia underwent pneumatic dilation for treatment.Using mixed model analyses,correlations between abnormal UES and treatment response were calculated among subjects with typeⅡachalasia.RESULTS Of the 498 consecutive patients,246(49.40%)were found to have UES abnormalities.Impaired relaxation alone was the most common UES abnormality(52.85%,n=130).The incidence rate of typeⅡachalasia was significantly higher in subjects with abnormal UES than those with normal UES(9.77%vs 2.58%,P=0.01).After pneumatic dilation,LES resting pressure,LES integrated relaxation pressure,and UES residual pressure were significantly decreased(41.91±9.20 vs 26.18±13.08,38.94±10.28 vs 16.71±5.65,and 11.18±7.93 vs 5.35±4.77,respectively,P<0.05).According to the Eckardt score,subjects with typeⅡachalasia and abnormal UES presented a significantly poorer treatment response than those with normal UES(83.33%vs 0.00%,P<0.05).CONCLUSION Impaired relaxation alone is the most common UES abnormality.The incidence of typeⅡachalasia is associated with abnormal UES.TypeⅡachalasia with abnormal UES has a poorer treatment response,which is a potentially prognostic indicator of treatment for this disease.

High-Resolution Esophageal Manometry in Teenagers with Esophageal Atresia

Introduction: Children with surgically repaired esophageal atresia (EA) show esophageal dysmotility. Due to the performance of high-resolution manometry (HRM), three motility alteration patterns have been described, which allowed to know the segmental alterations. Objective: To describe the esophageal motility patterns found through HRM in teenagers with EA and to relate these with the associated esophageal pathology and its severity. Materials and Method: Ten teenagers were included with no history of esophageal blockage or dilations in the last six months, who were orally fed and asymptomatic. Through performance of HRM, we found surgical and endoscopic history, as well as of esophageal biopsies and pH monitoring. Results: We found the following patterns: aperistalsis, pressurization and distal contraction. 70% showed distal contraction, and 100% of esophageal endoscopies and biopsies were normal. 57% of the esophageal pH monitoring analyzed was pathologic. In the pressurization and aperistalsis groups, we observed severe esophagitis and requirement of Nissen antireflux procedure in 100% of the cases. Esophageal pH monitoring analyzed was 100% pathologic. Conclusion: We described the esophageal segmental alterations in teenagers with atresia by means of HRM. The distal contraction group showed better development, without severe esophagitis or requirement of antireflux procedure. Therefore, by performing an HRM in teenagers with EA, we could predict the future esophageal behavior, according to the peristaltic pattern, since there are significant differences among the groups in study.

Distal esophageal spasm:Update on diagnosis and management in the era of high-resolution manometry

Distal esophageal spasm (DES) is a rare major motility disorder in the Chicago dassification of esophageal motility disorders (CC).DES is diagnosed by finding of≥20%premature contractions,with normal lower esophageal sphincter (LES)relaxation on high-resolution manometry (HRM) in the latest version of CCv3.0.This feature differentiates it from achalasia type 3,which has an elevated LES relaxation pressure.Like other spastic esophageal disorders,DES has been linked to conditions such as gastroesophageal reflux disease,psychiatric conditions,and narcotic use.In addition to HRM,ancillary tests such as endoscopy and barium esophagram can provide supplemental information to differentiate DES from other conditions.Functional lumen imaging probe (FLIP),a new cutting-edge diagnostic tool,is able to recognize abnormal LES dysfunction that can be missed by HRM and can further guide LES targeted treatment when esophagogastric junction outflow obstruction is diagnosed on FLIP.Medical treatment in DES mostly targets symptomatic relief and often fails.Botulinum toxin injection during endoscopy may provide a temporary therapy that wears off over time.Myotomy through peroral endoscopic myotomy or via surgical Heller myotomy can provide long term relief in cases with persistent symptoms.

