Factors affecting esophageal motility in gastroesophageal reflux disease

BACKGROUND: There are conflicting data concerning the effect of gastroesophageal reflux disease (GERD) on esophageal motor function. HYPOTHESIS: Duration of GERD might affect severity of symptoms, grade of esophageal mucosal injury, and esophageal motor behavior. DESIGN: Retrospective study of a defined cohort. SETTINGS: Two referral centers, one of them academic, for esophageal gastrointestinal motility disorders. PATIENTS: One hundred forty-seven patients with documented GERD. MAIN OUTCOME MEASURES: Symptoms, grade of mucosal injury on esophagoscopy, esophageal manometry, ambulatory esophageal pH monitoring, and esophagogram. RESULTS: Patients with GERD had significantly decreased lower esophageal sphincter resting pressure (P =.02), lower amplitude of esophageal peristalsis at all levels of measurement (P<.001), and more delayed esophageal transit (P =.007) compared with control subjects. Patients with dysphagia, severe esophagitis, and Barrett esophagus presented with a longer history of the disease, significantly worse esophageal motor function (P<.01), and more prolonged esophageal transit than patients without the above features of the disease. Impairment of esophageal peristalsis and lower esophageal sphincter resting pressure were significantly inversely related to the duration of the disease (P<.001). Also, delay of esophageal transit was significantly related to the duration of the disease (P =.002) and inversely related to the amplitude of esophageal peristalsis (P<.001). Unlike the manometric variables, the extent of reflux, as assessed by ambulatory 24-hour esophageal pH monitoring, was not related to the duration of the disease. CONCLUSION: A long history of GERD is more commonly associated with presence of dysphagia, delayed esophageal transit, severe esophagitis, presence of Barrett esophagus, and impaired esophageal motility.     

Laparoscopic toupet fundoplication for gastroesophageal reflux disease with poor esophageal body motility

Impaired esophageal body motility is a complication of chronic gastroesophageal reflux disease (GERD). In patients with this disease, a 360-degree fundoplication may result in severe postoperative dysphagia. Forty-six patients with GERD who had a weak lower esophageal sphincter pressure and a positive acid reflux score associated with impaired esophageal body peristalsis in the distal esophagus (amplitude <30 mm Hg and >10% simultaneous or interrupted waves) were selected to undergo laparoscopic Toupet fundoplication. They were compared with 16 similar patients with poor esophageal body function who underwent Nissen fundoplication. The patients who underwent Toupet fundoplication had less dysphagia than those who had the Nissen procedure (9% vs. 44%;P=0.0041). Twenty-four-hour ambulatory pH monitoring and esophageal manometry were repeated in 31 Toupet patients 6 months after surgery. Percentage of time of esophageal exposure to pH <4.0, DeMeester reflux score, lower esophageal pressure, intra-abdominal length, vector volume, and distal esophageal amplitude all improved significantly after surgery. Ninety-one percent of patients were free of reflux symptoms. The laparoscopic Toupet fundoplication provides an effective antireflux barrier according to manometric, pH, and symptom criteria. It avoids potential postoperative dysphagia in patients with weak esophageal peristalsis and results teria. It avoids potential postoperative dysphagia in patients with weak esophageal peristalsis and results in improved esophageal body function 6 months after, surgery. Presented at the Thirty-Seventh Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, Calif., May 19–22, 1996.     

Laparoscopic fundoplication for gastroesophageal reflux: effects on esophageal motility

Laparoscopic Nissen-Rossetti fundoplication is now recognized as a valid therapy for the treatment of gastroesophageal reflux disease. This retrospective study evaluates the effects of laparoscopic fundoplication on esophageal motility and correlates these effects to postsurgical symptoms. A total of 123 patients underwent laparoscopic fundoplication at our institution. Pre- and postoperative esophageal manometric data were analyzed with regard to the effect of surgery and postsurgical outcome. Postoperative lower esophageal sphincter pressure was significantly increased compared wtih preoperative values (1.7 +/- 0.8 kPa vs 0.9 +/- 0.7 kPa). Duration and amplitude of esophageal body contractions were not modified. The percentage of deglutition-induced complete peristaltic waves and the velocity of propagation were significantly decreased after surgery (P < 0.05). Postoperative symptoms were significantly correlated with postoperative lower esophageal sphincter pressure only. Laparoscopic fundoplication significantly increases lower esophageal sphincter pressure. It significantly decreases esophageal body peristaltic efficiency, a decrease that is most likely of minor clinical significance.     

