Vladimir M. Kushnir

Multiple rapid swallow responses during esophageal high-resolution manometry reflect esophageal body peristaltic reserve.

OBJECTIVES:Dysphagia may develop following antireflux surgery as a consequence of poor esophageal peristaltic reserve. We hypothesized that suboptimal contraction response following multiple rapid swallows (MRS) could be associated with chronic transit symptoms following antireflux surgery.METHODS:Wet swallow and MRS responses on esophageal high-resolution manometry (HRM) were characterized collectively in the esophageal body (distal contractile integral (DCI)), and individually in each smooth muscle contraction segment (S2 and S3 amplitudes) in 63 patients undergoing antireflux surgery and in 18 healthy controls. Dysphagia was assessed using symptom questionnaires. The MRS/wet swallow ratios were calculated for S2 and S3 peak amplitudes and DCI. MRS responses were compared in patients with and without late postoperative dysphagia following antireflux surgery.RESULTS:Augmentation of smooth muscle contraction (MRS/wet swallow ratios >1.0) as measured collectively by DCI was seen in only 11.1% with late postoperative dysphagia, compared with 63.6% in those with no dysphagia and 78.1% in controls (P≤0.02 for each comparison). Similar results were seen with S3 but not S2 peak amplitude ratios. Receiver operating characteristics identified a DCI MRS/wet swallow ratio threshold of 0.85 in segregating patients with late postoperative dysphagia from those with no postoperative dysphagia with a sensitivity of 0.67 and specificity of 0.64.CONCLUSIONS:Lack of augmentation of smooth muscle contraction following MRS is associated with late postoperative dysphagia following antireflux surgery, suggesting that MRS responses could assess esophageal smooth muscle peristaltic reserve. Further research is warranted to determine if antireflux surgery needs to be tailored to the MRS response.

EVALUATION OF GI BLEEDING AFTER IMPLANTATION OF LEFT VENTRICULAR ASSIST DEVICE

BACKGROUND Left ventricular assist devices (LVADs) have revolutionized the management of end-stage heart failure (ESHF). However, unexpectedly high rates of GI bleeding (GIB) have been described, and etiology and outcome remain unclear. OBJECTIVE To determine the prevalence, etiology, and outcome of GIB in LVAD recipients. DESIGN Retrospective case series. SETTING Tertiary care academic university hospital. PATIENTS 154 ESHF patients (55.4 years, 122 men/32 women) with LVADs implanted over a 10-year period. MAIN OUTCOME MEASUREMENTS Overt or occult GIB prompting endoscopic evaluation ≥ 7 days after LVAD implantation. RESULTS Over a mean of 0.9 ± 0.1 years of follow-up, 29 patients (19%) experienced 44 GIB episodes. Patients with GIB were older and received anticoagulation therapy before devices were implanted (P ≤ .02 for each). GIB was overt (n = 31) rather than occult (n = 13), and most patients presented with melena (n = 22, 50%); hemodynamic instability was observed in 13.6%. Each bleeding episode required 2.1 ± 0.1 diagnostic or therapeutic procedures, and a source was localized in 71%. Upper endoscopy provided the highest diagnostic yield; peptic bleeding (n = 14) and vascular malformations (n = 8) dominated the findings. Endoscopy was safe and well tolerated. Overall mortality was 35%, none directly from GIB. LIMITATION Retrospective design. CONCLUSIONS Rates of GIB with LVADs are higher than that seen in other patient populations, including those receiving anticoagulation and antiplatelet therapy. GIB episodes are mostly overt and predominantly from the upper GI tract. Endoscopy is safe in the LVAD population.

Obesity as a risk factor for sedation-related complications during propofol-mediated sedation for advanced endoscopic procedures

