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A new focus on pharyngoesophageal interaction in achalasia
October 1994
A NEW FOCUS ON PHARYNGOESOPHAGEAL INTERACTION IN ACHALASIA
H. Thomas, A.P. Ireland, J. Heirnbucher, G.W.B. Clark, C.G. Bremner, T.R. DeMeester Department of Surgery, University of Southern California, Los Angeles, California. Previous studies of Upper Esophageal Sphincter (UES) function have suggested a failure of relaxation in patients with achalasia. These studies have measured absolute UES relaxation with reference to atmospheric pressure. We conceptualize oropharyngeal swallowing as a closed system of interacting pressures between pharynx, UES and esophagus. Thus, functional assessment of UES relaxation must be related to the pressure in the receptive organ, i.e. to esophageal baseline pressure. Pharyngoesophageal characteristics were measured in 20 patients with achalasia by means of a water perfused manometry system and the results were compared to those of 20 healthy volunteers. We found an elevated esophageal baseline pressure in achalasia (17.1 zb 1.4 mmHg vs. 4.0 f 0.6 mmHg in the controls, pc?p< 01) an i there was a direct correlation between the amp etude of the pharyngeal pressure waves and the extent of the elevation in esophageal baseline pressure. (1-0.57, p
INTRAOPERATIVE ESOPHAGEAL MANOMETRY IN LAPAROSCOPIC FUNDOPLICATION. Teramoto OT. Dept. of GI Motility, ABC Hospital Mexico. There have been several authors favouring the use of intraoperative manometry during the execution of anti-reflux operations, mainly in patients with achalasia. Laparoscopic fundoplication (LF) is a new approach which seems to be a very promising and preliminary reports give good results. Our goal was to evaluate the lower esophageal sphincter (LES) changes during the laparoscopic technique. We included 16 patiens, all of them fulfilled criteria of gastroesophageal reflux and esophagitis. 5 had Barrett’s by histology. All were operated successfully by laparoscopy, 13 with Nissen fundoplication and 3 with Touppet hemifundoplication. Manometric records were done with a Synectics polygram using a solid state catheter. The initial mean pressure was 5.15 (2-10) mmHg with a mean length of 1.42 (1-2) cm. After the procedure the mean pressure was 23.61 (19-35) mmHg and a lenght of 3.1 (2.5-4.5) cm. Clinical follow-up of these patients have been done during a period of 2 months (l-6) and, all of them, except two, are asymptomatic. Two had moderate dysphagia that were treated with dilation. We concluded that, even though further investigation is needed, intraoperative manometry allows the assessment of lenght and pressure of fundoplication during the procedure. LES pressure changes are similar to previous reports with the open techniche.
ABSTRACTS OF PAPERS
LINGUAL KINETICS AND PI-LARYNGEAL CLEARANCE DURING DEGLUTITION IN A CONSCIOUS MONKEY. Gz CR Larson. S Liu. R Shaker, PJ ICahrllas. Depts. of Univ., Chicago IL Medicine. Cnmm. Sci. & Dia.. Northw&un The tongue is essential in bolua loading
trained a radlcqque marker was implanted iuto the genioglossus muscle, near the glossopalatal junction. The monkey was then fluoroscoped as it swallowed juice/barium mixture, bolus size: 0.5-1~~. Pluoroscouic imarzes were recorded and later di itized for computer analysis. The lingual marker was tracked relative to a fixed point. The timing of the DES opening and glossopalatal closure were measured. Results: After bolus loading (Figure) and pulsion, the intrinsic tongue motion ceases leaving a “bulge” at the tongue base. The Graph shows cascading events of loading, $ion, UES opening, the finally
I~~~~~~~ 0 0
0.1
msec.
Sued.Dev.pharyngeal
0.2
stripping
0.3 wav=.
Conclusion: The intrinsic tongue musculature appears to move as a unit during bolus pulsion but remains stationary during bolus clearance. Hypopharyngeal clearance is achieved by the subsequent contraction of the pharyugeal constrictors.
DEVELOPMENT OF OBSOPHAGEAL BODY FUNCTION IN PRETERhI INFANTS. T.Omari. Goldswotthv. M. Bakewell. R. Haslam. Departments of Nmnablogy and Gastroenterology, Wonzen’s and Children’s Hospital, North Adelaide, South Australia and Detwtmcot of Gastroenterolo~y. Royal Adelaide Hospital, Adelaide, Ate&a. The development of oesopbageal motor function was investigated in 9 preterm infants using * miniaturised perfUsed mawmetric c&eta consisting of an oval extrusion 1.75 x 1.45 mm containing 3 manometric luminn and P feeding lumen (itemal diameters 0.35 mm and 0.6 mm respectively) which were 1.5 cm apart and pafused at 0.05 ml/min/lumen. Infants of gestational age 27 to 35 weeks were. studied at a post conceptional age (PCA) of 34 to 37 weeks. The catheter was introduced until the sideholes recorded intragastric pressure and the assembly then gradually pulled back to position tbe sideholes astride the oesophagogastric junction. Following intragastric instillation of a liquid meal the catheter was withdrawn so that the distal sidehole was 2 cm above the high pressure zone. Swallowing was induced at 1 min lntewals for 20 min by a puff of air on the baby’s face [Santmyer Reflex
(=)I r=1942r-453712r=0698
c&&xl the
SR in
occurred’lnre&nse to children
older
than
34
In conclusion tbis study shows that there is an mcrased response to swallowing stimulation with increased PCA. We bwe also demonstrated that purpose designed extrusions allow oesophageal manometry in association with the inhdxtion required for feeding. T%is is an effective technique to study oewphageal motor function m premature. infants.
