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Sa1360 Efficacy and Safety of Pneumatic Dilatation in Patients With Achalasia Who Relapse Post Heller Myotomy
Sa1358
AGA Abstracts
Clinical Correlates of Swallow Perception to Esophageal Bolus Clearance in Patients With Globus Sensation Chien-Lin Chen, Chih-Hsun Yi, Tso-Tsai Liu Background/Aims: Globus sensation is a common finding with multiple plausible pathogenesis. This study aimed to determine simultaneous relationship between subjective perception of swallowing and esophageal motility by combined multichannel intraluminal impedance and manometry (MII-EM) in patients with globus sensation. We also investigated the hypothesis whether application with solid bolus was more sensitive than that with viscous bolus in provoking esophageal sensation and motility abnormality. Methods: Combined MII-EM was performed in 25 consecutive patients and 18 healthy controls. Swallow was abnormal if hypocontractivity or simultaneous contractions occurred. Bolus transit was incomplete if bolus exit was not found at one or more of the measuring sites. Proximal bolus transit was incomplete if bolus exit was not found at one or more of proximal two measuring sites. Perception of each swallow was assessed using a standardized scoring system, and was enhanced if score was > 1. Results: The prevalence of complete bolus transit was lower in patients with globus sensation compared to healthy controls during viscous (p = 0.001) and solid (p = 0.018) swallowings. In patients with globus sensation, the presence of incomplete bolus transit did not differ between viscous and solid swallowing regarding proximal (25.2% vs. 25.7%) or total esophagus (34% vs. 32.5%). Enhanced perception of swallowing was similar between viscous swallows (32 of 250 swallows [12.8%]) and solid swallows (45 of 250 solid swallows [18%]). Agreement between enhanced perception and proximal bolus clearance was greater during solid swallowing (κ = 0.45, 95% CI: 0.32-0.58) than viscous swallowing (κ = 0.13, 95% CI: 0-0.25). Similarly, agreement between enhanced perception and total bolus clearance was greater during solid swallowing (κ = 0.46, 95% CI: 0.34−0.58) than viscous swallowing (κ = 0.11, 95% CI: 0-0.22). Conclusions: Abnormal esophageal bolus clearance occurs in patients with globus sensation. Despite lower prevalence of enhanced swallow perception, patients with globus sensation show good correlation between enhanced esophageal perception and bolus clearance. Application of solid bolus may help better delineation of interrelationship between subjective perception of bolus passage and objective measurement of bolus clearance by combined MII-EM.
Example of a supragastric belch as measured by combined high-resolution manometry and impedance monitoring Sa1360 Efficacy and Safety of Pneumatic Dilatation in Patients With Achalasia Who Relapse Post Heller Myotomy Vivek Kumbhari, Jason Behary, Michal M. Szczesniak, Mahendra Naidoo, Ian J. Cook Background and Aims: Idiopathic achalasia is a chronic relapsing condition, irrespective of primary treatment modality. A paucity of data exists to guide the clinician on how best to treat symptom recurrence following primary therapy with Heller myotomy. The aim of this study was to evaluate the efficacy and safety of pneumatic dilatation to “salvage” symptomatic recurrence in patients treated initially with Heller myotomy for idiopathic achalasia. Methods: A retrospective, single centre, cross sectional study from 1995 - 2010, identified 27 patients treated with pneumatic dilatation for symptom recurrence following prior Heller myotomy. The institutional protocol is to perform sequential, graded (Rigiflex® balloon: 30-35-40mm) dilatations until a therapeutic response is achieved. After implementation of this protocol, patients were classified as ‘responder' or ‘non-responder' as assessed by one experienced clinician. In those who ‘responded', the relapse rate was defined as the time to any further therapy. If a patient relapsed then they were offered to again undergo pneumatic dilatation “on demand” as per institutional protocol. To determine the long-term remission rate, all responders to the initial treatment protocol completed a validated 10item achalasia severity questionnaire. Those with an achalasia severity score of <50 were considered to be in long term remission. Results: Of the 27 patients who commenced the sequential dilatations, 23 (85%) complied with the institutional protocol. Despite compliance with the protocol, 1 patient did not achieve adequate symptomatic benefit and was deemed a ‘non-responder'. The 4 patients who did not comply with the institutional protocol were also deemed ‘non-responders' as per intention to treat analysis. Therefore, 22 of 27 (81%) patients were ‘responders' on an intention to treat analysis. When considering only those who complied with the protocol 22 of 23 (96%) were ‘responders'. The relapse rate for the 22 ‘responders' was 16% at 24 months and 42% at 48 months. Questionnaires were returned in 20 of 22 (91%) ‘responders'. Long term remission at a median follow up of 30 months was 19 of 20 (95%). Of a total of 48 dilatations in 27 patients, there were no perforations. Conclusions: Graded pneumatic dilatation, together with “on demand” dilatation thereafter, is a safe and effective treatment for post-Heller myotomy symptom relapse in idiopathic achalasia.
