Esophageal motor function in congenital esophageal stenosis

Background/Purpose: Congenital esophageal stenosis (CES) is a rare condition that is associated with various foregut symptoms. The aim of the current study was to investigate esophageal motor function in pediatric patients with isolated CES.Methods: Four boys with CES (age, 3 weeks to 4 years old) were studied before treatment. The initial symptoms were dysphagia or stridor. The CES was caused by fibromuscular stenosis (FMS) in 2, tracheobronchial remnants (TBR) in 1, and membranous diaphragm (MD) in 1. An esophagram, endoscopy, 24-hour esophageal pH monitoring, and manometry were conducted.Results: The esophagram showed the stasis of contrast medium proximally to the distal esophageal narrowing in FMS/TBR patients. Endoscopic esophagitis was not found in any patients. Three patients were documented with pathologic esophageal acid exposure by 24-hour esophageal pH monitoring. Manometry showed that esophageal contractions predominantly were synchronous in FMS/TBR patients but were peristaltic in an MD patient. Basal lower esophageal sphincter (LES) pressure was at least 20 mm Hg in all. Swallow-induced LES relaxations were incomplete in FMS/TBR patients.Conclusions: The presence of gastroesophageal reflux and impaired esophageal motility are common in patients with CES.     

Esophageal manometrical assessment after esophageal circular myotomy for wide-gap esophageal atresia

We treated 3 children with wide-gap esophageal atresia by a circular myotomy of Livaditis technique, after which no postoperative complaints, such as heartburn, vomiting or dysphagia, were seen. Esophageal manometry, performed to evaluate the postoperative esophageal motor function revealed; (1) that lower esophageal sphincter pressure (LESP) increased gradually with time, (2) esophageal contraction waves (ECW) were evident at the site of the circular myotomy with swallowing, though these contractions were simultaneous; and (3) relaxation of the LES with swallowing was evident. These findings, as determined by the esophageal manometrical assessments, indicate that there is no difference between the postoperative esophageal function after either repair with a circular myotomy or primary anastomosis for esophageal atresia.     

Esophageal manometrical assessment after esophageal circular myotomy for wide-gap esophageal atresia

We treated 3 children with wide-gap esophageal atresia by a circular myotomy of Livaditis technique, after which no postoperative complaints, such as heartburn, vomiting or dysphagia, were seen. Esophageal manometry, performed to evaluate the postoperative esophageal motor function revealed; (1) that lower esophageal sphincter pressure (LESP) increased gradually with time, (2) esophageal contraction waves (ECW) were evident at the site of the circular myotomy with swallowing, though these contractions were simultaneous; and (3) relaxation of the LES with swallowing was evident. These findings, as determined by the esophageal manometrical assessments, indicate that there is no difference between the postoperative esophageal function after either repair with a circular myotomy or primary anastomosis for esophageal atresia.     

Esophagoscopy and endoscopic esophageal ultrasound in the assessment of esophageal function

Esophagoscopy is an ideal method to detect mucosal or structural abnormalities of the esophagus and proximal stomach. The exclusion of malignant dysphagia is the prime role of esophagoscopy in assessment of esophageal function. Esophagoscopy and biopsy are mandatory for mucosal assessment of patients with gastroesophageal reflux disease (GERD). Indirect and sometimes subtle evidence of abnormal esophageal motility is a valuable and underused aspect of esophagoscopy in the evaluation of swallowing disorders. Esophagoscopy has multiple roles in the appraisal and treatment of esophageal motility disorders, including the detection of secondary or pseudoachalasia, placement of manometry catheters, and dilation of peptic strictures caused by GERD associated with disorders such as scleroderma.     

Esophageal carcinoma: esophageal ultrasound assessment of preoperative chemotherapy.

The effect of preoperative chemotherapy in the treatment of esophageal carcinoma is difficult to assess because of the inadequacies of clinical staging. Endoscopic esophageal ultrasound (EUS) has been shown to be accurate in the clinical determination of depth of tumor invasion (T) and regional lymph node status (N). Therefore, EUS may be useful in assessing the effect of preoperative chemotherapy in the treatment of esophageal carcinoma. Eleven patients with operable adenocarcinoma of the esophagus or esophagogastric junction underwent staging by EUS before treatment. This was followed by two courses (10 patients) or one course (1 patient) of chemotherapy: etoposide, 120 mg/m2 for 3 days; doxorubicin hydrochloride, 20 mg/m2; and cisplatin, 100 mg/m2. Restaging by EUS was done after treatment. Ten patients then underwent resection of the tumor with lymphadenectomy. One patient was found to have metastatic disease at thoracotomy and did not undergo resection. However, tissue sampling was adequate for the determination of pathological stage. Independent pathological determinations of T and N were then obtained. On completion of chemotherapy, 9 patients (82%) had relief or reduction of preoperative symptoms, and 9 patients (82%) had either no evidence of tumor or reduction of tumor size by endoscopy. Despite this clinical and endoscopic response, no patient had EUS-documented and pathology-confirmed reduction of T. However, 2 patients had EUS-documented and pathology-confirmed progression of N. The accuracy of EUS in the determination of T was 82% and of N, 73%.(ABSTRACT TRUNCATED AT 250 WORDS)     

