Pharyngoesophageal (Zenker's) diverticulum: a reappraisal

Manometric evaluation of pharyngeal contraction and upper esophageal sphincter relaxation was performed in a group of patients with Zenker's diverticulum using a specially designed low compliance manometric recording system. The results were compared with those in normal controls. In all cases, the upper esophageal sphincter showed complete relaxation during swallowing and no incoordination between pharyngeal contraction and upper esophageal sphincter relaxation could be demonstrated compared to time intervals found in the control group. Resting upper esophageal sphincter pressures were significantly lower in diverticulum patients than in controls. It is concluded that symptomatic patients with Zenker's diverticulum have normal pharyngeal-upper esophageal sphincter coordination, exhibit complete upper esophageal sphincter relaxation on swallowing, and have low resting upper esophageal sphincter pressures. These results seriously question the previous concept of abnormalities of pharyngeal-upper esophageal sphincter coordination in patients with Zenker's diverticulum.     

Manometric aspects of Zenker's diverticulum.

Zenker's diverticulum is thought to result from disordered coordination between the pharynx and upper esophageal sphincter. Manometric studies of the upper esophagus have been helpful in testing the hypothesis of dysmotility in the formation and growth of a Zenker's diverticulum; however, the data have provided conflicting evidence. Manometric studies show that resting upper esophageal sphincter pressure is normal in some patients with Zenker's diverticulum and decreased in others. Abnormal premature relaxation and contraction of the upper esophageal sphincter seen in some patients with Zenker's diverticulum may be accompanied by pharnygeal contractions against a closed sphincter. This abnormality is thought by some investigators to be the cause of Zenker's diverticulum, but not by others who have found normal upper sphincter relaxation. Future manometric studies will very likely elucidate the pathogenesis of Zenker's diverticulum.     

Characterization of Esophageal Striated Muscle in Patients with Achalasia

Many studies have been conducted analyzing the manometric properties of patients with achalasia, but the striated portion of the esophagus has never been analyzed and is often overlooked. We retrospectively reviewed 120 manometric tracings (20 achalasia, 100 controls) performed between 1994 and 1997 and excluded tracings from patients with chronic cough and nutcracker esophagus. The data were assessed for age, sex, symptoms, duration of symptoms, lower esophageal sphincter pressure, gastroesophageal gradient, upper esophageal sphincter pressure, smooth muscle contraction amplitude and duration, striated muscle contraction amplitude and duration, length from upper esophageal sphincter to maximal striated muscle contraction, and esophageal length. The maximum striated muscle contraction amplitude was significantly decreased in achalasia patients with a median amplitude of 45 mm Hg (range 12–95) vs 76 mm Hg (range 30–210) in the control group (P = 0.002). Although the wave forms were similar, the maximum striated muscle contraction duration and the distance from the upper esophageal sphincter in achalasia patients was not significantly different from controls. The length of the esophagus was significantly longer in achalasia patients with a median value of 25 cm (range 21–30) vs 21 cm (range 17–26) in the control group (P < 0.001). Patients with achalasia have significantly lower maximum striated muscle contraction amplitudes and longer esophagi, but the duration of the contractions and the configuration of the wave forms are not different.     

Efficacy of Adjunctive Cricopharyngeus Myotomy in Supraglottic Laryngectomy

This study investigates prospectively the effect of concurrent cricopharyngeus myotomy (CPM) on swallowing following horizontal supraglottic laryngectomy (SL) using fiberoptic, radiographic, and manometric evaluations and suggests possible mechanisms regarding the role of CPM following SL. Six patients undergoing horizontal SL between 1995 and 1997 were enrolled in a prospective evaluation with a followup of 0.5–2.25 years. Three patients underwent concurrent CPM and three did not. Fiberoptic, radiographic, and manometric assessments were performed postoperatively. Although mean resting pressures at the upper esophageal sphincter were reduced significantly by myotomy (12 mm Hg) compared with nonmyotomized patients (57 mm Hg), p < 0.01, no rehabilitative advantage was observed in the former group. In fact, of the myotomized patients, two required feeding gastrostomy tubes with resumption of an oral diet in one year and in two months, respectively, while the nonmyotomized patients were all capable of resuming a full oral diet within four weeks. It appears that CPM provides no rehabilitative advantage in patients undergoing SL.     