Semi-Solid and Solid Bolus Swallows in High-Resolution Oesophageal Manometry for the Detection of Motility Disorders

Background/Aims: High-resolution oesophageal manometry utilises water swallows to evaluate oesophageal function. However, small volumes of water are not representative of normal eating and as a result often produce normal manometry studies in patients with dysphagia. This study sets out to establish optimal diagnostic thresholds for semi-solid solid swallows and evaluate their ability to uncover motility abnormalities in patients with motility disorders. Method: Manometry was performed using ten 5-mL single water swallows followed by two semi-solid and two solid swallows in the upright position. Normative values for the adjunctive tests were obtained from patient controls while patients with major motility disorders were used to establish the optimal diagnostic thresholds. Diagnostic thresholds identified were prospectively tested in patients with normal water swallows but oesophagus related symptoms and in those with minor and major motility disorders. Results: Normal values for semi-solid and solid were determined in patient controls (n = 100). Development of diagnostic thresholds included 120 patients with major motility disorders. Optimal diagnostic thresholds identified for oesophagogastric junction dysfunction in semi-solid and solid swallows (IRP > 15.5 mmHg). Hypercontractilty and spasm used existing thresholds (>8000 mmHg-s-cm and < 4.5 s, respectively) but modified frequency of ≥50% of adjunctive swallows. Diagnostic thresholds were applied to symptomatic patients with normal water swallows (n = 70) identifying 12/70 (17%) to have abnormal adjunctive swallows. One of 30 patients (3%) with ineffective motility had abnormal adjunctive swallow and 12 patients with oesophageal spasm, oesophagogastric junction obstruction, and hypercontractility had abnormal adjunctive swallows that moved them up the motility disorder hierarchy. Conclusions: Semi-solid and solid challenge increase diagnostic yield of motility disorders.

Evaluation of esophageal function in patients with esophageal motor abnormalities using multichannel intraluminal impedance esophageal manometry

AIM: To evaluate the functional aspect of esophageal motility in healthy subjects and in patients who were referred for esophageal function testing using multichannel intraluminal impedance-esophageal manometry (MII-EM), and to assess the clinical utility of MII-EM. METHODS: From September 2003 to January 2004, we performed the MII-EM on healthy volunteers and all the patients who were referred for esophageal function testing. Each patient received 10 liquid and 10 viscous swallows. We analyzed the results, the impedance and the manometric findings. Some of the subjects had additional ambulatory 24-h pH study performed to diagnose gastroesophageal reflux disease (GERD). RESULTS: Among 89 studied subjects, the MII-EM findings showed normal esophageal motility in 50 (56.17%), ineffective esophageal motility (IEM) in 17 (19.10%), nutcracker esophagus in 7 (7.86%), achalasia in 4 (4.49%), and scleroderma esophagus in 11 (12.35%) cases. The completeness and the speed of bolus transit were in the order of nutcracker esophagus, normal manometry and IEM. Some of the swallows showing normal manometry and IEM had incomplete transit. In the achalasia and scleroderma esophagus, almost all the swallows had incomplete transit. The body amplitudes were higher for the swallows with complete transit than for the swallows with incomplete transit. There was not a significant difference in the manometric and impedance findings between the subjects with and without GERD. CONCLUSION: MII-EM is a useful tool in assessing theesophageal function in the patients having esophageal motility abnormality. The primary factors influencing the bolus transit are the amplitude of the esophageal body and normal peristalsis.