Sa1359 Gastric Belching and Supragastric Belching are Two Distinct Pathophysiological Entities: A Study Using Combined High-Resolution Manometry and Impedance Monitoring Boudewijn F. Kessing, Albert J. Bredenoord, Andreas J. Smout Background: Supragastric belches, but not gastric belches, are associated with severe belching complaints. However, the exact mechanism of supragastric belching is not known. We aimed to compare the esophageal pressure characteristics during supragastric belches and gastric belches using combined high-resolution manometry and impedance monitoring. Methods: We included 10 patients with complaints of severe and frequent belching. Combined highresolution manometry and impedance monitoring was performed during 90 minutes after a standardized meal. Results: Nine patients exhibited supragastric belches during the measurement. Eight out of nine patients exhibited a specific pattern of supragastric belches which was characterized by concurrent (i) movement of the diaphragm in aboral direction (median (IQR) displacement: 2 (1-2) cm) and increase in median (IQR) EGJ pressure (20 (10-51) mmHg), (ii) pressure decrease in the esophagus (5 cm: -10.7 (-13.2- -4.3), 10 cm: -9.3 (12.4- -3.6), 15 cm: -7.7 (-8.3- -5.4) mmHg), (iii) upper esophageal sphincter (UES) relaxation preceding the airflow, (iv) antegrade airflow and (v) increase in esophageal pressure (5 cm: 17.7 (8.5-23.3), 10 cm: 13.2 (5.5-27.3), 15 cm: 20.6 (4.7-36.4) mmHg) and air being forced out of the esophagus in retrograde direction. In contrast, gastric belches were characterized by (i) decreased or unchanged EGJ pressure which was significantly lower than during supragastric belches (0 (-2.5-0) mmHg, p<0.05), (ii) significantly higher esophageal pressure or unchanged esophageal pressures, compared to supragastric belches, preceding the esophageal airflow (5 cm: 2.5 (-0.6-5.7) (p<0.05), 10 cm: -2.3 (-12-2) (NS), 15 cm: 0 (-4-2.3) (p<0.05) mmHg), (ii) retrograde airflow into the esophagus, (iii) common cavity phenomenon characterized by an increase in esophageal pressure (5 cm: 16.3 (5.4-18.3), 10 cm: 14.0 (1.318.1), 15 cm: 18.0 (9.3-27.5) mmHg) which was not different from supragastric belches and (iv) UES relaxation after the onset of the retrograde airflow. A specific phenomenon of repetitive supragastric belches but not of repetitive gastric belches was observed in the majority of patients. Notably, one out of nine patients exhibited a different pattern of supragastric belches in which the antegrade airflow was preceded by an increase in pharyngeal pressure up to 250 mmHg and not by a decrease in esophageal pressure. Conclusions: Supragastric belches and gastric belches are characterized by two clearly distinct esophageal pressure patterns. Movement of the diaphragm in aboral direction, negative esophageal pressure and UES relaxation are essential events in the generation of a supragastric belch.