Gastric emptying and gastroesophageal reflux: Effects of surgery and correlation with esophageal motor function

A new method of measuring gastric emptying for solids was developed and validated. With this new method, gastric emptying of solids was evaluated in 40 patients with gastroesophageal reflux. Gastric emptying of solids was delayed in 42 percent of patients independent of the severity of the reflux symptoms. Liquids emptied in a normal fashion, supporting the observations of others that liquid emptying is not a valid measure of gastric emptying. A high incidence of esophageal motor abnormalities was present in these patients when tested with radionuclide transit studies using a liquid bolus. The coexistence of esophageal and gastric emptying abnormalities was present in 45 percent of patients who had delayed gastric emptying of solids. Three months after surgical correction of reflux as measured by pH study, abnormalities in both the esophagus and stomach remained unchanged. Since the symptoms were corrected, delayed gastric emptying is not adequate indication for a gastric emptying procedure at the time of antireflux surgery.     

Gastric emptying in children with gastroesophageal reflux and in healthy children

Purpose

The aim of this report is to examine whether children with gastroesophageal reflux (GER) have delayed gastric emptying compared to healthy children.

Methods

All patients had GER verified by 24-hour pH monitoring. Gastric emptying of cow’s milk was examined by radionuclide scintigraphy in 51 patients with GER and in 24 controls. Gastric emptying rate was expressed as exponential half time (T_1/2).

Results

Median age was 4.4 years [range 0.1–15.4] in patients and 6.1 years [range 2.5–10.0] in controls (p = .10). A wide range of gastric emptying rates was observed both in GER patients [range 16–121] and controls [range 29–94]. One GER patient (2%) had slower gastric emptying (T_1/2 = 121 min) than the healthy child with the longest T_1/2 (94 min). Mean T_1/2 was 49 minutes (SD 20.1) and 46 minutes (SD 14.2) in GER patients and controls, respectively (p = .51).

Conclusions

Gastric emptying rate of milk was not significantly different between children with GER and healthy children. A wide range of gastric emptying rates was observed in both groups.     

Circadian esophageal motor function in patients with gastroesophageal reflux disease

Effective esophageal peristalsis is a major determinant of esophageal clearance function and may contribute to the development of complications in gastroesophageal reflux disease. Using 24-hour ambulatory esophageal manometry, we compared the circadian esophageal motor activity of normal volunteers to that of patients with increased esophageal exposure to gastric juice and various grades of mucosal injury (no mucosal injury, esophagitis, stricture, or Barrett's esophagus). The prevalence of a mechanically defective lower esophageal sphincter, esophageal acid exposure time, and the frequency of nonperistaltic esophageal contractions during the supine, upright, and meal periods increased with increasing severity of mucosal injury. The median amplitude of esophageal contractions was compromised only in patients with a mechanically defective sphincter. This was particularly so in patients with stricture or Barrett's esophagus and was associated with an increased frequency of ineffective contractions (less than 30 mm Hg). These data show that esophageal motor function deteriorates with increasing severity of mucosal injury. This appears to be caused by persistent reflux of gastric juice across a mechanically defective lower esophageal sphincter. The need for surgical correction of a mechanically defective sphincter before the loss of esophageal body function is implicated.     

Abnormal preoperative and postoperative esophageal peristalsis in gastroesophageal reflux

Extended 24-hour pH monitoring and esophageal manometry before and 6 months after Nissen fundoplication in a group of 14 children with symptomatic gastroesophageal reflux (GER), of whom 12 had esophagitis, have shown that all patients were clinically cured and their initially abnormal pH-monitoring parameters significantly decreased to normal values after operation. Whereas lower esophageal sphincter pressure (LESP) was not modified by surgery, lower esophageal sphincter length (LESL) was significantly increased. The percentage of tertiary, nonpropulsive esophageal waves, that was very high in basal conditions (74.9 +/- 34.5%) and following instillation of acid into the esophagus (79.8 +/- 20.2%) remained high (58 +/- 23.2% and 72.1 +/- 18.2% respectively) several months postoperatively. The persistence of abnormal peristalsis after surgical cure of GER suggests that severe symptoms in this group of patients resulted from the simultaneous failure of both components of the antireflux mechanism (LES and esophageal peristaltic "pump"), which led to increased acid exposure. The good results of surgical establishment of an effective valve-like barrier alone illustrate the possibility of compensation by only one of the components when the other fails. According to this interpretation, whereas patients with good peristalsis would tolerate GER fairly well, those with GER and bad peristalsis would have increased acid exposure and, consequently, esophageal damage.     