Manometric study in Kearns–Sayre syndrome

Although swallowing difficulties have been described in patients with Kearns-Sayre syndrome (KSS), the spectrum of manometric characteristics of dysphagia is not yet well known. Moreover, it is conceivable that a combination of various degrees of swallowing difficulties with different patterns in manometric studies exist, each playing a major role in the prognosis, natural history, and quality of life of KSS patients. An 18-year-old girl diagnosed at the age of 5 years with KSS (muscle biopsy) was admitted to our department with an upper respiratory tract infection and dysphagia. Clinical examination revealed growth retardation, external ophthalmoplegia, pigmentary retinopathy, impaired hearing, and ataxia. An electrocardiogram revealed cardiac conduction defects (long Q-T), and brain magnetic resonance imaging showed abnormalities in the cerebellar hemispheres. A manometric and motility study for dysphagia was conducted and the pharynx and upper esophageal sphincter (UES) resting pressures were similar to control group values, but the swallowing peak contraction pressure of the pharynx and the closing pressure of the UES were very low and could not promote effective peristaltic waves. Relaxation and coordination of the UES were not affected although pharyngeal and upper esophagus peristaltic waves proved to be very low and, consequently, were practically ineffective. The patient was started on treatment comprising a diet rich in potassium, magnesium, and calcium, and oral administration of vitamin D and co-enzyme Q10 100 mg daily; she was discharged 6 days later with apparent clinical improvement.     

Intraesophageal pressure during esophageal speech in laryngectomized patients rehabilitated or no rehabilitated for oral communication

BACKGROUND: After laryngectomy for treatment of pharyngeal/laryngeal carcinomas the patients may be rehabilitated, for oral communication, with the esophageal speech. AIM: To study the intra-esophageal pressure during the esophageal speech. PATIENTS AND METHODS: It was measured the intra-esophageal pressure in 25 laryngectomized patients aged 40 to 70 years (median 57 years), 10 rehabilitated with esophageal speech and 15 unable to do so. The manometric method with continuous perfusion was used. The esophageal pressures was measured 3 to 5 cm below the upper esophageal sphincter when the patients tried to speak the vowel "a". Sometimes the air swallowed went to the stomach, with a peristaltic or simultaneous contraction in the esophageal body. RESULTS: During the attempt of esophageal speech the intra-esophageal pressure was higher in patients able to have esophageal speech (26.4 +/- 10.1 mm Hg, mean +/- SD) than in patients unable to do so (13.7 +/- 7.2 mm Hg). The esophageal contraction after a swallow of air was also higher in patients with esophageal speech (45.3 +/- 8.6 mm Hg) than in patients unable to do so (33.8 +/- 13.1 mm Hg). CONCLUSION: Laryngectomized patients rehabilitated with esophageal speech has a higher intra-esophageal pressure during speech than patients unable to do so, what may be consequence of the capacity to retain air inside the esophagus.     

Normal esophageal function after myotomy in a patient with idiopathic diffuse esophageal spasm.

A 52-year-old man with idiopathic diffuse esophageal spasm and hypertensive lower esophageal sphincter presented with dysphagia for several years. After unsuccessful therapy with forceful pneumatic dilation of the cardia, a myotomy of the cardia and distal esophagus was performed. The patient became asymptomatic, lower esophageal sphincter pressure diminished to less than 10 mm Hg, and esophageal body motor activity was normalized. This situation remains unchanged 6 years after the operation.     

Esophageal function in portal hypertension before and after sclerotherapy

An examination of esophageal function using manometric techniques and long-term pH measurement was carried out on 14 patients suffering from cirrhosis of the liver who had esophageal varices. The resting pressure in the lower esophageal sphincter was found to be slightly reduced in 50 per cent of those examined, while 100 per cent showed a slightly reduced contraction amplitude in the distal tubular esophagus which became progressively lower in the distal direction, and a pathological gastro-esophageal reflux was observed in 57 per cent. We were able to carry out a control examination on 10 of these patients after sclerosing procedure. Sclerotherapy was found to have lowered resting pressures in the lower esophageal sphincter in 80 per cent of those patients, while all of them showed a grossly impaired tubular peristalsis in the form of simultaneous, mostly repetitive contractions with a considerably lowered contraction amplitude, however it had no negative influence on gastro-esophageal reflux patterns.     

Aging-related alterations in human upper esophageal sphincter function

Recent improvements in manometric catheters have made measurement of pharyngeal (P) and upper esophageal sphincter (UES) swallowing mechanics more reliable. Few studies have attempted to evaluate the effect of normal aging on P and UES mechanics. Pharyngeal and upper esophageal sphincter dynamics were studied in 10 healthy elderly adults (age greater than 60; range 62-79 yr) and 10 younger adults (age less than 60; range 24-59 yr). A solid-state intraluminal transducer system was used with a proximal unidirectional Konigsberg microtransducer and a circumferential (sphincter) transducer located 5 cm distally. Mean resting UES pressure was significantly (p less than 0.05) lower in the elderly than in the younger subjects (52 +/- 5 vs 72 +/- 6 (SE)) mm Hg. A significant inverse relation (R = -0.54; p less than 0.02) was found between age and resting UES pressure. Time from peak of pharyngeal contraction to UES nadir was significantly (p less than 0.05) shortened in the healthy elderly vs younger controls (10 +/- 30 vs 90 +/- 20 ms) during dry swallows. Our studies indicate that aging is associated with lower resting UES pressure and delayed UES relaxation, relative to the pharyngeal peak.     