BACKGROUND There are limited data on the safety of anesthesia-assisted endoscopy by using propofol-mediated sedation in obese individuals undergoing advanced endoscopic procedures (AEPs). OBJECTIVE To study the association between obesity (as measured by body mass index [BMI]) and the frequency of sedation-related complications (SRCs) in patients undergoing AEPs. DESIGN Prospective cohort study. SETTING Tertiary referral center. PATIENTS A total of 1016 consecutive patients undergoing AEPs (BMI <30, 730 [72%]; 30-35, 159 [16%]; >35, 127 [12%]). INTERVENTION Monitored anesthesia sedation with propofol alone or in combination with benzodiazepines and/or opioids. MAIN OUTCOME MEASUREMENTS SRCs, airway maneuvers (AMs), hypoxemia, hypotension requiring vasopressors, and early procedure termination were compared across 3 groups. RESULTS There were 203 AMs in 13.9% of patients, hypoxemia in 7.3%, need for vasopressors in 0.8%, and premature termination in 0.6% of patients. Increasing BMI was associated with an increased frequency of AMs (BMI <30, 10.5%; 30-35, 18.9%; >35-26.8%; P < .001) and hypoxemia (BMI <30, 5.3%; 30-35, 9.4%; >35, 13.4%; P = .001); there was no difference in the frequency of need for vasopressors (P = .254) and premature termination of procedures (P = .401). On multivariable analysis, BMI (odds ratio [OR] 2.0; 95% CI, 1.3-3.1), age (OR 1.1; 95% CI, 1.0-1.1), and American Society of Anesthesiologists class 3 or higher (OR 2.4; 95% CI, 1.1-5.0) were independent predictors of SRCs. In obese individuals (n = 286), there was no difference in the frequency of SRCs in patients receiving propofol alone or in combination (P = .48). LIMITATIONS Single tertiary center study. CONCLUSIONS Although obesity was associated with an increased frequency of SRCs, propofol sedation can be used safely in obese patients undergoing AEPs when administered by trained professionals.

High-resolution manometric characteristics help differentiate types of distal esophageal obstruction in patients with peristalsis.

Background  High‐resolution manometry (HRM) can identify obstructive motor features at the esophagogastric junction and abnormalities in esophageal bolus transit. We sought to determine if HRM patterns can differentiate functional from organic mechanical lower esophageal sphincter (LES) obstruction.

Impact of Retroflexion Vs. Second Forward View Examination of the Right Colon on Adenoma Detection: A Comparison Study

OBJECTIVES:Although screening colonoscopy is effective in preventing distal colon cancers, effectiveness in preventing right-sided colon cancers is less clear. Previous studies have reported that retroflexion in the right colon improves adenoma detection. We aimed to determine whether a second withdrawal from the right colon in retroflexion vs. forward view alone leads to the detection of additional adenomas.METHODS:Patients undergoing screening or surveillance colonoscopy were invited to participate in a parallel, randomized, controlled trial at two centers. After cecal intubation, the colonoscope was withdrawn to the hepatic flexure, all visualized polyps removed, and endoscopist confidence recorded on a 5-point Likert scale. Patients were randomized to a second exam of the proximal colon in forward (FV) or retroflexion view (RV), and adenoma detection rates (ADRs) compared. Logistic regression analysis was used to evaluate predictors of identifying adenomas on the second withdrawal from the proximal colon.RESULTS:A total of 850 patients (mean age 59.1±8.3 years, 59% female) were randomly assigned to FV (N=400) or RV (N=450). Retroflexion was successful in 93.5%. The ADR (46% FV and 47% RV) and numbers of adenomas per patient (0.9±1.4 FV and 1.1±2.1 RV) were similar (P=0.75 for both). At least one additional adenoma was detected on second withdrawal in similar proportions (10.5% FV and 7.5% RV, P=0.13). Predictors of identifying adenomas on the second withdrawal included older age (odds ratio (OR)=1.04, 95% confidence interval (CI)=1.01–1.08), adenomas seen on initial withdrawal (OR=2.8, 95% CI=1.7–4.7), and low endoscopist confidence in quality of first examination of the right colon (OR=4.8, 95% CI=1.9–12.1). There were no adverse events.CONCLUSIONS:Retroflexion in the right colon can be safely achieved in the majority of patients undergoing colonoscopy for colorectal cancer screening. Reexamination of the right colon in either retroflexed or forward view yielded similar, incremental ADRs. A second exam of the right colon should be strongly considered in patients who have adenomas discovered in the right colon, particularly when endoscopist confidence in the quality of initial examination is low.

Abnormal GERD parameters on ambulatory pH monitoring predict therapeutic success in noncardiac chest pain.