Manometric findings in patients with isolated distal gastroesophageal reflux

AIM： To analyze manometric abnormalities in patients with isolated distal reflux and compare these findings in patients with erosive and non-erosive disease, METHODS： Five hundred and fifty patients who presented to the outpatient clinic of Turkiye Yuksek Ihtisas Hospital with gastroesophageal reflux disease-like symptoms were enrolled, Each individual was evaluated with esophageal manometry, 24-h ambulatory pH monitoring, and upper gastrointestinal endoscopy, Manometric findings for the patients with isolated distal reflux were compared to findings in controls who were free of reflux disorders or hypersensitive esophagus, Findings for isolated distal reflux patients with and without erosive reflux disease were also compared, RESULTS： Of the 550 subjects enrolled, 97 （17.6%, mean age 48 years） had isolated distal reflux and i00 had no abnormalities on ambulatory pH monitoring （control group, mean age 45 years）. There were no significant differences between the isolated distal reflux group and control group with respect to age, body mass index, and esophageal body contraction amplitude （EBCA）. Mean lower esophageal sphincter pressure was significantly higher in the control group （12.7 ± 10.3 mmHg vs 9.6 ± 7.4 mmHg, P = 0.01）. Fifty-five （56.7%） of the 97 patients with isolated distal reflux had erosive reflux disease. There were no statistical differences between the erosive reflux disease and non-erosive reflux disease subgroups with respect to mean EBCA, lower esophageal sphincter pressure, or DeMeester score.However, 13% of patients with gastroesophageal reflux disease had distal wave amplitudes ≤ 30 mmHg, whereas none of the patients with non-erosive reflux disease had distal wave amplitudes in this low category. CONCLUSION： Patients with erosive and non-erosive disease present with similar manometric abnormalities. The only striking difference is the observation of very low EBCA exclusively in patients with erosive disease.

High-resolution colonic manometry and its clinical application in patients with colonic dysmotility: A review

The detailed process and mechanism of colonic motility are still unclear, and colonic motility disorders are associated with numerous clinical diseases. Colonic manometry is considered to the most direct means of evaluating colonic peristalsis. Colonic manometry has been studied for more than 30 years;however, the long duration of the examination, high risk of catheterization, huge amount of real-time data, strict catheter sterilization, and high cost of disposable equipment restrict its wide application in clinical practice. Recently, highresolution colonic manometry (HRCM) has rapidly developed into a major technique for obtaining more effective information involved in the physiology and/or pathophysiology of colonic contractile activity in colonic dysmotility patients. This review focuses on colonic motility, manometry, operation, and motor patterns, and the clinical application of HRCM. Furthermore, the limitations, future directions, and potential usefulness of HRCM in the evaluation of clinical treatment effects are also discussed.

New technologies in the gastrointestinal clinic and research: Impedance and high-resolution manometry

The last five years have been an exciting time in the study of esophageal motor disorders due to the recent advances in esophageal function testing. New technologies have emerged, such as intraluminal impedance, while conventional techniques, such as manometry, have enjoyed many improvements due to advances in transducer technology, computerization and graphic data presentation. While these techniques provide more detailed information regarding esophageal function, our understanding of whether they can improve our ability to diagnose and treat patients more effectively is evolving. These techniques are also excellent research tools and they have added substantially to our understanding of esophageal motor function in dysphagia. This review describes the potential benefits that these new technologies may have over conventional techniques for the evaluation of dysphagia.

Exertional esophageal pH-metry and manometry in recurrent chest pain

AIM: To investigate the diagnostic efficacy of 24-h and exertional esophageal pH-metry and manometry in patients with recurrent chest pain. METHODS: The study included 111 patients (54% male) with recurrent angina-like chest pain, non-respon- sive to therapy with proton pump inhibitors. Sixty-five (59%) had non-obstructive lesions in coronary artery angiography, and in 46 (41%) significant coronary artery narrowing was found. In all patients, 24-h esophageal pH-metry and manometry, and treadmill stress tests with simultaneous esophageal pH-metry and manometry monitoring were performed. During a 24-h examination the percentage of spontaneous chest pain (sCP) episodes associated with acid reflux or dysmotility (symptom index, SI) was calculated. Patients with SI > 50% for acid gastroesophageal reflux (GER) were classified as having GER-related sCP. The remaining symptomatic individuals were determined as having non-GER-related sCP. During the stress test, the occurrence of chest pain, episodes of esophageal acidification (pH < 4 for 10 s) and esophageal spasm with more than 55% of simultaneous contractions (exercise-provoked esophageal spasm or EPES) were noted. RESULTS: Sixty-eight (61%) individuals reported sCP during 24-h esophageal function monitoring. Eleven of these (16%) were classified as having GER-related sCP and 53/68 (84%) as having non-GER-related sCP. The exercise-provoked chest pain during a stress test occurred in 13/111 (12%) subjects. In order to compare the clinical usefulness of 24-h esophageal function monitoring and its examination limited only to the treadmill stress test, the standard parameters of diagnostic test evaluation were determined. The occurrence of GER- related or non-GER-related sCP was assumed as a "gold standard". Afterwards, accuracy, sensitivity and specificity were calculated. These parameters expressed a prediction of GER-related or non-GER-related sCP occurrence by the presence of chest pain, esophageal acidification and EPES. Accuracy, sensitivity and specificity of chest pain during the stress test predicting any sCP occurrence were 28%, 35% and 80%, respectively, predicting GER- related sCP were 42%, 0% and 83%, respectively, and predicting non-GER-related sCP were 57%, 36% and 83%, respectively. Similar values were obtained for exercise-related acidification with pH < 4 longer than 10 s in the prediction of GER-related sCP (44%, 36% and 92%, respectively) and EPES in relation to non-GER-related sCP (48%, 23% and 84%, respectively). CONCLUSION: The presence of chest pain, esophageal acidification and EPES had greater than 80% specificity to exclude the GER-related and non-GER-related causes of recurrent chest pain.