Surgical myotomy in patients with high-amplitude peristaltic esophageal contractions

High-amplitude peristaltic esophageal contractions, or the nutcracker esophagus, may be associated with chest pain or dysphagia. Medical treatment for this disorder is sometimes not satisfactory. We report the manometric and clinical effects of myotomy in four patients with high-amplitude peristaltic contractions who underwent surgery because of the severity of their symptoms and recalcitrance to various medical treatments. Manometry 1-5 years after surgery showed a reduction in amplitude, duration, and percent bipeaked waves at 5 and 10 cm above the lower esophageal sphincter. Peristalsis was abolished or decreased in the distal 10 cm of the esophageal body but was not affected more proximally. Lower esophageal sphincter pressure was decreased in all patients. The manometric changes were least marked in one patient, who was the only one who had some chest pain when last seen five years after myotomy. We conclude that in severely symptomatic patients with high-amplitude peristaltic contractions, myotomy results in marked manometric changes and marked clinical improvement. Patients with this disorder and whose chest pain is recalcitrant to extensive medical therapy may be successfully treated by surgical myotomy.     

Esophageal manometry: a comparison of findings in younger and older patients

Objective: We sought to determine the utility of esophageal manometry in an older patient population.
Methods: Consecutively performed manometry studies (470) were reviewed and two groups were chosen for the study, those ≥ 75 yr of age (66 patients) and those ≤ 50 years (122 patients). Symptoms, manometric findings (lower esophageal sphincter [LES], esophageal body, upper esophageal sphincter [UES]) and diagnoses were compared between the groups.
Results: Dysphagia was more common (60.6% vs 25.4%), and chest pain was less common (17.9 vs 26.2%) in older patients. In the entire group, there were no differences in LES parameters. Older patients with achalasia had lower LES residual pressures after deglutition (2.7 vs 12.0 mm Hg), but had similar resting pressures (31.4 vs 35.2 mm Hg) compared with younger achalasia patients. Duration and amplitude of peristalsis were similar in both groups, whereas peristaltic sequences were more likely to be simultaneous in the older group (15% vs 4%). The UES had a lower resting pressure in the older patients (49.6 vs 77.6 mm Hg) and a higher residual pressure (2.0 vs −2.7 mm Hg). The older patients were less likely to have normal motility (30.3% vs 44.3%) and were more likely to have achalasia (15.2% vs 4.1%) or diffuse esophageal spasm (16.6% vs 5.0%). When only patients with dysphagia were analyzed, achalasia was still more likely in the older group (20.0% vs 12.9%).
Conclusions: When older patients present with dysphagia, esophageal manometry frequently yields a diagnosis to help explain their symptoms.     

Concurrent Fluoroscopy and Manometry Reveal Differences in Laparoscopic Nissen and Anterior Fundoplication

A prospective double-blind randomized trial wasinitiated to examine two types of laparoscopicfundoplication (Nissen and anterior). Thirty-twopatients with proven gastroesophageal reflux diseasepresenting for primary laparoscopic antireflux surgerywere randomized to undergo either Nissen fundoplication(N = 13) or anterior hemifundoplication (N = 19).Postoperative fluoroscopic and manometric examinationwas carried out concomitantly. Nissenfundoplication resulted in significantly greaterelevation of resting (33.5 vs 23 mm Hg) and residuallower esophageal sphincter pressures (17 vs 6.5 mm Hg)and lower esophageal ramp pressure (26 vs 20.5 mm Hg) than theanterior partial fundoplication. A smallerradiologically measured sphincter opening diameter wasseen following Nissen fundoplication (9 mm) comparedwith anterior fundoplication (12 mm). Lower esophageal ramppressure correlated weakly (r = 0.37, P = 0.04) withpostoperative dysphagia. It is concluded that the typeof fundoplication performed significantly influences postoperative manometric and video bariumradiology outcomes. The clinical relevance of thisrequires further investigation.     