AGA Abstracts
Sa1361 The Effect of Aging on Esophageal Motility Noriyuki Kawami, Katsuhiko Iwakiri, Hirohito Sano, Yuriko Tanaka, Mariko Umezawa, Yoshio Hoshihara, Choitsu Sakamoto Background: The prevalence of reflux esophagitis (RE) in the elderly is higher than in the young and it is thought that one of the reasons for the increased prevalence of RE in elderly people is that esophageal motility decreases with age. A decrease in esophageal motility however, may also be caused by esophagitis due to acid reflux itself, therefore, the effect of aging on esophageal motility is not completely understood. The aim of this study is to investigate the effect of aging on esophageal motility using both elderly and young people with neither reflux symptoms nor RE. Methods: 25 young (under 45) subjects and 25 elderly (over 65) subjects with neither reflux symptoms nor RE, underwent esophageal high resolution manometry with a 21-lumen perfused assembly, which monitored pressure in the pharynx, the upper esophageal sphincter, the esophageal body, the LES and the proximal stomach. An infusion port, located 18 cm above the distal side hole, was used to inject air. End expiratory basal LES pressure was referenced to end expiratory intragastric pressure. Primary peristalsis was tested with 5 ml water swallows, each swallow separated by a 30 second interval and the process repeated 10 times. Secondary peristalsis was triggered by esophageal distention, using a 20 ml bolus of air, which was injected rapidly into the middle esophagus by hand. After 20 seconds each stimulus was followed by a dry swallow to clear any of the residual air and then repeated 5 times. Results: There was no difference in the basal LES pressure and the distal contractile integral (DCI: volume of domain of distal esophagus) in primary or secondary peristalsis, between the young and the elderly (Table). The success rate of primary peristalsis in the elderly was similar to that of the young however, the success rate of secondary peristalsis in the elderly was significantly lower than in the young (Table). Conclusions: The only difference in esophageal motility between the young and the elderly is the success rate of secondary peristalsis.
S-282
AGA Abstracts
Clinical Correlates of Swallow Perception to Esophageal Bolus Clearance in Patients With Globus Sensation Chien-Lin Chen, Chih-Hsun Yi, Tso-Tsai Liu Background/Aims: Globus sensation is a common finding with multiple plausible pathogenesis. This study aimed to determine simultaneous relationship between subjective perception of swallowing and esophageal motility by combined multichannel intraluminal impedance and manometry (MII-EM) in patients with globus sensation. We also investigated the hypothesis whether application with solid bolus was more sensitive than that with viscous bolus in provoking esophageal sensation and motility abnormality. Methods: Combined MII-EM was performed in 25 consecutive patients and 18 healthy controls. Swallow was abnormal if hypocontractivity or simultaneous contractions occurred. Bolus transit was incomplete if bolus exit was not found at one or more of the measuring sites. Proximal bolus transit was incomplete if bolus exit was not found at one or more of proximal two measuring sites. Perception of each swallow was assessed using a standardized scoring system, and was enhanced if score was > 1. Results: The prevalence of complete bolus transit was lower in patients with globus sensation compared to healthy controls during viscous (p = 0.001) and solid (p = 0.018) swallowings. In patients with globus sensation, the presence of incomplete bolus transit did not differ between viscous and solid swallowing regarding proximal (25.2% vs. 25.7%) or total esophagus (34% vs. 32.5%). Enhanced perception of swallowing was similar between viscous swallows (32 of 250 swallows [12.8%]) and solid swallows (45 of 250 solid swallows [18%]). Agreement between enhanced perception and proximal bolus clearance was greater during solid swallowing (κ = 0.45, 95% CI: 0.32-0.58) than viscous swallowing (κ = 0.13, 95% CI: 0-0.25). Similarly, agreement between enhanced perception and total bolus clearance was greater during solid swallowing (κ = 0.46, 95% CI: 0.34−0.58) than viscous swallowing (κ = 0.11, 95% CI: 0-0.22). Conclusions: Abnormal esophageal bolus clearance occurs in patients with globus sensation. Despite lower prevalence of enhanced swallow perception, patients with globus sensation show good correlation between enhanced esophageal perception and bolus clearance. Application of solid bolus may help better delineation of interrelationship between subjective perception of bolus passage and objective measurement of bolus clearance by combined MII-EM.