Technological insights:combined impedance manometry for esophageal motility testing-current results and further implications

This review focuses on current aspects of the novel technology of combined impedance manometry for esophageal motility testing. It presents methodological features, summarizes current results and discusses implications for further research. The combined technique assesses simultaneously bolus transport and associated peristalsis, thus allowing detailed analysis of the relationships between bolus transit and esophageal motility. Recent studies demonstrate that combined impedance manometry provides important additional information about esophageal motility as compared to conventional manometry: (1) monitoring of bolus transport patterns, (2) calculation of bolus transit parameters, (3) evaluation of bolus clearance, (4) monitoring of swallow associated events such as air movement and reflux, and (5) investigation of the relationships between bolus transit and LES relaxation. Studies with healthy subjects have identified several useful parameters for comprehensive assessment of eosphageal function. These parameters were found to be pathological in patients with classical achalasia, mild GERD, and ineffective esophageal motility. The technology of combined impedance manometry provides an important new tool for esophageal function testing, advancing both clinical and basic research. However, several important issues remain to be standardized to make the technique suitable for widely clinical use.

Anorectal dysfunction in patients with mid-low rectal cancer after surgery: A pilot study with three-dimensional high-resolution manometry

BACKGROUND The quality of life in patients who develop low anterior resection syndrome(LARS)after surgery for mid-low rectal cancer is seriously impaired.The underlying pathophysiological mechanism of LARS has not been fully investigated.AIM To assess anorectal function of mid-low rectal cancer patients developing LARS perioperatively.METHODS Patients diagnosed with mid-low rectal cancer were included.The LARS score was used to evaluate defecation symptoms 3 and 6 mo after anterior resection or a stoma reversal procedure.Anorectal functions were assessed by threedimensional high resolution anorectal manometry preoperatively and 3-6 mo after surgery.RESULTS The study population consisted of 24 patients.The total LARS score was decreased at 6 mo compared with 3 mo after surgery(P<0.05),but 58.3%(14/24)lasted as major LARS at 6 mo after surgery.The length of the high-pressure zone of the anal sphincter was significantly shorter,the mean resting pressure and maximal squeeze pressure of the anus were significantly lower than those before surgery in allpatients (P < 0.05), especially in the neoadjuvant therapy group after surgery (n = 18). The focalpressure defects of the anal canal were detected in 70.8% of patients, and those patients had higherLARS scores at 3 mo postoperatively than those without focal pressure defects (P < 0.05). Spasticperistaltic contractions from the new rectum to anus were detected in 45.8% of patients, whichwere associated with a higher LARS score at 3 mo postoperatively (P < 0.05).CONCLUSIONThe LARS score decreases over time after surgery in the majority of patients with mid-low rectalcancer. Anorectal dysfunctions, especially focal pressure defects of the anal canal and spasticperistaltic contractions from the new rectum to anus postoperatively, might be the majorpathophysiological mechanisms of LARS.