Esophageal function after injection sclerotherapy: pathogenesis of esophageal stricture

Injection sclerotherapy effectively controls hemorrhage from esophageal varices. Treatment must be repeated at intervals to obliterate varices. Long-term sequelae of such treatment are unknown but may include stricture formation. To assess the impact of repeated sclerotherapy on esophageal function, this prospective study measured lower esophageal sphincter pressure, reflux, and motility in patients before and after treatment. Injection sclerotherapy had no effect on lower esophageal sphincter pressure. Reflux was common before treatment and became even more prevalent after treatment, with reflux occurring in 60 percent of postsclerotherapy patients. Striking disturbances in esophageal motility were observed after treatment. Injection sclerotherapy induces a chemical esophagitis that impairs esophageal motility. Delayed acid clearance in the presence of reflux results in superimposed acid esophagitis. Esophageal strictures may thus be produced. We advise a standard antireflux medical regimen in our sclerotherapy patients.     

Esophageal function following Livaditis repair of long gap esophageal atresia

Proximal pouch esophagomyotomy (Livaditis) allows for repair of long gap esophageal atresia (EA). Postoperative esophageal functional studies in these patients are lacking. Six such infants were followed for up to 42 months. Esophageal function was assessed clinically and by barium swallow, manometry, 24 hr pH monitoring, esophagoscopy, and biopsy. Operative complications included two minor anastomotic leaks and two asymptomatic diverticula at the myotomy site. All patients had dysmotility on barium swallow. Gastroesophageal reflux (GER) was seen in four. Manometry showed a variable aperistaltic segment in each infant but lower esophageal sphincter pressures and relaxation were retained. Twenty-four hour pH monitoring showed an increase in frequency and duration of GER. All four patients biopsied had esophagitis. Five of the six patients showed normal growth velocity. Livaditis modified repair of EA was not associated with significant surgical complications. Esophageal motility showed abnormalities similar to those reported after the standard repair of EA. Myotomy did not adversely affect the esophageal function.     

Twenty-four hour pH monitoring in the assessment of esophageal function

Ambulatory 24-hour esophageal pH monitoring is an important test in the management of patients with gastroesophageal reflux disease. It quantifies esophageal acid exposure while patients pursue their everyday activities without restrictions. The test is performed with a compact portable data logger, miniature pH electrode, and computerized data analysis. The pH electrode should be positioned 5 cm above the manometrically defined lower esophageal sphincter. The patient is asked to press a button on the data logger indicating the onset of the symptom in question, which allows symptoms and acid reflux correlation. Twenty-four hour pH monitoring is generally performed after a therapeutic trial of antireflux medications, preferably proton pump inhibitors.     

Esophageal motility disorders in the morbidly obese population

Background Most studies investigating esophageal motility among the morbidly obese have focused on the relationship between lower esophageal sphincter (LES) pressure and gastroesophageal reflux disease (GERD). Very few studies in the literature have examined motility disorders among the morbidly obese population in general outside the context of GERD. This study aimed to determine the prevalence of esophageal motility disorders in obese patients selected for bariatric surgery. Methods A total of 116 obese patients (81 women and 35 men) selected for laparoscopic gastric banding underwent manometric evaluation of their esophagus from January to March 2003. Tracings were retrospectively reviewed for the end points of LES resting pressure, LES relaxation, and esophageal peristalsis. Results The study patients had a body mass index (BMI) of 42.9 kg/m², and a mean age of 48.6 years. The following abnormal manometric findings were demonstrated in 41% of the patients: nonspecific esophageal motility disorders (23%), nutcracker esophagus (peristaltic amplitude >180 mmHg) (11%), isolated hypertensive LES pressure (>35 mmHg) (3%), isolated hypotensive LES pressure (<12 mmHg) (3%), diffuse esophageal spasm (1%), and achalasia (1%). Only one patient with abnormal esophageal motility reported noncardiac chest pain. Conclusions Despite a high prevalence of esophageal dysmotility in our morbidly obese study population, there was a conspicuous absence of symptoms. Although the patients in this study were not directly questioned with regard to esophageal symptoms, several studies in the literature support our conclusion. Podium presentation at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), 26–29 April 2006, Dallas, TX, USA     