Example of a supragastric belch as measured by combined high-resolution manometry and impedance monitoring Sa1360 Efficacy and Safety of Pneumatic Dilatation in Patients With Achalasia Who Relapse Post Heller Myotomy Vivek Kumbhari, Jason Behary, Michal M. Szczesniak, Mahendra Naidoo, Ian J. Cook Background and Aims: Idiopathic achalasia is a chronic relapsing condition, irrespective of primary treatment modality. A paucity of data exists to guide the clinician on how best to treat symptom recurrence following primary therapy with Heller myotomy. The aim of this study was to evaluate the efficacy and safety of pneumatic dilatation to “salvage” symptomatic recurrence in patients treated initially with Heller myotomy for idiopathic achalasia. Methods: A retrospective, single centre, cross sectional study from 1995 - 2010, identified 27 patients treated with pneumatic dilatation for symptom recurrence following prior Heller myotomy. The institutional protocol is to perform sequential, graded (Rigiflex® balloon: 30-35-40mm) dilatations until a therapeutic response is achieved. After implementation of this protocol, patients were classified as ‘responder' or ‘non-responder' as assessed by one experienced clinician. In those who ‘responded', the relapse rate was defined as the time to any further therapy. If a patient relapsed then they were offered to again undergo pneumatic dilatation “on demand” as per institutional protocol. To determine the long-term remission rate, all responders to the initial treatment protocol completed a validated 10item achalasia severity questionnaire. Those with an achalasia severity score of <50 were considered to be in long term remission. Results: Of the 27 patients who commenced the sequential dilatations, 23 (85%) complied with the institutional protocol. Despite compliance with the protocol, 1 patient did not achieve adequate symptomatic benefit and was deemed a ‘non-responder'. The 4 patients who did not comply with the institutional protocol were also deemed ‘non-responders' as per intention to treat analysis. Therefore, 22 of 27 (81%) patients were ‘responders' on an intention to treat analysis. When considering only those who complied with the protocol 22 of 23 (96%) were ‘responders'. The relapse rate for the 22 ‘responders' was 16% at 24 months and 42% at 48 months. Questionnaires were returned in 20 of 22 (91%) ‘responders'. Long term remission at a median follow up of 30 months was 19 of 20 (95%). Of a total of 48 dilatations in 27 patients, there were no perforations. Conclusions: Graded pneumatic dilatation, together with “on demand” dilatation thereafter, is a safe and effective treatment for post-Heller myotomy symptom relapse in idiopathic achalasia.