Transmitted cardiovascular pulsations on high resolution esophageal impedance manometry, and their significance in dysphagia

AIM To investigate the behavior of pulsatile pressure zones(PPZ's) as noted on high resolution esophageal impedance manometry(HREIM), and determine their association with dysphagia.METHODS Retrospective, single center case control design scr-eening HREIM studies for cases(dysphagia) and controls(no dysphagia). Thoracic radiology studies were reviewed further in cases for(thoracic cardiovascular) thoracic cardiovascular(TCV) structures in esophageal proximity to compare with HREIM findings. Manometric data was collected for number, location, axial length, PPZ pressure and esophageal clearance function(impedance). RESULTS Among 317 screened patients, 56% cases and 64% controls had PPZ's. Fifty cases had an available thoracic radiology comparison. The distribution of PPZ's in these 50 cases and 59 controls was similar(average 1.4 PPZ/patient). Controls(mean 31.2 ± SD 12 years) were a significantly younger population than cases(mean 67.3 ± SD 14.9 years) with P < 0.0001. The upright posture PPZ pressure was higher in controls(15.7 ± 10.0 mm Hg) than cases(10.8 ± 9.7 mm Hg). Although statistically significant(P = 0.005), it was a weak predictor using logistic regression and ROC model(AUC = 0.65). Three dysphagia patients had partial compression from external TCV on radiology(1 aberrant subclavian artery, 2 dilated left atrium). The posture(supine vs upright) with more prominent PPZ's impaired bolus clearance in 9 additional cases by > 20%. CONCLUSION Transmitted TCV pulsations observed in HREIM bear no significant impact on swallowing. However, in older adults with dysphagia, evidence of impaired bolus clearance on impedance should be evaluated for external TCV compression. These associations have never been explored previously in literature, and are novel.

Transcutaneous cervical esophagus ultrasound in adults: Relation with ambulatory 24-h pH-monitoring and esophageal manometry

AIM: To determine the gastroesophageal refl uxate in the cervical esophagus (CE) and measure transcutaneous cervical esophageal ultrasound (TCEUS) f indings [anterior wall thickness (WT) of CE, esophageal luminal diameter (ELD), esophageal diameter (ED)]; to compare TCEUS findings in the patient subgroups divided according to 24-h esophageal pH monitoring and manometry; and to investigate possible cut-off values according to the TCEUS f indings as a predictor of gastroesophageal refl ux (GER). METHODS: In 45/500 patients, refl uxate was visualized in TCEUS. 38/45 patients underwent esophagogastroduo denoscopy (EGD), 24-h pH monitoring and manometry. RESULTS: The 38 patients were grouped according to 24-h pH monitoring as follows: Group A: GER-positive (n = 20) [Includes Group B: isolated proximal refl ux (PR) (n = 6), Group C: isolated distal reflux (DR) (n = 6), and Group D: both PR/DR (n = 8)]; Group E: no refl ux (n = 13); and Group F: hypersensitive esophagus (HSE) (n = 5). Groups B + D indicated total PR patients (n = 14), Groups E + F refl ux-negatives with HSE (n = 18), and Groups A + F refl ux-positives with HSE (n = 25). When the 38 patients were grouped according to manometry fi ndings, 24 had normal esophageal manometry; 7 had hypotensive and 2 had hypertensive lower esophageal sphincter (LES); and 5 had ineffective esophageal motility disorder (IEM). The ELD measurement was greater in group A + F than group E (P = 0.023, 5.0 ± 1.3 vs 3.9 ± 1.4 mm). In 27/38 patients, there was at least one pathologic acid refl ux and/or pathologic manometry fi nding. The cut-off value for ELD of 4.83 mm had 79% sensitivity and 61% specificity in predicting the PRbetween Groups B + D and E (AUC = 0.775, P = 0.015). CONCLUSION: Visualizing refluxate in TCEUS was useful as a pre-diagnostic tool for estimating GER or manometric pathology in 71.1% of adults in our study, but it was not diagnostic for CE WT.