Influence of esophageal carcinoma operations on gastroesophageal reflux

Background

Gastroesophageal reflux occurs more easily after esophageal carcinoma operations. Our objective was to compare the influence of three kinds of esophageal carcinoma operations on reflux.

Methods

From May 1999 to May 2002, esophageal carcinoma operations were performed on 30 consecutive patients through left thoracotomy, including 10 cases completed with supraaortic, ante-aortic gastroesophageal anastomosis, 10 cases with subaortic gastroesophageal anastomosis, and 10 cases with apicothoracic retro-aortic gastroesophageal anastomosis. A 24-hour esophageal pH was recorded for every patient 3 months after the operation.

Results

The number of reflux episodes per 24 hours (No. of episodes), the number of reflux episodes greater than or equal to 5 minutes per 24 hours (No. ≥ 5 min), the time in minutes of the longest reflux episode recorded (longest episode) and the cumulative time of the esophageal pH less than 4 (total time that pH < 4) are all beyond normal limits. The difference in number of episodes between supraaortic, ante-aortic, and subaortic gastroesophageal anastomosis groups is not significant; but the other indexes are higher in the supraaortic, ante-aortic anastomosis group with significance (p < 0.05). The difference in number of episodes between supraaortic, ante-aortic, and apicothoracic retro-aortic gastroesophageal anastomosis groups is not significant while the other indexes are much higher in the supraaortic, ante-aortic anastomosis group with significance (p < 0.05); the difference in number of episodes between apicothoracic retro-aortic and subaortic gastroesophageal anastomosis groups is not significant while the other indexes are lower in the apicothoracic retro-aortic anastomosis group with significance (p < 0.05).

Conclusions

Gastroesophageal reflux occurred after all three types of esophageal carcinoma operations. The reflux is less severe in the apicothoracic retro-aortic anastomosis group than in the other two groups. The esophageal carcinoma operation with apicothoracic retro-aortic gastroesophageal anastomosis has more advantages to alleviate postoperative gastroesophageal reflux.     

Surgical treatment of gastroesophageal reflux with esophageal stricture in infancy and childhood

During the past 5 years, 26 infants and children with gastroesophageal reflux were operated on. The results have been highly satisfactory and unattended by serious complications or mortality. Barium fluoroscopy was the most reliable diagnostic method. The indications for operation were persistent vomiting with failure to thrive, recurrent aspiration pneumonia, gastrointestinal bleeding and peptic stricture of the esophagus, not relieved by medical treatment. The high incidence of peptic stricture of the esophagus (50 percent) may reflect delay in diagnosis and medical treatment, which is successful in 60 to 87 percent of the infants with gastroesophageal reflux. Surgical treatment consisted of Nissen fundoplication combined with gastrostomy in cases of esophageal stenosis where dilatations were indicated. Complications related to the operation were minimal. In a follow-up period of 9 months to 5 years, all patients had obtained relief of symptoms of reflux and had excellent nutritional status and normal growth.     

Management of patients with gastroesophageal reflux disease and esophageal or gastric dysmotility

Conclusion Knowledge of the presence of gastric or esophageal motility disorders is important to the surgeon treating GERD for a variety of reasons. Appropriate treatment of either condition remains controversial but almost certainly affects the patient’s long-term success and risk of side effects or morbidity. The best esophageal surgeons will take all aspects of the patient’s physiology into account when counseling them preoperatively and while performing antireflux procedures.     