Predictors of Outcome following Cricopharyngeal Disruption for Pharyngeal Dysphagia

The indications for, and predictors of outcome following cricopharyngeal disruption in pharyngeal dysphagia are not clearly defined. Our purpose was to examine the symptomatic response to cricopharyngeal disruption, by either myotomy or dilatation, in patients with oral-pharyngeal dysphagia and to determine pretreatment manometric or radiographic predictors of outcome. Using simultaneous pharyngeal videoradiography and manometry, we studied 20 patients with pharyngeal dysphagia prior to cricopharyngeal diltation (n = 11) or myotomy (n = 8), and 23 healthy controls. We measured peak pharyngeal pressure, hypopharyngeal intrabolus pressure, upper esophageal sphincter diameter, and coordination. Response rate to sphincter disruption was 65%. The extent of sphincter opening was significantly reduced in patients compared with controls (p= 0.004), but impaired sphincter opening was not a predictor of outcome. Increased hypopharyngeal intrabolus pressures (>19 mmHg for 10 ml bolus; >31 mmHg for 20 ml bolus) was a significant predictor of outcome (p= 0.01). Neither peak pharyngeal pressure nor incoordination were predictors of outcome. In pharyngeal dysphagia, hypopharyngeal intrabolus pressure, and not peak pharyngeal pressure, is a predictor of response to cricopharyngeal disruption. The relationship between intrabolus pressure and impaired sphincter opening is an indirect measure of sphincter compliance which helps predict therapeutic response.     

A case of giant esophageal epiphrenic diverticulum resected laparoscopically,followed by Heller myotomy and Dor fundoplication

A 66-year-old male patient visited our hospital with the chief complaints of difficulty in swallowing and vomiting. The upper gastrointestinal radiographic contrast study revealed a diverticulum with a diameter of about 10 cm in the diaphragm to the right of the esophagus. Upper gastrointestinal endoscopy revealed the inlet of the diverticulum on the right wall of the esophagus at a distance of 44–46 cm from the incisors. The patient was diagnosed as having a giant epiphrenic esophageal diverticulum with obstruction; dysfunction of the lower esophageal sphincter was also considered. Therefore, he was treated by laparoscopic resection of the diverticulum, followed by Heller myotomy and Dor fundoplication. The postoperative course was satisfactory, and the patient showed substantial improvement in his dysphagia. He was discharged from our hospital on the 9th postoperative day. At present, 2 years after the operation, he remains well without any recurrence of the symptoms.     

Measurement of upper esophageal sphincter pressure. Effect of acute emotional stress

Recent studies suggest that resting upper esophageal sphincter pressure is more labile than previously thought, being augmented during rapid manometric pull-through and markedly decreased during sleep and anesthesia. The effect of acute emotional stress on resting upper esophageal sphincter pressure was evaluated in 13 normal subjects with a manometric sleeve assembly. Manometric sideholes were positioned in the pharynx and cervical and thoracic esophagus while the sleeve sensor straddled the upper esophageal sphincter. Subjects were stressed intermittently by 14-min periods of a dichotic listening task. As incentive, a financial reward was offered and made commensurate with performance. Alterations of heart rate, blood pressure, and skin conductance confirmed the effectiveness of the stressor. The overall mean upper esophageal sphincter pressure during control periods was 46.5 mmHg (SEM = 4.7). During stress there was a significant mean increase (11.8 +/- 2.9 mmHg; p = 0.002) in upper esophageal sphincter pressure from control levels, and the pressure increase during the first 2-min epoch of stress was 20.8 +/- 3.9 mmHg (p = 0.0003). Emotional stress causes significant elevation of upper esophageal pressure in normal subjects. This effect is likely to influence resting sphincter pressure measurements, particularly if measurement conditions are stressful to the subject.     

Incomplete Lower Esophageal Sphincter Relaxation in Subjects with Peristalsis: Prevalence and Clinical Outcome

Incomplete lower esophageal sphincter relaxation is recognized in achalasia and has been reported in subjects with esophageal spasm. We reviewed 500 consecutive manometric studies from a 3-yr period to determine the prevalence of this manometric finding, its association with other motility abnormalities, and the clinical outcome of subjects without associated aperistalsis (i.e., without achalasia). We identified 60 subjects with incomplete lower sphincter relaxation, 17 of whom had at least some normal peristalsis (3.4% of the total). Mean lower sphincter residual pressure for these 17 subjects (4.5 +/- 2.8 mm Hg) was intermediate between those with achalasia (11.7 +/- 6.8 mm Hg) and those with normal relaxation (0.1 +/- 0.2 mm Hg). Both peristaltic and contraction abnormalities in the esophageal body were prevalent in the 17 subjects compared with those who had normal relaxation. Outcome with conservative medical therapy after a mean follow-up of 3.3 yr was not significantly related to presence of peristaltic or contraction abnormalities at presentation, and 71% of subjects with or without these concomitant findings had improvement or complete resolution of symptoms. Only one subject worsened and was treated with pneumatic dilation. We conclude that incomplete relaxation of the lower esophageal sphincter without aperistalsis is uncommon, symptom regression occurs with conservative therapy, and pneumatic dilation appears rarely required over a modest follow-up period.     