Esophageal manometry and 24-hour pH monitoring in esophagus surgery:28-year Chinese experience in a single center

Objective To retrospectively review the experience of esophageal manometry and 24-hour pH monitoring in e-sophagus surgery. Methods From 1982 to 2010,patients with unspecific chest pain and undergone esophageal surgery were received esophageal manometry and 24-hour pH monitoring. Results Among the patients with

Gastroesophageal reflux disease:From pathophysiology to treatment

This review focuses on the pathophysiology of gastroesophageal reflux disease (GERD) and its implications for treatment. The role of the natural anti-reflux mechanism (lower esophageal sphincter, esophageal peristalsis, diaphragm, and trans-diaphragmatic pressure gradient), mucosal damage, type of refluxate, presence and size of hiatal hernia, Helicobacter pylori infection, and Barrett’s esophagus are reviewed. The conclusions drawn from this review are: (1) the pathophysiology of GERD is multifactorial; (2) because of the pathophysiology of the disease, surgical therapy for GERD is the most appropriate treatment; and (3) the genesis of esophageal adenocarcinoma is associated with GERD.

Esophageal motility abnormalities in gastroesophageal reflux disease

Esophageal motility abnormalities are among the main factors implicated in the pathogenesis of gastroesophageal reflux disease. The recent introduction in clinical and research practice of novel esophageal testing has markedly improved our understanding of the mechanisms contributing to the development of gastroesophageal reflux disease, allowing a better management of patients with this disorder. In this context, the present article intends to provide an overview of the current literature about esophageal motility dysfunctions in patients with gastroesophageal reflux disease. Esophageal manometry, by recording intraluminal pressure, represents the gold standard to diagnose esophagealmotility abnormalities. In particular, using novel techniques, such as high resolution manometry with or without concurrent intraluminal impedance monitoring, transient lower esophageal sphincter (LES) relaxations, hypotensive LES, ineffective esophageal peristalsis and bolus transit abnormalities have been better defined and strongly implicated in gastroesophageal reflux disease development. Overall, recent findings suggest that esophageal motility abnormalities are increasingly prevalent with increasing severity of reflux disease, from nonerosive reflux disease to erosive reflux disease and Barrett's esophagus. Characterizing esophageal dysmotility among different subgroups of patients with reflux disease may represent a fundamental approach to properly diagnose these patients and, thus, to set up the best therapeutic management. Currently, surgery represents the only reliable way to restore the esophagogastric junction integrity and to reduce transient LES relaxations that are considered to be the predominant mechanism by which gastric contents can enter the esophagus. On that ground, more in depth future studies assessing the pathogenetic role of dysmotility in patients with reflux disease are warranted.

Effects of anti-hypertensive drugs on esophageal body contraction

AIM:To clarify the effects of anti-hypertensive drugs on esophageal contraction and determine their possi-ble relationship with gastro-esophageal reflux disease.METHODS:Thirteen healthy male volunteers were enrolled. Esophageal body peristaltic contractions and lower esophageal sphincter (LES) pressure were measured using high resolution manometry. All subjects were randomly examined on four separate occasions following administrations of nifedipine,losartan,and atenolol,as well as without any drug administration.RESULTS:Peristaltic contractions by the esophageal body were separated into three segments by two troughs. The peak peristaltic pressures in the mid and lower segments of the esophageal body under atenolol administration were signifi cantly higher than those without medication in a supine position. On the other hand,peristaltic pressures under nifedipine administration were lower than those observed without drug ad-ministration. Losartan did not change esophageal body peristalsis. Atenolol elevated LES pressure and slowed peristaltic wave transition,while the effects of nifedip-ine were the opposite. CONCLUSION:Among the anti-hypertensive drugs tested,atenolol enhanced esophageal motor activity,which was in contrast to nifedipine.