Esophageal motility changes in acute and late periods of caustic esophageal burns and their relation to prognosis in children

Background/Purpose: Esophageal burns as a result of accidental swallowing of caustic material are seen frequently in children. Severe motor function disorders of the esophagus after caustic burns are already reported covering the late periods. The aim of this study was to detect, follow, and report the clinical results of esophageal motility changes in acute as well as the late periods of caustic esophageal insult and its relation with prognosis in children. Methods: Esophageal motility was studied in 20 children aged 1.5 to 11 years (mean, 3.8). In the study group, motility of the esophagus was investigated on the fifth day of the burn (after decrease of the edema) and repeated at the end of the third month. To standardize the results, the amplitude and the duration of the pressure waves were recorded at 3 cm above the lower esophageal sphincter (LES), and the velocity in the distal esophagus was calculated. Then the mean values of amplitude, duration, and velocity of 15 swallows were obtained for each patient. Results: At the end of the fifth day, peristaltic response of the esophagus to swallowing was followed in 13 patients. Seven patients were able to swallow water, but no peristaltic response was detected. Therefore, the subjects were divided into 2 groups as motility (+) and motility ([minus ]), and each were compared with the control group separately. The amplitude of the pressure wave in the motility ([minus ]) group was significantly low when compared with the control group. All the subjects in this group had NaOH burns, and development of severe strictures was detected at the endoscopic examinations after 3 weeks. In motility (+) group, no pathologies were detected except significant decrease in the velocity of the peristaltic wave. Eleven of the subjects in this group had acid burns, and 2 had NaOH burns, and, at the follow-up endoscopic examination after 3 weeks, only one acid burn patient had a slight stricture. Motility measurements conducted at the end of the third month showed that the initial motility ([minus ]) group had no changes. No peristaltic response was detected after swallowing, and amplitude of the pressure wave measured at the distal esophagus was significantly lower than the controls. However, in the motility (+) group, decrease in the velocity of the peristaltic wave had disappeared, and there were no differences when compared with the control group. Conclusion: It is suggested that the manometric studies of the esophagus give important data about the severity of the initial esophageal injury and have an important role in determining the prognosis.     

Esophageal motility: effects of injection sclerotherapy

The purpose of this project was to evaluate the acute and chronic effects of sclerotherapy on esophageal motility and function. We studied motility in eight patients before and after injection sclerotherapy of esophageal varices. We injected the varices with 5% sodium morrhuate twice during the first week and then at 1, 2, 3, and 6 months. Lower esophageal sphincter pressure, contraction wave amplitude, and duration were not altered by sclerotherapy. However, the length of the high-pressure zone increased significantly from 3.6 +/- 0.3 cm to 4.2 +/- 0.2 cm during the first 3 days after initial treatment, and sclerotherapy caused considerable distortion of peristaltic wave form. Also, esophageal peristaltic velocity decreased in three patients who complained of dysphagia and subsequently developed esophageal stricture. The strictures have responded well to dilatation, and in two patients velocity has even returned toward the baseline value. Reflux esophagitis has not been a problem. Esophageal motility is altered by sclerotherapy of esophageal varices. Stricture formation seems to be reversible after sclerotherapy is stopped or discontinued.     

