Michael Manka

Increased frequency of transient lower esophageal sphincter relaxation induced by gastric distention in reflux patients with hiatal hernia

BACKGROUND & AIMS This study aimed to determine if hiatal hernia influences vulnerability to reflux and transient lower esophageal sphincter relaxation (tLESR) during gastric distention in patients with gastroesophageal reflux disease (GERD). METHODS Eight normal subjects and 15 patients with GERD were studied. A metal clip attached to the squamocolumnar junction (SCJ) was beneath the hiatus in all control subjects. Eight GERD patients with >/=1-cm SCJ-hiatus separation were considered hernia patients, and 7 with <1-cm separation were considered nonhernia patients. Manometry and esophageal pH were recorded for 30 minutes, after which the stomach was loaded with acid dextrose and the recording continued for 2 hours with intragastric air infusion of 15 mL/min. RESULTS Baseline reflux was comparable among groups. Gastric distention increased the frequency of reflux by the tLESR mechanism in all groups. Controls and nonhernia patients had median increases of 4.0 and 4.5 in tLESR frequency, respectively, and hernia patients had a median increase of 9.5/h. tLESR frequency was highly correlated with the SCJ-hiatus separation (r = 0.76; P < 0.001). CONCLUSIONS Gastric air infusion was a potent stimulus for tLESR and reflux. The resultant tLESR frequency was directly proportional to the separation between the SCJ and hiatus, suggesting that the perturbed anatomy associated with hiatal hernia predisposed to eliciting tLESRs in patients with GERD.

The effect of hiatus hernia on gastro-oesophageal junction pressure

BACKGROUND Hiatus hernia and lower oesophageal sphincter hypotension are often viewed as opposing hypotheses for gastro-oesophageal junction incompetence. AIMS To examine the interaction between hiatus hernia and lower oesophageal sphincter hypotension. METHODS In seven normal subjects and seven patients with hiatus hernia, the squamocolumnar junction and intragastric margin of the gastro-oesophageal junction were marked with endoscopically placed clips. Axial and radial characteristics of the gastro-oesophageal junction high pressure zone were mapped relative to the hiatus and clips during concurrent fluoroscopy and manometry. Responses to inspiration and abdominal compression were also analysed. RESULTS In normal individuals the squamocolumnar junction was 0.5 cm below the hiatus and the gastro-oesophageal junction high pressure zone extended 1.1 cm distal to that. In those with hiatus hernia, the gastro-oesophageal junction high pressure zone had two discrete segments, one proximal to the squamocolumnar junction and one distal, attributable to the extrinsic compression within the hiatal canal. Inspiration and abdominal compression mainly augmented the distal one. Simulation of hernia reduction by algebraically summing the proximal segment pressures with the hiatal canal pressures restored normal maximal pressure, radial asymmetry, and dynamic responses of the gastro-oesophageal junction. CONCLUSIONS Hiatus hernia reduces lower oesophageal sphincter pressure and alters its dynamic responsiveness by spatially separating pressure components derived from the intrinsic lower oesophageal sphincter and the extrinsic compression of the oesophagus within the hiatal canal.

Impact of fundoplication on bolus transit across esophagogastric junction

This study analyzed the effect of fundoplication on the mechanics of liquid and solid bolus transit across the esophagogastric junction (EGJ). The squamocolumnar junction was endoscopically clipped in seven controls, seven hiatal hernia patients, and seven patients after laparoscopic Nissen fundoplication. Concurrent manometry and fluoroscopy were done during swallows of liquid barium and a 13-mm-diameter marshmallow. The EGJ opening, pressure gradients, transit efficacy, and axial motion were measured. The axial motion of the EGJ was reduced in the fundoplication and hiatal hernia patients. The opening dimensions at the squamocolumnar junction were similar among groups, but in each case the constriction limiting flow to the stomach was at the hiatus and this was substantially narrowed with fundoplication. As a result, liquid intrabolus pressure was increased and marshmallow transit frequently required multiple swallows. We conclude that fundoplication limits the axial mobility of the EGJ and leads to a restricted hiatal opening. These alterations decrease the efficacy of solid and liquid transit into the stomach and are potential causes of dysphagia in this population.This study analyzed the effect of fundoplication on the mechanics of liquid and solid bolus transit across the esophagogastric junction (EGJ). The squamocolumnar junction was endoscopically clipped in seven controls, seven hiatal hernia patients, and seven patients after laparoscopic Nissen fundoplication. Concurrent manometry and fluoroscopy were done during swallows of liquid barium and a 13-mm-diameter marshmallow. The EGJ opening, pressure gradients, transit efficacy, and axial motion were measured. The axial motion of the EGJ was reduced in the fundoplication and hiatal hernia patients. The opening dimensions at the squamocolumnar junction were similar among groups, but in each case the constriction limiting flow to the stomach was at the hiatus and this was substantially narrowed with fundoplication. As a result, liquid intrabolus pressure was increased and marshmallow transit frequently required multiple swallows. We conclude that fundoplication limits the axial mobility of the EGJ and leads to a restricted hiatal opening. These alterations decrease the efficacy of solid and liquid transit into the stomach and are potential causes of dysphagia in this population.