Influence of endoscopic submucosal dissection on esophageal motility

AIM: To assess esophageal motility after esophageal endoscopic submucosal dissection (ESD). METHODS: Twelve patients (6 men and 6 women) aged 53-64 years (mean age, 58 years) who underwent regular examination 3-12 mo after esophageal ESD for neoplasms of the esophageal body were included in this study. The ESD procedure was performed under deep sedation using a combination of propofol and fentanyl, and involved a submucosal injection to lift the lesion and use of a dual-knife and an insulated-tip knife to create a circumferential incision around the lesion extending into the submucosa. Esophageal motility was examined using a high-resolution manometry system. Dysphagia was graded using a five-point scale according to the Mellow and Pinkas scoring system. Patient symptoms and the results of esophageal manometry were then analyzed. RESULTS: Of the 12 patients enrolled, 1 patient hadgrade 2 dysphagia, 1 patient had grade 1 dysphagia, and 3 patients complained of sporadic dysphagia. Ineffective esophageal motility was observed in 5 of 6 patients with above semi-circumference of resection extension. Of these 5 patients, 1 patient complained of grade 2 dysphagia (with esophageal stricture), one patient complained of grade 1 dysphagia, and 3 patients complained of sporadic dysphagia. Normal esophageal body manometry was observed in all 6 patients with below semi-circumference of resection extension. The 6 patients with normal esophageal motility did not complain of dysphagia. CONCLUSION: Extensive esophageal ESD may cause esophageal dysmotility in some patients, and might also have an influence on dysphagia although without esophageal stricture.

Gastroesophageal reflux in cirrhotic patients without esophageal varices

AIM: To evaluate the esophageal motility and abnormal acid and bile reflux incidence in cirrhotic patients without esophageal varices (EV). METHODS: Seventy-eight patients with liver cirrhosis without EV confirmed by upper gastroesophageal endoscopy and 30 healthy control volunteers were prospectively enrolled in this study. All the patients were evaluated using a modified protocol including Child-Pugh score, upper gastrointestinal endoscopy, esophageal manometry, simultaneous ambulatory 24-h esophageal pH and bilirubin monitoring. All the patients and volunteers accepted the manometric study. RESULTS: In the liver cirrhosis group, lower esophageal sphincter pressure (LESP, 15.32 ± 2.91 mmHg), peristaltic amplitude (PA, 61.41 ± 10.52 mmHg), peristaltic duration (PD, 5.32 ± 1.22 s), and peristaltic velocity (PV, 5.22 ± 1.11 cm/s) were all significantly abnormal in comparison with those in the control group (P < 0.05), and LESP was negatively correlated with Child-Pugh score. The incidence of reflux esophagitis (RE) and pathologic reflux was 37.18% and 55.13%, respectively(vs control, P < 0.05). And the incidence of isolated abnormal acid reflux, bile reflux and mixed reflux was 12.82%, 14.10% and 28.21% in patients with liver cirrhosis without EV. CONCLUSION: Cirrhotic patients without EV presented esophageal motor disorders and mixed acid and bile reflux was the main pattern; the cirrhosis itself was an important causative factor.

2011 update on esophageal achalasia

There have been some breakthroughs in the diagnosis and treatment of esophageal achalasia in the past few years.First,the introduction of high-resolution manometry with pressure topography plotting as a new diagnostic tool has made it possible to classify achalasia into three subtypes.The most favorable outcome is predicted for patients receiving treatment for type Ⅱ achalasia (achalasia with compression).Patients with typeⅠ(classic achalasia) and type Ⅲ achalasia (spastic achalasia) experience a less favorable outcome.Second,the first multicenter randomized controlled trial published by the European Achalasia Trial group reported 2-year follow-up results indicating that laparoscopic Heller myotomy was not superior to endoscopic pneumatic dilation (PD).Although the follow-up period was not long enough to reach a convincing conclusion,it merits the continued use of PD as a generally available technique in gastroenterology.Third,the novelendoscopic technique peroral endoscopic myotomy is a promising option for treating achalasia,but it requires increased experience and cautious evaluation.Despite all this good news,the bottom line is a real break-through from the basic studies to identify the actual cause of achalasia that may impede treatment success is still anticipated.