Manometric diagnosis of diffuse esophageal spasm

There are no requirements concerning the amplitude of simultaneous contractions among the present criteria for the manometric diagnosis of diffuse esophageal spasm. The purpose of this investigation was to determine whether the current criteria effectively identify an appropriately homogeneous patient population. Sixty consecutive motility tracings that met the criteria for diffuse esophageal spasm were evaluated. A bimodal distribution of the highest simultaneous esophageal contraction for each patient was observed. One group's (N=29) highest simultaneous esophageal contractile amplitude was 74 mm Hg, the other's (N=31) highest simultaneous esophageal contractile amplitude was 100 mm Hg. Group 1 had significantly decreased lower esophageal sphincter pressure, lower peristaltic amplitude, more aperistalsis, fewer simultaneous contractions, and fewer complaints of chest pain. These comparisons suggest that consideration be given to the amplitude of simultaneous esophageal contractions in the manometric diagnosis of diffuse esophageal spasm.     

The effect of manometric assembly diameter on intraluminal esophageal pressure recording

Recent studies indicate that lower esophageal sphincter pressure is influenced by manometric assembly diameter. This study determines the effect of assembly diameter on both esophageal sphincter pressure and peristaltic pressure in the esophageal body. We performed esophageal manometric studies in 6 normal subjects using graded assembly diameters. High-fidelity recording was achieved by using a noncompliant catheter-infusion system. The results indicate that increases in assembly diameter cause significant increases in peristaltic pressure amplitudes and in resting sphincter pressure in both the smooth and striated muscle portions of the esophagus. This phenomenon is best explained by the length-tension characteristics of esophageal muscle, increased stretch causing greater contraction force.     

The effect of esophageal myotomy and myectomy on the lower esophageal sphincter pressure profile: intraoperative computerized manometry study

SUMMARY. The surgical treatment of achalasia, based on Heller's myotomy is the procedure of choice to reduce the sphincterial high pressure zone, either by laparotomy or, most recently, by laparoscopy. What is the right length of the myotomy? Many authors have reported 10–15% postoperative residual dysphagia, due to the incomplete gastric myotomy and not to esophageal pouring. The aim of this study is to experimentally determine the modifications induced by Heller's myotomy and myectomy of the esophago‐gastric junction on lower esophageal sphincter (LES) pressure profile, using a computerized manometric system. Myotomy of the esophageal portion of the LES (i.e. without dissection of the gastric fibers) has not modified the parameters considered, while the dissection of gastric fibers for at least 2–3 cm on the anterior gastric wall has created a significant modification of the LES pressure profile. Our observations seem to confirm and more clearly demonstrate the important role played by gastric fibers in sustaining the sphincteric HPZ. Moreover, analysis of our data, showed the need to always perform a complete myotomy. This was objectively shown during the intervention by means of intraoperative manometry, in order to significantly reduce the possibility of a dysphagic relapse, caused by inadequate treatment.     

Monitoring of Pharyngeal and Upper Esophageal Sphincter Activity with an Arterial Dilation Balloon Catheter

In patients with dysphagia and radiologic signs of dysfunction of the upper esophageal sphincter (UES), manometry is helpful in giving a better understanding of muscular activity during swallowing. Traditional manometric methods include use of perfusion catheters or solid-state intraluminal strain gauges. The rapid and asymmetric pressure variations in the UES and difficulties compensating for the pharyngolaryngeal elevation during swallowing limit the value of these methods. We used an arterial balloon dilation catheter as a probe in manometric recording of the UES in 28 healthy volunteers. Simultaneous perfusion manometry of the pharynx with the same catheter was performed to assess the coordination of the muscular activity in the esophageal entrance during swallowing. The catheter was well tolerated by all subjects. We found an average resting pressure in the UES of 31.0 mmHg, and the average maximum pressure during contraction was 89.0 mmHg. The average duration of the swallowing act was 3.9 s. All subjects displayed a complete UES relaxation and a normal coordination of propagated pressure in the hypopharynx and UES. The results were highly reproducible and the interindividual range was low. Arterial dilation catheters are safe and have suitable physical properties for pressure monitoring in the UES.