1241
A NEW FOCUS ON PHARYNGOESOPHAGEAL INTERACTION IN ACHALASIA
H. Thomas, A.P. Ireland, J. Heirnbucher, G.W.B. Clark, C.G. Bremner, T.R. DeMeester Department of Surgery, University of Southern California, Los Angeles, California. Previous studies of Upper Esophageal Sphincter (UES) function have suggested a failure of relaxation in patients with achalasia. These studies have measured absolute UES relaxation with reference to atmospheric pressure. We conceptualize oropharyngeal swallowing as a closed system of interacting pressures between pharynx, UES and esophagus. Thus, functional assessment of UES relaxation must be related to the pressure in the receptive organ, i.e. to esophageal baseline pressure. Pharyngoesophageal characteristics were measured in 20 patients with achalasia by means of a water perfused manometry system and the results were compared to those of 20 healthy volunteers. We found an elevated esophageal baseline pressure in achalasia (17.1 zb 1.4 mmHg vs. 4.0 f 0.6 mmHg in the controls, p
INTRAOPERATIVE ESOPHAGEAL MANOMETRY IN LAPAROSCOPIC FUNDOPLICATION. Teramoto OT. Dept. of GI Motility, ABC Hospital Mexico. There have been several authors favouring the use of intraoperative manometry during the execution of anti-reflux operations, mainly in patients with achalasia. Laparoscopic fundoplication (LF) is a new approach which seems to be a very promising and preliminary reports give good results. Our goal was to evaluate the lower esophageal sphincter (LES) changes during the laparoscopic technique. We included 16 patiens, all of them fulfilled criteria of gastroesophageal reflux and esophagitis. 5 had Barrett’s by histology. All were operated successfully by laparoscopy, 13 with Nissen fundoplication and 3 with Touppet hemifundoplication. Manometric records were done with a Synectics polygram using a solid state catheter. The initial mean pressure was 5.15 (2-10) mmHg with a mean length of 1.42 (1-2) cm. After the procedure the mean pressure was 23.61 (19-35) mmHg and a lenght of 3.1 (2.5-4.5) cm. Clinical follow-up of these patients have been done during a period of 2 months (l-6) and, all of them, except two, are asymptomatic. Two had moderate dysphagia that were treated with dilation. We concluded that, even though further investigation is needed, intraoperative manometry allows the assessment of lenght and pressure of fundoplication during the procedure. LES pressure changes are similar to previous reports with the open techniche.
ABSTRACTS OF PAPERS
LINGUAL KINETICS AND PI-LARYNGEAL CLEARANCE DURING DEGLUTITION IN A CONSCIOUS MONKEY. Gz CR Larson. S Liu. R Shaker, PJ ICahrllas. Depts. of Univ., Chicago IL Medicine. Cnmm. Sci. & Dia.. Northw&un The tongue is essential in bolua loading
trained a radlcqque marker was implanted iuto the genioglossus muscle, near the glossopalatal junction. The monkey was then fluoroscoped as it swallowed juice/barium mixture, bolus size: 0.5-1~~. Pluoroscouic imarzes were recorded and later di itized for computer analysis. The lingual marker was tracked relative to a fixed point. The timing of the DES opening and glossopalatal closure were measured. Results: After bolus loading (Figure) and pulsion, the intrinsic tongue motion ceases leaving a “bulge” at the tongue base. The Graph shows cascading events of loading, $ion, UES opening, the finally
I~~~~~~~ 0 0
0.1
msec.
Sued.Dev.pharyngeal
0.2
stripping
0.3 wav=.
Conclusion: The intrinsic tongue musculature appears to move as a unit during bolus pulsion but remains stationary during bolus clearance. Hypopharyngeal clearance is achieved by the subsequent contraction of the pharyugeal constrictors.
DEVELOPMENT OF OBSOPHAGEAL BODY FUNCTION IN PRETERhI INFANTS. T.Omari. Goldswotthv. M. Bakewell. R. Haslam. Departments of Nmnablogy and Gastroenterology, Wonzen’s and Children’s Hospital, North Adelaide, South Australia and Detwtmcot of Gastroenterolo~y. Royal Adelaide Hospital, Adelaide, Ate&a. The development of oesopbageal motor function was investigated in 9 preterm infants using * miniaturised perfUsed mawmetric c&eta consisting of an oval extrusion 1.75 x 1.45 mm containing 3 manometric luminn and P feeding lumen (itemal diameters 0.35 mm and 0.6 mm respectively) which were 1.5 cm apart and pafused at 0.05 ml/min/lumen. Infants of gestational age 27 to 35 weeks were. studied at a post conceptional age (PCA) of 34 to 37 weeks. The catheter was introduced until the sideholes recorded intragastric pressure and the assembly then gradually pulled back to position tbe sideholes astride the oesophagogastric junction. Following intragastric instillation of a liquid meal the catheter was withdrawn so that the distal sidehole was 2 cm above the high pressure zone. Swallowing was induced at 1 min lntewals for 20 min by a puff of air on the baby’s face [Santmyer Reflex
(=)I r=1942r-453712r=0698
c&&xl the
SR in
occurred’lnre&nse to children
older
than
34
In conclusion tbis study shows that there is an mcrased response to swallowing stimulation with increased PCA. We bwe also demonstrated that purpose designed extrusions allow oesophageal manometry in association with the inhdxtion required for feeding. T%is is an effective technique to study oewphageal motor function m premature. infants.
1241