Fundoplication improves disordered esophageal motility

Patients with gastroesophageal reflux disease (GERD) and disordered esophageal motility are at risk for postoperative dysphagia, and are often treated with partial (270-degree) fundoplication as a strategy to minimize postoperative swallowing difficulties. Complete (360-degree) fundoplication, however, may provide more effective and durable reflux protection over time. Recently we reported that postfundoplication dysphagia is uncommon, regardless of preoperative manometric status and type of fundoplication. To determine whether esophageal function improves after fundoplication, we measured postoperative motility in patients in whom disordered esophageal motility had been documented before fundoplication. Forty-eight of 262 patients who underwent laparoscopic fundoplication between 1995 and 2000 satisfied preoperative manometric criteria for disordered esophageal motility (distal esophageal peristaltic amplitude ≤30 mm Hg and/or peristaltic frequency ≤80%). Of these, 19 had preoperative manometric assessment at our facility and consented to repeat study. Fifteen (79%) of these patients had a complete fun-doplication and four (21%) had a partial fundoplication. Each patient underwent repeat four-channel esophageal manometry 29.5 ± 18.4 months (mean ± SD) after fundoplication. Distal esophageal peristaltic amplitude and peristaltic frequency were compared to preoperative data by paired t test. After fun-doplication, mean peristaltic amplitude in the distal esophagus increased by 47% (56.8 ± 30.9 mm Hg to 83.5 ± 36.5 mm Hg; P < 0.001) and peristaltic frequency improved by 33% (66.4 ± 28.7% to 87.6 ± 16.3%; P< 0.01). Normal esophageal motor function was present in 14 patients (74%) after fundoplication, whereas in five patients the esophageal motor function remained abnormal (2 improved, 1 worsened, and 2 remained unchanged). Three patients with preoperative peristaltic frequencies of 0%, 10%, and 20% improved to 84%, 88%, and 50%, respectively, after fundoplication. In most GERD patients with esophageal dysmotility, fundoplication improves the amplitude and frequency of esophageal peristalsis, suggesting refluxate has an etiologic role in motor dysfunction. These data, along with prior data showing that postoperative dysphagia is not common, imply that surgeons should apply complete fun-doplication liberally in patients with disordered preoperative esophageal motility. Presented at the Forty-Third Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, California, May 19–22, 2002 (poster presentation).     

Surgical management of esophageal motility disturbances

During the past few decades, knowledge regarding normal and abnormal esophageal behavior has greatly increased because of the introduction of sophisticated techniques of studying esophageal function. As a result, the normal motility patterns of the esophagus are now well known, and conditions characterized by disturbances of esophageal motility can be readily recognized and therapy can be designed along more physiologic lines than heretofore.Motility disturbances of the esophagus can be classified as those involved with the upper esophageal sphincter and those involving the body of the esophagus and lower esophageal sphincter. Cricopharyngeal myotomy has played an increasing role in the management of abnormalities of function of the upper esophageal sphincter, particularly in patients with hypertension of the upper esophageal sphincter or incoordination of the upper esophageal sphincter as seen in pharyngoesophageal diverticulum. Esophagomyotomy has also found a useful place in the management of symptomatic patients with esophageal achalasia, in whom I believe it is the primary treatment of choice. Results of a properly performed myotomy suggest that an ancillary antireflux maneuver is not necessary. Although diffuse spasm of the esophagus and hypertensive sphincter represent different forms of esophageal motility disorders characterized by hypermotility rather than hypomotility, in properly selected patients a long esophagomyotomy has been useful in relieving the disabling symptoms of pain and dysphagia exhibited by most of these persons.Hypotension of the lower esophageal sphincter is now recognized as an underlying mechanism responsible for gastroesophageal reflux in a variety of disease states. Thus reflux and its debilitating sequence of ulcerative esophagitis and stricture formation should now be viewed as a physiologic abnormality rather than a strictly anatomic abnormality such as may occur in the presence of diaphragmatic hernia. Treatment is primarily medical and is designed to minimize the occasions of reflux and its effects by reducing gastric acids. Only in a small percentage of patients is surgical treatment in the form of an antireflux procedure required.     

Alteration in esophageal motility after laryngectomy.

Ten laryngectomees underwent esophageal motility studies to assess the effect of laryngectomy on esophageal function. When these patients are compared with controls, marked derangements in esophageal motility were noted in the upper esophageal sphincter (UES) and in the body of the esophagus. Lower esophageal sphincter (LES) function did not differ significantly from the controls. Dysphagia developed postoperatively in five of the ten laryngectomees. This preliminary analysis suggests that esophageal motility disturbances may be relatively frequent after laryngectomy and that these disturbances may be clinically significant. The theoretical basic for the motility abnormalities and areas of future research are discussed.     

食管动力性疾病的内镜诊治

食管动力性疾病包括贲门失弛缓症和胃食管反流病．是临床上常见的一组疾病．严重影响患者的生活质量。虽然食管测压为食管动力性疾病诊断的金标准,但消化内镜在该类疾病的诊断中发挥着重要作用。随着光学和机械学的革新．内镜器械得到了迅猛发展．目前已发展成为兼具治疗的检查手段。本文结合国内外最新研究进展．就近年来发展的内镜下黏膜切除术、内镜下黏膜下层剥离术和经口内镜下肌切开术等技术对食管动力性疾病的临床应用价值进行阐述。