Sa1359 Gastric Belching and Supragastric Belching are Two Distinct Pathophysiological Entities: A Study Using Combined High-Resolution Manometry and Impedance Monitoring Boudewijn F. Kessing, Albert J. Bredenoord, Andreas J. Smout Background: Supragastric belches, but not gastric belches, are associated with severe belching complaints. However, the exact mechanism of supragastric belching is not known. We aimed to compare the esophageal pressure characteristics during supragastric belches and gastric belches using combined high-resolution manometry and impedance monitoring. Methods: We included 10 patients with complaints of severe and frequent belching. Combined highresolution manometry and impedance monitoring was performed during 90 minutes after a standardized meal. Results: Nine patients exhibited supragastric belches during the measurement. Eight out of nine patients exhibited a specific pattern of supragastric belches which was characterized by concurrent (i) movement of the diaphragm in aboral direction (median (IQR) displacement: 2 (1-2) cm) and increase in median (IQR) EGJ pressure (20 (10-51) mmHg), (ii) pressure decrease in the esophagus (5 cm: -10.7 (-13.2- -4.3), 10 cm: -9.3 (12.4- -3.6), 15 cm: -7.7 (-8.3- -5.4) mmHg), (iii) upper esophageal sphincter (UES) relaxation preceding the airflow, (iv) antegrade airflow and (v) increase in esophageal pressure (5 cm: 17.7 (8.5-23.3), 10 cm: 13.2 (5.5-27.3), 15 cm: 20.6 (4.7-36.4) mmHg) and air being forced out of the esophagus in retrograde direction. In contrast, gastric belches were characterized by (i) decreased or unchanged EGJ pressure which was significantly lower than during supragastric belches (0 (-2.5-0) mmHg, p<0.05), (ii) significantly higher esophageal pressure or unchanged esophageal pressures, compared to supragastric belches, preceding the esophageal airflow (5 cm: 2.5 (-0.6-5.7) (p<0.05), 10 cm: -2.3 (-12-2) (NS), 15 cm: 0 (-4-2.3) (p<0.05) mmHg), (ii) retrograde airflow into the esophagus, (iii) common cavity phenomenon characterized by an increase in esophageal pressure (5 cm: 16.3 (5.4-18.3), 10 cm: 14.0 (1.318.1), 15 cm: 18.0 (9.3-27.5) mmHg) which was not different from supragastric belches and (iv) UES relaxation after the onset of the retrograde airflow. A specific phenomenon of repetitive supragastric belches but not of repetitive gastric belches was observed in the majority of patients. Notably, one out of nine patients exhibited a different pattern of supragastric belches in which the antegrade airflow was preceded by an increase in pharyngeal pressure up to 250 mmHg and not by a decrease in esophageal pressure. Conclusions: Supragastric belches and gastric belches are characterized by two clearly distinct esophageal pressure patterns. Movement of the diaphragm in aboral direction, negative esophageal pressure and UES relaxation are essential events in the generation of a supragastric belch.
AGA Abstracts
Sa1361 The Effect of Aging on Esophageal Motility Noriyuki Kawami, Katsuhiko Iwakiri, Hirohito Sano, Yuriko Tanaka, Mariko Umezawa, Yoshio Hoshihara, Choitsu Sakamoto Background: The prevalence of reflux esophagitis (RE) in the elderly is higher than in the young and it is thought that one of the reasons for the increased prevalence of RE in elderly people is that esophageal motility decreases with age. A decrease in esophageal motility however, may also be caused by esophagitis due to acid reflux itself, therefore, the effect of aging on esophageal motility is not completely understood. The aim of this study is to investigate the effect of aging on esophageal motility using both elderly and young people with neither reflux symptoms nor RE. Methods: 25 young (under 45) subjects and 25 elderly (over 65) subjects with neither reflux symptoms nor RE, underwent esophageal high resolution manometry with a 21-lumen perfused assembly, which monitored pressure in the pharynx, the upper esophageal sphincter, the esophageal body, the LES and the proximal stomach. An infusion port, located 18 cm above the distal side hole, was used to inject air. End expiratory basal LES pressure was referenced to end expiratory intragastric pressure. Primary peristalsis was tested with 5 ml water swallows, each swallow separated by a 30 second interval and the process repeated 10 times. Secondary peristalsis was triggered by esophageal distention, using a 20 ml bolus of air, which was injected rapidly into the middle esophagus by hand. After 20 seconds each stimulus was followed by a dry swallow to clear any of the residual air and then repeated 5 times. Results: There was no difference in the basal LES pressure and the distal contractile integral (DCI: volume of domain of distal esophagus) in primary or secondary peristalsis, between the young and the elderly (Table). The success rate of primary peristalsis in the elderly was similar to that of the young however, the success rate of secondary peristalsis in the elderly was significantly lower than in the young (Table). Conclusions: The only difference in esophageal motility between the young and the elderly is the success rate of secondary peristalsis.
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