Lower esophageal sphincter relaxation characteristics using a sleeve sensor in clinical manometry

Objective:We undertook this study to determine the characteristics of swallow-induced lower esophageal sphincter (LES) relaxation in the setting of clinical manometry using a standardized methodology.Methods:We reviewed 170 manometric recordings performed using a perfused manometric assembly with a sleeve sensor and a computer polygraph. Patients were categorized as patient controls, gastroesophageal reflux disease (GERD), diffuse esophageal spasm (DES), or achalasia. Tracing were semiautomatically analyzed for basal LES pressure, LES pressure during deglutitive relaxation (relaxation LES pressure), duration of LES relaxation, timing of LES relaxation, and the success rate of primary peristalsis.Results:Forty-six patient controls, 93 with GERD, five with DES, and 26 with achalasia were identified. GERD and achalasia patients had lower or higher basal LES pressures than patient controls, respectively. Compared with patient controls, achalasia patients had higher relaxation LES pressures, lower percent LES relaxation, and shorter durations of LES relaxation. The best single measure for distinguishing achalasia was the relaxation LES pressure; using the 95th percentile value of patient controls (12 mm Hg) as the upper limit of normal, its sensitivity and positive predictive value for the diagnosis of achalasia were 92% and 88%, respectively. Coupled with the finding of aperistalsis, a relaxation LES pressure ≥10 mm Hg achieved 100% sensitivity and positive predictive value among these patients.Conclusion:Sleeve sensor recording is a practical method for clinical manometry that reliably records LES relaxation characteristics and is amenable to both a standardized manometry protocol and a semiautomated analysis routine. Relaxation LES pressure has a high diagnostic value for achalasia.

Physician Report Cards and Implementing Standards of Practice Are Both Significantly Associated With Improved Screening Colonoscopy Quality

OBJECTIVES:Adenoma-detection rates (ADRs) are associated with decreased interval colorectal cancer (CRC) rates and CRC mortality; quality improvement strategies focus on improving physician ADRs. The objective of this study was to examine the sequential effect of physician report cards and implementing institutional standards of practice (SOP) on ADRs.METHODS:Colonoscopy metrics were prospectively evaluated at a single academic medical center over a 23-month period (November 2012 to October 2014). ADRs were evaluated over three time periods—Period 1: Before initial report card distribution or SOP (November 2012 to March 2013); Period 2: After individualized report card distribution detailing physician and institutional ADRs (April 2013 to March 2014); Period 3: After second report card and SOP implementation (April 2014 to October 2014). The SOP required physicians to have a minimum 5-min withdrawal time in normal colonoscopies (WT) and an ADR minimum of 20%; those who did not meet benchmarks would require further training or endoscopy block time alterations. Only endoscopists averaging >15 colonoscopies/month were included in this analysis.RESULTS:Twenty endoscopists met the inclusion criteria, performing 12,894 screening colonoscopies over the 23-month period. Following report card distribution, physician ADRs increased by 3% (P<0.001). SOP implementation resulted in a further significant increase in mean physician ADR of 8% (P<0.0001). Overall, mean ADR increased by 11% from Period 1 to Period 3 (P<0.0001). All physicians met the minimum 20% ADR benchmark during Period 3. Although ADRs significantly correlated with WT overall (r=0.45; 95% CI 0.01, 0.75; P=0.04), mean WT did not significantly increase from Period 1 to Period 3.CONCLUSIONS:Our data suggest that distributing colonoscopy quality report cards resulted in a significant ADR improvement. Further, we report evidence that implementing SOP significantly improved ADRs beyond report card distribution and resulted in all endoscopists meeting minimum benchmarks. This suggests that report cards and SOPs may have an additive effect in improving colonoscopy quality, and their implementation in endoscopy labs should be encouraged.

Manometric characteristics of the upper esophageal sphincter recorded with a microsleeve

OBJECTIVES:We compared manometric recordings of the upper esophageal sphincter (UES) recorded with a miniature sleeve to those obtained using standard manometry.METHODS:The UES pressure of eight volunteer subjects was measured by station pull-through (SPT), by rapid pull-through (RPT), and with a microsleeve sensor for 30 min, followed by 15 min of esophageal acid infusion. Deglutitive UES relaxation recorded with a microsleeve and solid state sensor were compared.RESULTS:The UES pressure recorded with the microsleeve (25 ± 9 mm Hg) was significantly less than that by SPT (114 ± 18 mm Hg) or RPT (152 ± 19 mm Hg), and was unaffected by acid infusion. Periods of low UES pressure were observed during long interswallow intervals (11 ± 4, range 6–18 mm Hg). Deglutitive relaxation duration and intrabolus pressure measured with the microsleeve were less than those recorded by the solid state transducer.CONCLUSIONS:“Normal” UES pressure is heavily dependent on measurement technique; pressures obtained with a miniature sleeve are a fraction of those obtained by SPT or RPT. During periods of relative comfort with minimal swallowing, UES tone is approximately 10 mm Hg, similar to that during sleep. Volume modulation of deglutitive UES relaxation is demonstrable with a microsleeve, albeit with less precision than with a solid-state transducer.