Treatment of morbid obesity with laparoscopic adjustable gastric banding affects esophageal motility

BACKGROUND: Laparoscopic adjustable gastric banding has become the prefered method for the surgical treatment of morbid obesity in Europe. It is not known whether this procedure may induce gastroesophageal reflux and whether it may impair esophageal peristalsis. METHODS: Laparoscopic adjustable gastric banding (Swedish band) was performed in 43 patients (median body mass index [BMI] 42.5 kg/m(2)). Preoperatively and 6 months postoperatively all patients were assessed for reflux symptoms. In addition all patients underwent preoperative and postoperative endoscopy, esophageal barium studies and manometry, and 24-hour esophageal pH-monitoring. RESULTS: The median BMI dropped significantly to 33.1 kg/m(2) (P <0.05). Preoperatively 12 patients complained of reflux symptoms. Mild esophagitis was detected in 10 patients. Postoperatively only 1 patient complained of heartburn and mild esophagitis was diagnosed in another patient. None of the patients had dysphagia. Preoperatively a defective LES and pathologic pH-testing were found in 9 and 15 patients, respectively. These parameters were normal in all of the patients postoperatively. Postoperatively there was significant impairment of LES relaxation and deterioration of esophageal peristalsis with dilatation of the esophagus in some of the patients. CONCLUSION: Laparoscopic adjustable gastric banding provides a sufficient antireflux barrier and therefore prevents pathologic gastroesophageal reflux. However, it impairs relaxation of the LES, leading to weak esophageal peristalsis.     

Evaluation of gastroesophageal function and mechanisms underlying gastroesophageal reflux in infants and adults born with esophageal atresia

Purpose

To evaluate the mechanisms underlying gastroesophageal reflux (GER) following esophageal atresia (EA) repair and gastroesophageal function in infants and adults born with EA.

Methods

Ten consecutive infants born with EA as well as 10 randomly selected adult EA patients were studied during their first postoperative follow-up visit and a purposely planned visit, respectively. A ¹³C-octanoate breath test and esophageal pH–impedance–manometry study were performed. Mechanisms underlying GER and esophageal function were evaluated.

Results

Transient lower esophageal sphincter relaxation (TLESR) was the most common mechanism underlying GER in infants and adults (66% and 62%, respectively). In 66% of all GER episodes, no clearing mechanism was initiated. On EFT, normal motility patterns were seen in six patients (four infants, two adults). One of these adults had normal motility overall (> 80% of swallows). Most swallows (78.8%) were accompanied by abnormal motility patterns. Despite this observation, impedance showed normal bolus transit in 40.9% of swallows. Gastric emptying was delayed in 57.1% of infants and 22.2% of adults.

Conclusions

TLESR is the main mechanism underlying GER events in patients with EA. Most infants and adults have impaired motility, delayed bolus clearance, and delayed gastric emptying. However, normal motility patterns were seen in a minority of patients.     

Medical treatment of gastroesophageal reflux disease does not prevent the development of Barrett's metaplasia and poor esophageal body motility

Objective: Duodenal contents refluxing into the esophagus may be involved in the pathophysiology of gastroesophageal reflux disease (GERD). This study was performed to investigate whether medical treatment of GERD aimed at suppression of gastric acid production can prevent the development of complications, such as Barrett's metaplasia or poor esophageal body motility.Design: Retrospective study.Setting: University hospital.Patients: 138 GERD patients were analyzed regarding the development of Barrett's metaplasia or poor esophageal body motility, despite intermittent or continuous treatment with H₂ blockers or omeprazole.Main outcome measures: The rate of patients with Barrett's metaplasia or poor esophageal body motility with or without effective medical treatment.Results: Barrett's metaplasia was found in 33.8% of patients receiving medical treatment, although it was not present when treatment was induced. This rate was 21.9% among patients who were not receiving therapy (not significant). In all, 41.9% of patients with medication had impaired esophageal body motility compared with 59.3% of patients not receiving treatment (P<0.05), but these patients had a significantly shorter history of GERD.Conclusions: Medical treatment with H₂ blockers or omeprazole does not prevent the development of Barrett's metaplasia or poor esophageal body motility.     

Influence of thoracoscopic esophageal atresia repair on esophageal motor function and gastroesophageal reflux

Background/Purpose

Thoracoscopic repair has recently been attempted in newborns with esophageal atresia (EA), but it remains unclear whether thoracoscopic dissection reduces pathological gastroesophageal reflux. We investigated the influence of a thoracoscopic approach on esophageal motor function in patients with EA.

