Response to multiple rapid swallows shows impaired inhibitory pathways in distal esophageal spasm patients with and without concomitant esophagogastric junction outflow obstruction

Summary Distal esophageal spasm (DES) is a motility disorder characterized by premature contraction of the esophageal body during single swallows. It is thought to be due to impairment of esophageal inhibitory pathways, but studies to support this are limited. The normal response to multiple rapid swallows (MRS) is deglutitive inhibition of the esophageal body during the MRS sequence. Our aim was to compare the response to MRS in DES patients and healthy control subjects. Response to MRS during HRM was evaluated in 19 DES patients (8 with and 11 without concomitant esophagogastric junction outflow obstruction [EGJOO]) and 24 asymptomatic healthy controls. Patients with prior gastroesophageal surgery, peroral endoscopic myotomy, pneumatic dilation, esophageal botulinum toxin injection within 6 months of HRM, opioid medication use, and esophageal stricture were excluded. Response to MRS was evaluated for complete versus impaired inhibition (esophageal body contractility with distal contractile integral [DCI] > 100 mmHg-sec-cm during MRS), presence of post-MRS contraction augmentation (DCI post MRS greater than single swallow mean DCI), and integrated relaxation pressure (IRP). Impaired deglutitive inhibition during MRS was significantly more frequent in DES compared to controls (89% vs. 0%, P < 0.001), and frequency was similar for DES with versus without concomitant EGJOO (100% vs. 82%, P = 0.48). The proportion of subjects with augmentation post MRS was similar for both groups (37% vs. 38%, P = 1.00), but mean DCI post MRS was higher in DES than controls (3360.0 vs. 1238.9, P = 0.009). IRP was lower during MRS compared to single swallows in all patients, and IRP during MRS was normal in 5 of 8 patients with DES and EGJOO. Our study suggests that impaired deglutitive inhibition during MRS is present in the majority of patients with DES regardless of whether they have concomitant EGJOO, and future studies should explore the usefulness of incorporating response to MRS in the diagnosis of DES.

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Tu1212 Per-Oral Endoscopic Myotomy for Achalasia, Esophagogastric Junction Outflow Obstruction and Diffuse Esophageal Spasm; A Us Tertiary Care Center Experience

Gastrointestinal Endoscopy ◽

10.1016/j.gie.2017.03.1349 ◽

2017 ◽

Vol 85 (5) ◽

pp. AB585-AB586 ◽

Cited By ~ 1

Author(s):

Maen M. Masadeh ◽

Subhash Chandra ◽

Huafeng Shen ◽

Jagpal Klair ◽

Mariam Naveed ◽

...

Keyword(s):

Esophagogastric Junction ◽

Care Center ◽

Tertiary Care ◽

Diffuse Esophageal Spasm ◽

Tertiary Care Center ◽

Outflow Obstruction ◽

Per Oral Endoscopic Myotomy ◽

Esophageal Spasm ◽

Endoscopic Myotomy ◽

Per Oral

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Insights into the endoscopic management of esophageal achalasia

Therapeutic Advances in Gastrointestinal Endoscopy ◽

10.1177/26317745211014706 ◽

2021 ◽

Vol 14 ◽

pp. 263177452110147

Author(s):

Elizabeth Brindise ◽

Mouen A. Khashab ◽

Rami El Abiad

Keyword(s):

Esophagogastric Junction ◽

Botulinum Toxin Injection ◽

Esophageal Achalasia ◽

Peroral Endoscopic Myotomy ◽

Inhibitory Neurons ◽

Treatment Modalities ◽

Endoscopic Management ◽

Pneumatic Dilation ◽

Esophageal Motility Disorder ◽

Endoscopic Myotomy

Achalasia is a primary esophageal motility disorder characterized by the loss of inhibitory neurons in the myenteric plexus, resulting in impaired relaxation of the esophagogastric junction. Achalasia is an incurable disease, and the treatment modalities are aimed at disruption of the esophagogastric junction and vary widely from pharmacological to endoscopic to surgical. Traditional endoscopic therapy includes pneumatic dilation, botulinum toxin injection, and peroral endoscopic myotomy. This review aims to provide an overview of the endoscopic management of achalasia, while focusing on the utilization of peroral endoscopic myotomy and other novel approaches.

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Esophageal peroral endoscopic myotomy (POEM) for treatment of esophagogastric junction outflow obstruction: results from the first prospective trial

Endoscopy International Open ◽

10.1055/a-1198-4643 ◽

2020 ◽

Vol 08 (09) ◽

pp. E1137-E1143

Author(s):

Yervant Ichkhanian ◽

Omid Sanaei ◽

Andrew Canakis ◽

Kia Vosoughi ◽

Erik Almazan ◽

...

Keyword(s):

Esophagogastric Junction ◽

Clinical Success ◽

Short Form ◽

Tertiary Care ◽

Prospective Trial ◽

Peroral Endoscopic Myotomy ◽

Outflow Obstruction ◽

Impedance Planimetry ◽

Sf 36 ◽

Endoscopic Myotomy

Abstract Background and study aims Esophagogastric junction outflow obstruction (EGJOO) is a rare esophageal dysmotility disease that is characterized by elevated integrated relaxation pressuse (IRP) with evidence of preserved peristalsis. The role of peroral endoscopic myotomy (POEM) in management of EGJOO is currently unknown. Patients and methods This is a prospective trial conducted in a single US tertiary care center from June 2015 to June 2019. Symptomatic patients, diagnosed with EGJOO on both HRM and endoluminal functional lumen imaging probe (EndoFLIP), who were eligible for POEM were recruited. Primary outcome was clinical success, defined as Eckardt score (ES) ≤ 3, at 6 months post-POEM. Other outcomes included dysphagia score, quality of life as measured by 36-item Short Form health survey scales (SF-36), post-POEM HRM, EndoFLIP, and pH measurements, and adverse events. Results A total of 15 patients (51.8 yr. 9 F) with EGJOO underwent POEM. Pre-POEM mean IRP on HRM and Distensibility index (DI) on EndoFLIP were 24.3 ± 2.2 mmHg and 1.1 ± 0.6 mm2/mmHg, respectively. Clinical success was achieved in 93 % at 6 months post-POEM. There was significant decrease in IRP (-17.6 mmHg) post-POEM. There was significant improvement at 6 months in two of the SF-36 subscales. Ten patients underwent post-POEM pH testing, seven of whom had abnormal DeMeester score. Seven patients underwent EGD evaluation revealing esophagitis in five (2 Los Angeles grade A and 3 grade B). Conclusions POEM offers a high clinical success rate for patients with EGJOO confirmed by impedance planimetry.

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