Operative manometry and endoscopy during laparoscopic Heller myotomy : An initial experience

AbstractBackground: We report our initial experience using operative esophageal manometry as an adjunct to endoscopy to determine the completeness of esophagogastric high-pressure zone (HPZ) obliteration during laparoscopic Heller myotomy. Methods: Between July 1997 and October 1998, we performed laparoscopic Heller myotomies in 20 patients (eight male, 12 female; median age, 41 years). Mean duration of symptoms was 3.2 ± 2.6 years (r= 0.5–11), and 45% of the patients had received prior dilation or toxin injection. A 16-channel esophageal manometry catheter was placed prior to anesthesia, with sites crossing the lower esophageal sphincter (LES). An endoscope was passed intraoperatively to localize the squamocolumnar junction, and the myotomy was performed. While the translucency was imaged in the area of the incision, we determined the adequacy of myotomy by visual assessment of LES and gastric cardia opening in response to endoscopic air insufflation. Manometry was then performed to detect any potential residual high pressure at the myotomized esophagogastric junction (EGJ). If it was found, the locus of persistent pressure was identified by probing along the myotomy, and residual muscle fibers were cut to yield a minimum pressure at the EGJ. Results: A persistent HPZ was identified after the initial myotomy in 10 of 20 patients (50%). A Dor fundoplasty completed the operation. The mean operating time was 2.6 ± 0.5 h (median, 2.5; r= 2–3.5 h), and the mean hospital stay was 1.6 ± 1 days (median, 1, r= 1–5 days). The mean LES pressure was 2 ± 3 mmHg immediately postmyotomy (p < 0.001 compared with preoperative value). Of 20 patients, only two have reported recurrence of dysphagia (10%). One had a recurrent HPZ on manometry, and one developed esophagitis, which resolved with omeprazole. Conclusions: Our initial experience suggests that operative esophageal manometry is a useful adjunct to upper endoscopy during laparoscopic Heller myotomy, quantitatively assuring obliteration of the nonrelaxing LES and HPZ.

Intravenous access during routine conscious sedated endoscopy

these findings, we realized that this tumor contained two neoplastic components—tubular adenoma for the epithelial neoplasm and neurofibroma for the mesenchymal neoplasm—and the pathological diagnosis of adenoneurofibroma was made. Other polypoid lesions showed common tubular adenomas with moderate dysplasia without neurofibromatous components. GI neurofibromas are usually accompanied by NF-1 (1), but they are rare in non–NF-1 patients (2, 3). The present case involved a non–NF-1 patient and had a neurofibromatous component in the background of colonic adenoma. No colorectal adenoma accompanied by a neurofibromatous background has been reported, and our case is the first colorectal adenoneurofibroma reported. Concerning the pathogenesis of adenoneurofibroma, atypical glands should be neoplastic because of the elevation of the nucleocytoplasmic ratio and hyperchromatic nuclei with prominent nucleoli, suggesting tubular adenoma. On the other hand, the presence of a neurofibromatous component in the colonic submucosa is unusual in non–NF-1 patients, and it can be understood that this component is also a neoplasm originating in a peripheral nervous system. As GI neurofibromas can arise both in an intramuscular plexus of Auerbach and in a submucosal plexus of Meissner (3, 4), the neurofibromatous component of this case is considered to originate in Meissner’s plexus because of the histological spread of the lesion. We would interpret that adenoneurofibroma of the colon is a neoplasm of mixed epithelial and peripheral nervous proliferation.

Pressure morphology of the gastroesophageal junction after fundoplication: How normal is it

Though effective in resolving esophagitis, fundoplication (FP) can impair belching, a venting mechanism that requires both a relaxed sphincter an d that intragastric pressure exceed extrasphincteric pressure. To better understand this limitation, we compared gastroesophageal junction (GEJ) pressure morphology after FP to that of normal volunteers (N1) and hiatal hernia (HH) patients. Methods: Metal clips were placed endoscopically to mark the intragastric margin of the GEJ and squamocolumnar junction (SCJ) in 7 Nls, 7 HH patients, and 7 patients after FP. GEJ pressure (0=atmospheric) referenced to the clips and hiatus was measured during concurrent videofluoroscopy and mechanized pull through of an 8-lumen manometer with radiopaque side holes at the same axial level but 45 ° apart radially. Subdiaphragmatic length (SDL) of the GEJ (shaded area in figure) was that distal to the hiatal canal, as localized in HH patients. Pull throughs were done during endexpiration, deep inspiration, and abdominal compression (AC) with a binder inflated to 100 mmHg. Results: Axial position of the SCJ was restored post-FP, but GEJ pressure morphology of each group was distinct (Figure & Table, All data mean -+ SE).