Methods

Clinical and gastrointestinal data of 10 patients with EA with open repair (group A) and 7 with thoracoscopic repair (group B) were analyzed retrospectively. Videomanometry was conducted to investigate esophageal motor patterns. Esophageal acid exposure was evaluated with 24-hour esophageal pH monitoring. Data are expressed as medians and ranges.

Results

Contractions in the distal esophagus were conspicuously absent in 1 and 3 patients in groups A and B, respectively (P = .26). There were no significant differences in esophageal acid exposure (5.5% [0.7%-24.6%] vs 3.7% [0.3%-56.8%]; P = .71) or mean esophageal acid reflux time (0.5 minutes [0.1-1.4 minutes] vs 0.5 minutes [0.1-1.3 minutes]; P = .87) between the 2 groups. Fundoplication was conducted in 2 patients in each group (P = .60), all of whom had conspicuously absent distal esophageal contractions. Those contractions were preserved in the remaining patients with the exception of 1 group B patient.

Conclusion

There are unlikely to be benefits from thoracoscopic repair of EA in terms of postoperative esophageal motor function.     

Long-term results and gastroesophageal reflux in a series of laparoscopic adjustable gastric banding

During the past decade, laparoscopic adjustable gastric banding has become the most popular surgical procedure in treating morbid obesity. On the other hand, significant drawbacks such as inadequate longterm weight loss, a high prevalence of reoperations, and frequent postoperative symptoms have been reported in the literature. This analysis summarizes our Department’s experience with this operation. Thirty-one patients (27 women and 4 men) with a mean body mass index of 46.5 kg/m² (range, 38.3-59.8 kg/m²) were operated upon laparoscopically between September 1997 and January 2003. The preoperative work-up of all patients included a psychological evaluation. Mean follow-up was 59.3 months (range, 19–84 months). Sixteen patients had esophageal pH-metry and 18 patients had upper gastrointestinal endoscopy preoperatively and postoperatively. Data were collected prospectively during the outpatient visits. Mean preoperative excess weight was 65.6 kg (range, 37.4-96.1 kg). Mean excess weight loss after 12, 24, 36, 48, 60, 72, and 84 months was 40.3%, 50.5%, 51.9%, 48.9%, 46.2%, 51.8%, and 30.2%, respectively. In total, six patients (19.4%) had an abdominal reoperation, including four patients (12.9%) for band removal. Upper gastrointestinal endoscopy was performed in 18 patients after 30.1 months (range, 5–67 months), showing a high prevalence of esophagitis (30.0%; grade 1: n = 3, grade 2: n = 3). Conversely, postoperative esophageal pH-metry performed in 16 patients was pathologic in 43.8%. Laparoscopic adjustable gastric banding produces significant weight loss even after long-term follow-up. However, the reoperation rate is high and postoperative symptoms are frequent. The high incidence of gastroesophageal reflux and esophagitis remains a matter of concern.     

Hypopharyngeal and distal esophageal pH monitoring in children with gastroesophageal reflux and respiratory symptoms

Purpose

Fundoplication is frequently required for gastroesophageal reflux (GER)-related respiratory disease. Correlation between esophageal pH data and respiratory symptoms is poor but may be improved by monitoring hypopharyngeal pH. Reflux to the hypopharynx is underestimated by salivary bicarbonate. The aim of this study was to determine if hypopharyngeal pH monitoring using pH 4 and pH 5 as reflux thresholds could predict children with reflux-related respiratory disease.

Methods

One hundred five children aged 4 months to 12 years underwent esophageal and hypopharyngeal pH monitoring. Hypopharyngeal pH data were analyzed using pH 4 and pH 5 as reflux thresholds. pH data from 4 groups were compared: group A, control group, no GER, no respiratory symptoms (n = 20); group B, respiratory symptoms, no GER (n = 16); group C, GER, no respiratory symptoms (n = 26); and group D, both GER and respiratory symptoms (n = 37).

Results

Comparing groups C and D, there was no significant difference in hypopharyngeal pH data. Using pH 5 as the reflux threshold, children in group B refluxed to the hypopharynx significantly more frequently than controls. This was most evident in children with wheeze.

Conclusion

Hypopharyngeal pH monitoring does not differentiate children with GER and respiratory symptoms from those with GER alone and is therefore of doubtful value in diagnosing recurrent aspiration.