373 ESOPHAGEAL BODY PERISTALSIS IN PATIENTS WITH NORMAL LOWER ESOPHAGEAL SPHINCTER: ARE VIDEO ESOPHAGOGRAM AND HIGH-RESOLUTION MANOMETRY IN AGREEMENT?

Peristaltic disorders of the esophageal body have been categorized according to how they appear on high-resolution manometry. Abnormalities in peristalsis may lead to abnormal esophageal clearance and dysphagia. The aim of our retrospective analysis was to study bolus transit patterns on barium esophagogram in patients with various grades of esophageal body peristalsis as diagnosed by high-resolution manometry. Methods After Institutional Review Board approval, we queried an esophageal center database to identify patients with normal lower esophageal sphincter parameters. Patients with jackhammer esophagus, esophageal spasm, previous foregut surgery, hiatal hernia, and fragmented peristalsis were excluded. Remaining patients were divided into 11 groups based on their percentages of normal swallows out of 10 swallows (0%–100% swallows normal, DCI > 450 mmHg.s.cm). All previously obtained video esophagograms were re-evaluated in blinded fashion. Bolus transit time through the esophagus was measured in upright and prone positions, using live time stamps at the entry and exit of the bolus. ANOVA and χ2 were used. Results In total, 146 patients were included in the analysis. 73 (50%) were men. Mean age and body mass index were 58.4 ± 14.7 years and 22.8 ± 10.4 kg/m2, respectively. Bolus transit time in prone-position swallows increased in tandem with increases in number of abnormal swallows (11.3 ± 3.7, 22 ± 15.5, 29.5 ± 24.3, 42.7 ± 39.5, 42.4 ± 46.9, 64 ± 70.8, 59.4 ± 34.6, 58.8 ± 37.9, 110 ± 66.6, 83.2 ± 49.6 and 105.6 ± 72.5 seconds, p < 0.0001) but no difference was noted in upright-position bolus transit time (p = 0.317). There was a dropoff in level of significance at Group 5 (60% swallows normal) compared to Group 11 (absent contractility), after which there were no inter-group differences (Fig. 1). Conclusion Bolus transit time in prone-position swallows progressively increases as percentage of normal swallows decreases. Further work associated with symptoms to define a cutoff between normal and ineffective peristalsis would be useful.

534 WHICH IS THE BEST SURGICAL MANAGEMENT OF GASTROESOPHAGEAL REFLUX DISEASE (GERD) IN PATIENTS WITH SYSTEMIC SCLEROSIS WITH PULMONARY INVOLVEMENT?

Systemic sclerosis (scleroderma) is frequently associated with both gastroesophageal reflux disease (GERD) and simultaneous esophageal dysmotility (ED). Antireflux surgery have to considerate the individual esophageal dysmotility degree of each patient. They need GERD treatment as a priority to help control worsening lung function, in patients developing pulmonary fibrosis or in lung transplantation patients. Another issue is the possibility that fundoplications in this patients can cause esophageal stasis, an event that can also disrupt lung function. Methods 113 patients were referred for surgical treatment of GERD, related with pulmonary impairment. SS patients are the most critical, once the ED may be an obstacle to fundoplication. We divided this patients in three groups regarding the esophageal function. A- Partial fundoplication—without important affection of ED, checked by manometry, confirmed with a complete emptying of esophagus in barium swallow test. B- Laparoscopic gastric bypass for treatment of GERD (RYGBP)—aperistalsis or atonic esophageal body, with normal esophageal empty at barium test. C- Esophagectomy—Atonic esophageal body with important delayed emptying of esophagus in barium swallow test. Results We could follow up 4 patients in group A, 3 patients in group B and 2 patients in group C. Median follow-up was 75, 30 and 18 months for Groups A,B and C respectively. All 3 patients in the RYGB group resolved all the symptoms including heartburn and regurgitation, with a sensitive improve in lung function. Only 1 patients in the fundoplication group reported symptom improvement or resolution. The Patients at Group C have no complain of Dysphagia but referred regurgitation and difficulty feedingtill first year. Conclusion Laparoscopic RYGB as an anti-reflux procedure is safe and may provide an alternative to fundoplication in the treatment of GERD for systemic sclerosis patients with esophageal dysmotility. Both reflux control and dysphagia rates were improved in the RYGBP group compared with fundoplication and esophagectomy.. This finding suggests that RYGBP may be an option for the primary manage- ment of scleroderma-associated gastroesophageal reflux in patients without importnat impairing of esophageal emptying.

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.