OBJECTIVES:The value of gastroesophageal reflux disease (GERD) indicators (acid exposure time (AET), symptom association probability (SAP), and symptom index (SI)) in predicting therapeutic success in noncardiac chest pain (NCCP) has not been systematically evaluated in outcome studies.METHODS:We retrospectively identified 98 subjects with NCCP (age 51.8±1.2 years, 75 women, mean duration of symptoms 7.3±0.4 years) who underwent pH monitoring off antireflux therapy. Distal esophageal AET (abnormal if ≥4.0%), SAP (measured as Ghillibert probability estimate, abnormal if P<0.05), and SI (abnormal if ≥50%) were calculated; symptom severity and change after therapy were assessed on a 10-point Likert scale. Subjects were interviewed 2.8±0.9 years after the pH study to determine the degree of symptom change (high-degree response (HDR), with definite, sustained symptom improvement) after antireflux therapy. Regression analysis was used to determine the independent predictors of HDR.RESULTS:GERD indicators were present in 61 subjects (62.2%); 52 subjects (53.1%) had abnormal AET, 26 (26.5%) had positive SAP, and 25 (25.5%) had positive SI. With therapy, mean symptom scores improved from 6.3±0.3 at the time of the pH study to 2.9±0.3 at the time of interview (P<0.001). A total of 58 subjects (59.2%) achieved HDR, and another 29.6% had moderate symptom improvement. On univariate analysis, HDR was associated with positive SAP (P=0.003) and elevated AET (P=0.015) but not with demographics, SI, or esophageal motor pattern. In regression analysis containing demographics, GERD indicators, psychiatric comorbidity, and esophageal motor pattern, positive SAP was retained as a significant predictor of HDR (P=0.003); elevated AET trended toward significance (P=0.055). Frequency of HDR was highest when subjects had all three GERD parameters abnormal (93.3% HDR) or both elevated AET and positive SAP (88.2% HDR, P<0.001 compared with only one or no GERD parameter abnormal).CONCLUSIONS:Positive statistical tests of symptom association predict the therapeutic success of GERD management in NCCP. When used hierarchically, response to antireflux therapy is best predicted when GERD parameters are all abnormal and poorest when parameters are normal. These results support the importance of GERD, the relevance of symptom association testing during ambulatory pH monitoring, and the value of intensive antireflux therapy in NCCP.

The Clinical Impact of Immediate On-Site Cytopathology Evaluation During Endoscopic Ultrasound-Guided Fine Needle Aspiration of Pancreatic Masses: A Prospective Multicenter Randomized Controlled Trial

Objectives:Observational data on the impact of on-site cytopathology evaluation (OCE) during endoscopic ultrasonography-guided fine needle aspiration (EUS–FNA) of pancreatic masses have reported conflicting results. We aimed to compare the diagnostic yield of malignancy and proportion of inadequate specimens between patients undergoing EUS–FNA of pancreatic masses with and without OCE.Methods:In this multicenter randomized controlled trial, consecutive patients with solid pancreatic mass underwent randomization for EUS–FNA with or without OCE. The number of FNA passes in the OCE+ arm was dictated by the on-site cytopathologist, whereas seven passes were performed in OCE− arm. EUS–FNA protocol was standardized, and slides were reviewed by cytopathologists using standardized criteria for cytologic characteristics and diagnosis.Results:A total of 241 patients (121 OCE+, 120 OCE−) were included. There was no difference between the two groups in diagnostic yield of malignancy (OCE+ 75.2% vs. OCE− 71.6%, P=0.45) and proportion of inadequate specimens (9.8 vs. 13.3%, P=0.31). Procedures in OCE+ group required fewer EUS–FNA passes (median, OCE+ 4 vs. OCE− 7, P<0.0001). There was no significant difference between the two groups with regard to overall procedure time, adverse events, number of repeat procedures, costs (based on baseline cost-minimization analysis), and accuracy (using predefined criteria for final diagnosis of malignancy). There was no difference between the two groups with respect to cytologic characteristics of cellularity, bloodiness, number of cells/slide, and contamination.Conclusions:Results of this study demonstrated no significant difference in the diagnostic yield of malignancy, proportion of inadequate specimens, and accuracy in patients with pancreatic mass undergoing EUS–FNA with or without OCE.

MULTIPLE RAPID SWALLOW RESPONSES SEGREGATE ACHALASIA SUBTYPES ON HIGH RESOLUTION MANOMETRY

Background  Multiple rapid swallows (MRS) inhibit esophageal peristalsis and lower esophageal sphincter (LES) tone; a rebound excitatory response then results in an exaggerated peristaltic sequence. Multiple rapid swallows responses are dependent on intact inhibitory and excitatory neural function and could vary by subtype in achalasia spectrum disorders.

The impact of psychiatric and extraintestinal comorbidity on quality of life and bowel symptom burden in functional GI disorders

Functional gastrointestinal disorders (FGID) patients report poor health‐related quality of life (HRQOL) and experience high rates of psychiatric and extraintestinal functional disorder (EIFD) comorbidity. The independent influence of these comorbidities on HRQOL and symptom burden remains unknown. We sought to determine whether FGID with mood or EIFD comorbidity have poorer HRQOL and greater GI symptom burdens; to determine the influence of comorbidities on HRQOL in FGID independent of bowel symptoms.

High resolution manometry patterns distinguish acid sensitivity in non-cardiac chest pain.

Background  High resolution manometry (HRM) has demonstrated two distinct smooth muscle contraction segments in the esophageal body; changes in these segments typify certain esophageal disorders. We investigated segmental characteristics in subgroups of non‐cardiac chest pain (NCCP).